Does relative remoteness affect chronic disease outcomes? Geographic variation in chronic disease mortality in Australia, 2002-2006

Patterns and predictors of ten-year mortality after discharge from community-based post-acute care for acquired brain injury: A retrospective cohort study (ABI-RESTaRT), Western Australia, 1991-2017

BACKGROUND

Survivors of acquired brain injury (ABI) are left with long-term disability and an increased risk of mortality years post-injury.

OBJECTIVE

To examine 10-year mortality in adults with ABI after discharge from post-acute care and identify modifiable risk factors to reduce long-term mortality risk.

METHODS

Retrospective cohort study of 586 adults with traumatic (TBI) or non-traumatic brain injury (NTBI), or neurologic condition, consecutively discharged from a post-acute rehabilitation service in Western Australia from 1-Mar-1991 to 31-Dec-2017. Data sources included rehabilitation records, and linked mortality, hospital, and emergency department data. Survival status at 10 years post-discharge was determined. All-cause and cause-specific age- and sex-adjusted standardised mortality ratios (SMR) by ABI diagnosis were calculated using Australian population reference data. Risk factors were examined using multilevel cox proportional hazards regression.

RESULTS

Compared with the Australian population, 10-year all-cause mortality was significantly elevated for all diagnosis cohorts, with the first 12 months the highest risk period. Accidents or intentional self-harm deaths were elevated in TBI (13.2, 95%CI 5.4; 12.1). Neurodegenerative disease deaths were elevated in Neurologic (21.9, 95%CI 13.0; 30.9) and Stroke (19.8; 95%CI 2.4; 27.2) cohorts. Stroke (20.8; 95%CI 7.9; 33.8) and circulatory disease deaths (6.2; 95%CI 2.3; 9.9) were also elevated in Stroke. Psychiatric comorbidity was the strongest risk factor followed by older age, geographical remoteness, and cardiac, vascular, genitourinary and renal comorbidity. Clinically significant improvement in functional independence and psychosocial functioning significantly reduced mortality risk.

CONCLUSIONS

Individuals with ABI have an elevated risk of mortality years post-injury. Comorbidity management, continuity of care, and rehabilitation are important to reduce long-term mortality risk.

Risk of major adverse cardiovascular events in rural vs urban settings among patients with erectile dysfunction: a propensity-weighted retrospective cohort study of 430 621 men

BACKGROUND

The relationship between erectile dysfunction (ED) and cardiovascular (CV) events has been postulated, with ED being characterized as a potential harbinger of CV disease. Location of residence is another important consideration, as the impact of rural residence has been associated with worse health outcomes.

AIM

To investigate whether men from rural settings with ED are associated with a higher risk of major adverse CV events (MACEs).

METHODS

A propensity-weighted retrospective cohort study was conducted with provincial health administrative databases. ED was defined as having at least 2 ED prescriptions filled within 1 year. MACE was defined as the first hospitalization for an episode of acute myocardial infarction, heart failure, or stroke that resulted in a hospital visit >24 hours. We classified study groups into ED urban, ED rural, no ED urban, and no ED rural. A multiple logistic regression model was used to determine the propensity score. Stabilized inverse propensity treatment weighting was then applied to the propensity score.

OUTCOMES

A Cox proportional hazard model was used to examine our primary outcome of time to a MACE.

RESULTS

The median time to a MACE was 2731, 2635, 2441, and 2508 days for ED urban (n = 32 341), ED rural (n = 18 025), no ED rural (n = 146 358), and no ED urban (n = 233 897), respectively. The cohort with ED had a higher proportion of a MACE at 8.94% (n = 4503), as opposed to 4.58% (n = 17 416) for the group without ED. As compared with no ED urban, no ED rural was associated with higher risks of a MACE in stabilized time-varying comodels based on inverse probability treatment weighting (hazard ratio, 1.06-1.08). ED rural was associated with significantly higher risks of a MACE vs no ED rural, with the strength of the effect estimates increasing over time (hazard ratio, 1.10-1.74).

CLINICAL IMPLICATIONS

Findings highlight the need for physicians treating patients with ED to address CV risk factors for primary and secondary prevention of CV diseases.

STRENGTHS AND LIMITATIONS

This is the most extensive retrospective study demonstrating that ED is an independent risk factor for MACE. Due to limitations in data, we were unable to assess certain comorbidities, including obesity and smoking.

CONCLUSIONS

Our study confirms that ED is an independent risk factor for MACE. Rural men had a higher risk of MACE, with an even higher risk among those who reside rurally and are diagnosed with ED.

Exploring the barriers and enablers of diabetes care in a remote Australian context: A qualitative study

OBJECTIVE

This qualitative study explored the current barriers and enablers of diabetes care in the Indian Ocean Territories (IOT).

METHODS

A constructivist grounded theory approach that incorporated semi-structured telephone interviews was employed. Initial analysis of the interview transcripts used a line-by-line approach, to identify recurring themes, connections, and patterns, before they were re-labelled and categorised. This was followed by axial coding, categorisation refinement, and mapping of diabetes triggers in the IOT.

