Mixed methods evaluation to explore participant experiences of a pilot randomized trial to facilitate self-management of people living with stroke: Inspiring virtual enabled resources following vascular events (iVERVE).

INTRODUCTION: Despite digital health tools being popular for supporting self-management of chronic diseases, little research has been undertaken on stroke. We developed and pilot tested, using a randomized controlled design, a multicomponent digital health programme, known as Inspiring Virtual Enabled Resources following Vascular Events (iVERVE), to improve self-management after stroke. The 4-week trial incorporated facilitated person-centred goal setting, with those in the intervention group receiving electronic messages aligned to their goals, versus limited administrative messages for the control group. In this paper, we describe the participant experience of the various components involved with the iVERVE trial. METHODS: Mixed method design: satisfaction surveys (control and intervention) and a focus group interview (purposively selected intervention participants). Experiences relating to goal setting and overall trial satisfaction were obtained from intervention and control participants, with feedback on the electronic message component from intervention participants. Inductive thematic analysis was used for interview data and open-text responses, and closed questions were summarized descriptively. Triangulation of data allowed participants' perceptions to be explored in depth. RESULTS: Overall, 27/54 trial participants completed the survey (13 intervention: 52%; 14 control: 48%); and 5/8 invited participants in the intervention group attended the focus group. Goal setting: The approach was considered comprehensive, with the involvement of health professionals in the process helpful in developing realistic, meaningful and person-centred goals. Electronic messages (intervention): Messages were perceived as easy to understand (92%), and the frequency of receipt was considered appropriate (11/13 survey; 4/5 focus group). The content of messages was considered motivational (62%) and assisted participants to achieve their goals (77%). Some participants described the benefits of receiving messages as a 'reminder' to act. Overall trial satisfaction: Messages were acceptable for educating about stroke (77%). Having options for short message services or email to receive messages was considered important. Feedback on the length of the intervention related to specific goals, and benefits of receiving the programme earlier after stroke was expressed. CONCLUSION: The participant experience has indicated acceptance and utility of iVERVE. Feedback from this evaluation is invaluable to inform refinements to future Phase II and III trials, and wider research in the field. PATIENT OR PUBLIC CONTRIBUTION: Two consumer representatives sourced from the Stroke Foundation (Australia) actively contributed to the design of the iVERVE programme. In this study, participant experiences directly contributed to the further development of the iVERVE intervention and future trial design.

Utilisation of pre-exposure prophylaxis (PrEP) for HIV prevention in the Australian general practice setting: a longitudinal observational study.

BACKGROUND: Pre-exposure prophylaxis (PrEP) became available through the Australian Pharmaceutical Benefits Scheme (PBS) on 1 April 2018 for HIV infection prevention in patients ≥18years at medium-to-high HIV risk. The aims were to investigate PrEP utilisation in general practice since PBS listing, and factors associated with discontinuation. METHODS: This longitudinal study included patients aged 18-74years attending general practices participating in MedicineInsight, a large-scale national primary care database of deidentified electronic health records, between October 2017 and September 2019. RESULTS: PrEP utilisation increased 10-fold following PBS listing. On average, patients had 9.7 PrEP prescriptions per year; a medication possession ratio of 80.8%. Of 1552 patients prescribed PrEP from April 2018, most were male (98.3%), aged 18-39years (59.3%), resided in major cities (86.7%) and in the two most socioeconomically advantaged quintiles (70.0%). Almost half (49.1%) of the patients were identified as new to PrEP. At study end, 65.1% were on active PrEP (16.5%, of whom had non-continuous use), 19.2% had discontinued PrEP and 15.7% were lost to follow up. Patients who discontinued were more likely to attend low rather than high PrEP caseload practices (adjusted odds ratio [aOR] 1.7; 95% CI: 1.0-2.8; P =0.047). The odds of non-continuous therapy was 2.9-fold higher in patients with bipolar disorder (aOR 2.89; 95% CI: 1.10-7.6; P =0.045). CONCLUSIONS: Following PBS listing, PrEP utilisation increased and stopping therapy was associated with attending low caseload practices. General practice education, particularly among low caseload practices, could help address these disparities.

Prevalence, incidence and management of atopic dermatitis in Australian general practice using routinely collected data from MedicineInsight.

