Geoff McDonnell

A Literature Review on Care at the End-of-Life in the Emergency Department.

The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.

An exploration of opportunities and challenges facing cervical cancer managers in Kenya

BackgroundKenya like other developing countries is low in resource setting and is facing a number of challenges in the management of cervical cancer. This study documents opportunities and challenges encountered in managing cervical cancer from the health care workers’ perspectives. A qualitative study was conducted among cervical cancer managers who were defined as nurses and doctors involved in operational level management of cervical cancer. The respondents were drawn from four provincial hospitals and the only two main National public referral hospitals in Kenya. Twenty one [21] nurse managers and twelve [12] medical doctors were interviewed using a standardized interview guide. The responses were audio recorded, transcribed verbatim and the content analyzed in emerging themes.FindingsFour themes were identified. Patient related challenges included a large number of patients, presenting in the late stage of disease, low levels of knowledge on cancer of the cervix, low levels of screening and a poor attitude towards screening procedure. Individual health care providers identified a lack of specialised training, difficulty in disclosure of diagnosis to patients, a poor attitude towards cervical cancer screening procedure and a poor attitude towards cervical cancer patients. Health facilities were lacking in infrastructure and medical supplies. Some managers felt ill-equipped in technological skills while the majority lacked access to the internet. Mobile phones were identified as having great potential for improving the management of cervical cancer in Kenya.ConclusionKenya faces a myriad of challenges in the management of cervical cancer. The peculiar negative attitude towards screening procedure and the negative attitude of some managers towards cervical cancer patients need urgent attention. The potential use of mobile phones in cervical cancer management should be explored.

Effectiveness of hospital-wide methicillin-resistant Staphylococcus aureus (MRSA) infection control policies differs by ward specialty.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of preventable nosocomial infections and is endemic in hospitals worldwide. The effectiveness of infection control policies varies significantly across hospital settings. The impact of the hospital context towards the rate of nosocomial MRSA infections and the success of infection control is understudied. We conducted a modelling study to evaluate several infection control policies in surgical, intensive care, and medical ward specialties, each with distinct ward conditions and policies, of a tertiary public hospital in Sydney, Australia. We reconfirm hand hygiene as the most successful policy and find it to be necessary for the success of other policies. Active screening for MRSA, patient isolation in single-bed rooms, and additional staffing were found to be less effective. Across these ward specialties, MRSA transmission risk varied by 13% and reductions in the prevalence and nosocomial incidence rate of MRSA due to infection control policies varied by up to 45%. Different levels of infection control were required to reduce and control nosocomial MRSA infections for each ward specialty. Infection control policies and policy targets should be specific for the ward and context of the hospital. The model we developed is generic and can be calibrated to represent different ward settings and pathogens transmitted between patients indirectly through health care workers. This can aid the timely and cost effective design of synergistic and context specific infection control policies.

Developing a policy simulator at the acute–aged care interface

This paper describes the development of a computer simulation of the interactions between the acute and aged care systems in Australia, using system dynamics modeling enhanced by agent-based techniques. National and regional simulations will be developed, enabling the impact of a variety of policy scenarios to be forecast over the next 10 years. The paper includes a description of the relevant policy environment and some of the associated key policy issues.

A Computer Model of Dementia Prevalence in Australia: Foreseeing Outcomes of Delaying Dementia Onset, Slowing Disease Progression, and Eradicating Dementia Types

Background: A computer model was designed to test hypothetical scenarios regarding dementia prevalence in Australia (2001–2040). Methods: The study implemented 3 scenarios: delaying dementia onset, slowing disease progression and, in a previously unpublished experiment, eradicating dementia types. Sensitivity analysis and parameter variation were the main methods of experimentation. Results: The model predicts that delaying dementia onset by 5 years will reduce the 2040 prevalence by 37%. An onset delay of 2 years, introduced in 2010, will reduce the 2040 prevalence by 16%. Slowing disease progression increases the 2040 prevalence by 4–7%. Total eradication of Alzheimer’s disease (currently approximately 50% of all dementia cases) in 2020 will decrease the 2040 prevalence by 42%. Conclusion: Computer modeling of future scenarios and interventions helps health and aged care planners understand the likely challenges society will face with the ageing of the world’s population.

The acute-aged care interface: Exploring the DYNAMICS of 'bed blocking'

Objective:  To understand the dynamics underlying ‘bed‐blocking’ in Australian public hospitals that is frequently blamed on older patients.