PARTICIPANTS AND SETTING

The IOT, consisting of Christmas Island and the Cocos (Keeling) Islands, are some of the most remote areas in Australia. When compared with mainland Australia, the prevalence of type 2 diabetes in the IOT is disproportionately higher. There were no known cases of type 1 diabetes at the time of the study. Like other remote communities, these communities experience difficulties in accessing health services to prevent and manage diabetes. Twenty health care professionals and health service administrators in the IOT took part in semi-structured telephone interviews held during April-June 2020. Participants included GPs, nurses, dietitians, social and community services workers, school principals, and administrators. The interview questions focused on their perceptions of the current diabetes care in place in the IOT and their views on the challenges of providing diabetes care in the IOT.

RESULTS

We identified four main barriers and two main enabling factors to the provision of effective diabetes care in the IOT. The barriers were: (i) societal influences; (ii) family; (iii) changing availability of food; (v) sustainability and communication. The two main enablers were: (i) tailoring interventions to meet local and cultural needs and values; and (ii) proactive compliance with the medical model of care.

CONCLUSION

Due to the cultural and linguistic diversity within the IOT, many of the identified barriers and enablers are unique to this community and need to be considered and incorporated into routine diabetes care to ensure successful and effective delivery of services in a remote context.

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background

Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.

Methods

A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.

Results

In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001).

Conclusions

This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.

Behavioral and Cognitive Outcomes of an Online Weight Loss Program for Men With Low Mood: A Randomized Controlled Trial

BACKGROUND

Depression and obesity are major health concerns and commonly co-exist, but men rarely seek help for these conditions. SHED-IT: Recharge was a gender-tailored eHealth program for men that generated clinically meaningful improvements in weight and depressive symptoms.

PURPOSE

To evaluate behavioral and psychological outcomes from the SHED-IT: Recharge intervention designed for overweight/obese men with low mood.

METHODS

Overall, 125 men (18-70 years) with a BMI between 25 and 42 kg/m2 and depressive symptoms (PHQ-9 ≥ 5) were randomly allocated to SHED-IT: Recharge (n = 62) or wait-list control (n = 63) groups. The self-directed program targeted key health behaviors combined with online mental fitness modules based on cognitive behavioral therapy. Behavioral (e.g., physical activity) and psychological outcomes (e.g., cognitive flexibility) were assessed with validated measures at baseline, 3 months (post-test) and 6 months (follow-up). Intention-to-treat linear mixed models examined treatment effects, which were adjusted for covariates, and effect size estimated (Cohen's d).

RESULTS

At post-test, intervention men achieved small-to-medium improvements in several health behavior outcomes including moderate-to-vigorous physical activity, light physical activity, sedentary behavior, sleep, energy intake, portion size, and risky alcohol consumption (range, d = 0.3-0.5), when compared with the control group. Intervention effects were also observed for perceived physical self-worth, perceived physical strength, cognitive flexibility, and behavioral activation (range, d = 0.3-0.8). No effects were found for fruit and vegetable intake, or mindful attention. Most effects were maintained at follow-up.

CONCLUSIONS

This gender-tailored, eHealth program with integrated mental fitness support elicited meaningful improvements in health behaviors and psychological outcomes for men with low mood. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12619001209189).

Men's Perceptions of a Gender-Tailored eHealth Program Targeting Physical and Mental Health: Qualitative Findings from the SHED-IT Recharge Trial

Despite increasing rates of co-morbid depression and obesity, few interventions target both conditions simultaneously, particularly in men. The SHED-IT: Recharge trial, conducted in 125 men with depressive symptoms and overweight or obesity, tested the efficacy of a gender-tailored eHealth program with integrated mental health support. The aims of this study were to examine the perceptions of men who received the SHED-IT: Recharge intervention in relation to recruitment, satisfaction with the program, and suggestions to improve the program. Individual semi-structured interviews were conducted in a random sub-sample, stratified by baseline depression and weight status (n = 19, mean (SD) age 49.6 years (11.6), PHQ-9 score 9.0 (3.7), BMI 32.5 kg/m2 (4.6)). Transcripts were analyzed using an inductive process by an independent qualitative researcher. Four themes emerged, namely, (i) specific circumstances determined men's motivation to enroll, (ii) unique opportunity to implement sustained physical and mental health changes compared to previous experiences, (iii) salience of the program elements, and (iv) further opportunities that build accountability could help maintain focus. Gender-tailored, self-directed lifestyle interventions incorporating mental health support are acceptable and satisfying for men experiencing depressive symptoms. These findings provide important insights for future self-guided lifestyle interventions for men with poor physical and mental health.

Impact of remoteness on patient outcomes for people with multiple sclerosis in Australia

BACKGROUND

Little is known about whether living in remote areas is associated with worse health outcomes in Australians with MS.

OBJECTIVES

To evaluate whether living in remote areas was associated with worse health outcomes, employment outcomes and different disease modifying therapy (DMTs) utilisation among Australians with MS.

METHODS

We included 1,611 participants from the Australian MS Longitudinal Study. Level of remoteness (major cities, inner regional, outer regional, remote, and very remote Australia) was determined using postcode. Data were analysed using linear, log-binomial, log-multinomial and negative binomial regression.

RESULTS

Living in more remote areas was not associated with substantial worse health/employment outcomes. There was a consistent pattern of those living in inner regional areas having worse outcomes, but the effect sizes were relatively small with no clear dose-response relationships with increasing remoteness. Those living in more remote areas were less likely to use high efficacy DMTs. Adjusting for age, disease duration, and education level only marginally reduced the associations.

