Mikaela Jorgensen

Narrative after traumatic brain injury: a comparison of monologic and jointly-produced discourse.

Primary objective: To investigate the effects of a familiar communication partner on the production of narrative after traumatic brain injury (TBI). Method: Ten participants with TBI were matched with 10 control participants for sex, age, and education. Participants independently retold a story from a picture sequence and also retold a video segment with a friend to a researcher. The resulting discourse was analyzed for productivity, cohesion, story grammar, informational content and exchange structure. Results: There was a significant difference between participants with and without TBI for all measures in the monologic narrative. In the jointly-produced narrative, there was no significant difference in performance and participation between individuals with TBI and control participants. Participants with TBI demonstrated a significant improvement between the monologic and the jointly-produced task in story grammar and informational content. Conclusions: The natural scaffolding provided by the friends of participants with TBI in a meaningful narrative task facilitated competent participation in and production of narrative. These findings indicate an avenue for training everyday communication partners in supporting narrative skills after TBI, and for the use of jointly-produced narrative as an additional assessment tool to create a holistic view of everyday skills.

Predictors of variation in colorectal cancer care and outcomes in New South Wales: a population-based health data linkage study.

Objective: To identify predictors of variation in colorectal cancer care and outcomes in New South Wales.

Adjuvant chemotherapy for colorectal cancer: Age differences in factors influencing patients' treatment decisions

Purpose Older colorectal cancer patients are significantly less likely than younger patients to receive guideline-recommended adjuvant chemotherapy. Previous research has indicated that patient refusal of treatment is a contributing factor. This study aimed to identify potential barriers to adjuvant chemotherapy use in older patients by examining the associations between patient age, factors influencing chemotherapy treatment decisions, and preferences for information and decision-making involvement. Patients and methods Sixty-eight patients who underwent surgery for colorectal cancer in Sydney, Australia, within the previous 24 months completed a self-administered survey. Results Fear of dying, health status, age, quality of life, and understanding treatment procedures and effects were significantly more important to older patients (aged ≥65 years) than younger patients in deciding whether to accept chemotherapy (all P < 0.05). Reducing the risk of cancer returning and physician trust were important factors for all patients. Practical barriers such as traveling for treatment and cost were rated lowest. Older patients preferred less information and involvement in treatment decision making than younger patients. However, 60% of the older group wanted detailed information about chemotherapy, and 83% wanted some involvement in decision making. Those preferring less information and involvement still rated many factors as important in their decision making, including understanding treatment procedures and effects. Conclusion A range of factors appears to influence patients’ chemotherapy decision making, including, but not limited to, survival benefits and treatment toxicity. For older patients, balancing the risks and benefits of treatment may be made more complex by the impact of emotional motivators, greater health concerns, and conflicts between their need for understanding and their information and decision-making preferences. Through greater understanding of perceived barriers to treatment and unique motivators for treatment choice, physicians may be better able to support older patients to make informed decisions about their care.

Optimal delivery of colorectal cancer follow-up care: improving patient outcomes

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. With population aging and increases in survival, the number of CRC survivors is projected to rise dramatically. The time following initial treatment is often described as a period of transition from intensive hospital-based care back into “regular life.” This review provides an overview of recommended follow-up care for people with CRC who have been treated with curative intent, as well as exploring the current state of the research that underpins these guidelines. For patients, key concerns following treatment include the development of recurrent and new cancers, late and long-term effects of cancer and treatment, and the interplay of these factors with daily function and general health. For physicians, survivorship care plans can be a tool for coordinating the surveillance, intervention, and prevention of these key patient concerns. Though much of the research in cancer survivorship to date has focused on surveillance for recurrent disease, many national guidelines differ in their conclusions about the frequency and timing of follow-up tests. Most CRC guidelines refer only briefly to the management of side effects, despite reports that many patients have a range of ongoing physiological, psychosocial, and functional needs. Guidance for surveillance and intervention is often limited by a small number of heterogeneous trials conducted in this patient group. However, recently released survivorship guidelines emphasize the potential for the effectiveness of secondary prevention strategies, such as physical activity, to improve patient outcomes. There is also emerging evidence for the role of primary care providers and nurse coordinated care to support the transition and increase the cost-effectiveness of follow-up. The shift in focus from recurrence alone to the assessment and management of a range of survivorship issues will be important for ensuring that this growing group of patients achieves optimal outcomes.

Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery

Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators.

A mortality risk prediction model for older adults with lymph node‐positive colon cancer

Clinicians are less likely to recommend adjuvant chemotherapy for older adults based on their age alone. This study aimed to develop a mortality risk model to assist treatment decision making by identifying patients who are unlikely to live to benefit from chemotherapy. All lymph node-positive colon cancer patients ≥65 years who received surgery in New South Wales, Australia in 2007/2008 were identified using a linked population-based dataset (n = 1550). A model predicting 1-year all-cause mortality was built using multilevel logistic regression. Risk scores derived from model factors were summed for each patient. One-year mortality was 11.5%. The risk model consisted of 14 factors, including comorbidities, hospital admission factors and other markers of frailty or health status. People with a total score of 0, 1 or 2 were considered at low risk (predicted 1-year mortality of 2.9%), those scoring 3 to 8 at medium risk (7.4% mortality) and those scoring 9 or above at high risk (24.7% mortality). The model had good discrimination (area under the receiver operating characteristic curve = 0.788, 95% confidence interval: 0.752-0.825) and calibration (P = 0.46). The risk model accurately predicts mortality for this cohort and could be useful in shifting the emphasis in chemotherapy decision making from chronological age to the identification of those of any age who will benefit.

