Nicholas Graves

Effect of Lifestyle-Focused Text Messaging on Risk Factor Modification in Patients With Coronary Heart Disease: A Randomized Clinical Trial

IMPORTANCE Cardiovascular disease prevention, including lifestyle modification, is important but underutilized. Mobile health strategies could address this gap but lack evidence of therapeutic benefit. OBJECTIVE To examine the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text message on cardiovascular risk factors. DESIGN AND SETTING The Tobacco, Exercise and Diet Messages (TEXT ME) trial was a parallel-group, single-blind, randomized clinical trial that recruited 710 patients (mean age, 58 [SD, 9.2] years; 82% men; 53% current smokers) with proven coronary heart disease (prior myocardial infarction or proven angiographically) between September 2011 and November 2013 from a large tertiary hospital in Sydney, Australia. INTERVENTIONS Patients in the intervention group (n = 352) received 4 text messages per week for 6 months in addition to usual care. Text messages provided advice, motivational reminders, and support to change lifestyle behaviors. Patients in the control group (n=358) received usual care. Messages for each participant were selected from a bank of messages according to baseline characteristics (eg, smoking) and delivered via an automated computerized message management system. The program was not interactive. MAIN OUTCOMES AND MEASURES The primary end point was low-density lipoprotein cholesterol (LDL-C) level at 6 months. Secondary end points included systolic blood pressure, body mass index (BMI), physical activity, and smoking status. RESULTS At 6 months, levels of LDL-C were significantly lower in intervention participants, with concurrent reductions in systolic blood pressure and BMI, significant increases in physical activity, and a significant reduction in smoking. The majority reported the text messages to be useful (91%), easy to understand (97%), and appropriate in frequency (86%). [table: see text]. CONCLUSIONS AND RELEVANCE Among patients with coronary heart disease, the use of a lifestyle-focused text messaging service compared with usual care resulted in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors. The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000161921.

Effect of pressure ulcers on length of hospital stay.

OBJECTIVE To identify the independent effect of pressure ulcers on excess length of stay and control for all observable factors that may also contribute to excess length of stay. Hospitalized patients who develop a pressure ulcer during their hospital stay are at a greater risk for increased length of stay as compared with patients who do not. DESIGN Cross-sectional, observational study. SETTING Tertiary-care referral and teaching hospital in Australia. PATIENTS Two thousand hospitalized patients 18 years and older who had a minimum stay in the hospital of 1 night and admission to selected clinical units. METHODS Two thousand participants were randomly selected from 4,500 patients enrolled in a prospective survey conducted between October 2002 and January 2003. Quantile median robust regression was used to assess risk factors for excess length of hospital stay. RESULTS Having a pressure ulcer resulted in a median excess length of stay of 4.31 days. Twenty other variables were statistically significant at the 5% level in the final model. CONCLUSIONS Pressure ulcers make a significant independent contribution to excess length of hospitalization beyond what might be expected based on admission diagnosis. However, our estimates were substantially lower than those currently used to make predictions of the economic costs of pressure ulcers; existing estimates may overstate the true economic cost.

Overcrowding and understaffing in modern health-care systems: Key determinants in meticillin-resistant Staphylococcus aureus transmission

Recent decades have seen the global emergence of meticillin-resistant Staphylococcus aureus (MRSA), causing substantial health and economic burdens on patients and health-care systems. This epidemic has occurred at the same time that policies promoting higher patient throughput in hospitals have led to many services operating at, or near, full capacity. A result has been limited ability to scale services according to fluctuations in patient admissions and available staff, and hospital overcrowding and understaffing. Overcrowding and understaffing lead to failure of MRSA control programmes via decreased health-care worker hand-hygiene compliance, increased movement of patients and staff between hospital wards, decreased levels of cohorting, and overburdening of screening and isolation facilities. In turn, a high MRSA incidence leads to increased inpatient length of stay and bed blocking, exacerbating overcrowding and leading to a vicious cycle characterised by further infection control failure. Future decision making should use epidemiological and economic evidence to evaluate the effect of systems changes on the incidence of MRSA infection and other adverse events.

Effect of healthcare‐acquired infection on length of hospital stay and cost

OBJECTIVE To estimate the independent effect of a single lower respiratory tract infection, urinary tract infection, or other healthcare-acquired infection on length-of-stay and variable costs and to demonstrate the bias from omitted variables that is present in previous estimates. DESIGN Prospective cohort study.Setting. A tertiary care referral hospital and regional district hospital in southeast Queensland, Australia. PATIENTS Adults aged 18 years or older with a minimum inpatient stay of 1 night who were admitted to selected clinical specialities. RESULTS Urinary tract infection was not associated with an increase in length of hospital stay or variable costs. Lower respiratory tract infection was associated with an increase of 2.58 days in the hospital and variable costs of AU

A systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units

24, whereas other types of infection were associated with an increased length of stay of 2.61 days but not with variable costs. Many other factors were found to be associated with increased length of stay and variable costs alongside healthcare-acquired infection. The exclusion of these variables caused a positive bias in the estimates of the costs of healthcare-acquired infection. CONCLUSIONS The existing literature may overstate the costs of healthcare-acquired infection because of bias, and the existing estimates of excess costs may not make intuitive sense to clinicians and policy makers. Accurate estimates of the costs of healthcare-acquired infection should be made and used in appropriately designed decision-analytic economic models (ie, cost-effectiveness models) that will make valid and believable predictions of the economic value of increased infection control.

Telephone counseling for physical activity and diet in primary care patients.

