Observing the use of knee arthroplasty appropriateness tools in clinical practice: do appropriateness criteria tools predict surgeon decision-making?

OBJECTIVE: The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally. METHODS: A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated. RESULTS: There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%). CONCLUSIONS: Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar.

General practitioners' knowledge of whiplash guidelines improved with online education.

OBJECTIVE: The primary objective of this study was to evaluate the effect of an online education program used to implement the Australian (New South Wales) whiplash guidelines with general practitioners (GP). The secondary aim was to identify factors associated with learning. METHODS: An online educational and evaluation activity was developed to reflect the key messages for GP from the Australian whiplash guidelines. The educational activity was hosted on the Royal Australian College of General Practitioners' website (www.gplearning.com.au) for a period of 3 years. Participants were recruited through advertisement and media releases. Participants completed a baseline evaluation of their knowledge, participated in the interactive educational activity and completed a post-knowledge questionnaire. The primary outcome was change in professional knowledge, predictors of learning were computed using linear regression. RESULTS: Two hundred and fifteen GP participated. Knowledge significantly improved between baseline and post-knowledge questionnaire scores (P < 0.00001). A total of 57.2% of participants improved their knowledge by more than 20%, indicating a large effect. Low baseline knowledge predicted learning, accounting for 71% of the variance. CONCLUSIONS: Online education of GP significantly improved their knowledge in relation to guidelines for whiplash. Those with low baseline knowledge improved their knowledge the most, suggesting that implementation strategies should be targeted at this group.

Shared decision making: really putting patients at the centre of healthcare.

Although many clinicians feel they already use shared decision making, research shows a perception-reality gap. A M Stiggelbout and colleagues discuss why it is important and highlight some best practices.

A comparative case study of bowel cancer screening in the UK and Australia: evidence lost in translation?

OBJECTIVES: (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. SETTING: United Kingdom and Australia. METHODS: A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. RESULTS: Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. CONCLUSIONS: Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Are current psychometric tools suitable for measuring outcomes of diabetes education?

AIMS: To critically appraise the suitability, validity, reliability, feasibility and sensitivity to change of available psychometric tools for measuring the education outcomes identified in the (Australian) National Consensus on Outcomes and Indicators for Diabetes Patient Education. METHODS: Potentially suitable psychometric measurement tools were identified through a two-step process. Step 1: a structured semi-systematic literature review and consultation with experts; step 2: development of inclusion criteria and a formal, purpose-designed, systematically derived Appraisal Checklist-from the literature and with expert psychometric advice-to critically appraise the identified tools for relevance, validity, reliability, responsiveness to change, burden, feasibility and acceptability. RESULTS: Searching medline, PubMed, PsycINFO and cinhal yielded 37 diabetes-specific and generic measurement tools. Eleven of these did not address the research questions, leaving 26 tools. Of these, 11 assessed indicators of psychological adjustment; seven assessed various domains of self-determination; five measured self-management behaviours, for example, foot care, blood glucose testing and lifestyle domains; and three measured diabetes knowledge und understanding, respectively. When the Appraisal Checklist was applied, only three tools met all criteria, namely the Problem Areas in Diabetes (PAID) scale, the Summary of Diabetes Self-Care Activities (SDSCA) scale and the Appraisal of Diabetes Scale (ADS). However, a number of other suitable tools [i.e. the Diabetes Integration Scale (ATT19), the Diabetes Health Profile (DHP-1/18), the Self-Care Inventory-Revised (SCI-R), the Diabetes Management Self Efficacy Scale Australian/English version (DMSES-A/E), the Diabetes Empowerment Scale-Short Form (DES-SF)] met all except one criteria, that is, either no formal test-retest or no responsiveness to change data. CONCLUSIONS: Although numerous tools were identified, few met rigorous psychometric appraisal criteria. Issues of suitability, adequate psychometric testing for the intended purpose, burden and feasibility need to be considered before adopting tools for measuring diabetes education outcomes.

Impact of privacy legislation on the number and characteristics of people who are recruited for research: a randomised controlled trial.

