What constitutes brilliant aged care? A qualitative study of practices that exceed expectation.

AIM: This study aimed to explore what constitutes brilliant aged care. BACKGROUND: Although many aged care services do not offer the care that older people and carers need and want, some perform better. Rather than focus on problems with aged care, this study examined brilliant aged care-practices that exceeded expectation. DESIGN: The methodology for this study was informed by grounded theory, underpinned by constructionism to socially construct meaning. METHODS: This study invited nominations for a Brilliant Award via a survey, and interviews with the nominees via web conference. After receiving survey responses from 10 nominators, interviews were conducted with 12 nominees. Data were analysed using reflexive thematic analysis and documented according to COREQ guidelines to optimise rigour and transparency. RESULTS: According to participants, brilliant aged care involved being relationally attuned to older people, a deep understanding of the older person, recognition of aged care as more than a job, innovative practices and permission to reprioritise. CONCLUSIONS: This study suggests that, in aged care, brilliance happens. It emphasises the importance of meaningful connections and relationships in aged care, where thoughtful acts acknowledge an older person's value and humanity as well as creativity and innovation. RELEVANCE TO CLINICAL PRACTICE: For those who manage and deliver aged care, the findings suggest that small practice changes can make a positive difference to older people. Brilliant aged care can involve acts of empathy; enthusiasm for aged care; innovative practices, even those that are small scale; and reprioritising workplace tasks to spend time with older people. For policymakers, this study highlights the need to recognise and raise the profile of the pockets of brilliance within the aged care sector. This might be achieved via awards and other initiatives that serve to celebrate and learn from brilliance in its myriad forms. PATIENT OR PUBLIC CONTRIBUTION: The nominees, who included carers, were invited to participate in workshops with other carers and older people to co-design a model of brilliant aged care, during which workshop participants discussed and critiqued the findings constructed from the data.

Implementing the Patient Activation Measure (PAM) in clinical settings for patients with chronic conditions: a scoping review.

Objective: The Patient Activation Measure (PAM) assesses the knowledge, skills and confidence of patients to manage their health, and has been consistently used as an outcome measure of health interventions. Using the PAM to tailor interventions to a patient's activation level is less understood. This literature review aimed to examine evidence for interventions using the PAM to tailor care for patients with chronic conditions, including enablers and barriers to implementation, and the impact on quality of care. Methods and analysis: A scoping review methodology was used to identify literature reporting on PAM-tailored interventions. The Insignia Health website and Medline database were searched. Included papers were published in English from 2004 to 2017, from Organisation for Economic Cooperation and Development countries, included adult patients with chronic conditions, and a PAM-tailored intervention. Eligible full-text papers were assessed against the inclusion criteria. Data were extracted into tables and summarised to assess the key findings, recurring themes and differences across papers. Results: Twenty-one papers describing the use of PAM-tailored interventions (n=21) were identified. Interventions included motivational interviewing, health coaching, self-management planning and risk profile assessment. The perceived value and function of the PAM held by organisations, clinicians and patients influenced implementation and use. Evidence for the impact of PAM-tailored interventions on quality of care was limited. Conclusion: The PAM is being used to tailor a range of interventions for patients with chronic conditions. Clinician perceptions and understanding about the PAM's value and purpose influenced implementation. Further research is needed about how PAM-tailored interventions can be integrated into clinical practice, and guide the patient-clinician interaction, in ways that improve the quality of patient care.

Treatment of irritable bowel syndrome with diarrhoea using titrated ondansetron (TRITON): study protocol for a randomised controlled trial.

BACKGROUND: Irritable bowel syndrome with diarrhoea (IBS-D) affects up to 4% of the general population. Symptoms include frequent, loose, or watery stools with associated urgency, resulting in marked reduction of quality of life and loss of work productivity. Ondansetron, a 5HT3 receptor antagonist, has had an excellent safety record for over 20 years as an antiemetic, yet is not widely used in the treatment of IBS-D. It has, however, been shown to slow colonic transit and in a small randomised, placebo-controlled, cross-over pilot study, benefited patients with IBS-D. METHODS: This trial is a phase III, parallel group, randomised, double-blind, multi-centre, placebo-controlled trial, with embedded mechanistic studies. Participants (n = 400) meeting Rome IV criteria for IBS-D will be recruited from outpatient and primary care clinics and by social media to receive either ondansetron (dose titrated up to 24 mg daily) or placebo for 12 weeks. Throughout the trial, participants will record their worst abdominal pain, worst urgency, stool frequency, and stool consistency on a daily basis. The primary endpoint is the proportion of "responders" in each group, using Food and Drug Administration (FDA) recommendations. Secondary endpoints include pain intensity, stool consistency, frequency, and urgency. Mood and quality of life will also be assessed. Mechanistic assessments will include whole gut transit, faecal tryptase and faecal bile acid concentrations at baseline and between weeks 8 and 11. A subgroup of participants will also undergo assessment of sensitivity (n = 80) using the barostat, and/or high-resolution colonic manometry (n = 40) to assess motor patterns in the left colon and the impact of ondansetron. DISCUSSION: The TRITON trial aims to assess the effect of ondansetron across multiple centres. By defining ondansetron's mechanisms of action we hope to better identify patients with IBS-D who are likely to respond. TRIAL REGISTRATION: ISRCTN, ISRCTN17508514 , Registered on 2 October 2017.

