Kirsty Douglas

Health behaviours and potentially preventable hospitalisation: a prospective study of older Australian adults

Objective Several studies have demonstrated the effects of health behaviours on risk of chronic diseases and mortality, but none have investigated their contribution to potentially preventable hospitalisation (PPH). We aimed to quantify the effects on risk of PPH of six health behaviours: smoking; alcohol consumption; physical activity; fruit and vegetables consumption; sitting time; and sleeping time. Design/Setting Prospective observational study in New South Wales, Australia. Subjects 267,006 men and women aged 45 years and over. Outcome Measures PPH admissions and mortality during follow-up according to individual positive health behaviours (non-smoking, <14 alcoholic drinks per week, ≥2.5 hours of physical activity per week, ≥2 servings of fruit and 5 servings of vegetables per day, <8 hours sitting and ≥7 hours sleeping per day) and the total number of these behaviours. Results During an average of 3 years follow-up, 20971 (8%) participants had at least one PPH admission. After adjusting for potential confounders, participants who reported all six positive health behaviours at baseline had 46% lower risk of PPH admission (95% CI 0.48–0.61), compared to those who reported having only one of these behaviours. Based on these risk estimates, approximately 29% of PPH admissions in Australians aged 45 years and over were attributable to not adhering to the six health behaviours. Estimates were similar for acute, chronic and vaccine-preventable categories of PPH admissions. Conclusions Individual and combined positive health behaviours were associated with lower risk of PPH admission. These findings suggest that there is a significant opportunity to reduce PPH by promoting healthy behaviours.

Smoking and potentially preventable hospitalisation: The benefit of smoking cessation in older ages

AIMS Reducing preventable hospitalisation is a priority for health systems worldwide. This study sought to quantify the contribution of smoking to preventable hospitalisation in older adults and the potential benefits of smoking cessation. METHODS Self-reported smoking data for 267,010 Australian men and women aged 45+ years linked with administrative hospital data were analysed using Coxs models to estimate the effects on risk of hospitalisation for congestive heart failure (CHF), diabetes complications, chronic obstructive pulmonary disease (COPD) and angina. The impacts of smoking and quitting smoking were also quantified using risk advancement periods (RAP). RESULTS The cohort included 7% current smokers, 36% former smokers and 57% never smokers. During an average follow-up of 2.7 years, 4% of participants had at least one hospitalisation for any of the study conditions (0.8% for CHF, 1.7% for diabetes complications, 0.8% for COPD and 1.4% for angina). Compared to never smokers, the adjusted hazard ratio for hospitalisation for any of the conditions for current smokers was 1.89 (95% CI 1.75-2.03), and the RAP was 3.8 years. There were strong dose-response relationships between smoking duration, smoking intensity and cumulative smoking dose on hospitalisation risk. The excess risk of hospitalisation and RAP for COPD was reduced within 5 years of smoking cessation across all age groups, but risk reduction for other conditions was only observed after 15 years. CONCLUSION Smoking is associated with increased risk of preventable hospitalisation for chronic conditions in older adults and smoking cessation, even at older ages, reduces this risk.

Undiagnosed diabetes from cross-sectional GP practice data: an approach to identify communities with high likelihood of undiagnosed diabetes