BACKGROUND/OBJECTIVES: The prevalence of atopic dermatitis (AD) has increased significantly in industrialised countries in recent decades but data about the incidence or prevalence of AD in Australia are sparse. We aimed to determine the prevalence and incidence of AD among patients seen in Australian general practice and the use of specified medicines. METHODS: This was a cross-sectional study of 2.1 million patients attending 494 general practices in the MedicineInsight program from 1 January 2017 to 31 December 2018. We assessed the prevalence (lifetime and current), incidence, management and severity of AD. RESULTS: The lifetime (ever diagnosed) prevalence of AD in this general practice population was 16.4% and was greater in females (17.3%) than males (15.3%). One in five patients with AD were classified as having moderate-to-severe disease. Prevalence over the last two years was 6.3%. The incidence of AD in 2018 was 2.0% and was greater in females (2.2%) and for patients aged 0-4 years (3.9%). Patients with AD had an increased risk of insomnia, anxiety and depression, compared to those with no recorded AD. For AD patients, topical corticosteroids were the most commonly prescribed AD medication (36.5%) and topical calcineurin inhibitors the least (0.1%), with systemic corticosteroids (15.6%) more commonly prescribed than other immunosuppressants (0.9%). CONCLUSIONS: Our findings provide important insights into the epidemiology of AD and its management in Australian general practice. This information is likely to be useful in planning effective interventions to support GPs in the optimal management of patients with AD.

The Quality of Discharge Care Planning in Acute Stroke Care: Influencing Factors and Association with Postdischarge Outcomes.

BACKGROUND: Comprehensive discharge planning is important for successful transitions from hospital to home after stroke. The aim of this study was to describe the quality of discharge planning received by patients discharged home from acute care, identify factors associated with a positive discharge experience, and assess the influence of discharge quality on outcomes. METHOD: Patients discharged to the community and registered in the Australian Stroke Clinical Registry in 2014 were invited to participate. Patient-perceived discharge quality was evaluated using the Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations, Empowerment, Directed to appropriate services questionnaire (recall at 3-9 months). Factors associated with higher discharge quality scores were identified and associations between quality scores of more than 80% and outcomes were investigated using multivariable, multilevel regression analyses. RESULTS: There were 200 of 434 eligible registrants who responded; responders and nonresponders were similar with respect to age, sex, and type of stroke. The average overall quality score was 73% (standard deviation: 21). However, only 18% received all aspects of discharge care planning. Quality scores of more than 80% were independently associated with receiving hospital specific information (odds ratio: 5.7, 95% confidence interval [CI]: 2.7, 12.4), and referral to a local support group (odds ratio: 2.5, 95% CI: 1.1, 5.9). Discharge quality scores of more than 80% were associated with higher European Quality of Life-5 Dimensions EQ-5D scores (coefficient: .1, 95% CI: .04, .2) and a reduction in the rate of unmet needs reported at 3-9 months postdischarge (incidence rate ratio: .5, 95% CI: .3, .7). CONCLUSION: We provide new information on the quality of discharge planning from acute care after stroke. Aspects of discharge planning that correlate with quality of care may reduce unmet needs and improve quality of life outcomes.

Adiposity has a greater impact on hypertension in lean than not-lean populations: a systematic review and meta-analysis.

More than 75 % of people with hypertension live in low-to-middle income countries (LMICs). Based on the mismatch theory of developmental origins of disease, we hypothesised that the impact of adiposity on hypertension is augmented in lean compared with not-lean populations in rural areas of LMICs (RLMICs). We reviewed studies from RLMICs in which the association between body mass index (BMI) or waist circumference (WC) and hypertension was assessed using multivariable models. Applying random effect models, we conducted separate meta-analyses, depending on whether BMI/WC was assessed as a continuous or categorical variable. In each analysis, the studies were ranked by the mean BMI of the total population. Those populations with a mean BMI below the median were categorised as lean and those above the median as not-lean. We identified 46 studies of BMI and 12 of WC. The risk of hypertension was greater in lean than in not-lean populations. Obese males in lean populations were 45 % more likely to be hypertensive compared to obese males in not-lean populations, ratio of the two effect sizes: 1.45 (95 % CI 1.04, 2.03), p = 0.027. Also, individuals with WC above normal in lean populations were 52 % more likely to be hypertensive than their counterparts in not-lean populations, ratio of the two effect sizes: 1.52 (95 % CI 1.06, 2.17), p = 0.021. We conclude that the risk of hypertension associated with adiposity is greater in lean than in not-lean populations. This provides further evidence for the mismatch theory and highlights the need for strategies to improve nutrition in disadvantaged RLMICs.

