Stephanie J. Hollis

A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting

BackgroundDespite growing interest and urges by leading experts for the routine collection of patient reported outcome (PRO) measures in all general care patients, and in particular cancer patients, there has not been an updated comprehensive review of the evidence regarding the impact of adopting such a strategy on patients, service providers and organisations in an oncologic setting.MethodsBased on a critical analysis of the three most recent systematic reviews, the current systematic review developed a six-method strategy in searching and reviewing the most relevant quantitative studies between January 2000 and October 2011 using a set of pre-determined inclusion criteria and theory-based outcome indicators. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to rate the quality and importance of the identified publications, and the synthesis of the evidence was conducted.ResultsThe 27 identified studies showed strong evidence that the well-implemented PROs improved patient-provider communication and patient satisfaction. There was also growing evidence that it improved the monitoring of treatment response and the detection of unrecognised problems. However, there was a weak or non-existent evidence-base regarding the impact on changes to patient management and improved health outcomes, changes to patient health behaviour, the effectiveness of quality improvement of organisations, and on transparency, accountability, public reporting activities, and performance of the health care system.ConclusionsDespite the existence of significant gaps in the evidence-base, there is growing evidence in support of routine PRO collection in enabling better and patient-centred care in cancer settings.

Incidence, Risk, and Protective Factors of Mild Traumatic Brain Injury in a Cohort of Australian Nonprofessional Male Rugby Players

Background Mild traumatic brain injury (mTBI) is an emerging public health issue in high-contact sports. Understanding the incidence along with the risk and protective factors of mTBI in high-contact sports such as rugby is paramount if appropriate preventive strategies are to be developed. Purpose To estimate the incidence and identify the risk and protective factors of mTBI in Australian nonprofessional rugby players. Study Design Cohort study; Level of evidence, 2. Methods A cohort of 3207 male nonprofessional rugby players from Sydney, Australia, was recruited and followed over 1 or more playing seasons. Demographic information, history of recent concussion, and information on risk and protective factors were collected. The incidence of mTBI was estimated and the putative risk and protective factors were modeled in relation to mTBI. Results The incidence of mTBI was 7.97 per 1000 player game hours, with 313 players (9.8%) sustaining 1 or more mTBIs during the study. Players who reported always wearing protective headgear during games were at a reduced risk (incident rate ratio [IRR], 0.57; 95% confidence interval [CI], 0.40–0.82) of sustaining an mTBI. In contrast, the likelihood of mTBI was almost 2 times higher among players who reported having sustained either 1 (IRR, 1.75; 95% CI, 1.11–2.76) or more mTBIs (IRR, 1.65; 95% CI, 1.11–2.45) within the 12 months before recruitment. Conclusion Nonprofessional rugby has a high incidence of mTBI, with the absence of headgear and a recent history of mTBI associated with an increased risk of subsequent mTBI. These findings highlight that both use of headgear and the management of prior concussion would likely be beneficial in reducing the likelihood of mTBI among nonprofessional rugby players, who compose more than 99% of rugby union players in Australia.

Traumatic brain injury among Australian prisoners: Rates, recurrence and sequelae

Primary objective: To establish the prevalence, severity, recurrence and sequelae of past traumatic brain injury (TBI) among individuals recently received into custody. Research design: Cross-sectional random sample of men recently received into the New South Wales’ (NSW) criminal justice system. Procedures: Participants were screened for a history of TBI including the injury setting, severity, treatment and sequelae of up to five separate TBI episodes. Outcomes and results: Of 200 study participants, 82% endorsed a history of at least one TBI of any severity and 65% a history of TBI with a loss of consciousness (LOC). Multiple past TBIs were common, as were ongoing sequelae. Treatment for the TBI was more common among those TBIs with a LOC compared with no LOC (66% vs. 39%). Conclusions: Among individuals entering the criminal justice system, past TBI is common and often associated with ongoing neuropsychiatric and social sequelae. Screening for TBI at the point of reception may be warranted to better understand and treat those with ongoing neuropsychiatric sequelae arising from the TBI.

Compliance with return-to-play regulations following concussion in Australian schoolboy and community rugby union players

Background There is a risk of concussion when playing rugby union. Appropriate management of concussion includes compliance with the return-to-play regulations of the sports body for reducing the likelihood of premature return-to-play by injured players. Purpose To describe the proportion of rugby union players who comply with the sports bodys regulations on returning to play postconcussion. Study design Prospective cohort study. Methods 1958 community rugby union players (aged 15–48 years) in Sydney (Australia) were recruited from schoolboy, grade and suburban competitions and followed over ≥1 playing seasons. Club doctors/physiotherapists/coaches or trained injury recorders who attended the game reported players who sustained a concussion. Concussed players were followed up over a 3-month period and the dates when they returned to play (including either a game or training session) were recorded, as well as any return-to-play advice they received. Results 187 players sustained ≥1 concussion throughout the follow-up. The median number of days before players returned to play (competition game play or training) following concussion was 3 (range 1–84). Most players (78%) did not receive return-to-play advice postconcussion, and of those who received correct advice, all failed to comply with the 3-week stand-down regulation. Conclusions The paucity of return-to-play advice received by community rugby union players postconcussion and the high level of non-compliance with return-to-play regulations highlight the need for better dissemination and implementation of the return-to-play regulations and improved understanding of the underlying causes of why players do not adhere to return-to-play practices.

