Paul Dugdale

Challenges for co-morbid chronic illness care and policy in Australia: a qualitative study

BackgroundIn response to the escalating burden of chronic illness in Australia, recent health policies have emphasised the promotion of patient self-management and better preventive care. A notable omission from these policies is the acknowledgment that patients with chronic illness tend to have co-morbid conditions. Our objectives were: to identify the common challenges co-morbidity poses to patients and carers in their experiences of self-management; to detail the views and perceptions of health professionals about these challenges; and to discuss policy options to improve health care for people with co-morbid chronic illness. The method included semi-structured interviews and focus groups with 129 purposively sampled participants. Participants were people with Type 2 diabetes, chronic obstructive pulmonary disease and/or chronic heart failure as well as carers and health care professionals. Content analysis of the interview data was conducted using NVivo7 software.ResultsPatients and their carers found co-morbidity influenced their capacity to manage chronic illness in three ways. First, co-morbidity created barriers to patients acting on risk factors; second, it complicated the process of recognising the early symptoms of deterioration of each condition, and third, it complicated their capacity to manage medication.ConclusionFindings highlight challenges that patients with multiple chronic conditions face in relation to preventive care and self-management. Future clinical policy initiatives need to move away from single illness orientation toward strategies that meet the needs of people with co-morbid conditions and strengthen their capacity to self-manage. These patients will benefit directly from specialised education and services that cater to the needs of people with clusters of co-morbidities.

Proactive asthma care in childhood: general practice based randomised controlled trial

Abstract Objectives To assess the feasibility and effectiveness of a general practice based, proactive system of asthma care in children. Design Randomised controlled trial with cluster sampling by general practice. Setting General practices in the northern region of the Australian Capital Territory. Participants 174 children with moderate to severe asthma who attended 24 general practitioners. Intervention System of structured asthma care (the 3+ visit plan), with participating families reminded to attend the general practitioner. Main outcome measures Process measures: rates for asthma consultations with general practitioner, written asthma plans, completion of the 3+ visit plan; clinical measures: rates for emergency department visits for asthma, days absent from school, symptom-free days, symptoms over the past year, activity limitation over the past year, and asthma drug use over the past year; spirometric lung function measures before and after cold air challenge. Results Intervention group children had significantly more asthma related consultations (odds ratio for three or more asthma related consultations 3.8 (95% confidence interval 1.9 to 7.6; P = 0.0001), written asthma plans (2.2 (1.2 to 4.1); P = 0.01), and completed 3+ visit plans (24.2 (5.7 to 103.2); P = 0.0001) than control children and a mean reduction in measurements of forced expiratory volume in one second after cold air challenge of 2.6% (1.7 to 3.5); P = 0.0001) less than control children. The number needed to treat (benefit) for one additional written asthma action plan was 5 (3 to 41) children. Intervention group children had lower emergency department attendance rates for asthma (odds ratio 0.4 (0.2 to 1.04); P = 0.06) and less speech limiting wheeze (0.2 (0.1 to 0.4); P = 0.0001) than control children and were more likely to use a spacer (2.8 (1.6 to 4.7); P = 0.0001). No differences occurred in number of days absent from school or symptom-free day scores. Conclusions Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.

A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness

BackgroundThe Wagner Model provides a framework that can help to facilitate health system transition towards a chronic care oriented model. Drawing on elements of this framework as well as health policy related to patient centred care, we describe the health needs of patients with chronic illness and compare these with services which should ideally be provided by a patient-centred health system. This paper aims to increase understanding of the challenges faced by chronically ill patients and family carers in relation to their experiences with the health care system and health service providers.MethodWe interviewed patients, carers and health care professionals (HCPs) about the challenges faced by people living with complicated diabetes, chronic heart failure or chronic obstructive pulmonary disease.ResultsPatients indicated that they had a range of concerns related to the quality of health care encounters with health care professionals (HCPs), with these concerns being expressed as needs or wants. These included: 1) the need for improved communication and information delivery on the part of HCPs; 2) well organised health services and reduced waiting times to see HCPs; 3) help with self care; 4) greater recognition among professionals of the need for holistic and continuing care; and 5) inclusion of patients and carers in the decision making processes.ConclusionsIn order to address the challenges faced by people with chronic illness, health policy must be more closely aligned with the identified needs and wants of people affected by chronic illness than is currently the case.

Time's up. descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey.