CONCLUSIONS

There is no large inequity in health outcomes in the Australian MS population due to remoteness. However, modest and consistent differences in health outcomes and DMTs treatment are likely to have a substantial cumulative impact at an individual level.

Cohort study examining the relationship between remoteness and requirement for surgery to treat peripheral artery disease at a tertiary hospital in North Queensland

OBJECTIVE

To assess whether outcomes of peripheral artery disease (PAD) were related to remoteness from the treating tertiary vascular centre.

SETTING AND PARTICIPANTS

Participants with a variety of types of occlusive and aneurysmal diseases were recruited from a tertiary hospital in North Queensland, Australia. Remoteness was assessed by residence outside Townsville and estimated distance to the vascular centre. Cox proportional hazard analyses were used to examine the association of remoteness with outcome.

DESIGN

Cohort study.

MAIN OUTCOME MEASURES

The primary outcome was requirement for surgery to treat PAD. Secondary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality.

RESULTS

Of 2487 patients recruited, 1274 (51.2%) had at least one PAD surgery, 720 (29.0%) at least one MACE, and 909 (36.6%) died during a median of 4.2 (inter-quartile range 1.3-7.7) years. Compared to Townsville residents (n = 1287), those resident outside Townsville (n = 1200) had higher rates of PAD surgery (hazard ratio, HR 1.55, 95% confidence intervals, CI, 1.39, 1.73) but no increased risk of MACE (HR 1.00, 95% CI 0.86, 1.16) or death (HR 1.03, 95% CI 0.90, 1.17). This association was attenuated when adjusting for distance from the vascular centre (HR 1.31, 95% CI 1.14, 1.51). Patients in the highest quartile of distance presented with lower ankle-brachial pressure index, more severe carotid artery disease and larger aortic diameter.

CONCLUSIONS

People with PAD in North Queensland residing furthest from the tertiary hospital presented with more severe artery disease and had greater rates of PAD surgery.

Efficacy of an m-Health Physical Activity and Sleep Intervention to Improve Sleep Quality in Middle-Aged Adults: The Refresh Study Randomized Controlled Trial

BACKGROUND

Poor sleep health is highly prevalent. Physical activity is known to improve sleep quality but not specifically targeted in sleep interventions.

PURPOSE

To compare the efficacy of a combined physical activity and sleep intervention with a sleep-only intervention and a wait-list control, for improving sleep quality in middle-aged adults without a diagnosed sleep disorder.

METHODS

Three-arm randomized controlled trial (Physical Activity and Sleep Health (PAS), Sleep Health Only (SO), Wait-list Control (CON) groups; 3-month primary time-point, 6-month follow-up) of 275 (PAS = 110, SO = 110, CON = 55) inactive adults (40-65 years) reporting poor sleep quality. The main intervention component was a smartphone/tablet "app" to aid goal setting and self-monitoring physical activity and/or sleep hygiene behaviors (including stress management), and a pedometer for PAS group. Primary outcome was Pittsburgh Sleep Quality Index (PSQI) global score. Secondary outcomes included several self-reported physical activity measures and PSQI subcomponents. Group differences were examined stepwise, first between pooled intervention (PI = PAS + SO) and CON groups, then between PAS and SO groups.

RESULTS

Compared with CON, PI groups significantly improved PSQI global and subcomponents scores at 3 and 6 months. There were no differences in sleep quality between PAS and SO groups. The PAS group reported significantly less daily sitting time at 3 months and was significantly more likely to report ≥2 days/week resistance training and meeting physical activity guidelines at 6 months than the SO group.

CONCLUSIONS

PIs had statistically significantly improved sleep quality among middle-aged adults with poor sleep quality without a diagnosed sleep disorder. The adjunctive physical activity intervention did not additionally improve sleep quality.

CLINICAL TRIAL INFORMATION

Australian New Zealand Clinical Trial Registry: ACTRN12617000680369; Universal Trial number: U1111-1194-2680; Human Research Ethics Committee, Blinded by request of journal: H-2016-0267.

Experiences of older adults accessing specialized health care services in rural and remote areas: a qualitative systematic review

OBJECTIVE

The objective of this review was to synthesize the literature on the experiences of older adults accessing specialized health care services while living in remote or rural areas.

INTRODUCTION

Older persons with chronic illnesses often need specialized health care services. Those who live in remote or rural areas may have limited access to these specialized health care services, potentially leading to an increase in morbidity and mortality. Little is known about the experiences of older adults accessing specialized health care services while living in remote or rural areas.

INCLUSION CRITERIA

This review considered studies of persons 65 years and older who have self-identified as living in remote or rural areas. They will have, on at least one occasion, sought access in person to specialized health care services for a chronic condition such as cardiovascular disease, renal disease, diabetes, cancer, mental illness, or a major health concern beyond the scope of a primary care clinician, such as palliative care.

