Alice Grady

A systematic review of behavioural weight-loss interventions involving primary-care physicians in overweight and obese primary-care patients (1999-2011)

OBJECTIVE The present review aimed to examine the effectiveness of behavioural weight-loss interventions involving primary-care physicians in producing weight loss in overweight and obese primary-care patients. DESIGN A systematic review was conducted by searching online databases (MEDLINE, EMBASE, Cochrane, PsycINFO and SCOPUS) from January 1999 to December 2011. All abstracts were screened and coded for eligibility. The Cochrane Effective Practice and Organisation of Care Group quality criteria were used to assess the methodological adequacy of included studies. Information related to study design, population characteristics and intervention details was extracted. SETTING Primary care. SUBJECTS Overweight or obese (defined as having a BMI > or = 25.0 kg/m2) primary care patients. RESULTS Sixteen different studies were included. Of these, six assessed primary care physicians’ delivery of weight-loss counselling; nine assessed weight-loss counselling delivered by non-physician personnel with monitoring by primary care physicians; and one assessed a multi-component intervention. Overall, high intensity weight-loss counselling by primary-care physicians resulted in moderate but not clinically significant weight loss. High-intensity weight-loss counselling delivered by non-physicians, meal replacements delivered in conjunction with dietitian counselling and referral to commercial weight-loss centre programmes accompanied by regular monitoring by a primary-care physician were effective in producing clinically significant weight loss. Dietitian-delivered care appeared effective in producing weight loss regardless of level of intervention intensity. CONCLUSIONS Overall, there were few studies on this topic and the methodological rigour of some included studies was poor. Additional studies assessing the effectiveness and acceptability of potential interventions are needed to confirm these findings.

Enablers of the implementation of tissue plasminogen activator in acute stroke care: a cross-sectional survey.

Objective To assess emergency physicians’ perceptions of individual and system enablers to the use of tissue Plasminogen Activator in acute stroke. Method Australian fellows and trainees of Australasian College for Emergency Medicine completed a 57-item online survey assessing enablers to implementation of evidence-based practice across six domains: knowledge, skills, modelling, monitoring, feedback, and maintenance. Demographic and workplace characteristics were obtained. Descriptive statistics were calculated to describe demographic and workplace characteristics of responders, and survey responses. Each domain received an overall score (%) based on the number of responders agreeing with all items within the domain. Results A total of 429 (13%) Australasian College for Emergency Medicine members responded. 17.7% of respondents reported they and/or their workplace met all knowledge-related enablers, however only 2.3% had all skill-related enablers in place. Of respondents who decide which patients receive tissue Plasminogen Activator treatment, 18.1% agreed that all maintenance-related enablers are in place at their hospital, compared to 6.6% for those who do not decide which patients receive tissue Plasminogen Activator treatment. None of the respondents had all items in place cross all domains. Conclusions Even when allowing for the low response rate, it seems likely there is a lack of individual and system enablers supporting the implementation of best-practice stroke care in a number of Australian hospitals. Quality improvement programs could target all domains, particularly the skills-training and feedback emergency physicians receive, to aid implementation of tissue Plasminogen Activator treatment for acute stroke.

GP detection of health risk factors among general practice patients at risk of primary and secondary stroke

BACKGROUND People with a history of stroke or heart disease are at increased risk of future stroke; therefore, identification of risk factors by GPs is critical. OBJECTIVES To compare the following among general practice patients with and without a history of stroke or heart disease: (i) self-reported prevalence rates of lifestyle risk factors; (ii) accuracy of GP detection of patient-reported risk factors and (iii) average proportion of patient-reported risk factors detected by GPs. METHODS Consecutive patients attending a participating general practice clinic were invited to participate in a cross-sectional touchscreen survey assessing lifestyle risk factors in 2010-11. The GP of each consenting patient completed a corresponding survey assessing the patients risk factors. Demographic characteristics of patients and GPs were obtained. RESULTS Data from 51 GPs and 564 patients were analysed. Patients without a history of stroke or heart disease reported significantly higher rates of smoking (12%) and risky alcohol consumption (56%) than patients with a history of stroke or heart disease (6% and 36%, respectively). Low sensitivity of GP detection of risk factors was found for all risk factors for all patients. Patients with a history of stroke or heart disease have a significantly higher mean proportion of risk factors detected by their GP compared to patients without a history of stroke or heart disease (P = 0.00). CONCLUSION Given low sensitivity and specificity of GP detection of risk factors among patients, alternate methods of identification are needed. Research is required to determine strategies to facilitate secondary care of patients with a history of stroke or heart disease by GPs.

