Frequent avoidable admissions amongst Aboriginal and non-Aboriginal people with chronic conditions in New South Wales, Australia: a historical cohort study.

BACKGROUND: Aboriginal and Torres Strait Islander people have high rates of avoidable hospital admissions for chronic conditions, however little is known about the frequency of avoidable admissions for this population. This study examined trends in avoidable admissions among Aboriginal and non-Aboriginal people with chronic conditions in New South Wales (NSW), Australia. METHODS: A historical cohort analysis using de-identified linked administrative data of Aboriginal patients and an equal number of randomly sampled non-Aboriginal patients between 2005/06 to 2013/14. Eligible patients were admitted to a NSW public hospital and who had one or more of the following ambulatory care sensitive chronic conditions as a principal diagnosis: diabetic complications, asthma, angina, hypertension, congestive heart failure and/or chronic obstructive pulmonary disease. The primary outcomes were the number of avoidable admissions for an individual in each financial year, and whether an individual had three or more admissions compared with one to two avoidable admissions in each financial year. Poisson and logistic regression models and a test for differences in yearly trends were used to assess the frequency of avoidable admissions over time, adjusting for sociodemographic variables and restricted to those aged ≤75 years. RESULTS: Once eligibility criteria had been applied, there were 27,467 avoidable admissions corresponding to 19,025 patients between 2005/06 to 2013/14 (71.2% Aboriginal; 28.8% non-Aboriginal). Aboriginal patients were 15% more likely than non-Aboriginal patients to have a higher number of avoidable admissions per financial year (IRR = 1.15; 95% CI: 1.11, 1.20). Aboriginal patients were almost twice as likely as non-Aboriginal patients to experience three or more avoidable admissions per financial year (OR = 1.90; 95% CI = 1.60, 2.26). There were no significant differences between Aboriginal and non-Aboriginal people in yearly trends for either the number of avoidable admissions, or whether or not an individual experienced three or more avoidable admissions per financial year (p = 0.859; 0.860 respectively). CONCLUSION: Aboriginal people were significantly more likely to experience frequent avoidable admissions over a nine-year period compared to non-Aboriginal people. These high rates reflect the need for further research into which interventions are able to successfully reduce avoidable admissions among Aboriginal people, and the importance of culturally appropriate community health care.

The impact of telephone follow up on adverse events for Aboriginal people with chronic disease in new South Wales, Australia: a retrospective cohort study.

BACKGROUND: Chronic diseases are more prevalent and occur at a much younger age in Aboriginal people in Australia compared with non-Aboriginal people. Aboriginal people also have higher rates of unplanned hospital readmissions and emergency department presentations. There is a paucity of research on the effectiveness of follow up programs after discharge from hospital in Aboriginal populations. This study aimed to assess the impact of a telephone follow up program, 48 Hour Follow Up, on rates of unplanned hospital readmissions, unplanned emergency department presentations and mortality within 28 days of discharge among Aboriginal people with chronic disease. METHODS: A retrospective cohort of eligible Aboriginal people with chronic diseases was obtained through linkage of routinely-collected health datasets for the period May 2009 to December 2014. The primary outcome was unplanned hospital readmissions within 28 days of separation from any acute New South Wales public hospital. Secondary outcomes were mortality, unplanned emergency department presentations, and at least one adverse event (unplanned hospital readmission, unplanned emergency department presentation or mortality) within 28 days of separation. Logistic regression models were used to assess outcomes among Aboriginal patients who received 48 Hour Follow Up compared with eligible Aboriginal patients who did not receive 48 Hour Follow Up. RESULTS: The final study cohort included 18,659 patients with 49,721 separations, of which 8469 separations (17.0, 95% confidence interval (CI): 16.7-17.4) were recorded as having received 48 Hour Follow Up. After adjusting for potential confounders, there were no significant differences in rates of unplanned readmission or mortality within 28 days between people who received or did not receive 48 Hour Follow Up. Conversely, the odds of an unplanned emergency department presentation (Odds ratio (OR) = 0.92; 95% CI: 0.85, 0.99; P = 0.0312) and at least one adverse event (OR = 0.91; 95% CI: 0.85,0.98; P = 0.0136) within 28 days were significantly lower for separations where the patient received 48 Hour Follow Up compared with those that did not receive follow up. CONCLUSIONS: Receipt of 48 Hour Follow Up was associated with both a reduction in emergency department presentations and at least one  adverse event within 28 days of discharge, suggesting there may be merit in providing post-discharge telephone follow up to Aboriginal people with chronic disease.