Knowledge, Skill, and Confidence in People Attending Pulmonary Rehabilitation: A Cross-Sectional Analysis of the Effects and Determinants of Patient Activation.

BACKGROUND: Patient activation is a significant predictor of health behaviors; however, the level of activation in people attending a pulmonary rehabilitation program and the effect of pulmonary rehabilitation on patient activation have not been measured. Furthermore, the potential determinants and relationship between patient activation and characteristics of people attending pulmonary rehabilitation have not previously been reported. METHODS: The Patient Activation Measure (PAM) was measured in people with a chronic respiratory disease or congestive cardiac failure at a baseline pulmonary rehabilitation assessment and again at the completion of the 8-week outpatient program. RESULTS: This study included 194 people with chronic respiratory disease or congestive cardiac failure (41% male; mean [standard deviation, SD] age: 73 [11] years; mean [SD] forced expiratory volume in 1 second % predicted: 60% [20%]). The pulmonary rehabilitation program was completed by 61% (n = 118) of participants. The mean (SD) PAM score at baseline was 60.5 (15.7), which improved to 65.4 (15.5) after completion of the pulmonary rehabilitation program (P = .001). In a stepwise forward multiple regression analysis, anxiety, lung information needs, and health-related quality of life impact were found to be significant determinants of baseline PAM. This model explained 12% (P < .001) of the variance. CONCLUSION: People with a chronic respiratory disease or congestive cardiac failure commencing a pulmonary rehabilitation program demonstrated a moderate level of activation, which improved following an 8-week hospital outpatient pulmonary rehabilitation program. Anxiety, a higher level of lung information needs, and greater health-related quality of life impact were significantly associated with poor patient activation.

Shaping interventions to address waterpipe smoking in Arabic-speaking communities in Sydney, Australia: a qualitative study.

BACKGROUND: Waterpipe smoking is a traditional method of tobacco smoking that is being increasingly practiced worldwide. However, the research evidence describing the practice and prevalence of waterpipe smoking in Australia is limited. Arabic-speaking communities residing in an area of metropolitan Sydney identified increasing rates of waterpipe smoking as a community health concern during a tobacco intervention project. A qualitative research project was conducted to explore community perceptions about waterpipe smoking and the health promotion interventions that would be acceptable to Arabic speaking communities. METHODS: Participants from Arabic-speaking community groups and networks were recruited by trained bilingual community research assistants (BCRAs). Ten focus groups were conducted, eight by the BCRAs and two by the research team, and included a total of 88 participants. Notes were taken during the focus groups by the BCRAs and provided to the research team. The data was coded and managed using NVivo 11, and examined for themes and subthemes. RESULTS: Eleven themes were identified from the data relating to the perceptions of waterpipe smoking (practices, cultural identity, acceptability, social connectedness, knowledge and perceptions of harm, trend and fashion, availability and access) and possible health promotion interventions (health information and social marketing, health education, policy and legislation, intervention target groups and messages). Waterpipe smoking was reported to be widely practiced and was related to a number of factors including feelings of cultural identity and belonging. The study highlighted the misconceptions of harm that exist in communities about the health effects of waterpipe smoking, as well as the significant role of the family in passing on the practice of waterpipe smoking. These factors should be considered in the development of health promotion interventions. CONCLUSIONS: Our findings suggest that until waterpipe smoking is perceived as a problem, community readiness for accepting health promotion interventions will be limited. Interventions should focus on debunking the myths that contribute toward a reduced perception of harm. A culturally sensitive approach, that considers the cultural connection to waterpipe smoking, should be taken toward the development and implementation of interventions.

A Scoping Review of the Evidence on Health Promotion Interventions for Reducing Waterpipe Smoking: Implications for Practice.