A systematic review of patient-practitioner communication interventions involving treatment decisions

OBJECTIVES To examine the: 1) methodological quality of interventions examining strategies to improve patient-practitioner communication involving treatment decisions; 2) effectiveness of strategies to improve patient-practitioner communication involving treatment decisions; and 3) types of treatment decisions (emergency/non-emergency) in the included studies. METHODS Medline, PsychINFO, CINAHL, and Embase were searched to identify intervention studies. To be included, studies were required to examine patient-practitioner communication related to decision making about treatment. Study methodological quality was assessed using Cochranes Effective Practice and Organisation of Care risk of bias criteria. Study design, sample characteristics, intervention details, and outcomes were extracted. RESULTS Eleven studies met the inclusion criteria. No studies were rated low risk on all nine risk of bias criteria. Two of the three interventions aimed at changing patient behaviour, two of the five practitioner directed, and one of the three patient-practitioner directed interventions demonstrated an effect on decision-making outcomes. No studies examined emergency treatment decisions. CONCLUSIONS Existing studies have a high risk of bias and are poorly reported. There is some evidence to suggest patient-directed interventions may be effective in improving decision-making outcomes. PRACTICE IMPLICATIONS It is imperative that an evidence-base is developed to inform clinical practice.

A randomised controlled trial of an online menu planning intervention to improve childcare service adherence to dietary guidelines: a study protocol

Introduction The implementation of dietary guidelines in childcare settings is recommended to improve child public health nutrition. However, foods provided in childcare services are not consistent with guidelines. The primary aim of the trial is to assess the effectiveness of a web-based menu planning intervention in increasing the mean number of food groups on childcare service menus that comply with dietary guidelines regarding food provision to children in care. Methods and analysis A parallel group randomised controlled trial will be undertaken with 54 childcare services that provide food to children within New South Wales, Australia. Services will be randomised to a 12-month intervention or usual care. The experimental group will receive access to a web-based menu planning and decision support tool and online resources. To support uptake of the web program, services will be provided with training and follow-up support. The primary outcome will be the number of food groups, out of 6 (vegetables, fruit, breads and cereals, meat, dairy and ‘discretionary’), on the menu that meet dietary guidelines (Caring for Children) across a 1-week menu at 12-month follow-up, assessed via menu review by dietitians or nutritionists blinded to group allocation. A nested evaluation of child dietary intake in care and child body mass index will be undertaken in up to 35 randomly selected childcare services and up to 420 children aged approximately 3–6 years. Ethics and dissemination Ethical approval has been provided by Hunter New England and University of Newcastle Human Research Ethics Committees. This research will provide high-quality evidence regarding the impact of a web-based menu planning intervention in facilitating the translation of dietary guidelines into childcare services. Trial findings will be disseminated widely through national and international peer-reviewed publications and conference presentations. Trial registration Prospectively registered with Australian New Zealand Clinical Trial Registry (ANZCTR) ACTRN12616000974404.

Improving the public health impact of eHealth and mHealth interventions

Australian and New Zealand Journal of Public Health 2018 vol. 42 no. 2

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.