Objectives To estimate undiagnosed diabetes prevalence from general practitioner (GP) practice data and identify areas with high levels of undiagnosed and diagnosed diabetes. Design Data from the North-West Adelaide Health Survey (NWAHS) were used to develop a model which predicts total diabetes at a small area. This model was then applied to cross-sectional data from general practices to predict the total level of expected diabetes. The difference between total expected and already diagnosed diabetes was defined as undiagnosed diabetes prevalence and was estimated for each small area. The patterns of diagnosed and undiagnosed diabetes were mapped to highlight the areas of high prevalence. Setting North-West Adelaide, Australia. Participants This study used two population samples—one from the de-identified GP practice data (n=9327 active patients, aged 18 years and over) and another from NWAHS (n=4056, aged 18 years and over). Main outcome measures Total diabetes prevalence, diagnosed and undiagnosed diabetes prevalence at GP practice and Statistical Area Level 1. Results Overall, it was estimated that there was one case of undiagnosed diabetes for every 3–4 diagnosed cases among the 9327 active patients analysed. The highest prevalence of diagnosed diabetes was seen in areas of lower socioeconomic status. However, the prevalence of undiagnosed diabetes was substantially higher in the least disadvantaged areas. Conclusions The method can be used to estimate population prevalence of diabetes from general practices wherever these data are available. This approach both flags the possibility that undiagnosed diabetes may be a problem of less disadvantaged social groups, and provides a tool to identify areas with high levels of unmet need for diabetes care which would enable policy makers to apply geographic targeting of effective interventions.

Untreated hypertension: Prevalence and patient factors and beliefs associated with under-treatment in a population sample

Identifying barriers to hypertension management may facilitate cardiovascular risk reduction. Therefore, our objective, was to determine the prevalence of hypertension not managed with medication (‘untreated’) in a representative adult sample and identify patient factors/beliefs, and aspects of the patient–general practitioner (GP) relationship associated with untreated hypertension. The North West Adelaide Health Study, a biomedical cohort study over three stages from 2000–2009, assesses hypertension (systolic⩾140 mm Hg and/or⩾90 mm Hg or current treatment with anti-hypertensive medication), chronic disease and associated risk factors and health-care experiences, including risk perception, decision-making preferences, GP/primary care provider affiliation and satisfaction with care (n=2425). The prevalence of hypertension was 32.1% (n=781) comprised of treated (19.0%, n=462) and untreated (13.1%, n=319) hypertension. Thus, 40.8% of hypertension was untreated. Among hypertensive subjects, non-treatment was significantly associated with male sex, age <45 years, workforce participation, infrequent GP visits, dissatisfaction with recent medical care, high total cholesterol, moderate-level physical activity and lower body weights. Compared with participants without hypertension (and no treatment), untreated subjects demonstrated significant (15%) 10-year Framingham general cardiovascular risk (odds ratio=6.44, 95% confidence interval=4.52–9.17). Novel screening strategies and public health messages to address beliefs and perceptions of both patients and the health system are required to identify untreated, at-risk hypertensive individuals.

Feasibility and acceptability of a physician-delivered weight management programme

Background. Primary health care requires new approaches to assist patients with overweight and obesity. This is a particular concern for patients with limited access to specialist or allied health services due to financial cost or location. The Change Program is a toolkit that provides a structured approach for GPs working with patients on weight management. Objective. To assess the acceptability and feasibility of a GP-delivered weight management programme. Methods. A feasibility trial in five Australian general practices with 12 GPs and 23 patients. Mixed methods were used to assess the objective through participant interviews, online surveys and the NOrmalization MeAsure Development (NoMAD) tool based on Normalization Process Theory. Content analysis of interviews is presented alongside Likert scales, free text and the NoMAD tool. Results. The Change Program was acceptable to most GPs and patients. It was best suited to patient–GP dyads where the patient felt a strong preference for GP involvement. Patients’ main concerns were the time and possible cost associated with the programme if run outside a research setting. For sustainable implementation, it would have been preferable to recruit a whole practice rather than single GPs to enable activation of systems to support the programme. Conclusion. A GP-delivered weight management programme is feasible and acceptable for patients with obesity in Australian primary health care. The addition of this structured toolkit to support GPs is particularly important for patients with a strong preference for GP involvement or who are unable to access other resources due to cost or location.

Obesity and asthma at school entry: Co-morbidities and temporal trends

A decline in asthma prevalence from 2000 to 2005 was reported previously. The objective is to examine the temporal trends for the prevalence of obesity and other childhood disorders and consider the extent to which associations between asthma and other co‐morbidities can be accounted for by body mass index.