Unplanned readmission or death after discharge for Aboriginal and non-Aboriginal people with chronic disease in NSW Australia: a retrospective cohort study.

BACKGROUND: Admitted patients with chronic disease are at high risk of an unplanned hospital readmission, however, little research has examined unplanned readmission among Aboriginal people in Australia. This study aimed to examine whether rates of unplanned 28 day hospital readmission, or death, significantly differ between Aboriginal and non-Aboriginal patients in New South Wales, Australia, over a nine-year period. METHODS: A retrospective cohort analysis of a sample of de-identified linked hospital administrative data was conducted. Eligible patients were: 1) aged ≥18 years old, 2) admitted to an acute facility in a NSW public hospital between 30th June 2005 and 1st July 2014, and 3) admitted with either cardiovascular disease, chronic respiratory disease, diabetes or renal disease. The primary composite outcome was unplanned readmission or death within 28 days of discharge. Generalized linear models and a test for trend were used to assess rates of unplanned readmission or death over time in Aboriginal and non-Aboriginal patients with chronic disease, accounting for sociodemographic variables. RESULTS: The final study cohort included 122,145 separations corresponding to 48,252 patients (Aboriginal = 57.2%, n = 27,601; non-Aboriginal = 42.8%, n = 20,651). 13.9% (n = 16,999) of all separations experienced an unplanned readmission or death within 28 days of discharge. Death within 28 days of discharge alone accounted for only a small number of separations (1.4%; n = 1767). Over the nine-year period, Aboriginal separations had a significantly higher relative risk of an unplanned readmission or death (Relative risk = 1.34 (1.29, 1.40); p-value < 0.0001) compared with non-Aboriginal separations once adjusted for sociodemographic, disease variables and restricted to < 75 years of age. A test for trend, including an interaction between year and Aboriginal status, showed there was no statistically significant change in proportions over the nine-year period for Aboriginal and non-Aboriginal separations (p-value for trend = 0.176). CONCLUSION: Aboriginal people with chronic disease had a significantly higher risk of unplanned readmission or death 28 days post discharge from hospital compared with non-Aboriginal people, and there has been no significant change over the nine year period. It is critical that effective interventions to reduce unplanned readmissions for Aboriginal people are identified.

Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: a systematic review.

BACKGROUND: Rates of readmission to hospital within 30 days are highest amongst those with chronic diseases. Effective interventions to reduce unplanned readmissions are needed. Providing support to patients with chronic disease via telephone may help prevent unnecessary readmission. This systematic review aimed to determine the methodological quality and effectiveness of interventions utilising telephone follow up (TFU) alone or in combination with other components in reducing readmission within 30 days amongst patients with cardiovascular disease, chronic respiratory disease and diabetes. METHODS: A systematic search of MEDLINE, the Cochrane Library and EMBASE were conducted for articles published from database inception to 19(th) May 2015. Interventions which included TFU alone, or in combination with other components, amongst patients with chronic disease, reported 30 day readmission outcomes and met Effective Practice and Organisation of Care design criteria were included. The titles and abstracts of all identified articles were initially assessed for relevance and rejected on initial screening by one author. Full text articles were assessed against inclusion criteria by two authors with discrepancies resolved through discussion. RESULTS: Ten studies were identified, of which five were effective in reducing readmissions within 30 days. Overall, the methodological quality of included studies was poor. All identified studies combined TFU with other intervention components. Interventions that were effective included three studies which provided TFU in addition to pre-discharge support; and two studies which provided TFU with both pre- and post-discharge support which included education, discharge planning, physical therapy and dietary consults, medication assessment, home visits and a resident curriculum. There was no evidence that TFU and telemedicine or TFU and post-discharge interventions was effective, however, only one to two studies examined each of these types of interventions. CONCLUSIONS: Evidence is inconclusive for the effectiveness of interventions utilising TFU alone or in combination with other components in reducing readmissions within 30 days in patients with chronic disease. High methodological quality studies examining the effectiveness of TFU in a standardised way are needed. There is also potential importance in focusing interventions on enhancing provider skills in patient education, transitional care and conducting TFU.