METHODS

The search strategy aimed to find both published and unpublished studies in English from 1980 onward. An initial limited search of MEDLINE and CINAHL was undertaken in February 2017, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. This informed the development of a search strategy, which was tailored for each information source. The search was first conducted in December 2018 and rerun in November 2019. The databases searched included CINAHL, PubMed, PsycINFO, and AgeLine. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and MedNar. Papers meeting the inclusion criteria were appraised by two independent reviewers for methodological quality. Data extraction was conducted according to the standardized data extraction tool from JBI. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Three papers were included in the review yielding a total of five findings and two categories. The categories were aggregated to form one synthesized finding: Distance often results in challenges accessing health care. For almost all older adults, the long distance to drive for specialized services was a barrier, especially for those living far out in the country, and led to delayed care. Lack of health education and peer support was also viewed as an issue. For one older adult, however, the distance was not seen as an issue; rather, it was viewed as an opportunity to enjoy time with family members. Participants noted that they had access to emergency care and, therefore, believed they were not putting their lives at risk by living in a rural area. The overall ConQual score was low.

CONCLUSION

We believe that the distance to travel to obtain specialized services, as well as living in an area without specialized services, impacted this population's experience of obtaining specialized health care as well as their health. The spectrum of findings for our synthesized finding suggests that this was the case for some people, but not all. We speculate that people who have chosen to live outside an urban area or have lived in a rural area for a prolonged period come to accept their access to health care, including the distance to travel for health care and their potential for this to impact their health. The findings also suggest the older adults have a range of experiences; for some, distance was an issue and for others, it was not an issue. Some participants found living in a rural area impacted their care while others did not.

Does community size or commute time affect severity of illness at diagnosis or quality of care in a centralized care model of pulmonary hypertension?

BACKGROUND

Centralized care models are often used for rare diseases like pulmonary hypertension (PH). It is unknown how living in a rural or remote area influences outcomes.

METHODS

We identified all patients from our PH database who carried a diagnosis of WHO Group 1 or WHO Group 4 PH. Using Canadian postal code data, patients were classified as living in a rural area; or a small, medium or large community size. The commute time from patient residence to our clinic was determined using mapping software. We compared baseline catheterization data according to community size and commute time. At follow up, we evaluated the association between community size and commute time with prognostic parameters of functional class, walk distance and echocardiography.

RESULTS

Of the 342 patients identified, 72(21%) patients lived in rural areas, while 26(8%), 49(14%) and 195(57%) resided in small, medium and large population centres, respectively. The commute time was <1 h for 160(47%), 1-3 h for 62(18%), and >3 h for 120(35%). There was no association seen for any catheterization parameter by either community size or commute time. At last follow up, there was no association between any prognostic parameter and community size or commute time.

CONCLUSIONS

We found no association between community size or commute time with severity of illness at diagnosis, or markers of prognosis at follow up. This suggests that patients who reside in rural or remote environments are not experiencing deficiencies in care compared to urban patients.

Survival following abdominal aortic aneurysm repair in North Queensland is not associated with remoteness of place of residence

Objective

To assess whether survival and clinical events following elective abdominal aortic aneurysm (AAA) repair were associated with remoteness of residence in North Queensland, Australia.

Methods

This retrospective cohort study included participants undergoing elective AAA repair between February 2002 and April 2020 at two hospitals in Townsville, North Queensland, Australia. Outcomes were all-cause survival and AAA-related events, defined as requirement for repeat AAA repair or AAA-related mortality. Remoteness of participant’s place of residence was assessed by the Modified Monash Model classifications and estimated distance from the participants’ home to the tertiary vascular centre. Cox proportional hazard analysis examined the association of remoteness with outcome.

Results

The study included 526 participants undergoing elective repair by open (n = 204) or endovascular (n = 322) surgery. Fifty-four (10.2%) participants had a place of residence at a remote or very remote location. Participants' were followed for a median of 5.2 (inter-quartile range 2.5–8.3) years, during which time there were 252 (47.9%) deaths. Survival was not associated with either measure of remoteness. Fifty (9.5%) participants had at least one AAA-related event, including 30 (5.7%) that underwent at least one repeat AAA surgery and 23 (4.4%) that had AAA-related mortality. AAA-related events were more common in participants resident in the most remote areas (adjusted hazard ratio 2.83, 95% confidence intervals 1.40, 5.70) but not associated with distance from the participants’ residence to the tertiary vascular centre

Conclusions

The current study found that participants living in more remote locations were more likely to have AAA-related events but had no increased mortality following AAA surgery. The findings emphasize the need for careful follow-up after AAA surgery. Further studies are needed to examine the generalisability of the findings.

Augmenting disease maps: a Bayesian meta-analysis approach

Analysis of spatial patterns of disease is a significant field of research. However, access to unit-level disease data can be difficult for privacy and other reasons. As a consequence, estimates of interest are often published at the small area level as disease maps. This motivates the development of methods for analysis of these ecological estimates directly. Such analyses can widen the scope of research by drawing more insights from published disease maps or atlases. The present study proposes a hierarchical Bayesian meta-analysis model that analyses the point and interval estimates from an online atlas. The proposed model is illustrated by modelling the published cancer incidence estimates available as part of the online Australian Cancer Atlas (ACA). The proposed model aims to reveal patterns of cancer incidence for the 20 cancers included in ACA in major cities, regional and remote areas. The model results are validated using the observed areal data created from unit-level data on cancer incidence in each of 2148 small areas. It is found that the meta-analysis models can generate similar patterns of cancer incidence based on urban/rural status of small areas compared with those already known or revealed by the analysis of observed data. The proposed approach can be generalized to other online disease maps and atlases.

