Safeguarding against Dementia in Aboriginal and Torres Strait Islander Communities through the Optimisation of Primary Health Care: A Project Protocol.

This protocol describes the methodology and methods for a collaborative project with eight Aboriginal and Torres Strait Islander primary health care (PHC) organisations, across three Australian states and one territory, to increase clinical service performance and access to preventive health and health promotion services for preventing, identifying, treating, and managing dementia risk in Aboriginal and Torres Strait Islander communities. Aboriginal participatory action research (APAR) methodology will be the framework for this project, incorporating continuous quality improvement (CQI), informed by research yarning with stakeholder groups, comprising community members and PHC staff and service providers and data collected from the auditing of client health records and the mapping of existing clinical processes and health services at each partnering PHC organisation. The qualitative and quantitative data will be summarised and discussed with stakeholder groups. Priorities will be identified and broken down into tangible PHC organisation deliverable strategies and programs, which will be co-developed with stakeholder groups and implemented cyclically over 24 months using the Plan, Do, Study, Act model of change. Key project outcome measures include increased clinical service performance and availability of preventive health and health promotion services for safeguarding against dementia. Project implementation will be evaluated for quality and transparency from an Indigenous perspective using an appropriate appraisal tool. The project processes, impact, and sustainability will be evaluated using the RE-AIM framework. A dementia safeguarding framework and accompanying tool kit will be developed from this work to support Aboriginal and Torres Strait Islander PHC organisations to identify, implement, and evaluate dementia safeguarding practice and service improvements on a broader scale.

Challenges of conducting kidney health checks among patients at risk of chronic kidney disease and attending an urban Aboriginal and Torres Strait Islander primary healthcare service.

BACKGROUND: The increasing incidence of chronic kidney disease (CKD) globally highlights the importance of early targeted screening of at-risk persons in primary healthcare settings. This study investigated the early detection of CKD among Aboriginal and Torres Strait Islander patients attending an urban primary healthcare service. METHODS: Routine data extracted for all patients with an active electronic medical record on 7 December 2017 were used to identify patients who were eligible to have a kidney health check (KHC), comprising estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (UACR) tests. A subsequent manual search of electronic health records identified the presence of CKD risk factors and follow-up KHCs. RESULTS: Of the 1181 eligible patients, 171 (15%) had a complete initial KHC. Of the eight patients with an initial abnormal eGFR, two (25%) had a repeat eGFR assessment within 3 months to confirm the presence of CKD. Of the 30 patients who had an initial abnormal UACR result, three (10%) had at least one repeat UACR measurement within 3 months. In patients with diabetes and/or hypertension and a normal initial KHC, 51% had a repeat eGFR and 36% had UACR within the recommended time frame of 12 months. Similar findings were observed for the recommended time frame of 24 months in patients without diabetes or hypertension. CONCLUSION: Accurate documentation of risk factors for CKD and processes to address the barriers to implementation of Kidney Health Australia guidelines will assist in preventing or delaying progression of CKD.

Visual impairment among Aboriginal and Torres Strait Islander patients attending an Australian Indigenous primary health service: a cross-sectional study.

This cross-sectional study aimed to identify the period prevalence of visual impairment (VI) and blindness among Aboriginal and Torres Strait Islander people attending an Indigenous urban primary healthcare service, eye care practitioner referrals for those with VI and any opportunities to improve care delivery. Visual acuity (VA) examinations, using a Snellen chart, are performed as part of routine annual health assessments offered to children and adults. This study included patients aged ≥5 years (n=1442) who had a health assessment conducted between 1 January 2015 and 31 December 2016 and provided consent for the use of their health assessment information for research. Of patients with available data, 2.4% (33/1374) experienced VI, defined as presenting VA worse than 6/12 to 6/60 in the better-seeing eye. VI was more common in those aged ≥60 years (14/136; 10.3%) and was significantly associated with increasing age (P<0.001). No patients experienced blindness, defined as presenting VA worse than 6/60 in the better-seeing eye. All patients with VI were aged ≥16 years. Nine (27%) of the 33 patients with VI in the better-seeing eye were referred to an optometrist or an ophthalmologist. The low period prevalence of VI and no blindness in this study are positive findings. The findings also indicate that routine VA testing of older adults, especially those aged ≥60 years, should be conducted to avoid missing those not having an annual health assessment.

Optimising Hepatitis C care in an urban Aboriginal and Torres Strait Islander primary health care clinic.