The role of photographic and video documentation in the investigation and prosecution of child sexual assault.

Despite its widespread acceptance by medical investigators, the use of colposcopy to document ano-genital examinations after sexual assault allegations has attracted controversy. Concerns have been expressed about potentially negative effects arising from the misuse of photo-documentation with some arguing that colposcopic photo-documentation should not occur. We discuss the extent to which these concerns, so far as they relate to the medical examination of children and young people, are supported by the research evidence. We raise and answer four questions: are there negative impacts for children and young people from the use of colposcopy in the medical assessment of suspected child sexual assault? Does the use of colposcopy improve the reliability of the medical assessment? Does the use of colposcopy affect the outcomes in trials, and in particular, criminal prosecutions? Is there any legal or medical benefit to the retention of photo-documentation when the ano-genital examination reveals no abnormalities? We discuss whether the current practices in the use of colposcopy should continue, and what reforms to the law might be needed to protect against the misuse of photo-documentation of ano-genital examinations.

Unassisted detection of depression by GPs: who is most likely to be misclassified?

BACKGROUND: Meta-analyses indicate 50% of cases of depression are not detected by GPs. It is important to examine patient and GP characteristics associated with misclassification so that systems can be improved to increase accurate detection and optimal management for groups at risk of depression. OBJECTIVE: To examine patient and GP characteristics associated with GP misclassification of depression for patients classified by the Patient Health Questionnaire-9 as depressed. METHODS: A cross-sectional study within general practices in two states of Australia. GPs completed a one-page paper and pencil survey indicating whether they thought each patient was clinically depressed. Patients completed a computer tablet survey while waiting for their appointment to provide demographic information and indicate depression status. Chi-square analyses were used to determine whether patient and GP characteristics were associated with a false-negative and false-positive result. The probability of misclassification was modelled using Generalized Estimating Equations to account for clustering of patients. RESULTS: Fifty GPs from 12 practices participated. GPs completed surveys for 1880 patients. Younger patients aged 25-44, and those with a health care card were less likely to have a false-negative assessment. Patients with 0-3 GP visits in the past 12 months, and those with private health insurance were less likely to have a false-positive assessment. GPs who worked five sessions or fewer per week were more likely to make false-positive assessments.

Child sexual abuse in the Anglican Church of Australia.

This article reports on a retrospective study of cases of child sexual abuse complaints made against clergy, other employed pastoral staff, and volunteers in the Anglican Church of Australia between 1990 and 2008. There were 191 allegations of sexual abuse made by 180 complainants against 135 individuals. Twenty-seven of those 135 had more than one complaint made against them. Three-quarters of all complainants were male. The most likely explanation for the large proportion of abused males is that the church gives many more opportunities for abusers to be alone with boys than with girls. Prevention strategies need to focus on reducing the opportunities for abuse to occur as well strategies concerning the recruitment of professional staff and volunteers.

Exploring experiences and perceptions of Aboriginal and Torres Strait Islander peoples readmitted to hospital with chronic disease in New South Wales, Australia: a qualitative study.