Psychosocial disadvantage and residential remoteness is associated with Aboriginal women's mental health prior to childbirth

Introduction

Optimal mental health in the pre-conception, pregnancy and postpartum periods is important for both maternal and infant wellbeing. Few studies, however, have focused on Indigenous women and the specific risk and protective factors that may prompt vulnerability to perinatal mental disorders in this culturally diverse population.

Objectives

To assess mental health contacts in the period before childbirth among Australian Aboriginal and Torres Strait Islander women, the association with socioeconomic factors and whether it differs by geographic remoteness.

Methods

This is a retrospective cohort study of 19,165 Aboriginal mothers and includes all Aboriginal mothers and their children born in Western Australia from January 1990 to March 2015. It draws on population-level, linked administrative data from hospitals and mental health services, with a primary focus on the mental health contacts of Aboriginal women in the 5 years leading up to childbirth.

Results

The prevalence of maternal mental health contacts in the five years prior to birth was 27.6% (93.6% having a single mental health disorder), with a greater likelihood of contact in metropolitan areas compared with regional and remote settings. There was a positive relationship between socioeconomic advantage and the likelihood of a mental health contact for women in Metropolitan (β = 0.044, p=0.003) and Inner regional areas (β = 0.033, p=0.018), and a negative association in Outer regional (β = -0.038, p=0.022), Remote (β = -0.019, p=0.241) and Very remote regions (β = -0.053, p<0.001).

Conclusions

The findings from this study provide new insights on the dynamic relationship between SES, geographic location and mental health issues among Aboriginal women in the 5 years leading up to childbirth. The results underscore the need to apply location-specific approaches to addressing the material and psychosocial pathways that lead to mental health problems and the provision of culturally safe, appropriate and accessible services for Aboriginal women

Provincial Differences in the Diagnosis and Care of Amyotrophic Lateral Sclerosis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease resulting in muscle weakness, dysarthria and dysphagia, and ultimately respiratory failure leading to death. Half of the ALS patients survive less than 3 years, and 80% of the patients survive less than 5 years. Riluzole is the only approved medication in Canada with randomized controlled clinical trial evidence to slow the progression of ALS, albeit only to a modest degree. The Canadian Neuromuscular Disease Registry (CNDR) collects data on over 140 different neuromuscular diseases including ALS across ten academic institutions and 28 clinics including ten multidisciplinary ALS clinics.

METHODS

In this study, CNDR registry data were analyzed to examine potential differences in ALS care among provinces in time to diagnosis, riluzole and feeding tube use.

RESULTS

Significant differences were found among provinces, in time to diagnosis from symptom onset, in the use of riluzole and in feeding tube use.

CONCLUSIONS

Future investigations should be undertaken to identify factors contributing to such differences, and to propose potential interventions to address the provincial differences reported.

Continuity of care: why it matters and what we can do

Continuity of care matters; however, expansion and specialisation of the health system tends to fragment care. Continuity of care is accompanied by a range of patient benefits, including reduced all-cause mortality; lower rates of hospital presentation and preventable admission; and improved patient satisfaction. Potential concerns have been raised about some aspects of continuity of care, but these are outweighed by the perceived benefits. There are many barriers to achieving continuity, especially in rural and remote settings. Some practical solutions have been proposed that include adapting clinic procedures, utilising a small team approach, improving staff retention and ongoing advocacy.

Association between area-level socioeconomic status, accessibility and diabetes-related hospitalisations: a cross-sectional analysis of data from Western Victoria, Australia

OBJECTIVE

Hospitalisation rates for many chronic conditions are higher in socioeconomically disadvantaged and less accessible areas. We aimed to map diabetes hospitalisation rates by local government area (LGA) across Western Victoria, Australia, and investigate their association with socioeconomic status (SES) and accessibility/remoteness.

DESIGN

Cross-sectional study METHODS: Data were acquired from the Victorian Admitted Episodes Dataset for all hospitalisations (public and private) with a diagnosis of type 1 or type 2 diabetes mellitus during 2011-2014. Crude and age-standardised hospitalisation rates (per 1000 population per year) were calculated by LGA for men, women and combined data. Associations between accessibility (Accessibility/Remoteness Index of Australia, ARIA), SES (Index of Relative Socioeconomic Advantage and Disadvantage, IRSAD) and diabetes hospitalisation were investigated using Poisson regression analyses.

RESULTS

Higher LGA-level accessibility and SES were associated with higher rates of type 1 and type 2 diabetes hospitalisation, overall and for each sex. For type 1 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men incidence rate ratio [IRR]=2.14, 95% CI 1.64 to 2.80; women IRR=2.45, 95% CI 1.87 to 3.19; combined IRR=2.30, 95% CI 1.69 to 3.13; all p<0.05). Higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.25, 95% CI 1.09 to 1.43; women IRR=1.32, 95% CI 1.16 to 1.51; combined IRR=1.23, 95% CI 1.07 to 1.42; all p<0.05). Similarly, for type 2 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men IRR=2.49, 95% CI 1.81 to 3.43; women IRR=2.34, 95% CI 1.69 to 3.25; combined IRR=2.32, 95% CI 1.66 to 3.25; all p<0.05) and higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.15, 95% CI 1.02 to 1.30; women IRR=1.14, 95% CI 1.01 to 1.28; combined IRR=1.13, 95% CI 1.00 to 1.27; all p<0.05).