Characteristics of patients aged 50–74 years with a request for an immunochemical faecal occult blood test in the Australian general practice setting.

Objective To support improving participation in the National Bowel Cancer Screening Program (NBCSP), we aimed to identify Medicare-subsidised test requests for immunochemical faecal occult blood tests (FOBT) in Australian general practice for patients aged 50-74 years, eligible for the NBCSP, and describe sociodemographics, risk factors, indications and outcomes. Methods A cross-sectional study was conducted using de-identified data from 441 Australian general practice sites in the MedicineInsight database, recorded from 1 January 2018 to 31 December 2019. Results Of the 683 625 eligible patients, 45 771 (6.7%) had a record of a general practitioner (GP)-requested FOBT, either to aid diagnosis in symptomatic patients, or for screening; 144 986 (21.2%) patients had only an NBCSP FOBT. A diagnosis of polyps, gastrointestinal inflammatory condition or haemorrhoids, or a referral to a gastroenterologist or general surgeon, was more commonly recorded in the 6 months after a GP-requested FOBT than after an NBCSP FOBT. Uptake of NBCSP FOBTs was lower among those with obesity, high alcohol consumption and current smokers, who are at higher risk of bowel cancer. Conclusions This study describes the patient characteristics, reasons and outcomes associated with GP-requested FOBTs, identifies under-screened population sub-groups, and suggests involvement of GPs to improve participation in the NBCSP.

Association of hypertension with infection and inflammation in a setting of disadvantage in rural India.

We assessed the association of hypertension with markers of inflammation and infection in a rural and disadvantaged Indian population. In a case-control study, we age- and gender-matched 300 cases with hypertension to 300 controls without hypertension. Blood pressure was measured according to a strict protocol. We measured markers of inflammation and infection including serum high-sensitivity C-reactive protein (hs-CRP), blood lymphocyte count, serum homocysteine, tooth loss, overcrowding and exposure to fecal contamination. Multivariable conditional logistic regression was used to determine their association with hypertension. Median serum hs-CRP was 42% greater in cases than controls, while median serum homocysteine was 10% greater. In multivariable conditional logistic regression, elevated homocysteine (OR 1.75, 95% CI 1.09-2.82), greater lymphocyte count (OR 1.49, 95% CI 1.01-2.01) and exposure to fecal contamination, defined as a distance from the field used for toilet purposes to the household of ≤50 m (OR 2.38, 95% CI 1.07-5.29), were independently associated with hypertension in this rural population. In separate analyses for each gender, elevated hs-CRP (OR 2.62, 95% CI 1.04-6.58) was associated with hypertension in men, whereas edentulism (OR 4.75, 95% CI 1.62-13.96) was associated with greater odds of hypertension in women. Our findings demonstrate specific associations between hypertension and markers of inflammation and infection including hs-CRP, homocysteine, lymphocyte count, edentulism and exposure to fecal contamination. Thus, strategies aimed at reducing inflammation and infection may reduce the burden of hypertension in such settings of disadvantage in rural India.

Prevalence of inflammatory bowel disease in the Australian general practice population: A cross-sectional study.

