Craig Veitch

Systematic Review of Prognostic Factors Related to Overall Survival in Patients with Stage IV Colorectal Cancer and Unresectable Metastases

BackgroundWith the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision.MethodA literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review.ResultsFourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients’ performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases.ConclusionEach patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.

Addressing the barriers to accessing therapy services in rural and remote areas

Abstract Purpose: Throughout the world, people with a disability who live in rural and remote areas experience difficulty accessing a range of community-based services including speech-, physio- and occupational therapy. This paper draws on information gathered from carers and adults with a disability living in a rural area in New South Wales (NSW), Australia to determine the extent to which people living in rural areas may receive a person-centred therapy service. Methods: As part of a larger study in rural NSW into the delivery of therapy services, focus groups and individual interviews were conducted with 78 carers and 10 adults with a disability. Data were analysed using constant comparison and thematic analysis. Results: Three related themes emerged: (i) travelling to access therapy; (ii) waiting a long time to get therapy; and (iii) limited access to therapy past early childhood. The themes overlaid the problems of recruiting and retaining sufficient therapists to work in rural areas. Conclusions: Community-based rehabilitation principles offer possibilities for increasing person-centred therapy services. We propose a person-centred and place-based approach that builds on existing service delivery models in the region and involves four inter-related strategies aimed at reducing travel and waiting times and with applicability across the life course. Implications for Rehabilitation Therapy service delivery in rural and remote areas requires: Place-based and person centred strategies to build local capacity in communities. Responsive outreach programs working with individuals and local communities. Recognition of the need to support families who must travel to access remotely located specialist services. Innovative use of technology to supplement and enhance service delivery.

The need for new models for delivery of therapy intervention to people with a disability in rural and remote areas of Australia

OPINIONS & PERSPECTIVES The need for new models for delivery of therapy intervention to people with a disability in rural and remote areas of Australia ANGELA DEW, CRAIG VEITCH, MICHELLE LINCOLN, JENNIE BRENTNALL, KIM BULKELEY, GISSELLE GALLEGO, ANITA BUNDY & SCOTT GRIFFITHS Faculty of Health Sciences, University of Sydney, Australia, and NSW Department of Family & Community Services, Ageing, Disability & Home Care, Australia

A retrospective review of place of death of palliative care patients in regional north Queensland

Background: Palliative care strives to offer patients and their families choice in the location of their management and final terminal care. The place of death has been shown to be related to various patient, carer and health service factors. Aim: This study explores place of death of palliative care patients in regional north Queensland, and investigates which patient, disease, and other factors impact on place of death. Methods: All patients under the care of the specialist Palliative Care Service (PCS) at The Townsville Hospital, who died in 2004, were identified. Medical charts for these patients were analysed for various demographic data, disease-related information and place of death. Results: Some 270 patients were analysed. A total of 162 were male, median age was 72 years, and 146 (54%) were married. Home death rate was 19% (54 patients), with 64% (173) of patients dying in hospital. Factors significantly associated with home death included younger age, married, a diagnosis of colorectal carcinoma, and the involvement of community nurses. There was a trend towards male patients being more likely to die at home. Logistic regression analysis indicated that younger age and community nurse involvement were significantly associated with home death. Discussion: The results of this study are in keeping with available, largely urban-based literature, with respect to predictive factors of home death. Further prospective study, with an emphasis on choice regarding place of care and GP involvement with palliative care patients, is warranted.

Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the 'wobbly hub and double spokes' project

BackgroundPolicy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia.Methods/DesignThe project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability.Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation.Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences.Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects.Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages.DiscussionThe project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice.