Background: Waterpipe tobacco smoking is a traditional method of tobacco use, especially in the Eastern Mediterranean Region (EMR), but its prevalence is growing worldwide, especially among young people. Although often perceived as less harmful than other methods of tobacco use because the smoke passes through water, accumulating evidence shows harmful effects and that some smokers become addicted. Interventions that deglamourise and denormalise use have been recommended but little is known about the range and impact of different health prevention and promotion interventions. Methods: A scoping review of literature was undertaken to explore the breadth of literature and assess the range and impact of community based health promotion interventions for waterpipe smoking. Searches were conducted in Medline, Embase, CINAHL, Psychinfo, and the Cochrane database of systematic reviews. Interventions were classified using a health promotion framework and data extracted on the aspects of prevention/promotion addressed; key strategies employed, evidence of effectiveness or impact on behavior change as well as barriers to implementation and perceived success factors. Results: Ten studies were included in the review. They include brief interventions to increase quit rates; community campaigns to raise awareness and increase knowledge; web based health education and skill development to increase perceived risks and intention to quit; as well as studies that evaluated product labeling and opportunities for policy interventions to create healthy environments. Conclusions: The evidence base is small but growing. Brief interventions for waterpipe users, community campaigns, and web based tailored information can modify perceptions of addiction and increase intentions to quit. Product labeling may be an effective policy tool to curb waterpipe smoking. A range of policy interventions have been identified but not evaluated.

Context matters for primary health care access: a multi-method comparative study of contextual influences on health service access arrangements across models of primary health care.

BACKGROUND: Equitable access to primary health care (PHC) is an important component of integrated chronic disease management. Whilst context is known to influence access to PHC, it is poorly researched. The aim of this study was to determine the contextual influences associated with access arrangements in four Australian models of integrated PHC. METHODS: A multi-method comparative case study design. Purposive sampling identified four models of PHC across six sites in two Australian states. Complexity theory informed the choice of contextual factors that influenced access arrangements, which were analysed across five dimensions: availability and accommodation, affordability, acceptability, appropriateness and approachability. Semi-structured interviews, document/website analysis and non-participant observation were used to collect data from clinicians, administrative staff and other key stakeholders. Within and cross-case thematic analysis identified interactions between context and access across sites. RESULTS: Overall, financial viability, objectives of the PHC model and relationships with the local hospital network (LHN) underpinned access arrangements. Local supply of general practitioners and financial viability were strong influences on availability of after-hours services. Influences on affordability were difficult to determine because all models had nil/low out-of-pocket costs for general practitioner services. The biggest influence on acceptability was the goal/objectives of the PHC model. Appropriateness and to a lesser degree affordability arrangements were influenced by the relationship with the LHN. The provision of regular outreach services was strongly influenced by perceived population need, referral networks and model objectives. CONCLUSIONS: These findings provide valuable insights for policy makers charged with improving access arrangements in PHC services. A financially sustainable service underpins attempts to improve access that meets the needs of the service population. Smaller services may lack infrastructure and capacity, suggesting there may be a minimum size for enhancing access. Access arrangements may be facilitated by aligning the objectives between PHC, LHN and other stakeholder models. While some access arrangements are relatively easy to modify, improving resource intensive (e.g. acceptability) access arrangements for vulnerable and/or chronic disease populations will require federal and state policy levers with input from primary health networks and LHNs.

The informatics capability maturity of integrated primary care centres in Australia.

CONTEXT: Integrated primary care requires systems and service integration along with financial incentives to promote downward substitution to a single entry point to care. Integrated Primary Care Centres (IPCCs) aim to improve integration by co-location of health services. The Informatics Capability Maturity (ICM) describes how well health organisations collect, manage and share information; manage eHealth technology, implementation, change, data quality and governance; and use "intelligence" to improve care. AIM: Describe associations of ICM with systems and service integration in IPCCs. METHODS: Mixed methods evaluation of IPCCs in metropolitan and rural Australia: an enhanced general practice, four GP Super Clinics, a "HealthOne" (private-public partnership) and a Community Health Centre. Data collection methods included self-assessed ICM, document review, interviews, observations in practice and assessment of electronic health record data. Data was analysed and compared across IPCCs. FINDINGS: The IPCCs demonstrated a range of funding models, ownership, leadership, organisation and ICM. Digital tools were used with varying effectiveness to collect, use and share data. Connectivity was problematic, requiring "work-arounds" to communicate and share information. The lack of technical, data and software interoperability standards, clinical coding and secure messaging were barriers to data collection, integration and sharing. Strong leadership and governance was important for successful implementation of robust and secure eHealth systems. Patient engagement with eHealth tools was suboptimal. CONCLUSIONS: ICM is positively associated with integration of data, systems and care. Improved ICM requires a health workforce with eHealth competencies; technical, semantic and software standards; adequate privacy and security; and good governance and leadership.

Beginning the trajectory to ESKD in adult life: albuminuria in Australian aboriginal children and adolescents.

