Jon Willis

The Effects of Clinical Pathways on Professional Practice, Patient Outcomes, Length of Stay, and Hospital Costs: Cochrane Systematic Review and Meta-Analysis

This paper is a summary version of the previously published Cochrane review. It may increase the reach of the topic to health researchers and practitioners and encourage further discussion. The systematic review aims to summarize the evidence and assess the effect of clinical pathways on professional practice, patient outcomes, length of hospital stay, and hospital costs. The authors searched the Database of Abstracts of Reviews of Effectiveness, the Effective Practice and Organisation of Care Register, the Cochrane Central Register of Controlled Trials and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED, and Global Health. Twenty-seven studies considering a total of 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications (odds ratio 0.58: 95% CI [0.36, 0.94] and improved documentation (odds ratio 11.95: 95% CI [4.72, 30.30]) associated with clinical pathways. Considerable variation in study design and settings prevented statistical pooling of results for length of stay (LOS) and hospital costs. The authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation.

What do gay men know about human papillomavirus? Australian gay men's knowledge and experience of anal cancer screening and human papillomavirus

Objective: The objective of this study was to determine levels of experience and knowledge concerning anal dysplasia, anal Pap smear tests, and human papillomavirus (HPV) among gay and other homosexually active men. Study Design: Three hundred eighty-four men attending a large gay community event in Melbourne completed a short survey. Results: Ninety-two percent identified as gay and 4.8% as bisexual. A total of 6.4% were HIV-positive and a further 3.5% did not know their HIV status. On a range of measures, it was clear that the men knew very little about anal cancer (19% scored zero on a 12-point knowledge scale) and virtually nothing about HPV (47% scored zero on an 8-point knowledge scale). A total of 55.1% had never heard of an anal Pap smear and 44.8% had ever heard of HPV; 56.4% did not know whether it affected men and/or women. Conclusions: The test for anal dysplasia is still largely unknown among Australian gay men and they currently have poor sense of personal susceptibility to the disease. Health education strategies are suggested to improve this situation.

Rural Australian community pharmacists' views on complementary and alternative medicine: a pilot study

BackgroundComplementary and alternative medicines (CAMs) are being used increasingly across the world. In Australia, community pharmacists are a major supplier of these products but knowledge of the products and interactions with other medicines is poor. Information regarding the use of CAMs by metropolitan pharmacists has been documented by the National Prescribing Service (NPS) in Australia but the views of rural/regional community pharmacists have not been explored. The aim of this pilot study was to explore the knowledge, attitudes and information seeking of a cohort of rural community pharmacists towards CAMs and to compare the findings to the larger NPS study.MethodsA cross sectional self-administered postal questionnaire was mailed to all community pharmacists in one rural/regional area of Australia. Using a range of scales, data was collected regarding attitudes, knowledge, information seeking behaviour and demographics.ResultsEighty eligible questionnaires were returned. Most pharmacists reported knowing that they should regularly ask consumers if they are using CAMs but many lacked the confidence to do so. Pharmacists surveyed for this study were more knowledgeable in regards to side effects and interactions of CAMs than those in the NPS survey. Over three quarters of pharmacists surveyed reported sourcing CAM information at least several times a month. The most frequently sought information was drug interactions, dose, contraindications and adverse effects. A variety of resources were used to source information, the most popular source was the internet but the most useful resource was CAM text books.ConclusionsPharmacists have varied opinions on the use of CAMs and many lack awareness of or access to good quality CAMs information. Therefore, there is a need to provide pharmacists with opportunities for further education. The data is valuable in assisting interested stakeholders with the development of initiatives to address the gaps in attitudes, knowledge and to improve effectiveness of information seeking behaviour.

What really improves employee health and wellbeing

Purpose – Factors for successful workplace health promotion (WHP) are well described in the literature, but often sourced from evaluations of wellness programmes. Less well understood are the features of an organisation that contribute to employee health which are not part of a health promotion programme. The purpose of this paper is to inform policy on best practice principles and provide real life examples of health promotion in regional Victorian workplaces. Design/methodology/approach – Individual case studies were conducted on three organisations, each with a health and wellbeing programme in place. In total, 42 employers and employees participated in a face to face interview. Interviews were transcribed verbatim and the qualitative data were thematically coded. Findings – Employers and senior management had a greater focus on occupational health and safety than employees, who felt that mental/emotional health and happiness were the areas most benefited by a health promoting workplace. An organisatio...

A systematic review of psychotropic drug prescribing for prisoners

Objective: To conduct a review of the literature on prescribing psychotropic drugs for prisoners. Methods: Articles were retrieved from nine databases, reference lists, citations, governmental prison websites, and contact with authors. The articles included were written in English, focused on adults’ time as prisoners, included at least one drug of interest, and discussed prescribing. Thirty-two articles met these inclusion criteria. Results: Five main themes were identified from the reviewed studies: polypharmacy, high-dose therapy, duration of treatment, documentation and monitoring, and issues associated with the prisoners’ environment. Conclusions: Consideration of these themes within the included studies identified areas for future research, particularly models of good practice, as numerous descriptions of poor practice exist. Policy-makers and prescribers should review current systems and practices, to ensure the care being offered to prisoners is optimal.

Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?

