Anne-marie Boxall

Managing chronic obstructive pulmonary disease in the community. A randomized controlled trial of home-based pulmonary rehabilitation for elderly housebound patients.

PURPOSE Pulmonary rehabilitation is essential for managing chronic obstructive pulmonary disease (COPD). Housebound COPD patients are frequently excluded from this treatment because they are unable to access outpatient pulmonary rehabilitation programs because of the severity of their disease. This randomized controlled trial assesses the effects of a 12-week home-based pulmonary rehabilitation program for 60 housebound COPD patients older than 60 years. METHODS Intervention patients received an individually tailored supervised walking and arm exercise program as well as individual multidisciplinary education sessions on COPD and its management. Outcomes were assessed using the 6-minute walk test, St Georges respiratory questionnaire, and Borg score of perceived breathlessness. Healthcare utilization was assessed using hospital admission rates with exacerbation of COPD and average length of stay at readmission. RESULTS Complete data for 23 patients in each group were available for analysis. There was no significant difference between groups on baseline measures. Compared with the control group, intervention patients demonstrated a significant improvement in 6-minute walk test (P = .023), Borg score of perceived breathlessness (P = .024), St Georges respiratory questionnaire total score (P = .020), and impact subscore (P = .024). At 6 months, the intervention group had a significantly shorter average length of stay at readmission to hospital with exacerbation (P = .035). CONCLUSION A 12-week home-based pulmonary rehabilitation is effective in improving exercise tolerance, perception of breathlessness, and quality of life for housebound COPD patients. To manage COPD in the community more effectively, health services should focus on expanding home-based pulmonary rehabilitation.

Management of Medicines in Chronic Illness: Views of Community Pharmacists in New South Wales

Healthcare reforms are needed to meet the predicted increase in the chronic disease burden. A multidisciplinary team approach has been extensively evaluated and shown to improve health outcomes. There is also support for including pharmacists in these teams. Pharmacists have valuable insight, from a medication perspective, to improve the management of patients with chronic illness.

Political economy and population health: is Australia exceptional?

BackgroundIt is accepted knowledge that social and economic conditions – like education and income – affect population health. What remains uncertain is whether the degree of inequality in these conditions influences population health and if so, how. Some researchers who argue that inequalities are important, say there is a relationship between political economy, inequality and population health. Their evidence comes from comparative studies showing that countries with neo-liberal political economies generally have poorer population health outcomes than those with social or Christian democratic political economies. According to these researchers, neo-liberal political economies adopt labour market and welfare state policies that lead to greater levels of inequality and poorer population health outcomes for us all.DiscussionAustralia has experienced considerable social and economic reforms over the last 20 years, with both major political parties increasingly adopting neo-liberal policies. Despite these reforms, population health outcomes are amongst the best in the world.SummaryAustralia appears to contest theories suggesting a link between political economy and population health. To progress our understanding, researchers need to concentrate on policy areas outside health – such as welfare, economics and industrial relations. We need to do longitudinal studies on how reforms in these areas affect levels of social and economic inequality, as well population health. We need to draw on social scientific methods, especially concerning case selection, to advance our understanding of casual relationships in policy studies. It is important to find out if, and why, Australia has resisted the affects of neo-liberalism on population health so we ensure our high standards are maintained in the future.

Commissioning services and Primary Health Networks

Commissioning is set to become a stronger feature in the Australian health system as Primary Health Networks embrace it as a tool for improving population health outcomes. International experience shows that developing into a commissioning organisation is not always easy. Drawing on international experiences of commissioning, as well as those from the Australian hospital sector, will help smooth the path for Primary Health Networks.

Is Hospital in the Home as safe and effective as inpatient care

When Activity-Based Funding (ABF) for public hospitals begins on 1 July this year, it should make it easier for hospitals to establish Hospital in the Home (HITH) services. The pricing framework underpinning the ABF system stipulates that public hospital services should be priced in a way that facilitates the timely roll-out of evidence-based innovations in the most appropriate care setting. HITH services have been operating in some Australian hospitals for nearly 20 years. However before starting up a service of their own, many hospital managers will want to know if HITH is safe, and for which patients. This paper briefly outlines the evidence on the safety, quality and costs of HITH services. A list of resources is provided for those who want to know more. What does the evidence say? Many health services provide care in patients’ homes. To qualify as a HITH service it must provide active treatment by health care professionals in patients’ homes for conditions that otherwise would require hospital in-patient care. Examples of acute treatments delivered in the home include blood transfusions, intravenous antibiotic treatments for infections, and anticoagulation for patients with deep venous thrombosis and pulmonary emboli. Some HITH services (early - discharge HITH) also provide subacute treatment such as rehabilitation at home after orthopaedic injuries and procedures. The range of conditions that are treatable at home continues to expand as technology and confidence in HITH improves. Cochrane Reviews are generally regarded as an authoritative source of research evidence. A systematic review of the evidence on HITH was conducted by the Cochrane Collaboration in 2008 (it was updated in 2011 and no changes were made to the conclusions). After searching the main medical databases, the Cochrane reviewers found 10 randomised controlled trials (RCTs) that compared HITH with inpatient care; RCTs are generally thought to produce high quality evidence. Data from five of the RCTs on admission - substitution HITH services were broadly comparable, so they were pooled and used to conduct a more high-powered statistical analysis, a meta-analysis.