The burden of inflammatory bowel disease (IBD) in Australia is increasing but national data about the current prevalence are limited. We aimed to estimate the prevalence of IBD (including Crohn's disease, ulcerative colitis and unspecified IBD) as well as Crohn's disease and ulcerative colitis separately in a general practice population in Australia. We also assessed risk factors associated with Crohn's disease and ulcerative colitis. We conducted a cross-sectional study using data from MedicineInsight, a national database of general practice electronic health records, from 1 July 2017 to 30 June 2019. The prevalence of IBD was calculated and stratified by sociodemographic characteristics. Logistic regression analysis was conducted to assess risk factors associated with Crohn's disease and ulcerative colitis. The study comprised 2,428,461 regular patients from 481 practices. The estimated crude prevalence of IBD was 653 per 100,000 patients; Crohn's disease was 306 per 100,000 and ulcerative colitis was 334 per 100,000. Males were independently associated with a lower risk of Crohn's disease (OR: 0.86; 95% CI: 0.81, 0.90) but a greater risk of ulcerative colitis (OR: 1.12; 95% CI: 1.06, 1.17) than females. Compared to non-smokers, patients who were current smokers were associated with a greater risk of Crohn's disease (OR: 1.13; 95% CI: 1.04, 1.23) but a lower risk of ulcerative colitis (OR: 0.52; 95% CI: 0.47, 0.57). Other factors positively associated with both Crohn's disease and ulcerative colitis were age (≥ 25 years), non-Indigenous status and socioeconomic advantage. Our findings provide a current estimate of the prevalence of IBD, Crohn's disease and ulcerative colitis in a large national general practice population in Australia and an assessment of the factors associated with Crohn's disease and ulcerative colitis. These data can assist in estimating the health burden and costs, and planning for health services.

Pregabalin prescribing patterns in Australian general practice, 2012-2018: a cross-sectional study.

BACKGROUND: In 2013 pregabalin was subsidised by Australia's Pharmaceutical Benefits Scheme (PBS) for neuropathic pain. Since the subsidy, pregabalin prescribing has been increasing in Australia and so has related harm. There are concerns it is being prescribed for indications other than neuropathic pain, which have little evidence of efficacy. AIM: To describe pregabalin prescribing in Australian general practice. DESIGN & SETTING: A cross-sectional study of patients attending 445 general practice sites in the national MedicineInsight database from March 2012-February 2018. METHOD: The following aspects were calculated: the proportion of prescriptions that were for pregabalin per year; the prevalence of pain conditions in patients prescribed pregabalin; and same-day prescribing of pregabalin with opioids or benzodiazepines. RESULTS: Prescribing increased from 13 per 10 000 to 104 per 10 000 prescriptions between 2012-2013 and 2017-2018. A total of 1 891 623 patients were identified of whom 114 123 (6.0%) were prescribed pregabalin; 49.7% (n = 56 772) had a recorded diagnosis of neuropathic pain. Among people prescribed pregabalin without a recorded diagnosis of neuropathic pain, 43.5% (n = 24 927) had a diagnosis of back problems, 8.8% (n = 5073) chronic pain, and 26.4% (n = 30 146) had no pain diagnosis. Pregabalin was prescribed the same day as an opioid to 38.1% of patients (95% confidence interval [CI] = 37.1% to 39.1%) and a benzodiazepine to 13.1% of patients (95% CI = 12.5% to 13.7%). Patients with a diagnosis of chronic pain had the highest rate of same-day prescribing of pregabalin with an opioid (70.4%, 95% CI = 68.9% to 71.9%) or a benzodiazepine (25.8%, 95% CI = 24.2% to 27.4%) CONCLUSION: Substantial increases in pregabalin prescribing were identified in Australian general practice, but only half of patients had a neuropathic pain diagnosis recorded, the only approved indication for subsidy. High rates of same-day prescribing with opioids and benzodiazepines may put patients at increased risk of harm.

The changing characteristics of patients with chronic hepatitis C prescribed direct acting antiviral medicines in general practice since listing of the medicines on the Australian Pharmaceutical Benefits Scheme.

BACKGROUND AND AIM: The primary objective of this study was to determine whether the characteristics of patients prescribed direct acting antiviral (DAA) medicines have changed since initial listing of the medicines on the Australian Pharmaceutical Benefits Scheme (PBS). METHODS: A cross-sectional study was conducted using data from MedicineInsight, an Australian database of general practice electronic health records, from March 2016 to August 2018. We compared sociodemographic, comorbidity, and clinical characteristics of patients aged at least 18 years who were prescribed at least one DAA in the first 4 months of PBS listing in 2016 with those prescribed at least one DAA in 2018. RESULTS: There were 2251 eligible adult patients prescribed a DAA during the study period, 62% were men and 59% were aged 50 years and older. Patients prescribed DAA medicines initially were older (aged ≥50 years: 67.9% vs 49.3%; P < 0.001), and more likely to have liver cirrhosis (14.2% vs 8.4%; P = 0.01) and an aminotransferase to platelet ratio index (APRI) score >1 (20.4% vs 8.9%; P < 0.001) than those prescribed DAA medicines in 2018. A greater proportion of patients in regional/remote (46.5% vs 35.6%; P < 0.001) and socioeconomically disadvantaged areas (44.4% vs 34.5%; P = 0.003) accessed treatment in 2018 compared with 2016. CONCLUSIONS: Despite evidence of decreasing uptake of DAA medicines across Australia, this study indicates broadened uptake among younger age groups and those residing in regional/remote and socioeconomically disadvantaged areas since 2016. While uptake of DAA medicines in some population subgroups appears to have improved, continuous efforts to improve uptake across the Australian population are essential.