CONCLUSION

Our observations could indicate self-motivated treatment seeking, and better specialist and hospital services availability in the advantaged and accessible areas in the study region. The determinants for such variations in hospitalisation rates, however, are multifaceted and warrant further research.

Acute circulatory complications in people with diabetes mellitus type 2: How admission varies between urban and rural Victoria

OBJECTIVE

To identify the extent to which rurality influences the admission and mortality rates for acute circulatory complications among people with type 2 diabetes mellitus.

DESIGN

Retrospective study.

SETTING

All Victorian hospitals.

PARTICIPANTS

State-wide hospital admissions from 1 July 2010 to 30 June 2015 using the Victorian Admitted Episodes Dataset. Data included patients with type 2 diabetes mellitus and diagnosis of acute cardiovascular events, acute cerebrovascular haemorrhage or infarction, acute peripheral vascular events or hypertensive diseases.

MAIN OUTCOME MEASURE

Rates of admission and mortality were calculated for local government areas and Department of Health regions. Regression analysis identified the influence between admission rates and various predictor variables.

RESULTS

In total, 5785 emergency hospital admissions occurred during the study period, with the highest and lowest mortality and admission rates occurring in rural areas. Moderately high admission rates were identified in urban areas. Cardiovascular events far outnumbered other acute circulatory admissions. Regression analysis identified a number of significant socioeconomic variables, primarily for metropolitan residents. Socioeconomic disadvantage was the only significant factor in rural areas.

CONCLUSION

Victorian admission and mortality rates for acute circulatory complications are greatest in rural areas; yet, there is considerable heterogeneity in the admission rates within both rural and metropolitan areas. Furthermore, socioeconomic status is more influential than remoteness in determining emergency admissions. Further research needs to investigate the particular variables that lead to poorer outcomes rurally, investigate socioeconomic disadvantage in rural areas and have greater emphasis on peripheral vascular disease prevention.

Regional South Australia Health (RESONATE) survey: study protocol

INTRODUCTION

Access to quality healthcare services is considered a moral right. However, for people living in regional locations, timely access to the services that they need may not always be possible because of structural and attitudinal barriers. This suggests that people living in regional areas may have unmet healthcare needs. The aim of this research will be to examine the healthcare needs, expectations and experiences of regional South Australians.

METHODS AND ANALYSIS

The Regional South Australia Health (RESONATE) survey is a cross-sectional study of adult health consumers living in any private or non-private dwelling, in any regional, rural, remote or very remote area of South Australia and with an understanding of written English. Data will be collected using a 45-item, multidimensional, self-administered instrument, designed to measure healthcare need, barriers to healthcare access and health service utilisation, attitudes, experiences and satisfaction. The instrument has demonstrated acceptable psychometric properties, including good content validity and internal reliability, good test-retest reliability and a high level of acceptability. The survey will be administered online and in hard-copy, with at least 1832 survey participants to be recruited over a 12-month period, using a comprehensive, multimodal recruitment campaign.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Research Ethics Committee of the University of South Australia. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media, the internet and various community/stakeholder engagement activities.

An Overview of Indigenous Australian Disadvantage in Terms of Ischaemic Heart Disease

BACKGROUND

Indigenous Australians experience poorer health outcomes than non-Indigenous Australians and a significant life expectancy gap exists. Ischaemic heart disease (IHD) represents the leading specific cause of death in Indigenous Australians and is a significant, if not the most significant, contributor to the mortality gap. With this narrative review we aim to describe the burden of IHD within the Indigenous Australian community and explore the factors driving this disparity.

METHODS

A broad search of the literature was undertaken utilising an electronic search of the PubMed database along with national agency databases-the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS).

RESULTS

A complex interplay between multiple factors contributes to the excess burden of IHD in the Indigenous Australian population: CONCLUSIONS: In terms of IHD, Indigenous Australians experience disadvantage at multiple stages of the disease process. Ongoing efforts are needed to continue to inform clinicians of both this disadvantage and strategies to assist negating it. Further research is needed to develop evidence based practices which may help reduce this disparity in outcomes.

Disparities in cancer stage at diagnosis and survival of Aboriginal and non-Aboriginal South Australians

BACKGROUND/AIM

This study tested the utility of retrospectively staging cancer registry data for comparing stage and stage-specific survivals of Aboriginal and non-Aboriginal people. Differences by area level factors were also explored.

METHODS

This test dataset comprised 950 Aboriginal cases and all other cases recorded on the South Australian cancer registry with a 1977-2010 diagnosis. A sub-set of 777 Aboriginal cases diagnosed in 1990-2010 were matched with randomly selected non-Aboriginal cases by year of birth, diagnostic year, sex, and primary site of cancer. Competing risk regression summarised associations of Aboriginal status, stage, and geographic attributes with risk of cancer death.

RESULTS

Aboriginal cases were 10 years younger at diagnosis, more likely to present in recent diagnostic years, to be resident of remote areas, and have primary cancer sites of head & neck, lung, liver and cervix. Risk of cancer death was associated in the matched analysis with more advanced stage at diagnosis. More Aboriginal than non-Aboriginal cases had distant metastases at diagnosis (31.3% vs 22.0, p<0.001). After adjusting for stage, remote-living Aboriginal residents had higher risks of cancer death than Aboriginal residents of metropolitan areas. Non-Aboriginal cases had the lowest risk of cancer death.