OBJECTIVE  The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infarction (AMI) clinical pathway (CPW) on thrombolytic administration in rural emergency departments. DESIGN  Cluster randomised controlled trial. SETTING   Six rural Victorian emergency departments participated. INTERVENTION   The five-step CPW implementation process comprised (i) engaging clinicians; (ii) CPW development; (iii) reminders; (iv) education; and (v) audit and feedback. MAIN OUTCOME MEASURES The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic and time to thrombolysis and electrocardiogram. RESULTS Nine hundred and fifteen medical records were audited, producing a final sample of 108 patients eligible for thrombolysis. There was no significant difference between intervention and control groups for median door-to-needle time (29 mins versus 29 mins; P = 0.632), proportion of those eligible receiving a thrombolytic (78% versus 84%; P = 0.739), median time to electrocardiogram (7 mins versus 6 mins; P = 0.669) and other outcome measures. Results showed superior outcome measures than other published studies. CONCLUSIONS The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample. Results suggest that quality of AMI treatment in rural emergency departments (EDs) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas.

Dying in country: Implications of culture in the delivery of palliative care in indigenous Australian communities

Abstract In recent years, palliative care and hospice service providers have been criticised for their contribution to the increasing medical rationalisation of death and dying. At the same time, efforts to make palliative care more culturally appropriate for different ethnic minorities are also being criticised for their reification of cultural practices. In this paper, I examine three aspects of the process of dying for Pitjantjatjara Aboriginal people of Central Australia—their preference for dying in their home ‘country’, their preference for provision of palliative care through matrilineal kin structures, and the difficulties of providing complex treatments in the remote settings in which they live. I show that the cultural and historical specificity of the Pitjantjatjara way of dying exemplifies the way in which dying is a culturally mediated part of a specific way of living, the elements of which relate structurally to other aspects of the way of living. Because the underlying assumptions of pallia...

Systematic review of progesterone use by midlife and menopausal women

Progesterone treatment for menopausal symptoms is still controversial. Progesterone levels fall during menopause transition, therefore some menopausal women may benefit from progesterone therapy. A systematic review was conducted of studies published from 2001 reporting on progesterone use to treat symptoms associated with menopause or postmenopausal women. Fourteen data bases were searched using the search terms progesterone, menopause, aged, female and human; exclusions were breast cancer, animal and contraception. Thirteen studies were selected for inclusion (11 clinical trials, 1 cohort study and 1 qualitative study), evaluating progesterone effects on menopausal symptoms, bone, sleep, skin, cognition, plasma lipids and plaque progression. Most studies were of low methodological quality (GRADE low or very low). Progesterone improved vasomotor symptoms and sleep quality, with minimal risk. Large studies designed to identify confounders, such as hormone levels, menopausal status and metabolism are required to understand the place of progesterone in clinical practice.

A cluster randomised trial to assess the impact of clinical pathways on AMI management in rural Australian emergency departments

BackgroundPeople living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities. While several factors, including time taken to access hospital care, contribute to this risk, it is also partially attributable to the lower uptake of evidence-based guidelines for the administration of thrombolytic drugs in rural emergency departments where up to one-third of eligible patients do not receive this life-saving intervention. Clinical pathways have the potential to link evidence to practice by integrating guidelines into local systems, but their impact has been hampered by variable implementation strategies and sub-optimal research designs. The purpose of this study is to determine the impact of a five-step clinical pathways implementation process on the timely and efficient administration of thrombolytic drugs for acute myocardial infarctions managed in rural Australian emergency departments.Methods/DesignThe design is a two-arm, cluster-randomised trial with rural hospital emergency departments that treat and do not routinely transfer acute myocardial infarction patients. Six rural hospitals in the state of Victoria will participate, with three in the intervention group and three in the control group. Intervention hospitals will participate in a five-step clinical pathway implementation process: engagement of clinicians, pathway development according to local resources and systems, reminders, education, and audit and feedback. Hospitals in the control group will each receive a hard copy of Australian national guidelines for chest pain and acute myocardial infarction management. Each group will include 90 cases to give a power of 80% at 5% significance level for the two primary outcome measures: proportion of those eligible for thrombolysis receiving the drug and time to delivery of thrombolytic drug.DiscussionImproved compliance with thrombolytic guidelines via clinical pathways will increase acute myocardial infarction survival rates in rural hospitals and thereby help to reduce rural-urban mortality inequalities. Such knowledge translation has the potential to be adapted for a range of clinical problems in a wide array of settings.Trial registrationAustralia New Zealand Clinical Trials Registry code ACTRN12608000209392.

Application of cognitive interviewing to improve self-administered questionnaires used in small scale social pharmacy research

Validating questionnaires for social pharmacy research with smaller sample sizes can be unnecessarily time-consuming and costly, a solution to this is cognitive interviewing with 2 interviews per iteration. This paper shows how cognitive interviewing with pairs of interviews per iteration of the questionnaire can be used to identify overt and covert issues with comprehension, retrieval, judgment and response experienced by respondents when attempting to answer a question or navigate around the questionnaire. When used during questionnaire development in small scale social pharmacy research studies cognitive interviewing can reduce both respondent burden and response error and should result in more reliable survey results. The process of cognitive interviewing is illustrated by a case study from the development of the Perspectives on Progesterone questionnaire.