Projected future trends of hospital service use for selected obesity-related conditions

Disease burden of diabetes, diabetic retinopathy and their future projections in the UK: cross-sectional analyses of a primary care database

OBJECTIVES

To estimate the current disease burden, trends and future projections for diabetes mellitus (DM) and diabetic retinopathy (DR) in the IQVIA Medical Research Data (IMRD).

PARTICIPANTS/DESIGN/SETTING

We performed a cross-sectional study of patients aged 12 and above to determine the prevalence of DM and DR from the IMRD database (primary care database) in January 2017, involving a total population of 1 80 824 patients with DM. We also carried out a series of cross-sectional studies to investigate prevalence trends, and then applied a double exponential smoothing model to forecast the future burden of DM and DR in the UK.

RESULTS

The crude DM prevalence in 2017 was 5.2%. The DR, sight-threatening retinopathy (STR) and diabetic maculopathy prevalence figures in 2017 were 33.78%, 12.28% and 7.86%, respectively, in our IMRD cross-sectional study. There were upward trends in the prevalence of DM, DR and STR, most marked and accelerating in STR in type 1 DM but slowing in type 2 DM, and in the overall prevalence of DR.

CONCLUSION

Our results suggest differential rising trends in the prevalence of DM and DR. Preventive strategies, as well as treatment services planning, can be based on these projected prevalence estimates. Improvements that are necessary for the optimisation of care pathways, and preparations to meet demand and capacity challenges, can also be based on this information. The limitations of the study can be overcome by a future collaborative study linking DR screening and hospital eye services data.

Multicentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial

INTRODUCTION

Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established.

METHODS AND ANALYSIS

This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums.

TRIAL REGISTRATION NUMBER

ACTRN12618000642280.

Studying Biofilm and Clinical Issues in Orthopedics

The association between biofilm-forming microorganisms and prosthetic joint infection influences all aspect of management including approaches to diagnosis, management and prevention. This article will provide an overview of new anti-biofilm strategies for management of prosthetic joint infection.

Relationship of weight and obesity with the risk of knee and hip arthroplasty for osteoarthritis across different levels of physical performance: a prospective cohort study

OBJECTIVE

To examine the association between obesity and knee and hip arthroplasty for osteoarthritis across a range of physical performance.

METHOD

The body mass index and physical performance (on the 36-item Short Form Health Survey) of 9135 Australian Diabetes, Obesity and Lifestyle Study participants were measured in 1999-2000. The incidence of knee and hip arthroplasty during 2002-2011 was determined by linking the cohort records to the Australian Orthopaedic Association National Joint Replacement Registry.

RESULTS

Over 9.1 ± 2.3 years (mean ± sd)) of follow-up, 317 participants had knee and 202 had hip arthroplasty for osteoarthritis. Using those with neither obesity nor significantly impaired physical performance as the reference group, participants with both obesity and significantly impaired physical performance had a higher knee arthroplasty risk [hazard ratio (HR) = 5.25, 95% confidence interval (CI) 3.85-7.14] than those with obesity alone (HR = 2.49, 95% CI 1.81-3.44) or impaired physical performance alone (HR = 2.19, 95% CI 1.59-3.02). Similar results were observed for hip arthroplasty (obesity and impaired physical performance: HR = 2.67, 95% CI 1.72-4.15; obesity alone: HR = 1.65, 95% CI 1.08-2.51; impaired physical performance alone: HR = 1.83, 95% CI 1.26-2.66). Among overweight/obese patients, 5 kg greater baseline weight increased the knee arthroplasty risk across all levels of physical performance, and hip arthroplasty risk in those with the highest level of physical performance.

CONCLUSION

Although impaired physical performance is an independent risk factor for knee and hip arthroplasty, greater weight increased knee arthroplasty for overweight/obese participants at all levels of physical performance, but hip arthroplasty only in those with good physical performance. Targeting weight loss has the potential to reduce the risk of knee arthroplasty and improve patient outcomes, even in those with poor physical performance.

What is the role of catheter antibiotic prophylaxis for patients undergoing joint arthroplasty?

BACKGROUND

Antimicrobial prophylaxis at the time of urinary catheter insertion and removal is commonly administered in patients undergoing joint arthroplasty, despite the lack of evidence to support this practice. The rationale is the theoretical risk of prosthetic joint infection arising from bacterial seeding from the urinary tract at the time of catheterization. In an era of antimicrobial stewardship, further assessment is warranted.

METHODS

This study aimed to investigate the incidence of catheter-associated (CA) bacteriuria and bacteraemia in patients undergoing total joint arthroplasty and to assess the antimicrobial susceptibility of any isolated microorganisms. This prospective observational study undertaken over a 6-month period (May to October 2014) included 99 patients undergoing elective primary hip and knee arthroplasty at St Vincent's Hospital, Melbourne. Urine specimens were collected at insertion and removal of urinary catheters along with blood cultures upon urinary catheter removal.