Patterns of real-world opioid prescribing in Australian general practice (2013-18).

Little is known about private-market opioid prescribing and how Australian opioid policies impact prescribing across public and private markets in Australia. We aimed to investigate publicly subsidised and private-market opioid prescribing from 2013 to 2018. We used prescribing records from MedicineInsight, an Australian primary care database, to examine trends in prescriptions for non-injectable opioid formulations from October 2013 to September 2018. We examined annual opioid prescribing trends overall, by opioid agent, and by market (public and private). We further examined patterns of fentanyl patch prescribing focusing on co-prescribed medicines and use in opioid-naïve patients. Opioids accounted for 8% of all prescriptions over the study period and 468 893 patients were prescribed at least one opioid of interest. Prescribing rates for oxycodone/naloxone and tapentadol increased, whereas those for fentanyl patches, morphine and single-agent oxycodone decreased over the study period. Private-market prescribing rates of codeine (schedule 4) increased notably following its up-scheduling to prescription-only status. Among patients prescribed fentanyl patches, 29% were potentially opioid-naïve and 49% were prescribed another opioid on the same day. The private-medicines market is a small but growing component of opioid use in Australia and one way in which prescribers and patients can avoid access restrictions in the public market for these medicines. Although fentanyl patch prescribing declined, there is room for improvement in prescribing fentanyl patches among opioid-naïve patients, and co-prescribing of fentanyl patches with other sedatives.

Renal and dietary factors associated with hypertension in a setting of disadvantage in rural India.

Using a case-control design, we determined risk factors associated with hypertension in a disadvantaged rural population in southern India. Three hundred adults with hypertension and 300 age- and sex-matched controls were extensively phenotyped. Underweight (29%, body mass index < 18.0 kg m-2), chronic kidney disease (25%, estimated glomerular filtration rate <60 ml min-1 1.73 m-2) and anemia (82%) were highly prevalent. The ratio of sodium to potassium excretion was high (8.2). In multivariable conditional logistic regression of continuous variables dichotomized by their median value, hypertension was independently associated with greater abdominal adiposity as assessed by waist-hip ratio [odds ratio (95% confidence interval), 1.89 (1.21-2.97)], lesser protein intake as assessed by 24 h urea excretion [0.39 (0.24-0.65)], and lesser plasma renin activity [0.54 (0.35-0.84)]. Hypertension tended to be independently associated with lesser serum potassium concentration [0.66 (0.44-1.01), P = 0.06]. Furthermore, those with hypertension reported less frequent intake of vegetables and urinary sodium-potassium ratio correlated positively with serum sodium-potassium ratio (r = 0.18). Hypertension was also independently associated with lesser blood hemoglobin concentration [0.48 (0.26-0.88)]. Blood hemoglobin concentration was positively associated with serum iron (r = 0.41) and ferritin (r = 0.25) concentration and negatively associated with total iron binding capacity (r = -0.17), reflecting iron-deficiency anemia. Our findings indicate potential roles for deficient intake of potassium and protein, and iron-deficiency anemia, in the pathophysiology of hypertension in a setting of disadvantage in rural India. Imbalanced intake of potassium and sodium may be driven partly by deficient intake of vegetables or fruit.

Additive association of knowledge and awareness on control of hypertension: a cross-sectional survey in rural India.