A collaborative process for developing a weight management toolkit for general practitioners in Australia—an intervention development study using the Knowledge To Action framework

BackgroundObesity is commonly seen in the Australian general practice population; however, few resources are specifically targeted at GPs working with these patients. The National Health and Medical Research Council (Australia) guideline for managing patients who are overweight and obese supports the involvement of a regular health professional. As 85 % of the population visit a GP annually, resources to support GPs working with this patient population are needed.This study describes the collaborative process used to develop an obesity management programme based on current Australian guidelines for GPs and their patients to be used in primary care. The Knowledge To Action framework was applied to develop a weight management toolkit for GPs based on current Australian guidelines. This draft was then reviewed by clinical GPs, GP registrars, consumer representatives and allied health professionals using focus groups and interviews. The participants gave feedback on the content, layout and acceptability of the documents. The feedback from the stakeholder groups was evaluated, and changes were incorporated into the final documents. A graphic designer was contracted to assist with the layout to improve useability and attractiveness of the documents. ResultsA total of 38 participants gave feedback on the draft weight management programme, and the research team amalgamated their responses to further improve the documents. The general response from GPs and consumer representatives was positive with most conveying their wish to try the programme themselves.Conclusions“The Change Program” is a practical tool for Australian GPs to use with their patients who are overweight or obese. It was developed in collaboration with GPs, allied health professionals and consumer stakeholders based on current Australian guidelines. It is currently being piloted in five general practices.

Obesity management in Australian primary care: where has the general practitioner gone?

Obesity is a chronic condition with significant health and economic consequences that requires more effective management in Australia. General practitioners (GPs) currently act as care co-ordinators in line with national guidelines for overweight and obesity. Australian patients indicate that they would appreciate more involvement from their GP in the management of obesity, and this is in line with international findings. Not all patients have access to specialist obesity services or affordable allied health care because of location, cost and time, particularly in rural and remote areas where there is a greater prevalence of obesity. Empowering GPs to use their skills as expert generalists to manage obesity is an option that should be explored to improve access for all individuals. GPs will require evidence-based tools to assist them in structuring obesity management within their own general practice environment.

Increasing Pap smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement

This article describes translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to Pap smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS). Rapid Plan-Do-Study-Act (PDSA) cycles were conducted, informed by client surveys, a data collection tool, focus groups and internal research. There was a statistically significant increase in Pap smear numbers during PDSA cycles, continuing at 10 months follow up. The use of TR with CQI appears to be an effective and acceptable way to affect Pap smear screening. Community and service collaboration should be at the core of research in Aboriginal and Torres Strait Islander health settings. This model is transferrable to other settings and other health issues.

People-centred integration in a refugee primary care service: A complex adaptive systems perspective

Purpose Services for refugees and asylum seekers frequently experience gaps in delivery and access, poor coordination, and service stress. The purpose of this paper is to examine the approach to integrated care within Companion House (CH), a refugee primary care service, whose service mix includes counselling, medical care, community development, and advocacy. Like all Australian refugee and asylum seeker support services, CH operates within an uncertain policy environment, constantly adapting to funding challenges, and changing needs of patient populations. Design/methodology/approach Interviews with staff, social network analysis, group patient interviews, and service mapping. Findings CH has created fluid links between teams, and encouraged open dialogue with client populations. There is a high level of networking between staff, much of it informal. This is underpinned by horizontal management and staff commitment to a shared mission and an ethos of mutual respect. The clinical teams are collectively oriented towards patients but not necessarily towards each other. Research limitations/implications Part of the service’s resilience and ongoing service orientation is due to the fostering of an emergent self-organising form of integration through a complex adaptive systems approach. The outcome of this integration is characterised through the metaphors of “home” for patients, and “family” for staff. CH’s model of integration has relevance for other services for marginalised populations with complex service needs. Originality/value This study provides new evidence on the importance of both formal and informal communication, and that limited formal integration between clinical teams is no bar to integration as an outcome for patients.