OBJECTIVE: Describe the sociodemographic and clinical characteristics of patients with Hepatitis C Virus (HCV) attending an urban Indigenous primary health clinic (IPHC) in Brisbane, Australia. METHODS: A retrospective chart review of sociodemographic characteristics, presence of liver disease and treatments, lifestyle behaviours and comorbidities in patients with a HCV infection was conducted between October 2015 and March 2016. RESULTS: One hundred and thirteen patients with confirmed HCV infection were aged between seven and 63 years; 66% were male, and 84% were Indigenous. Sixty-nine per cent had been incarcerated; 41% had experienced conflict or domestic violence; 47% were injecting drugs; 72% had depression; and 61% had anxiety. Cirrhosis was present in 7/95 patients with adequate data and associated with age (p=0.02). Eleven patients had commenced direct acting antiviral (DAA) therapy in the 18 months that it had been available. CONCLUSIONS: The study highlights the opportunities for enhancing treatment of patients with HCV infection. Opportunities to improve treatment rates in an Indigenous primary healthcare include optimising diagnostic pathways, improving patient engagement, and general practitioner and peer worker participation. Implications for public health: HCV poses a serious threat to public health in Australia and IPHCs are key sites to addressing this for Indigenous people. Optimising care of patients with HCV attending IPHC requires recognition of the complex health needs and social context, to reduce the incidence and consequences of HCV infection.

Understanding health talk in an urban Aboriginal and Torres Strait Islander primary healthcare service: a cross-sectional study.

Health literacy is an important determinant of health status. This cross-sectional study aimed to describe the prevalence of adequate health literacy among Aboriginal and Torres Strait Islander patients or their carers including parents of sick children attending an urban primary healthcare clinic in Australia, and their experiences of communication with General Practitioners (GPs). A questionnaire, including questions from the Brief Health Literacy Screen (BHLS) and questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS): Communication with Provider, was administered to 427 participants. Descriptive statistics, Pearson's Chi-Square test and logistic regression analysis were used to describe the prevalence and risk factors associated with health literacy and any associations between the CAHPS questions and health literacy. In total, 72% of participants had adequate health literacy. An age of ≥50 years was independently associated with inadequate health literacy, and completion of secondary or post-secondary schooling was protective. Communication questions that identified areas for improvement included less use of incomprehensible medical words and more frequent use of visual aids. The study provides useful information on health literacy among Aboriginal and Torres Strait Islander patients, or their carers, and their experiences of communication with GPs. Further population-based research is required to investigate the effect of health literacy on health outcomes of Aboriginal and Torres Strait Islander patients.

Surgical site infections following coronary artery bypass graft procedures: 10 years of surveillance data.

BACKGROUND: Surgical site infections following coronary artery bypass graft (CABG) procedures pose substantial burden on patients and healthcare systems. This study aims to describe the incidence of surgical site infections and causative pathogens following CABG surgery over the period 2003-2012, and to identify risk factors for complex sternal site infections. METHODS: Routine computerised surveillance data were collected from three public hospitals in Queensland, Australia in which CABG surgery was performed between 2003 and 2012. Surgical site infection rates were calculated by types of infection (superficial/complex) and incision sites (sternal/harvest sites). Patient and procedural characteristics were evaluated as risk factors for complex sternal site infections using a logistic regression model. RESULTS: There were 1,702 surgical site infections (518 at sternal sites and 1,184 at harvest sites) following 14,546 CABG procedures performed. Among 732 pathogens isolated, Methicillin-sensitive Staphylococcus aureus accounted for 28.3% of the isolates, Pseudomonas aeruginosa 18.3%, methicillin-resistant Staphylococcus aureus 14.6%, and Enterobacter species 6.7%. Proportions of Gram-negative bacteria elevated from 37.8% in 2003 to 61.8% in 2009, followed by a reduction to 42.4% in 2012. Crude rates of complex sternal site infections increased over the reporting period, ranging from 0.7% in 2004 to 2.6% in 2011. Two factors associated with increased risk of complex sternal site infections were identified: patients with an ASA (American Society of Anaesthesiologists) score of 4 or 5 (reference score of 3, OR 1.83, 95% CI 1.36-2.47) and absence of documentation of antibiotic prophylaxis (OR 2.03, 95% CI 1.12-3.69). CONCLUSIONS: Compared with previous studies, our data indicate the importance of Gram-negative organisms as causative agents for surgical site infections following CABG surgery. An increase in complex sternal site infection rates can be partially explained by the increasing proportion of patients with more severe underlying disease.

Geriatric syndromes predict postdischarge outcomes among older emergency department patients: findings from the interRAI Multinational Emergency Department Study.

OBJECTIVES: Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. METHODS: A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. RESULTS: A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. CONCLUSIONS: Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study.

STUDY OBJECTIVE: We examine functional profiles and presence of geriatric syndromes among older patients attending 13 emergency departments (EDs) in 7 nations. METHODS: This was a prospective observational study of a convenience sample of patients, aged 75 years and older, recruited sequentially and mainly during normal working hours. Clinical observations were drawn from the interRAI Emergency Department Screener, with assessments performed by trained nurses. RESULTS: A sample of 2,282 patients (range 98 to 549 patients across nations) was recruited. Before becoming unwell, 46% were dependent on others in one or more aspects of personal activities of daily living. This proportion increased to 67% at presentation to the ED. In the ED, 26% exhibited evidence of cognitive impairment, and 49% could not walk without supervision. Recent falls were common (37%). Overall, at least 48% had a geriatric syndrome before becoming unwell, increasing to 78% at presentation to the ED. This pattern was consistent across nations. CONCLUSION: Functional problems and geriatric syndromes affect the majority of older patients attending the ED, which may have important implications for clinical protocols and design of EDs.