BACKGROUND Bloodstream infection related to a central venous catheter is a substantial clinical and economic problem. To develop policy for managing the risks of these infections, all available evidence for prevention strategies should be synthesized and understood. METHODS We evaluate evidence (1985-2006) for short-term antimicrobial-coated central venous catheters in lowering rates of catheter-related bloodstream infection (CRBSI) in the adult intensive care unit. Evidence was appraised for inclusion against predefined criteria. Data extraction was by 2 independent reviewers. Thirty-four studies were included in the review. Antiseptic, antibiotic, and heparin-coated catheters were compared with uncoated catheters and one another. Metaanalysis was used to generate summary relative risks for CRBSI and catheter colonization by antimicrobial coating. RESULTS Externally impregnated chlorhexidine/silver sulfadiazine catheters reduce risk of CRBSI relative to uncoated catheters (RR, 0.66; 95% CI: 0.47-0.93). Minocycline and rifampicin-coated catheters are significantly more effective relative to CHG/SSD catheters (RR, 0.12; 95% CI: 0.02-0.67). The new generation chlorhexidine/silver sulfadiazine catheters and silver, platinum, and carbon-coated catheters showed nonsignificant reductions in risk of CRBSI compared with uncoated catheters. CONCLUSION Two decades of evidence describe the effectiveness of antimicrobial catheters in preventing CRBSI and provide useful information about which catheters are most effective. Questions surrounding their routine use will require supplementation of this trial evidence with information from more diverse sources.

Malnutrition and pressure ulcer risk in adults in Australian health care facilities.

BACKGROUND The delivery of effective interventions to assist patients to improve their physical activity and dietary behaviors is a challenge in the busy primary care setting. DESIGN Cluster RCT with practices randomized to telephone counseling intervention or usual care. Data collection took place from February 2005 to November 2007, with analysis from December 2007 to April 2008. SETTING/PARTICIPANTS Four-hundred thirty-four adult patients with type 2 diabetes or hypertension (mean age=58.2 [SD=11.8]; 61% female; mean BMI=31.1 [SD=6.8]) from a disadvantaged community were recruited from ten primary care practices. INTERVENTION Twelve-month telephone counseling intervention. MAIN OUTCOME MEASURES Physical activity and dietary intake were assessed by self-report at baseline, 4, and 12 months. RESULTS At 12 months, patients in both groups increased moderate-to-vigorous physical activity by a mean of 78 minutes per week (SE=10). Significant intervention effects (telephone counseling minus usual care) were observed for: calories from total fat (decrease of 1.17%; p<0.007), energy from saturated fat (decrease of 0.97%; p<0.007), vegetable intake (increase of 0.71 servings; p<0.039), fruit intake (increase of 0.30 servings; p<0.001), and grams of fiber (increase of 2.23 g; p<0.001). CONCLUSIONS The study targeted a challenging primary care patient sample and, using a telephone-delivered intervention, demonstrated modest improvements in diet and in physical activity. Results suggest that telephone counseling is a feasible means of delivering lifestyle intervention to primary care patients with chronic conditions-patients whose need for ongoing support for lifestyle change is often beyond the capacity of primary healthcare practitioners.

Modeling the economic losses from pressure ulcers among hospitalized patients in Australia

OBJECTIVE To determine the effect of nutritional status on the presence and severity of pressure ulcer. METHODS A multicenter, cross-sectional audit of nutritional status of a convenience sample of subjects was carried out as part of a large audit of pressure ulcers in a sample of Queensland, Australia, public healthcare facilities in 2002 and 2003. Dietitians in 20 hospitals and 6 residential aged care facilities conducted single-day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment. The effect of nutritional status on the presence and severity (highest stage and number of pressure ulcers) was determined by logistic regression in a model controlling for age, gender, medical specialty, and facility location. The potential clustering effect of facility was accounted for in the model using an analysis of correlated data approach. RESULTS Subjects with malnutrition had adjusted odds ratios of 2.6 (95% confidence interval 1.8-3.5, P<0.001) of having a pressure ulcer in acute care facilities and 2.0 (95% confidence interval 1.5-2.7, P<0.001) for residential aged care facilities. There was also increased odds ratio of having a pressure ulcer, and having a more severe pressure ulcer (higher stage pressure ulcer and/or a higher number) with increased severity of malnutrition. CONCLUSION Malnutrition was associated with at least twice the odds ratio of having a pressure ulcer of in public health care facilities in Queensland. Action must be taken to identify, prevent, and treat malnutrition, especially in patients at risk of pressure ulcer.

Estimating the cost of health care-associated infections: mind your p's and q's.

The objective of this study was to predict the number of cases of pressure ulcer, the bed days lost, and the economic value of these losses at Australian public hospitals. All adults (≥ 18 years of age) with a minimum stay of 1 night and discharged from selected clinical units from all Australian public hospitals in 2001–02 were included in the study. The main outcome measures were the number of cases of pressure ulcer, bed days lost to pressure ulcer, and economic value of these losses. We predict a median of 95,695 cases of pressure ulcer with a median of 398,432 bed days lost, incurring median opportunity costs of AU

Cost-Effectiveness of a Telephone-Delivered Intervention for Physical Activity and Diet

285 M. The number of cases, and so costs, were greatest in New South Wales and lowest in Australian Capitol Territory. We conclude that pressure ulcers represent a serious clinical and economic problem for a resource‐constrained public hospital system. The most cost‐effective, risk‐reducing interventions should be pursued up to a point where the marginal benefit of prevention is equalized with marginal cost. By preventing pressure ulcers, public hospitals can improve efficiency and the quality of the patients experience and health outcome.