RESULTS

Overall 98% of the cohort received catheter antimicrobial prophylaxis for urinary catheter insertion and removal; the majority of patients received gentamicin (94%). Bacteriuria on catheter insertion had an incidence of 4.4%. The incidence of CA bacteriuria was 1.3%. All cultured organisms were sensitive to commonly used antibiotics including cephazolin. There were no cases of bacteraemia with urinary catheter removal. Increasing age, American Society of Anesthesiologists status and female gender were associated with the development of bacteriuria.

CONCLUSION

The incidence of CA bacteriuria and bacteraemia with antimicrobial prophylaxis is low. This study provokes discussion about the requirement of catheter prophylaxis in this surgical context and the utility of preoperative urine screening.

Alcoholic Chlorhexidine or Alcoholic Iodine Skin Antisepsis (ACAISA): protocol for cluster randomised controlled trial of surgical skin preparation for the prevention of superficial wound complications in prosthetic hip and knee replacement surgery

INTRODUCTION

Wound complications following arthroplasty are associated with significant impact on the patient and healthcare system. Skin cleansing prior to surgical incision is a simple and effective method to prevent wound complications however, the question of which agent is superior for surgical skin antisepsis is unresolved.

METHODS AND ANALYSIS

This cluster randomised controlled trial aims to compare the incidence of superficial wound complications in patients undergoing elective prosthetic hip or knee replacement surgery receiving surgical skin antisepsis with either: 0.5% chlorhexidine gluconate (CHG) in 70% alcohol or 10% povidone in 70% alcohol. The trial will be conducted at an Australian tertiary, university affiliated hospital over a 3-year period involving 750 participants. Participants will be drawn from the surgical waiting list. Consent for this study will be 'opt-out' consent. On a given day, all eligible participants will have skin preparation either with 0.5% chlorhexidine in 70% alcohol or 10% povidone iodine in 70% alcohol. The primary outcome is superficial wound complications (comprised of superficial incisional surgical site infections (SSI) and/or prolonged wound ooze) in the first 30 days following prosthetic joint replacement surgery. Secondary outcomes will include the incidence of wound complications according to the joint replaced, assessment of the causative agents of SSI and cost-effectiveness analysis. The primary analysis is an intention-to-treat analysis including all participants who undergo randomisation and will be performed at the individual level taking into account the clustering effect.

ETHICS AND DISSEMINATION

The study design and protocol was reviewed and approved by the St Vincent's Hospital Human Research Ethics Committee (HREC-A 016/14 10/3/2014). Study findings will be disseminated in the printed media, and learned forums. A written lay summary will be available to study participants on request.

TRIAL REGISTRATION NUMBER

The trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000177651.

Baby boomers, obesity, and social change

SUMMARY

Baby boomers are currently in mid-life and over the next several decades they will swell the ranks of those aged 65 and over. Their entry into this age group will have a significant impact in a number of areas but particularly in relation to the type and extent of health services required. Obesity is a major health issue for this cohort as its members are significantly over-represented in both the overweight and obese categories compared to the rest of the population. In addition, they are significantly more likely to have multiple risk factors. This review considers how alterations to lifestyle, initiated by the rapid social changes of the last half century, might have contributed to obesity within this cohort. In providing this broad overview it focuses on how increased affluence and changes to everyday institutions have affected the cultures around food consumption. This includes a consideration of both the internal and external ways in which eating environments are now constructed. This review suggests that further research is needed to identify the factors which facilitate or constrain healthy ageing in the baby boom cohort. Research along these lines also needs to consider both macro- and micro-level changes to the social context within which these factors arise. This is essential as the high levels of obesity in this cohort may reflect both an individual and a structural lag in adapting lifestyles and policies to meet the needs of this very different social environment.:

The Australian Baby Boomer Population—Factors Influencing Changes to Health-Related Quality of Life Over Time

Objectives: Identify factors associated with changes to health-related quality of life (HRQoL) in baby boomers. Methods: Panel data were collected on baby boomers at two time points, 2000-2002 and 2004-2006. A fixed-effects model was used to identify associations between changes in the dependent variable (SF-36 summary scales) and changes in independent variables (health indicators/employment status). Results: Mental health problems, being out of labor force, sedentary behavior, and severe lung disease were associated with deterioration in physical and mental HRQoL. Obesity was associated with deterioration in physical HRQoL whereas cardiovascular disease was associated with deterioration in mental HRQoL. Unemployment, full-time employment, and absence of lung disease symptoms were associated with improvements in physical and mental HRQoL. Discussion: If we are to maximize the future labor participation, and HRQoL, of this cohort, it will be necessary to reduce obesity and sedentary behavior and to further investigate the association between health and employment.