Hospital readmission among older adults with congestive heart failure.

INTRODUCTION: To examine the factors associated with unplanned readmission among older adults with congestive heart failure (CHF) within 28 days of discharge from an index admission, within a large Australian health service. METHODS: Using a comparative cohort design, a multivariate logistic regression model was used to compare readmitted patients with non-readmitted patients and identify risk factors associated with readmission. RESULTS: Significant risk factors identified were male gender, numerous diagnoses, length of stay 3 days or longer and patients being admitted from acute, subacute or aged-care facilities. CONCLUSIONS: The high risk of patients being readmitted from acute, subacute and aged-care services requires further review as these readmissions may be avoidable. It may also be useful to develop a readmission risk screening tool so that patients at risk of readmission can be identified. What is known about this topic? Older adults with CHF are likely to experience multiple readmissions to hospital. There have been several studies conducted on hospital readmissions; however, generalising the findings is problematic due to the use of variable definitions of what constitutes a readmission. What does this paper add? This paper addresses the absence of Australian research comparing groups of older patients with CHF who are readmitted to hospital with those who are not readmitted. It also adopts one of the more frequently used definitions of readmission to aid in future comparability of research. What are the implications for practice? Further work is necessary to improve discharge planning and effectively manage chronic illnesses such as CHF in patients' homes. It may be useful to develop a readmission risk screening tool for staff of inpatient medical wards so that these at-risk patients can be identified before discharge.

The Higher Care At Discharge Index (HCDI): identifying older patients at risk of requiring a higher level of care at discharge.

A screening index, administered at admission, can be useful in identifying older hospitalised patients at risk of requiring a higher level care at discharge. The objective of this study was to describe the development of a risk stratification index for allocating patients into lower and higher risk of requiring higher level care at discharge. A prospective cohort study of general medical patients, aged ≥70 years admitted to three metropolitan acute care hospitals in Brisbane, Australia was conducted. Derivation cohort (n=360) was used to: identify significant predictive factors associated with discharge to a higher level care; and develop a screening index to stratify patients into lower and higher risk. Predictive performance of the index was examined in the validation cohort (n=142). Five independent factors associated with requiring higher level care (identified using stepwise logistic regression analysis) were used to develop the HCDI: no support person to assist with living in the community; received assistance with finances; received assistance with hygiene; short term memory problems; hospitalised in 90 days prior to current hospital admission. Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the dichotomised risk scores of the HCDI were: 76.3%; 73.3%; 36.0%; and 94.0% respectively; correctly classified 73.8%. In the validation cohort, sensitivity was 81.8%; specificity 68.7%; PPV 18.0%; NPV 97.8%, correctly classified 69.7%. Requirement for a higher level care at discharge has important consequences for health service delivery. The HCDI can be used to identify patients at higher risk.

A prospective cohort study of geriatric syndromes among older medical patients admitted to acute care hospitals.

OBJECTIVES: To identify the prevalence of geriatric syndromes in the premorbid for all syndromes except falls (preadmission), admission, and discharge assessment periods and the incidence of new and significant worsening of existing syndromes at admission and discharge. DESIGN: Prospective cohort study. SETTING: Three acute care hospitals in Brisbane, Australia. PARTICIPANTS: Five hundred seventy-seven general medical patients aged 70 and older admitted to the hospital. MEASUREMENTS: Prevalence of syndromes in the premorbid (or preadmission for falls), admission, and discharge periods; incidence of new syndromes at admission and discharge; and significant worsening of existing syndromes at admission and discharge. RESULTS: The most frequently reported premorbid syndromes were bladder incontinence (44%), impairment in any activity of daily living (ADL) (42%). A high proportion (42%) experienced at least one fall in the 90 days before admission. Two-thirds of the participants experienced between one and five syndromes (cognitive impairment, dependence in any ADL item, bladder and bowel incontinence, pressure ulcer) before, at admission, and at discharge. A majority experienced one or two syndromes during the premorbid (49.4%), admission (57.0%), or discharge (49.0%) assessment period. The syndromes with a higher incidence of significant worsening at discharge (out of the proportion with the syndrome present premorbidly) were ADL limitation (33%), cognitive impairment (9%), and bladder incontinence (8%). Of the syndromes examined at discharge, a higher proportion of patients experienced the following new syndromes at discharge (absent premorbidly): ADL limitation (22%); and bladder incontinence (13%). CONCLUSION: Geriatric syndromes were highly prevalent. Many patients did not return to their premorbid function and acquired new syndromes.