OBJECTIVE: To determine whether there is an interaction between knowledge about hypertension and awareness of hypertension on the treatment and control of hypertension in three regions of South India at different stages of epidemiological transition (see Video, Supplemental Digital Content 1, http://links.lww.com/HJH/B426). METHODS: Using a cross-sectional design, we randomly selected villages within each of rural Trivandrum, West Godavari, and Chittoor. Sampling was stratified by age group and sex. We measured blood pressure and administered a questionnaire to determine knowledge and awareness of hypertension. Logistic regression was used to assess associations of awareness and knowledge about hypertension with its treatment and control in participants with hypertension, while examining for statistical interaction. RESULTS: Among a total of 11 657 participants (50% male; median age 45 years), 3455 had hypertension. In analyses adjusted for age and sex, both knowledge score [adjusted odds ratio (aOR) 1.14 [95% confidence interval (CI) 1.12--1.17)] and awareness [aOR 104 (95% CI 82--134)] were associated with treatment for hypertension. Similarly, both knowledge score [aOR 1.10; 95% CI (1.08--1.12)] and awareness [aOR 13.4; 95% CI (10.7--16.7)], were positively associated with control of blood pressure in those with hypertension, independent of age and sex. There was an interaction between knowledge and awareness on both treatment and control of hypertension (P of attributable proportion <0.001 for each). CONCLUSION: Health education to improve knowledge about hypertension and screening programs to improve awareness of hypertension may act in an additive fashion to improve management of hypertension in rural Indian populations.

Pilot randomised clinical trial of an eHealth, self-management support intervention (iVERVE) for stroke: feasibility assessment in survivors 12-24 months post-event.

BACKGROUND: Electronic communication is used in various populations to achieve health goals, but evidence in stroke is lacking. We pilot tested the feasibility and potential effectiveness of a novel personalised electronic self-management intervention to support person-centred goal attainment and secondary prevention after stroke. METHODS: A phase I, prospective, randomised controlled pilot trial (1:1 allocation) with assessor blinding, intention-to-treat analysis, and a process evaluation. Community-based survivors of stroke were recruited from participants in the Australian Stroke Clinical Registry (AuSCR) who had indicated their willingness to be contacted for research studies. Inclusion criteria include 1-2 years following hospital admission for stroke and living within 50 km of Monash University (Melbourne). Person-centred goals were set with facilitation by a clinician using a standardised template. The intervention group received electronic support messages aligned to their goals over 4 weeks. The control group received only 2-3 electronic administrative messages. Primary outcomes were study retention, goal attainment (assessed using Goal Attainment Scaling method) and satisfaction. Secondary outcomes were self-management (Health Education Impact Questionnaire: 8 domains), quality of life, mood and acceptability. RESULTS: Of 340 invitations sent from AuSCR, 73 responded, 68 were eligible and 57 (84%) completed the baseline assessment. At the goal-setting stage, 54/68 (79%) were randomised (median 16 months after stroke): 25 to intervention (median age 69 years; 40% female) and 29 to control (median age 68 years; 38% female). Forty-five (83%) participants completed the outcome follow-up assessment. At follow-up, goal attainment (mean GAS-T score ≥ 50) in the intervention group was achieved for goals related to function, participation and environment (control: environment only). Most intervention participants provided positive feedback and reported that the iVERVE messages were easy to understand (92%) and assisted them in achieving their goals (77%). We found preliminary evidence of non-significant improvements between the groups for most self-management domains (e.g. social integration and support: ß coefficient 0.34; 95% CI - 0.14 to 0.83) and several quality-of-life domains in favour of the intervention group. CONCLUSION: These findings support the need for further randomised effectiveness trials of the iVERVE program to be tested in people with new stroke. TRIAL REGISTRATION: ANZCTR, ACTRN12618001519246 . Registered on 11 September 2018-retrospectively registered.

Knowledge of risk factors for hypertension in a rural Indian population.

OBJECTIVE: To study knowledge of risk factors and consequences of hypertension in a rural population in South India. METHODS: This is a community-based study conducted among adults of a rural population in the Rishi Valley, India. Residents of randomised rural villages were invited to participate in a study of hypertension. We obtained measures of blood pressure, height, weight, waist and hip circumferences and questionnaire-based information on knowledge about hypertension, sociodemographic characteristics and health behaviours. Multivariable logistic regression analyses were conducted to determine the factors associated with knowledge of risk factors for hypertension (knowledge of ≥2 risk factors). RESULTS: The study comprised 641 adults; 132 aware and 218 unaware of their hypertension, and 291 with normal blood pressure. Only 31% of participants knew that hypertension adversely affects an individual's health and 7% knew the benefits of treating hypertension. Almost a third (30%) of those aware of their hypertensive status, and 48% overall, did not know any of the risk factors for hypertension. Being aware of one's hypertensive status (OR 2.51, 95% CI 1.44 to 4.39), being treated for hypertension, male sex, younger age, having some schooling, abdominal obesity and physical inactivity were associated with better knowledge of risk factors for hypertension. CONCLUSION: Knowledge of risk factors and consequences of hypertension in this disadvantaged population was poor. There was better knowledge of risk factors in some, but not all, people who were aware of having hypertension. Screening and targeted educational programmes are warranted in this population to improve health behaviours and reduce the consequences of hypertension.