Most Western health systems remain single illness orientated despite the growing prevalence of multi-morbidity. Identifying how much time people with multiple chronic conditions spend managing their health will help policy makers and health service providers make decisions about areas of patient need for support. This article presents findings from an Australian study concerning the time spent on health related activity by older adults (aged 50 years and over), most of whom had multiple chronic conditions. A recall questionnaire was developed, piloted, and adjusted. Sampling was undertaken through three bodies; the Lung Foundation Australia (COPD sub-sample), National Diabetes Services Scheme (Diabetes sub-sample) and National Seniors Australia (Seniors sub-sample). Questionnaires were mailed out during 2011 to 10,600 older adults living in Australia. 2540 survey responses were received and analysed. Descriptive analyses were completed to obtain median values for the hours spent on each activity per month. The mean number of chronic conditions was 3.7 in the COPD sub-sample, 3.4 in the Diabetes sub-sample and 2.0 in the NSA sub-sample. The study identified a clear trend of increased time use associated with increased number of chronic conditions. Median monthly time use was 5–16 hours per month overall for our three sub-samples. For respondents in the top decile with five or more chronic conditions the median time use was equivalent to two to three hours per day, and if exercise is included in the calculations, respondents spent from between five and eight hours per day: an amount similar to full-time work. Multi-morbidity imposes considerable time burdens on patients. Ageing is associated with increasing rates of multi-morbidity. Many older adults are facing high demands on their time to manage their health in the face of decreasing energy and mobility. Their time use must be considered in health service delivery and health system reform.

General Practice and Pandemic Influenza: A Framework for Planning and Comparison of Plans in Five Countries

Background Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada. Methodology/Principal Findings We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyse 89 publicly-available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently. Conclusions This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research.

Health policy responses to rising rates of multi-morbid chronic illness in Australia and New Zealand

Objective: To examine current health policy in Australia and New Zealand and assess the extent to which the policies equip these countries to meet the challenges associated with increasing rates of multi‐morbid chronic illnesses.

Health work by older people with chronic illness: how much time does it take?

Purpose: People living with chronic illness report spending a lot of time managing their health, attempting to balance the demands of their illness/es with other activities. This study was designed to measure the time older people with chronic illness spend on specific health-related activities. Key methods: Data were collected in 2010 using a national survey of people aged 50 years and over selected from the membership of National Seniors Australia, the Diabetes Services Scheme and The Lung Foundation. Respondents provided recall data on time used for personal health care, non-clinical health activity; and health service interactions. Main results: While most people with a chronic illness spend on average less than 30 minutes a day on health-related activities, the highest decile of respondents averaged at least 2 hours each day. People with COPD report the highest expenditure of time. The greatest amount of time was spent on daily personal health care activities. Main conclusion: For a minority of people with chronic illness, time demands for health-related activities can be so great that other activities must be affected. Some time demands are amenable to system interventions that would result in a more patient-centered organisation of care.

Achieving patient‐centred care: the potential and challenge of the patient‐as‐professional role

The patient‐as‐professional concept acknowledges the expert participation of patients in interprofessional teams, including their contributions to managing and coordinating their care. However, little is known about experiences and perspectives of these teams.

Patient Safety First: Responsive Regulation in Health Care

Figures and Tables..Acknowledgments..List of Contributors..1. Regulatory strategies for safer patient health care..2. Leading from behind with plural regulation..3. International trends in patient safety governance..4. Voluntary initiatives by clinicians..5. Integrating corporate and clinical governance..6. Transforming clinical governance in Queensland Health..7. Regulating health professionals..8. Non-disciplinary pathways in practitioner regulation..9. Regulating clinical practice..10. Surgeon report cards..11. Disclosure of medical injury..12. Does litigation against doctors and hospitals improve quality?..13. Hospital licensure, certification and accreditation..14. Connecting health care through information technology..15. Do public inquiries improve health care?..Index

Socioeconomic related inequality in depression among young and middle-adult women in Indonesia׳s major cities

PURPOSE Difficult living conditions in urban areas could result in an increased risk of developing depression, particularly among women. One of the strong predictors of depression is poverty, which could lead to inequality in risk of depression. However, previous studies found conflicting results between poverty and depression. This study examines whether depression was unequally distributed among young and middle-adult women in Indonesia׳s major cities and investigate the factors contributed to the inequality. METHODS Data from 1117 young and middle-adult women in Indonesia׳s major cities (Jakarta, Surabaya, Medan, and Bandung) were analysed. Concentration Index (CI) was calculated to measure the degree of the inequality. The CI was decomposed to investigate the factor contributing most to the inequality. RESULTS The prevalence of depression was 15% and more concentrated among lower economic group (CI=-0.0545). Compared to the middle-adult group, the prevalence of depression among women in the young-adult group was significantly higher (18% vs 11%, p<0.05) and more equally distributed (CI=-0.0343 vs CI=-0.1001). Household consumption expenditure was the factor that contributed most to inequality in both group. Other factors contributing to inequality were smoking in young-adult group and marital status in middle-adult group. Contribution of education to inequality varied for different age groups. CONCLUSION Depression is more concentrated among the lower economic groups, with household expenditure being the major factor contributing to the inequality. This finding emphasises the importance of primary care level mental health services, particularly in poorer urban communities. LIMITATION This study is based on a cross-sectional data, and only assesses social determinants of depression. These determinants are important to address in addition to biological determinants and other factors.