BACKGROUND: Privacy laws have recently created restrictions on how researchers can approach study participants. METHOD: In a randomised trial of 152 patients, 50-74 years old, in a family practice, 60 were randomly selected to opt-out and 92 to opt-in methods. Patients were sent an introductory letter by their doctor in two phases, opt-out before and opt-in after introduction of the new Privacy Legislation in December 2001. Opt-out patients were contacted by researchers. Opt-in patients were contacted if patients responded by email, free telephone number or a reply-paid card. RESULTS: Opt-in recruited fewer patients (47%; 43/92) after invitation compared with opt-out (67%; 40/60); (-20%; [-4% to -36%]). No proportional difference in recruitment was found between opt-in and opt-out groups varied by age, sex or socioeconomic status. The opt-in group had significantly more people in active decision-making roles (+30%; [10% to 50%]; p = 0.003). Non-significant trends were observed towards opt-in being less likely to include people with lower education (-11.8%; [-30% to 6.4%]; p = 0.13) and people who were not screened (-19.1%; [-40.1% to 1.9%]; p = 0.08). Opt-in was more likely to recruit people with a family history of colorectal cancer (+12.7%; [-2.8%, 28.2%]; p = 0.12). CONCLUSIONS: The number of participants required to be approached was markedly increased in opt-in recruitment. Existing participants (eg, screening attendees) with a vested interest such as increased risk, and those preferring an active role in health decision making and with less education were likely to be recruited in opt-in. Research costs and generalisability are affected by implementing privacy legislation.

Soup kitchen consumer perspectives on the quality and frequency of health service interactions.

OBJECTIVE: Whilst previous research has repeatedly documented premature mortality and high morbidity among seriously disadvantaged and homeless populations, far less is known of the extent and nature of their interactions with health services. DESIGN AND SETTING: This cross-sectional case study describes health service utilization patterns and explores participant-reported difficulties in accessing health care, adhering to prescribed treatment and maintaining continuity of care amongst 100 users of a charity-run soup kitchen in urban Sydney. Participants and results. The study describes a largely welfare-dependent population sample with poor health who are frequent users of the health system (85% had seen a general practitioner in the preceding 6 months). The homeless were more likely to report difficulties accessing health care when needed [odds-ratio 3.15; 95% confidence interval (CI) 1.04-9.62]. One in three respondents reported difficulty adhering to prescribed treatment following their last health care visit. Affordability (P < 0.0001), not understanding instructions (P = 0.007), and not agreeing with advice (P < 0.0001) were the main factors associated with adherence difficulties. One in four failed to return for follow-up visits as advised, largely associated with attitudinal barriers such as a history of not believing problems would be addressed (P = 0.05), not trusting health professionals (P = 0.04), and not knowing where to get help in the past (P = 0.05). CONCLUSION: These results reinforce the important role of free primary care in reducing access barriers for the disadvantaged, but also highlight possible reasons for service interactions being ineffective in a substantial proportion of cases.

Cancer screening.

"Screening is the systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to benefit from further investigation or direct preventive action, among persons who have not sought medical attention on account of symptoms of that disorder."

Asking the right questions of disadvantaged and homeless communities: the role of housing, patterns of illness and reporting behaviours in the measurement of health status.

OBJECTIVE: To assess the self-reported health status and its relationship to key demographic variables among patrons of a charity-run meals service at The Exodus Foundation, in urban Sydney, Australia. METHOD: Random-sample cross-sectional study of 100 face-to-face interviews (79% recruitment rate). Self-reported health status was measured by subjective rating scale, open-ended and checklist questions about presence and type of acute and chronic disease. Anaysis by logistic regression of fair-poor health status on demographic variables in Exodus patrons and genera Sydney population adjusted for age and sex using the 1995 National Health Survey. RESULTS: Compared to housed but poor counterparts within the Exodus sample, homeless people were significantly more likely to report fair-poor health status (age-adjusted OR-3.0, 95% CI 1.3-7.1). Exodus patrons, as a whole, were much more likely than Sydney's general population to report fair-poor health status, after adjusting for age and sex (OR-4.5, 95% CI 2.9-7.0) and had a more serious pattern of illness (diseases of the digestive system; depression; common cold; bronchitis; refractive errors; drug and alcohol dependence; diabetes mellitus Type II). Exodus patrons reported fewer acute and chronic illnesses with open-ended questions than with a checklist (p<0.001). CONCLUSION: In this population there was a strong relationship between poor health and homelessness. When patterns of illness and injury were measured within this disadvantaged group, they showed more serious illness types than in the general population. Such patterns may not be identified by methods often used in traditional population health surveys.