CONCLUSION

Retrospective staging proved to be feasible using registry data. Results indicated more advanced stages for Aboriginal than matched non-Aboriginal cases. Aboriginal people had higher risks of cancer death, which persisted after adjusting for stage, and applied irrespective of remoteness of residence, with highest risk of death occurring among Aboriginal people from remote areas.

The impact of travel distance, travel time and waiting time on health-related quality of life of diabetes patients: An investigation in six European countries

AIMS

The effects of travel distance and travel time to the primary diabetes care provider and waiting time in the practice on health-related quality of life (HRQoL) of patients with type 2 diabetes are investigated.

RESEARCH DESIGN AND METHODS

Survey data of 1313 persons with type 2 diabetes from six regions in England (274), Finland (163), Germany (254), Greece (165), the Netherlands (354), and Spain (103) were analyzed. Various multiple linear regression analyses with four different EQ-5D-3L indices (English, German, Dutch and Spanish index) as target variables, with travel distance, travel time, and waiting time in the practice as focal predictors and with control for study region, patient's gender, patient's age, patient's education, time since diagnosis, thoroughness of provider-patient communication were computed. Interactions of regions with the remaining five control variables and the three focal predictors were also tested.

RESULTS

There are no interactions of regions with control variables or focal predictors. The indices decrease with increasing travel time to the provider and increasing waiting time in the provider's practice.

CONCLUSIONS

HRQoL of patients with type 2 diabetes might be improved by decreasing travel time to the provider and waiting time in the provider's practice.

Translating agricultural health and medicine education across the Pacific: a United States and Australian comparison study

BACKGROUND

Populations in agricultural communities require<b> </b>health care that is interdisciplinary and cross-sectoral to address the high rate of workplace deaths, preventable injuries and illness. These rates are compounded by limited access to services and the distinctive personal values and culture of farming populations, which both health and rural practitioners must be aware of to reduce the gap between rural and urban population health outcomes. To address the unique health and medical characteristics of agricultural populations, education in agricultural medicine was established through the College of Medicine and the College of Public Health at the University of Iowa in the USA. The course was initially developed in 1974 for teaching medical students, family medicine residents and nurses, and a postgraduate curriculum was added in 2006 to develop medical/health and rural professionals' cultural competence to work in agricultural communities. This article reviews the adaptation of the US course to Australia and the educational and practice outcomes of students who completed the agricultural medicine course in either Australia or the USA.

METHODS

Data were collected from students who completed either the Agricultural Medicine: Occupational and Environmental Health for Rural Health Professionals course in the state of Iowa in the USA or the Agricultural Health and Medicine course in the state of Victoria in Australia between 2010 and 2013 (inclusive). Data were analysed using descriptive statistics, frequencies and the &#967;2 test. Students were invited to make any other comments regarding the course.

RESULTS

One hundred and ten students completed the survey (59 from the USA and 51 from Australia) with over a 50% response from both countries, indicating the high level of commitment to this discipline. Responses were consistent across both continents, with more than 91% agreeing that the course improved their abilities to diagnose, prevent and treat rural and agricultural populations. Further, both courses successfully enabled a multidisciplinary and cross-sectoral approach to agricultural health and medicine.

CONCLUSIONS

More than 72% of previous students were practising in rural and /or mixed communities at the time of the survey, demonstrating a repeatable and transferable medical education program that supports multidisciplinary care and scholarship while addressing health inequities in agricultural populations. Findings from this study indicate there are opportunities to expand globally.

Doing it hard in the bush: Aligning what gets measured with what matters

What gets measured gets managed. Funding of health services is substantially determined by operational activity and specific outcome indicators. In day-to-day clinical decision-making, surrogate markers, such as glycosylated haemoglobin and blood pressure, are commonly used to modify risks of 'hard' outcomes that include kidney failure, ischaemic cardiac events, stroke and all-cause mortality. In many settings, surrogates are all we have to go on. As a consequence, current health funding models heavily rely on surrogate-based key performance indicators [KPIs]. While surrogates are convenient and provide immediate information, there is an obligation to ensure that they are appropriate, reliable and validated in context. In contrast, hard outcomes, the real consequences of illness, are usually realised over an extended timeframe. Additionally, and for a host of reasons, hard endpoints have the greatest social, emotional and economic impact for people at the far end of the health system; those in rural and remote settings - 'in the bush' - especially Indigenous Australians. We propose a health service assessment approach that aligns short-term decision-making with patient-centred and longer term hard outcomes, one that takes into account community, cultural and environmental factors, especially remoteness. Communities should have a major say in determining what health indicators are measured and managed.

Individual, social and environmental factors and their association with weight in rural-dwelling women

OBJECTIVE

Obesity is a major public health concern and women living in rural settings present a high-risk group. With contributing factors poorly explored, we evaluated their association with weight in rural Australian women.

METHODS

Women aged 18-50 years of any body mass index (BMI) were recruited between October 2012 and April 2013 as part of a larger, randomised controlled trial within 42 rural towns. Measured weight and height as well as self-reported measures of individual health, physical activity, dietary intake, self-management, social support and environmental perception were collected. Statistical analysis included linear regression for continuous variables as well as chi-squared and logistic regression for categorical variables with all results adjusted for clustering.