A matter of opinion: age differences in colorectal cancer patients' and physicians' views on chemotherapy treatment decisions

Abstract of a poster presentation presented at the Joint Meeting of the COSA 39th Annual Scientific Meeting and IPOS 14th World Congress of Psycho-Oncology, 13-15 November 2012, Brisbane Convention and Exhibition Centre.

Longitudinal variation in pressure injury incidence among long-term aged care facilities

Objective To examine variation in pressure injury (PI) incidence among long-term aged care facilities and identify resident- and facility-level factors that explain this variation. Design Longitudinal incidence study using routinely-collected electronic care management data. Setting A large aged care service provider in New South Wales and the Australian Capital Territory, Australia. Participants About 6556 people aged 65 years and older who were permanent residents in 60 long-term care facilities between December 2014 and November 2016. Main Outcome Measure Risk-adjusted PI incidence rates over eight study quarters. Results Incidence density over the study period was 1.33 pressure injuries per 1000 resident days (95% confidence interval (CI) = 1.29-1.37). Funnel plots were used to identify variation among facilities. On average, 14% of facilities had risk-adjusted PI rates that were higher than expected in each quarter (above 95% funnel plot control limits). Ten percent of facilities had persistently high rates in any three or more consecutive quarters (n = 6). The variation between facilities was only partly explained by resident characteristics in multilevel regression models. Residents were more likely to have higher-pressure injury rates in facilities in regional areas compared with major city areas (adjusted incidence rate ratio = 1.25, 95% CI = 1.04-1.51), and facilities with persistently high rates were more likely to be located in areas with low socioeconomic status (P = 0.038). Conclusions There is considerable variation among facilities in PI incidence. This study demonstrates the potential of routinely-collected care management data to monitor PI incidence and to identify facilities that may benefit from targeted intervention.

Leveraging new information technology to monitor medicine use in 71 residential aged care facilities: variation in polypharmacy and antipsychotic use

Objective The aim of this study was to use routinely collected electronic medicines administration (eMAR) data in residential aged care (RAC) to investigate the quality use of medicines. Design A cross-sectional analysis of eMAR data. Setting 71 RAC facilities in New South Wales and the Australian Capital Territory, Australia. Participants Permanent residents living in a participating facility on 1 October 2015. Intervention None. Main Outcome Measures Variation in polypharmacy (≥5 medications), hyper-polypharmacy (≥10 medications) and antipsychotic use across facilities was examined using funnel plot analysis. Results The study dataset included 4775 long-term residents. The mean resident age was 85.3 years and 70.6% of residents were female. The median facility size was 60 residents and 74.3% were in metropolitan locations. 84.3% of residents had polypharmacy, 41.2% hyper-polypharmacy and 21.0% were using an antipsychotic. The extent of polypharmacy (69.75-100% of residents), hyper-polypharmacy (38.81-76.19%) and use of antipsychotic medicines (0-75.6%) varied considerably across the 71 facilities. Conclusions Using eMAR data we found substantial variation in polypharmacy, hyper-polypharmacy and antipsychotic medicine use across 71 RAC facilities. Further investigation into the policies and practices of facilities performing above or below expected levels is warranted to understand variation and drive quality improvement.

Integrating social engagement instruments into Australian community aged care assessments to enhance service provision

Rich social relationships contribute to improved well-being and health outcomes, yet aged care client assessments tend to focus almost exclusively on physical issues. We aim to explore the experiences of aged care staff following their use of social engagement and well-being instruments as part of routine assessments for home-care clients. The social engagement (Australian Community Participation Questionnaire, ACPQ) and well-being (ICEpop CAPability Measure for Older Adults, ICECAP-O) instruments were embedded into the centralised information system of an Australian aged care provider. Staff administered these instruments during routine client assessments across a 9-month period involving 289 assessments. Semistructured interviews with 12 staff members were conducted and themes explored using qualitative content analysis. Key factors related to the acceptability of instrument adoption were found. Staff reported the instruments were convenient to use and were valuable in eliciting information for care plan development. Staff found that the instruments complemented their standard assessment procedures and did not disrupt their routine workload. They emphasised that the information gained greatly assisted their discussions with clients, identified social needs, and enhanced client involvement in decisions about desired services. There were also some challenging elements, including staff concerns regarding their ability to deal with emotional responses from clients evoked by the survey questions. ACPQ and ICECAP-O are useful tools for identifying psychosocial client needs, are feasible for use by large-scale aged care organisations and provide valuable information to guide decision-making about services. Future research should identify the long-term effects on improving social participation and client outcomes.