Investigating obstructive sleep apnoea: will the health system have the capacity to cope? A population study

Objective. To obtain prevalence estimates of clinical features of obstructive sleep apnoea (OSA) and identify the dimensions of the public health problem requiring further investigation for an Australian population. Methods. The South Australian Health Omnibus Survey is an annual representative population survey of South Australians aged ≥15 years, conducted via interviewer-administered questionnaire. In 2009, 3007 participants were asked the STOP-BANG instrument measure of obstructive sleep apnoea risk, which includes symptoms of loud snoring, frequent tiredness during daytime, observed apnoea, and high blood pressure (STOP), and measured body mass index, age, neck circumference and gender (BANG). Three or more positive response categorises a person at high risk for OSA. Results. Snoring was reported by 49.7% of adults. Tiredness after sleep more than 3 – 4 times per week was reported by 24.8%, and during wake-time by 27.7% of adults, with 8.8% reporting having fallen asleep while driving. Over half of the surveyed men (57.1%, n = 566) and 19.3% (n = 269) of the women were classified at high-risk of OSA with the STOP-BANG measure. In multivariable models, high risk was associated with less education, lower income, and residence in a regional rather than metropolitan area. Conclusion. The high prevalence of adults at risk for OSA suggests that the capacity currently available within the healthcare system to investigate and diagnose OSA is likely to be inadequate, particularly outside urban areas. This highlights an important public health problem that requires further detailed study and trials of new models of care. What is known about the topic? Obstructive sleep apnoea (OSA) is associated with obesity, and although it is associated with significant morbidity and mortality there is no simple clinical test for this condition. While the prevalence of snoring or sleepiness is reported to be high and increasing with obesity, there is little recent information on how many adults report combinations of frequent sleep-related breathing abnormalities, unsatisfactory sleep, or unexplained daytime sleepiness, that justify further investigation with tests such as polysomnography that require considerable health service investment. What does this paper add? In a representative adult population sample of 3007 adults, 27.8% were classified at high risk of OSA with a validated screening tool that uses symptoms and body measurements (STOP-BANG). Risk was greater with lower income and education, and residence outside of metropolitan areas. What are the implications for practitioners? Clinicians need to be aware that over a quarter of adults may need investigation for OSA, and should adopt an active approach to identifying people at risk. Health services and policy makers need to plan for this problem, and innovative approaches to provision of investigation and management need to be trialled.

The TrueBlue study: is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes?

Background

In the presence of type 2 diabetes (T2DM) or coronary heart disease (CHD), depression is under diagnosed and under treated despite being associated with worse clinical outcomes. Our earlier pilot study demonstrated that it was feasible, acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors. The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD.

Methods

This is a cluster-randomised intervention trial. Eighteen general practices from regional and metropolitan areas agreed to join this study, and were allocated randomly to an intervention or control group. We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practices. In the intervention group, practice nurses (PNs) will be trained for their enhanced roles in this nurse-led collaborative care study. Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner. The PN will assess psychological, physiological and lifestyle parameters then work with the patient to set management goals. The outcome of this assessment will form the basis of a GP Management Plan document. In the control group, the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol. The primary clinical outcome will be a reduction in the depression score. The study will also measure the impact on physiological measures, quality of life and on patient attitude to health care delivered by practice nurses.

Conclusion

The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological, lifestyle and psychological risk factors for high-risk patients with co-morbid depression, diabetes or heart disease. The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care.

Obesity: What is an elderly population growing into?

OBJECTIVES

Obesity is currently a major public health concern; however, there is little data available on the prevalence and impact of obesity within the elderly population. This review examines the prevalence and health effects of obesity among individuals aged > or =50.

METHODS

PubMed (1996-2008) and PsychInfo (2002-2008) search engines were used to retrieve qualified peer-reviewed articles focusing on obesity or a health condition correlated with obesity using BMI or other weight index as a defining variable; and studies limited to the elderly (age 60+) or pre-elderly (50+).

RESULTS

Worldwide, the elderly population is increasingly becoming obese regardless of socio-economic status. Among elderly persons, obesity increases the risks for a variety of morbidity conditions including cancers, diabetes, hypertension, stroke, heart disease, metabolic syndrome, obstructive sleep apnea syndrome, osteoarthritis, depression, disability, and lower scores on quality of life measures. In some reports, obesity has been linked to Alzheimer's disease and other forms of cognitive decline. Obesity significantly increases healthcare costs and nursing homes are currently ill equipped to address the needs of the rising number of obese residents.

CONCLUSIONS

Obesity is increasing in the elderly population worldwide and is expected to continue to rise. Obesity is associated with disease and disability in addition to escalating healthcare costs, and hospitals and nursing homes are ill equipped to serve the obese elderly. It is imperative that research efforts and funding be devoted to studying the effects and the reduction of obesity in the elderly population.