Is length of time in a stroke unit associated with better outcomes for patients with stroke in Australia? An observational study.

OBJECTIVE: Spending at least 90% of hospital admission in a stroke unit (SU) is a recommended indicator of receiving high-quality stroke care. However, whether this makes a difference to patient outcomes is unknown. We aimed to investigate outcomes and factors associated with patients with acute stroke spending at least 90% of their admission in an SU, compared with those having less time in the SU. DESIGN: Observational study using cross-sectional data. SETTING: Data from hospitals which participated in the 2015 Stroke Foundation National Audit: Acute Services (Australia) and had an SU. This audit includes an organisational survey and retrospective medical record audit of approximately 40 admissions from each hospital. PARTICIPANTS: Patients admitted to an SU during their acute admission were included. OUTCOME MEASURES: Hospital-based patient outcomes included length of stay, independence on discharge, severe complications and discharge destination. Patient, organisational and process indicators were included in multilevel logistic modelling to determine factors associated with spending at least 90% of their admission in an SU. RESULTS: Eighty-eight hospitals with an SU audited 2655 cases (median age 76 years, 55% male). Patients who spent at least 90% of their admission in an SU experienced: a length of stay that was 2 days shorter (coefficient -2.77, 95% CI -3.45 to -2.10), fewer severe complications (adjusted OR (aOR) 0.60, 95% CI 0.43 to 0.84) and were less often discharged to residential aged care (aOR 0.59, 95% CI 0.38 to 0.94) than those who had less time in the SU. Patients admitted to an SU within 3 hours of hospital arrival were three times more likely to spend at least 90% of their admission in an SU. CONCLUSION: Spending at least 90% of time in an SU is a valid measure of stroke care quality as it results in improved patient outcomes. Direct admission to SUs is warranted.

Development of an electronic health message system to support recovery after stroke: Inspiring Virtual Enabled Resources following Vascular Events (iVERVE).

PURPOSE: Worldwide, stroke is a leading cause of disease burden. Many survivors have unmet needs after discharge from hospital. Electronic communication technology to support post-discharge care has not been used for patients with stroke. In this paper, we describe the development of a novel electronic messaging system designed for survivors of stroke to support their goals of recovery and secondary prevention after hospital discharge. PARTICIPANTS AND METHODS: This was a formative evaluation study. The design was informed by a literature search, existing data from survivors of stroke, and behavior change theories. We established two working groups; one for developing the electronic infrastructure and the other (comprising researchers, clinical experts and consumer representatives) for establishing the patient-centered program. Following agreement on the categories for the goal-setting menu, we drafted relevant messages to support and educate patients. These messages were then independently reviewed by multiple topic experts. Concurrently, we established an online database to capture participant characteristics and then integrated this database with a purpose-built messaging system. We conducted alpha testing of the approach using the first 60 messages. RESULTS: The initial goal-setting menu comprised 26 subcategories. Following expert review, another 8 goal subcategories were added to the secondary prevention category: managing cholesterol; smoking; physical activity; alcohol consumption; weight management; medication management; access to health professionals, and self-care. Initially, 455 health messages were created by members of working group 2. Following refinement and mapping to different goals by the project team, 980 health messages across the health goals and 69 general motivational messages were formulated. Seventeen independent reviewers assessed the messages and suggested adding 73 messages and removing 16 (2%). Overall, 1,233 messages (18 administrative, 69 general motivation and 1,146 health-related) were created. CONCLUSION: This novel electronic self-management support system is ready to be pilot tested in a randomized controlled trial in patients with stroke.

Knowledge of risk factors for diabetes or cardiovascular disease (CVD) is poor among individuals with risk factors for CVD.