RESULTS

649 women with a mean baseline age and BMI of 39.6±6.7 years and 28.8±6.9 kg/m² respectively, were studied. Overall, 65% were overweight or obese and 60% overall reported recent weight gain. There was a high intention to self-manage weight, with 68% attempting to lose weight recently, compared to 20% of women reporting health professional engagement for weight management. Obese women reported increased weight gain, energy intake, sitting time and prevalence of pre-existing health conditions. There was an inverse relationship between increased weight and scores for self-management, social support and health environment perception.

CONCLUSIONS

Many women in rural communities reported recent weight gain and were attempting to self-manage their weight with little external support. Implications for public health: Initiatives to prevent weight gain require a multifaceted approach, with self-management strategies and social support in tandem with building a positive local environmental perception.

Men's Sheds function and philosophy: towards a framework for future research and men's health promotion

ISSUE ADDRESSED

The Men's Shed movement supports a range of men's health promotion initiatives. This paper examines whether a Men's Shed typology could inform future research and enable more efficient and targeted health promotion activities through Men's Sheds.

METHODS

The International Men's Shed Survey consisted of a cross-sectional exploration of sheds, their members, and health and social activities. Survey data about shed 'function' and 'philosophy' were analysed using descriptive and inferential statistics.

RESULTS

A framework of Men's Sheds based on function and philosophy demonstrated that most sheds serve a primary utility function, a secondary social function, but most importantly a primary social opportunity philosophy. Sheds with a primary health philosophy participated in fewer health promotion activities when compared with sheds without a primary health philosophy.

CONCLUSIONS

In addition to the uniform health promotion resources distributed by the Men's Shed associations, specific health promotion activities, such as prostate education, are being initiated from an individual shed level. This framework can potentially be used to enable future research and health promotion activities to be more efficiently and effectively targeted. SO WHAT? Men experience poorer health and well being outcomes than women. This framework offers a novel approach to providing targeted health promotion activities to men in an environment where it is okay to talk about men's health.

Bedside-to-Bench Translational Research for Chronic Heart Failure: Creating an Agenda for Clients Who Do Not Meet Trial Enrollment Criteria

Congestive heart failure (CHF) is a chronic condition usually without cure. Significant developments, particularly those addressing pathophysiology, mainly started at the bench. This approach has seen many clinical observations initially explored at the bench, subsequently being trialed at the bedside, and eventually translated into clinical practice. This evidence, however, has several limitations, importantly the generalizability or external validity. We now acknowledge that clinical management of CHF is more complicated than merely translating bench-to-bedside evidence in a linear fashion. This review aims to help explore this evolving area from an Australian perspective. We describe the continuation of research once core evidence is established and describe how clinician-scientist collaboration with a bedside-to-bench view can help enhance evidence translation and generalizability. We describe why an extension of the available evidence or generating new evidence is occasionally needed to address the increasingly diverse cohort of patients. Finally, we explore some of the tools used by basic scientists and clinicians to develop evidence and describe the ones we feel may be most beneficial.

Successes, challenges and developments in Australian rheumatology

Australia is a geographically vast but sparsely populated country with many unique factors affecting the practice of rheumatology. With a population comprising minority Indigenous peoples, a historically European-origin majority population, and recent large-scale migration from Asia, the effect of ethnic diversity on the phenotype of rheumatic diseases such as systemic lupus erythematosus (SLE) is a constant of Australian rheumatology practice. Australia has a strong system of universal healthcare and subsidized access to medications, and clinical and research rheumatology are well developed, but inequitable access to specialist care in urban and regional centres, and the complex disconnected structure of the Australian healthcare system, can hinder the management of chronic diseases.

Chronic obstructive pulmonary disease hospitalisations and mortality in Victoria: analysis of variations by socioeconomic status

OBJECTIVE

This paper analysed chronic obstructive pulmonary disease (COPD) hospitalisations, unplanned readmissions and deaths in Victoria to identify associations with socioeconomic status (SES).

METHODS

The data was taken from the Victorian Admitted Episodes Dataset, the Victorian Health Information Surveillance System, the Victorian Burden of Disease Study and the Australian Bureau of Statistics' Index of Relative Socioeconomic Disadvantage.

RESULTS

COPD separations have a greater variation by SES than all separations. The average age-standardised separation rate (10.43) for the top percentile Local Government Areas (LGA) was 5.8 times that of the bottom percentile LGAs (1.80). The top percentile group was the lowest SES group (effect size = 0.93). There were significant negative correlations between the age-standardised COPD separation rates and SES across LGAs (r = -0.60) and Regions (r = -0.89). Analysis of readmissions (r = -0.49), mortality data (r = -0.51) and the burden of disease data (r = -0.39) also showed significant inverse associations between COPD and SES.

CONCLUSIONS AND IMPLICATIONS

Victorians living in the most disadvantaged areas have a greater burden from COPD, highlighting a need to prioritise public health services interventions to improve outcomes.

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

BACKGROUND

Rural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients.

METHODS

A comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines.

RESULTS

Fifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural-urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I(2) = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I(2) = 91%).

CONCLUSIONS

We found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.