BACKGROUND: Globally, disadvantaged populations suffer a high burden of chronic kidney disease (CKD). The trajectory to CKD during childhood and adolescence remains unclear due to a paucity of longitudinal studies. METHODS: This was a prospective, population-based cohort study in which since 2002 we have followed 3418 children (1469 non-Aboriginal and 1949 Aboriginal) attending participating schools across New South Wales (NSW), Australia. The albumin:creatinine ratio was measured by dipstick every 2 years together with the body mass index (BMI) and blood pressure. We used multivariable logistic generalised estimating equation models to examine whether Aboriginal children had a higher prevalence of albuminuria compared with non-Aboriginal children with increasing age and to identify potential risk factors. RESULTS: The mean age at enrolment was 10.6 years, at which time 14.2 % of the children were obese and 16.0 % overweight, with 11.5 % found to have albuminuria. Over 8 years (11,387 participant-years) of follow-up the prevalence of albuminuria increased to 18.5 %, overweight to 16.1 % and obesity to 17.2 %. The BMI standard deviation score (SDS) was found to have a differential effect on the risk of albuminuria in Aboriginal and non-Aboriginal children (P interaction < 0.01). The prevalence of albuminuria decreased as the BMI SDS increased in both groups of children, but it increased more in non-Aboriginal children, leading to a 2.5 % higher prevalence of albuminuria in overweight Aboriginal children (95 % confidence interval 1.0-4.2 %). CONCLUSION: Compared with non-Aboriginal children, Aboriginal children are of higher risk of albuminuria when overweight or obese. We hypothesise that overweight and obesity are key contributors to the development of adult onset CKD among Aboriginal Australians, which needs further exploration in future studies.

A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy.

The aim of this systematic review was to assess evidence of the impact of commissioning on health service use, quality, outcomes and value for money and to consider findings in the Australian context. Systematic searches of the literature identified 444 papers and, after exclusions, 36 were subject to full review. The commissioning cycle (planning, contracting, monitoring) formed a framework for analysis and impacts were assessed at individual, subpopulation and population levels. Little evidence of the effectiveness of commissioning at any level was available and observed impacts were highly context-dependent. There was insufficient evidence to identify a preferred model. Lack of skills and capacity were cited as major barriers to the implementation of commissioning. Successful commissioning requires a clear policy framework of national and regional priorities that define agreed targets for commissioning agencies. Engagement of consumers and providers, especially physicians, was considered to be critically important but is time consuming and has proven difficult to sustain. Adequate information on the cost, volume and quality of healthcare services is critically important for setting priorities, and for contracting and monitoring performance. Lack of information resulted in serious problems. High-quality nationally standardised performance measures and data requirements need to be built into contracts and ongoing monitoring and evaluation. In Australia, there is significant work to be done in areas of policy and governance, funding systems and incentives, patient enrolment or registration, information systems, individual and organisational capacity, community engagement and experience in commissioning.

An unexpected increase in restraint duration alters the expression of stress response habituation.

While habituation develops to a repeated psychological stressor, manipulating certain parameters of the stress challenge experience may lead to dishabituation of the stress response. In this experiment, we investigated whether the behavioral, endocrine, and neural responses (c-fos mRNA immediate early gene expression) to a psychological stressor (restraint) differ when the duration of the stressor given on the test day violates expectations based on prior stress experience. Rats experienced 10 min of daily restraint on Days 1-4 followed by a challenge with either the same duration (10 min) or a longer duration (30 min) of restraint on Day 5. Rats' behavior was video recorded during the Day 5 restraint episode, and trunk blood and brain tissue were collected 30 min following restraint onset. Struggling behavior was manually scored as active attempts to escape the restraint device. Rats who experienced the same duration of repeated restraint showed a significant decrease of plasma corticosterone (CORT) compared to the 10 min acute restraint group (habituation). In addition, these rats showed decreased active struggling over repeated restraint trials. Conversely, the rats showed an increased CORT response (dishabituation) when they experienced a longer duration of restraint on Day 5 than they had previously. These rats showed a habituated behavioral response during the first 10 min of restraint, however struggling behavior increased once the duration of restraint exceeded the expected duration (with a peak at 12 min). This peak in struggling behavior did not occur during 30 min acute restraint, indicating that the effect was related to the memory of previous restraint experience and not due to a longer duration of restraint. In contrast, these animals showed habituated c-fos mRNA expression in the paraventricular nucleus (PVN), lateral septum (LS), and medial prefrontal cortex (mPFC) in response to the increased stressor duration. Thus, there was a dissociation between c-fos mRNA expression in key stress responsive brain regions and the behavioral and endocrine response to increased stressor duration. This dissociation may have been due to a greater lag time for c-fos mRNA responses to reflect the impact of a dishabituation response. In conclusion, habituation of the endocrine and behavioral stress response occurred when the duration of the stressor matches the previous experience, while dishabituation of the stress response was triggered (with remarkable temporal precision) by an unexpected increase in stress duration.