BACKGROUND: There is limited evidence on whether having pre-existing cardiovascular disease (CVD) or risk factors for CVD such as diabetes, ensures greater knowledge of risk factors important for motivating preventative behaviours. Our objective was to compare knowledge among the Australian public participating in a health check program and their risk status. METHODS: Data from the Stroke Foundation 'Know your numbers' program were used. Staff in community pharmacies provided opportunistic health checks (measurement of blood pressure and diabetes risk assessment) among their customers. Participants were categorised: 1) CVD ± risk of CVD: history of stroke, heart disease or kidney disease, and may have risk factors; 2) risk of CVD only: reported having high blood pressure, high cholesterol, diabetes or atrial fibrillation; and 3) CVD risk free (no CVD or risk of CVD). Multivariable logistic regression analyses were performed including adjustment for age and sex. FINDINGS: Among 4,647 participants, 12% had CVD (55% male, 85% aged 55+ years), 47% were at risk of CVD (40% male, 72% 55+ years) and 41% were CVD risk free (33% male, 27% 55+ years). Participants with CVD (OR: 0.66; 95% CI: 0.55, 0.80) or risk factors for CVD (OR: 0.65; 95% CI: 0.57, 0.73) had poorer knowledge of the risk factors for diabetes/CVD compared to those who were CVD risk free. After adjustment, only participants with risk factors for CVD (OR: 0.80; 95% CI: 0.69, 0.93) had poorer knowledge. Older participants (55+ years) and men had poorer knowledge of diabetes/CVD risk factors and complications of diabetes. CONCLUSIONS: Participants with poorer knowledge of risk factors were older, more often male or were at risk of developing CVD compared with those who were CVD risk free. Health education in these high risk groups should be a priority, as diabetes and CVD are increasing in prevalence throughout the world.

Association between salt and hypertension in rural and urban populations of low to middle income countries: a systematic review and meta-analysis of population based studies.

BACKGROUND AND OBJECTIVES: The prevalence of hypertension, the greatest contributor to mortality globally, is increasing in low-and-middle income countries (LMICs). In urban regions of LMICs, excessive salt intake is associated with increased risk of hypertension. We aimed to determine whether this is the case in rural regions as well. METHODS AND STUDY DESIGN: We performed a meta-analysis of studies in rural and urban areas of LMICs in which the association of salt and hypertension were assessed using multivariable models. RESULTS: We identified 18 studies with a total of 134,916 participants. The prevalence of high salt intake ranged from 21.3% to 89.5% in rural and urban populations. When salt was analysed as a continuous variable, a greater impact of salt on hypertension was found in urban (n=4) (pooled effect size (ES) 1.42, 95% CI 1.19, 1.69) than in rural populations (n=4) (pooled ES 1.07, 95% CI 1.04, 1.10, p for difference <0.001). In studies where salt was analysed continuously, a greater impact of salt on hypertension was observed in lean rural populations (BMI <23 kg/m2) than in non-lean rural populations (BMI >=23 kg/m2, p for difference <0.001). CONCLUSIONS: The prevalence of high salt intake is similar in rural and urban regions. Excessive salt intake has a greater impact on the prevalence of hypertension in urban than rural regions. BMI appears to modify the relationship between salt and hypertension in rural populations.

Neighborhood geographic disparities in heart attack and stroke mortality: comparison of global and local modeling approaches.

This study investigated neighborhood geographic disparities in myocardial infarction (MI) and stroke mortality risks in middle Tennessee and identified determinants of observed disparities. Descriptive and spatial analyses were performed on MI and stroke mortality data covering the time period 1999-2007. Besag, York and Molliè (BYM) model was used to investigate spatial patterns. Global (BYM) and local models [Poisson Geographically Weighted Generalized Linear Models (GWGLM)] were used to investigate determinants of the identified spatial patterns. Significant (p<0.05) differences in mortality risks by sex, race, age and education were observed. Rural census tracts (CT) and those with higher proportions of the older populations were associated with high MI and stroke mortality risks. Additionally, CTs with high proportions of widows had significantly higher mortality risks for stroke. There was evidence of geographical variability of all regression coefficients implying that local models complement the findings of the global models and provide useful information to guide local and regional disease control decisions and resource allocation. Identification of high risk CTs is essential for targeting resources and will aid the development of more needs-based prevention programs.