Recruitment and retention of allied health professionals in the disability sector in rural and remote New South Wales, Australia

Abstract Background People with disability living in rural areas are vulnerable to the loss of access to allied health services due to a critical shortage of allied health professionals (AHPs). This study aimed to investigate recruitment and retention issues of importance to AHPs providing services to people with disability in rural New South Wales, Australia. Method Focus groups and semistructured interviews were conducted with 97 purposively sampled service providers in the disability sector. Interviews and focus groups were digitally recorded and transcribed. A modified grounded theory approach using thematic analysis and constant comparison was used to analyse the data. Results Three major themes relating to recruitment and retention were identified: (a) flexible recruitment, (b) retention strategies that work, and (c) challenges to retention. Conclusions AHPs in the disability sector identified some of the same issues influencing recruitment and retention as AHPs in the health, education, and private sectors. Several unique issues were also identified that will assist policymakers to improve recruitment and retention of AHPs employed in the disability sector in rural areas.

INTERPRACTITIONER COMMUNICATION: TELEPHONE CONSULTATIONS BETWEEN RURAL GENERAL PRACTITIONERS AND SPECIALISTS

The results of a study that sought to investigate the utility of and satisfaction with telephone consultations from the perspective of general practitioners and specialists are reported. Semi-structured interviews with rural general practitioners and specialists were used to elicit information about their most recent telephone consultations. The telephone was found to be an important means of communication for rural practitioners, primarily in terms of organising referrals. General practitioners tended to called specialists who they knew and appeared to have fairly well-formed networks of specialists who they called for most of their concerns. Trust is an important element of interpractitioner communication as it increases understanding and confidence in the reliability of the information exchanged. Good working relationships ensure that rural general practitioners have an accessible source of acceptable specialist support.

Patients' experiences of referral for colorectal cancer

BackgroundOutcomes for colorectal cancer patients vary significantly. Compared to other countries, Australia has a good record with patient outcomes, yet there is little information available on the referral pathway. This paper explores the views of Australian patients and their experiences of referral for colorectal cancer treatment following diagnosis; the aim was to improve our understanding of the referral pathway and guide the development of future interventions.MethodsA purposive sampling strategy was used, recruiting 29 patients representing urban and rural areas from 3 Australian states who participated in 4 focus groups. Seven patients provided individual interviews to supplement the data. Recordings were transcribed verbatim, data was coded with NVivo software and analysed thematically before deductive analysis.ResultsFour aspects of the referral process were identified by patients, namely detection/diagnosis, referral for initial treatment/specialist care, the roles of the GP/specialist, and the patient’s perceived involvement in the process. The referral process was characterised by a lack of patient involvement, with few examples of shared decision-making and few examples of limited choice. However, patients did not always feel they had the knowledge to make informed decisions. Information exchange was highly valued by patients when it occurred, and it increased their satisfaction with the process. Other factors mediating care included the use of the public versus private health system, the quality of information exchange (GP to specialist and GP to patient), continuity of care between GP and specialist, and the extent of information provision when patients moved between specialist and GP care.ConclusionsPatients described poor GP continuity, ad hoc organisational systems and limited information exchange, at both interpersonal and inter-organisational levels, all leading to sub-optimal care. Implementation of a system of information feedback to GPs and engagement with them might improve information exchange for patients, enabling them to be more involved in improved referral outcomes.

Should I stay or should I go? Exploring the job preferences of allied health professionals working with people with disability in rural Australia