Self-reported use of internet by cervical cancer clients in two National Referral Hospitals in Kenya

BackgroundCervical cancer remains a devastating disease in Kenya accounting for more than 2000 deaths each year. Lack of information on cervical cancer prevention and management has been attributed to the apathy among women in seeking health interventions. Use of internet-based and mobile e-health tools could increase information access among cervical cancer patients. The objective of the study was; to establish the extent of use of mobile phones and internet by cervical cancer patients in accessing information related to cancer treatment and management.; find out the characteristics of patients associated with internet use and identify barriers faced by the patients in internet use. A cross sectional descriptive survey of 199 cervical patients visiting the two main referral hospitals in Kenya was done. A structured questionnaire was used to collect data.FindingsThe average length of illness was 2.43 years (SD ± 3.0). Only 7.5 %( n=15) reported to having used the internet as a source of information. 92.5 %( n=184) did not use internet. With Multiple options, 70.9% did not know how to use a computer, 29.2% did not have access to a computer, 14.6% lacked the money to use computers at the local cyber cafe while other barriers identified accounted for 11.1%. Patients reported that the internet had an important role in the management of cancer of the cervix in health education (17.6%), online consultation (14.6%), booking of patients (13.6%), referrals (8.5%) and collecting data (7%). The 96.5% of the respondents who had access to a mobile phone, recommended mobile phones for health education messages (31.7%), reminder alerts for medication (29.7%) and booking appointments (21.6%). There was a statistically significant association between income of the patients and internet use (p = 0.026) in this study.ConclusionsThere is low level use of the internet by cervical cancer clients attended in Public referral facilities in Kenya. This was attributed to; lack of knowledge on how to use computers and lack of access to a computer. High level of access to mobile phones was reported. This is an indicator of great potential for use of mobile phones in the management of cervical cancer through short messaging services (sms), without internet connectivity. There is even greater potential to internet use through web access via mobile phones.

Simulation modelling as a tool for knowledge mobilisation in health policy settings: a case study protocol

BackgroundEvidence-informed decision-making is essential to ensure that health programs and services are effective and offer value for money; however, barriers to the use of evidence persist. Emerging systems science approaches and advances in technology are providing new methods and tools to facilitate evidence-based decision-making. Simulation modelling offers a unique tool for synthesising and leveraging existing evidence, data and expert local knowledge to examine, in a robust, low risk and low cost way, the likely impact of alternative policy and service provision scenarios. This case study will evaluate participatory simulation modelling to inform the prevention and management of gestational diabetes mellitus (GDM). The risks associated with GDM are well recognised; however, debate remains regarding diagnostic thresholds and whether screening and treatment to reduce maternal glucose levels reduce the associated risks. A diagnosis of GDM may provide a leverage point for multidisciplinary lifestyle modification interventions. This research will apply and evaluate a simulation modelling approach to understand the complex interrelation of factors that drive GDM rates, test options for screening and interventions, and optimise the use of evidence to inform policy and program decision-making.Methods/DesignThe study design will use mixed methods to achieve the objectives. Policy, clinical practice and research experts will work collaboratively to develop, test and validate a simulation model of GDM in the Australian Capital Territory (ACT). The model will be applied to support evidence-informed policy dialogues with diverse stakeholders for the management of GDM in the ACT. Qualitative methods will be used to evaluate simulation modelling as an evidence synthesis tool to support evidence-based decision-making. Interviews and analysis of workshop recordings will focus on the participants’ engagement in the modelling process; perceived value of the participatory process, perceived commitment, influence and confidence of stakeholders in implementing policy and program decisions identified in the modelling process; and the impact of the process in terms of policy and program change.DiscussionThe study will generate empirical evidence on the feasibility and potential value of simulation modelling to support knowledge mobilisation and consensus building in health settings.

Who pays and who benefits? How different models of shared responsibilities between formal and informal carers influence projections of costs of dementia management

BackgroundThe few studies that have attempted to estimate the future cost of caring for people with dementia in Australia are typically based on total prevalence and the cost per patient over the average duration of illness. However, costs associated with dementia care also vary according to the length of the disease, severity of symptoms and type of care provided. This study aimed to determine more accurately the future costs of dementia management by taking these factors into consideration.MethodsThe current study estimated the prevalence of dementia in Australia (2010-2040). Data from a variety of sources was recalculated to distribute this prevalence according to the location (home/institution), care requirements (informal/formal), and dementia severity. The cost of care was attributed to redistributed prevalences and used in prediction of future costs of dementia.ResultsOur computer modeling indicates that the ratio between the prevalence of people with mild/moderate/severe dementia will change over the three decades from 2010 to 2040 from 50/30/20 to 44/32/24.Taking into account the severity of symptoms, location of care and cost of care per hour, the current study estimates that the informal cost of care in 2010 is AU

In silico modeling systems: Learning about the prevalence and dynamics of dementia through virtual experimentation

3.2 billion and formal care at AU