Are prisoners reliable survey respondents? A validation of self-reported traumatic brain injury (TBI) against hospital medical records

Aims: To compare prisoners’ self-reported history of TBI associated with hospital attendance with details extracted from relevant hospital medical records and to identify factors associated with the level of agreement between the two sources. Methods: From a sample of prison entrants, this study obtained a history of TBIs for which medical attention was sought at a hospital. Audit tools were developed for data extraction relevant to any possible TBI from records at a total of 23 hospitals located within New South Wales, Australia. The level of agreement between self-report and hospital records was compared in relation to demographic, psychological and criminographic characteristics. Results: Of the 200 participants in the study, 164 (82%) reported having sustained a past TBI giving a total of 420 separate TBI incidents. Of these, 156 (37%) were alleged to have resulted in attendance at a hospital emergency department including 112 (72%) at a hospital accessible for the validation exercise. For 93/112 (83%) of reported TBIs, a corresponding hospital medical record was located of which 78/112 (70%) supported the occurrence of a TBI. Lower education and a lifetime history of more than seven TBIs were associated with less agreement between self-report and medical record data with regard to specific details of the TBI. Conclusions: Overall, these findings suggest that prisoners’ self-report of TBI is generally accurate when compared with the ‘gold standard’ of hospital medical record. This finding is contrary to the perception of this group as ‘dishonest’ and ‘unreliable’.

The impact of implementing a rapid response system: A comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia

AIMS To compare clinical outcomes between a teaching hospital with a mature rapid response system (RRS), with three similar teaching hospitals without a RRS in Sydney, Australia. METHODS For the period 2002-2009, we compared a teaching hospital with a mature RRS, with three similar teaching hospitals without a RRS. Two non-RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality, overall hospital mortality and 1-year post discharge mortality after IHCA between the RRS hospital and the non-RRS hospitals based on three separate analyses: (1) pooled analysis during 2002-2008; (2) before-after difference between 2008 and 2009; (3) after implementation in 2009. RESULTS During the 2002-2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCA-related mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-year post-discharge mortality for survivors of IHCA over the study period. CONCLUSIONS Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

Objectives: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs).

Traumatic brain injury rates and sequelae: A comparison of prisoners with a matched community sample in Australia

Aim: To compare rates of past reported traumatic brain injury (TBI) in a prisoner sample with those in a control group drawn from the same location of usual residence. Method: The prisoner group comprised a consecutive sample of men (n = 200) received into custody and screened by face-to-face interview. The control group comprised men (n = 200) matched for location of usual residence screened by telephone interview. Participants were asked about past TBIs and screened for drug and alcohol abuse, impulsivity and dissocial personality disorder. Results: Eighty-two per cent of prisoners and 71.5% of community participants reported at least one past TBI of any severity (i.e. with or without a loss of consciousness (LOC)) and 64.5% of prisoners and 32.2% of community participants reported at least one TBI associated with a LOC. Prisoners were more likely to report persisting side-effects of TBI and were much more likely to screen positive for impulsivity and dissocial personality disorder. Multivariate analyses found no significant association between TBI frequency or severity and custody/community group membership. Conclusions: High reported rates of TBI in prisoner populations may reflect the excess of socio-demographic risk factors for TBI. Results of the current study do not support a role for TBI as causally related to criminal conduct.

Mild traumatic brain injury among a cohort of rugby union players: predictors of time to injury

This study reports the time to sustain a mild traumatic brain injury (mTBI) among a cohort of community rugby union players. Demographic and player characteristics were collected and players followed up for between one and three playing seasons. 7% of the cohort sustained an mTBI within 10 h of game time, increasing twofold to 14% within 20 h. The mean time to first mTBI was 8 h with an SD of 6.2 (median 6.8 h; IQR: 2.9–11.7 h). Players reporting a recent history of concussion were 20% more likely to sustain an mTBI after 20 h of game time compared with those with no recent history of concussion. Players were likely to sustain an mTBI in shorter time if they trained for <3 h/week (HR=1.48, p=0.03) or had a body mass index <27 (HR=1.77, p=0.007). The findings highlight modifiable characteristics to reduce the likelihood of shortened time to mTBI.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

Objectives Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals. Setting A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002–2009 in New South Wales, Australia. Participants Patients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included. Outcome measures VTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR). Results 2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE. Conclusions VTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.