Objective This study explored the experiences and perceptions of unplanned hospital readmissions from the perspective of Aboriginal and Torres Strait Islander peoples with chronic disease. Method We conducted semi-structured interviews with Aboriginal and Torres Strait Islander patients readmitted to hospital with chronic disease. Interviews covered perceptions of avoidable readmissions, experiences of health care, medications and carer support. Inductive thematic analysis was used to code and analyse the data. Results Fifteen patients with multiple chronic diseases were interviewed. Several participants believed their readmission was unavoidable due to their poor health, while others considered their readmission was avoidable due to perceived health professional and system failures. Enablers to chronic disease management included the importance of continuity of care and strong family networks, although a few participants struggled with isolation. Four themes emerged as barriers: poor communication from health professionals; low levels of health literacy and adherence to chronic disease management; poor access to community services; and health risk behaviours. Conclusions The participants in our study identified complex and interacting patient-, environmental-, encounter- and organisational-level factors as contributing to chronic disease management and unplanned readmissions. Our findings suggest systemic failures remain in access to basic services and access to culturally appropriate care. Family support and continuity of care were valued by participants. What is known about the topic? Aboriginal and Torres Strait Islander peoples with chronic diseases are more likely to be readmitted to hospital compared with non-Aboriginal people. Unplanned readmissions are associated with high health system costs, as well as poorer quality of life and psychological distress for the patient. What does this paper add? This paper describes the experiences and perceptions of unplanned readmissions by Aboriginal and Torres Strait Islander peoples with chronic disease. Our findings suggest systemic failures exist in access to basic services for a safe and secure living environment, and access to culturally appropriate care that is delivered in a manner which promotes health literacy and self-management capacity. What are the implications for practitioners? Practitioners and policy makers should consider involving family members in discharge planning and other medical care, and funding for Aboriginal and Torres Strait Islander health and community services to enhance transport, care coordination, culturally appropriate disability and housing services, and health promotion.

Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke.

BACKGROUND: Intravenous thrombolysis is one of few evidence-based treatments for acute stroke. Treatment uptake is low outside major stroke care centres. There is a need for greater understanding of barriers encountered by clinicians when seeking to increase thrombolysis rates. AIM: The aim of this study is to describe physicians' and nurses' perceptions regarding thrombolysis for acute stroke at hospitals in the earlier stages of thrombolysis implementation. METHODS: A cross-sectional paper survey completed by physicians' and nurses' was distributed to 1127 staff at stroke care units, emergency departments or equivalent stroke care facilities at 19 Australian hospitals, as part of a cluster randomised controlled trial for thrombolysis implementation and systems improvement. RESULTS: Of 1127 potential participants, 503 (148 physicians and 355 nurses) completed surveys (45% response rate). Over 90% agreed that thrombolysis improved the odds of independent survival. However, 42% to 58% agreed that there were limitations in the evidence base. A small proportion of staff indicated deficits in technical competencies. Interactive or competency-based training was reported by less than two-thirds of the sample. Challenges such as quick bed availability were identified. Emergency department physicians were less positive towards the treatment compared with nurses (p < 0.001), stroke care unit physicians were more positive than nurses (p = 0.047) and older clinicians were more positive than younger clinicians (p = 0.007). CONCLUSION: Australian hospitals seeking to address barriers to stroke thrombolysis implementation may benefit from the availability of interactive and competency-based training, staff performance feedback, support to make beds available quickly and bypass arrangements to quickly deliver acute stroke patients to appropriate facilities.

Can a multicomponent multidisciplinary implementation package change physicians' and nurses' perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial.

BACKGROUND: The Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals. METHODS: A survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time. RESULT: The response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses' responses. CONCLUSION: TIPS resulted in changes in some aspects of nurses' perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample. TRIAL REGISTRATION: ACTRN12613000939796, UTN: U1111-1145-6762.

The psychosocial outcomes of individuals with hematological cancers: Are we doing enough high quality research, and what is it telling us?