Barriers and Enablers to Implementation of Dietary Guidelines in Early Childhood Education Centers in Australia: Application of the Theoretical Domains Framework

Objective: To identify perceived barriers and enablers to implementation of dietary guidelines reported by early childhood education center cooks, and barriers and enablers associated with greater implementation based on assessment of center menu compliance. Design: Cross‐sectional telephone interview. Setting: Early childhood education centers, New South Wales, Australia. Participants: A total of 202 cooks responsible for menu planning; 70 centers provided a menu for review of compliance with dietary guidelines. Main Outcome Measure: Barriers and enablers to dietary guideline implementation were determined using a tool assessing constructs of the Theoretical Domains Framework (TDF). Higher scores (≥6) for each construct indicated enablers to guideline implementation; lower scores (<6) suggested barriers. Analysis: Multivariable linear regression identified TDF constructs associated with greater guideline implementation. Results: Scores were lowest for reinforcement (mean, 5.85) and goals (mean, 5.89) domains, and highest for beliefs about consequences (mean, 6.51) and social/professional role and identity (mean, 6.50). The skills domain was positively associated with greater implementation of guidelines based on menu review (P = .01). Conclusions and Implications: Cooks perceived social/professional role and identity, and beliefs about consequences to be enablers to dietary guideline implementation; however, only the skills domain was associated with greater implementation. There are opportunities to target the incongruence in perceptions vs reality of the barriers and enablers to implementation. Future research could examine the utility of the TDF to identify barriers and enablers to implementation to inform intervention development and for evaluating interventions to examine intervention mechanisms.

Evidence of the Potential Effectiveness of Centre-Based Childcare Policies and Practices on Child Diet and Physical Activity: Consolidating Evidence from Systematic Reviews of Intervention Trials and Observational Studies

Purpose of ReviewThe aims of this study are to synthesize the findings of systematic reviews to (1) determine whether centre-based childcare interventions are effective in improving child physical activity and diet and (2) identify promising modifiable centre policies and practices to improve child physical activity and diet. Four electronic databases were searched. The methodological quality of included reviews was assessed using the AMSTAR tool. For intervention effectiveness, reviews were categorized as ‘generally effective’ if more than two-thirds of primary studies demonstrated positive effects.Recent FindingsDatabase searches yielded 1164 unique citations of which 22 reviews were included. Three of 16 physical activity reviews, including one of the two higher quality reviews, and the largest and most recent review to date, reported that the interventions were generally effective in improving physical activity. One of nine nutrition reviews reported that interventions were generally effective at improving dietary intake. This review was of moderate quality and was the largest and most recent review of dietary outcomes in children in this setting. The most consistently reported policies and practices associated with improved child physical activity included those targeting the physical environment (playground markings, equipment, space), educator qualifications and training, and structured physical activities. Policies and practices associated with improved child diet included food availability and menu modification, positive peer modelling, and including parents.SummaryThere is increasing evidence from high-quality, recent systematic reviews that childcare-based interventions can be effective at improving child physical activity. Systematic review evidence regarding the effects of intervention on child diet is more equivocal.

Agreement with evidence for tissue Plasminogen Activator use among emergency physicians: a cross-sectional survey

BackgroundEmergency department staff play a crucial role in the triage of stroke patients and therefore the capacity to deliver time-dependent treatments such as tissue Plasminogen Activator. This study aimed to identify among emergency physicians, (1) rates of agreement with evidence supporting tissue Plasminogen Activator use in acute stroke care; and (2) individual and hospital factors associated with high agreement with evidence supporting tissue Plasminogen Activator use.MethodsAustralian fellows and trainees of the Australasian College for Emergency Medicine were invited to complete an online cross-sectional survey assessing perceptions of tissue Plasminogen Activator use in acute stroke. Demographic and hospital characteristics were also collected.Results429 Australasian College for Emergency Medicine members responded (13% response rate). Almost half (47.2%) did not agree with any statements regarding the benefits of tissue Plasminogen Activator use for acute stroke. Perceived routine administration of tissue Plasminogen Activator by the head of respondents’ emergency department was significantly associated with high agreement with the evidence supporting tissue Plasminogen Activator use in acute stroke.ConclusionsAgreement with evidence supporting tissue Plasminogen Activator use in acute stroke is not high among responding Australian emergency physicians. In order for tissue Plasminogen Activator treatment to become widely accepted and adopted in emergency settings, beliefs and attitudes towards treatment need to be in accordance with clinical practice guidelines.