IntroductionThe uneven distribution of allied health professionals (AHPs) in rural and remote Australia and other countries is well documented. In Australia, like elsewhere, service delivery to rural and remote communities is complicated because relatively small numbers of clients are dispersed over large geographic areas. This uneven distribution of AHPs impacts significantly on the provision of services particularly in areas of special need such as mental health, aged care and disability services.ObjectiveThis study aimed to determine the relative importance that AHPs (physiotherapists, occupational therapists, speech pathologists and psychologists – “therapists”) living in a rural area of Australia and working with people with disability, place on different job characteristics and how these may affect their retention.MethodsA cross-sectional survey was conducted using an online questionnaire distributed to AHPs working with people with disability in a rural area of Australia over a 3-month period. Information was sought about various aspects of the AHPs’ current job, and their workforce preferences were explored using a best–worst scaling discrete choice experiment (BWSDCE). Conditional logistic and latent class regression models were used to determine AHPs’ relative preferences for six different job attributes.ResultsOne hundred ninety-nine AHPs completed the survey; response rate was 51 %. Of those, 165 completed the BWSDCE task. For this group of AHPs, “high autonomy of practice” is the most valued attribute level, followed by “travel BWSDCE arrangements: one or less nights away per month”, “travel arrangements: two or three nights away per month” and “adequate access to professional development”. On the other hand, the least valued attribute levels were “travel arrangements: four or more nights per month”, “limited autonomy of practice” and “minimal access to professional development”. Except for “some job flexibility”, all other attributes had a statistical influence on AHPs’ job preference. Preferences differed according to age, marital status and having dependent children.ConclusionsThis study allowed the identification of factors that contribute to AHPs’ employment decisions about staying and working in a rural area. This information can improve job designs in rural areas to increase retention.ResumenIntroducciónLa distribución desigual de los profesionales de la salud en zonas rurales y distantes está bien documentada. Esto es aún más frecuente en áreas tales como salud mental y servicios para discapacitados. En Australia, al igual que en otros países, la prestación de servicios a las comunidades rurales y distantes se complica aún más debido a que un número relativamente pequeño de personas está dispersos en grandes áreas geográficas.Objetivodeterminar qué condiciones específicas de empleo influyen en la preferencia declarada de profesionales de la salud (fisioterapeutas, terapeutas ocupacionales, logopedas y psicólogos - “terapeutas”) que viven en una zona rural de Australia y que trabajan con personas con discapacidad.Métodoestudio transversal se llevó a cabo mediante un cuestionario en línea distribuido a terapeutas que trabajan con personas con discapacidad en una zona rural de Australia durante un período de tres meses. Se solicitó información sobre varios aspectos de trabajo actual y sus preferencias se determinaron mediante un experimento de elección discreta de escalas mejor/peor (BWSDCE). Se utilizaron modelos de regresión logística y de clase latente para determinar la importancia relativa de seis atributos de trabajo.ResultadosCiento noventa y nueve terapeutas completaron la encuesta; tasa de respuesta fue del 51 %. De ellos 165 completaron el BWSDCE. Para este grupo de profesionales de la salud “autonomía profesional: alta” es el nivel del atributo más valorado, seguido por “planes de viaje: una o menos noches al mes”, “planes de viaje: dos o tres noches por mes” y “acceso adecuado a desarrollo profesional”. Por otro lado los niveles de atributos menos valorados fueron “los arreglos de viaje: cuatro o más noches al mes”, “autonomía profesional: limitada” y “acceso mínimo a desarrollo profesional”. A excepción de “cierta flexibilidad en el trabajo” todos los demás atributos tuvieron una influencia estadística sobre las preferencias de estos profesionales. Las preferencias difieren de acuerdo a la edad, el estado civil y tener hijos a cargo.ConclusionesEste estudio permitió la identificación de los factores que contribuyen a la retención de terapeutas en una zona rural. Esta información puede mejorar las políticas de empleo en zonas rurales y distantes para aumentar la retención de estos profesionales en estas zonas.

Rural Carers of People with Disabilities: Making Choices to Move or to Stay

When a child is born with, or an individual acquires, a disability in rural Australia, one of the decisions faced by the family is whether to remain living in a rural area or move to a larger metropolitan centre to access support services such as therapy. Understanding the factors that rural carers weigh up in making the decision to move or stay can inform the successful implementation of the National Disability Insurance Scheme (NDIS) in rural areas. Seventy-eight rural carers were recruited to participate in individual interviews or focus groups to discuss access to therapy services. Data were analysed using modified grounded theory involving thematic analysis and constant comparison. Participants made decisions about whether to stay living in their rural community or to move to a larger centre to receive therapy services according to three interlinked factors: personal factors related to their other family caring responsibilities; social factors including their informal support networks of family, frie...