This systematic review assessed the quantity and quality of research examining the psychosocial outcomes among hematological cancer patients. Studies were categorised as either measurement, descriptive or intervention. Intervention studies were further assessed according to Effective Practice and Organisation of Care (EPOC) methodological criteria. A total of 261 eligible papers were identified. The number of publications increased by 8.8% each year (95% CI=7.5-10.2%; p<0.0001). The majority of studies were descriptive (n=232; 89%), with few measurement (n=8; 3%) and intervention (n=21; 8%) studies identified. Ten intervention studies met EPOC design criteria, however only two interventions, one targeted at individuals with Hodgkin's or Non-Hodgkin's lymphoma and one targeted at individuals with leukaemia, lymphoma or myelomatosis were successful in improving patients' psychosocial outcomes. Despite an increasing volume of research examining psychosocial outcomes of hematological cancer patients, there is a need for robust measurement and methodologically rigorous intervention research in this area.

Female genital mutilation, asylum seekers and refugees: the need for an integrated European Union agenda.

Asylum seekers and refugees (ASRs) are a heterogeneous population with distinct physical and psychological needs. ASRs with additional health needs are girls and women who have undergone, or are at risk of undergoing, female genital mutilation (FGM). Across the European Union (EU), variation exists in Member States' anti-FGM and asylum legislation, the rigour of existing research programmes, and the operational coherence of the multiple agencies combating the practice. ASRs' needs are, consequently, not being addressed satisfactorily. This paper proposes an integrated future agenda, applicable in all EU countries, capable of meeting these girls' and women's needs.

Early sexual risk among black and minority ethnicity teenagers: a mixed methods study.

PURPOSE: To determine how ethnic background influences early sexual activity among young adults. METHODS: Quantitative data were collected during the Research with East London Adolescents Community Health Survey study, a population-based survey of young adults belonging to white and black and minority ethnic groups and residing in east London in 2001 (n = 2,689) and 2003 (n = 2,675). Qualitative data were obtained from 146 young adults between January and September 2003. RESULTS: Black Caribbean, black African, white other, and mixed ethnicity young men were most likely to report high-risk sexual behaviors, that is, sexual debut at the age of ≤13 years, having unprotected sex, and having multiple sexual partners. There were marked variations within groups commonly collapsed as "black" or as "Muslim." Black Caribbean and black African young adults reported high rates of protective behaviors in addition to risk behaviors. Qualitative data confirmed variations in sexual behavior within ethnic groups. Longitudinally, risk of engaging in two or more high-risk sexual behaviors was predicted by low family support (OR: 2.8, 95% CI: 1.6-4.9), regular smoking (OR: 4.5, 95% CI: 1.7-12.0), and usage of illicit drugs (OR: 2.9, 95% CI: 1.5-5.8), with lower risk predicted by low peer support (OR: .3, 95% CI: .2-.6). CONCLUSIONS: Young adults belonging to black and minority ethnic groups reported a wide variation in sexual risk behaviors. High levels of high-risk behaviors were reported in ethnic groups known to have high rates of sexually transmitted infections. Effective sexual health interventions should be started early and they must focus on sexual debut and partner choices as well as messages regarding safe sex.

'People make assumptions about our communities': sexual health amongst teenagers from black and minority ethnic backgrounds in East london.

OBJECTIVES: (1) To explore sexual behaviour and relationships amongst Black and minority ethnic (BME) teenagers in East London. (2) To examine how these relationships are shaped by culture, gender, peer norms and religion. (3) To describe the implications for sexual health policy and practice in urban, multicultural areas. DESIGN: This report draws primarily on the qualitative arm of a mixed methods study which collected data from 126 young people, aged 15-18, largely through focus groups in the London boroughs of Hackney, Newham and Tower Hamlets. RESULTS: Previous research has reported culture influencing the patterning of risk/protection amongst BME groups. Our data suggest that this is mediated by gender, religion and youth. Religion reportedly influenced young women's sexual behaviour in multiple ways. Young people described gendered norms in meeting and flirting with partners, and the role of mobile phones and peer pressure. CONCLUSION: Our paper suggests culture, gender, religion and youth influence BME teenagers in aspects of sexual relationships, and that these social markers may have different contextual meanings for individuals. The multiplicity of factors affecting attitudes/behaviour requires a range of contraceptive, counselling, screening and sex education services available for all teenagers, although delivery patterns may differ in response to differing needs.