Estimating prevalence of common chronic morbidities in Australia

Efficacy and safety of pentosan polysulfate sodium in people with symptomatic knee osteoarthritis and dyslipidaemia: protocol of the MaRVeL trial

INTRODUCTION

Knee osteoarthritis (OA) is the most prevalent arthritis type and a leading cause of chronic mobility disability. While pain medications provide only symptomatic pain relief; growing evidence suggests pentosan polysulfate sodium (PPS) is chondroprotective and could have anti-inflammatory effects in knee OA. This study aims to explore the efficacy and safety of oral PPS in symptomatic knee OA with dyslipidaemia.

METHODS AND ANALYSIS

MaRVeL is a phase II, single-centre, parallel, superiority trial which will be conducted at Royal North Shore Hospital, Sydney, Australia. 92 participants (46 per arm) aged 40 and over with painful knee OA and mild to moderate structural change on X-ray (Kellgren and Lawrence grade 2 or 3) will be recruited from the community and randomly allocated to receive two cycles of either oral PPS or placebo for 5 weeks starting at baseline and week 11. Primary outcome will be the 16-week change in overall average knee pain severity measured using an 11-point Numeric Rating Scale. Main secondary outcomes include change in knee pain, patient global assessment, physical function, quality of life and other structural changes. A biostatistician blinded to allocation groups will perform the statistical analysis according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

The protocol has been approved by the NSLHD Human Research Ethics Committee (HREC) (2021/ETH00315). All participants will provide written informed consent online. Study results will be disseminated through conferences, social media and academic publications.

TRIAL REGISTRATION NUMBERS

Australian New Zealand Clinical Trial Registry (ACTRN12621000654853); U1111-1265-3750.

A comparison of Australian chronic disease prevalence estimates using administrative pharmaceutical dispensing data with international and community survey data

Introduction

Chronic disease (CD) is a leading cause of population mortality, illness and disability. Identification of CD using administrative data is increasingly used and may have utility in monitoring population health. Pharmaceutical administrative data using World Health Organization, Anatomic Therapeutic Chemical Codification (ATC) assigned to prescribed medicines may offer an improved method to define persons with certain CD and enable the calculation of population prevalence.

Objective

To assess the feasibility of Australian Pharmaceutical Benefits Scheme (PBS) dispensing data, to provide realistic measures of chronic disease prevalence using ATC codification, and compare values with international data using similar ATC methods and Australian community surveys.

Methods

Twenty-two chronic diseases were identified using World Health Organization (WHO) formulated ATC codes assigned to treatments received and recorded in a PBS database. Distinct treatment episodes prescribed to individuals were counted annually for prevalence estimates. Comparisons were then made with estimates from international studies using pharmaceutical data and published Australian community surveys.

Results

PBS prevalence estimates for a range of chronic diseases listed in European studies and Australian community surveys demonstrated good correlation. PBS estimates of the prevalence of diabetes, cardiovascular disease and hypertension, dyslipidemia, and respiratory disease with comparable Australian National Health Survey in older adults showed correlations of between (r = 0.82 - 0.99) and a range of percentage error of -11% to 59%. However, other conditions such as psychological disease and migraine showed greater disparity and correlated less well.

Conclusions

Although not without limitations, Australian administrative pharmaceutical dispensing data may provide an alternative perspective on population health and a useful resource to estimate the prevalence of a number of chronic diseases within the Australian population.

How effective are population health surveys for estimating prevalence of chronic conditions compared to anonymised clinical data?

INTRODUCTION

Population health surveys are used to record person-reported outcome measures for chronic health conditions and provide a useful source of data when evaluating potential disease burdens. The reliability of survey-based prevalence estimates for chronic diseases is unclear nonetheless. This study applied methodological triangulation via a data linkage method to validate prevalence of selected chronic conditions (angina, myocardial infarction, heart failure, and asthma).

METHODS

Linked healthcare records were used for a combined cohort of 11,323 adults from the 2013 and 2014 sweeps of the Welsh Health Survey (WHS). The approach utilised consented survey data linked to primary and secondary care electronic health record (EHR) data back to 2002 within the Secure Anonymised Information Linkage (SAIL) Databank.

RESULTS

This descriptive study demonstrates validation of survey and clinical data using data linkage for selected chronic cardiovascular conditions and asthma with varied success. The results indicate that identifying cases for separate cardiovascular conditions was limited without specific medication codes for each condition, but more straightforward for asthma, where there was an extensive list of medications available. For asthma there was better agreement between prevalence estimates based on survey and clinical data as a result.

CONCLUSION

Whilst the results provide external validity for the WHS as an instrument for estimating the burden of chronic disease, they also indicate that a data linkage appproach can be used to produce comparable prevalence estimates using clinical data if a defined condition-specific set of clinical codes are available.

How does parent/self-reporting of common respiratory conditions compare with medical records among Aboriginal and Torres Strait Islander (Indigenous) children and young adults?

AIM

Self-reporting and/or data from medical records are frequently used in studies to ascertain health history. Data on the discrepancies between these information sources is lacking for Indigenous Australians. This study reports such data for selected respiratory and atopic conditions common among Indigenous Australians.

METHODS

Data were extracted from the Indigenous respiratory reference value study, a multicentre cross-sectional study of Indigenous children and young adults (3-25 years) between June 2015 and November 2017. Only those living in rural/remote regions were included. Self-reported history was collected from parents (if participants <18 years) or participants. Medical records were manually reviewed. Participants with incomplete data (missing self-reported and/or medical record information) were excluded. Agreement between sources was examined using Cohen's kappa.

RESULTS

Of 1097 participants, 889 (97.1% <18 years) had sufficient self-reported and medical record histories for comparison. Asthma was self-reported by 15.7% of participants and was reported in medical records for 10.3% (κ = 0.53, 95% confidence interval (CI) 0.45-0.61). For bronchiectasis, the reported rates were 1.5 and 0.7% (κ = 0.52, 95% CI 0.25-0.80), pneumonia 1.1 and 5.8% (κ = 0.15, 95% CI 0.02-0.27), allergic rhinitis 6.6 and 0.6% (κ = 0.05, 95% CI -0.03, 0.13) and eczema 5.8 and 6.2% (κ = 0.30, 95% CI 0.18-0.42).

CONCLUSIONS

Within our cohort, agreement was moderate for asthma and bronchiectasis, fair for eczema and poor for pneumonia and allergic rhinitis. These results highlight the challenges associated with how best to obtain an accurate health history within Australian Indigenous rural/remote communities. Generalisability of findings and contributions of poor health knowledge and/or poor medical record documentation need further exploration.

Developing strategic priorities in osteoarthritis research: Proceedings and recommendations arising from the 2017 Australian Osteoarthritis Summit

Background

There is a pressing need to enhance osteoarthritis (OA) research to find ways of alleviating its enormous individual and societal impact due to the high prevalence, associated disability, and extensive costs.

Methods

Potential research priorities and initial rankings were pre-identified via surveys and the 1000Minds process by OA consumers and the research community. The OA Summit was held to decide key research priorities that match the strengths and expertise of the Australian OA research community and align with the needs of consumers. Facilitated breakout sessions were conducted to identify initiatives and strategies to advance OA research into agreed priority areas, and foster collaboration in OA research by forming research networks.

Results

From the pre-Summit activities, the three research priority areas identified were: treatment adherence and behaviour change, disease modification, and prevention of OA. Eighty-five Australian and international leading OA experts participated in the Summit, including specialists, allied health practitioners, researchers from all states of Australia representing both universities and medical research institutes; representatives from Arthritis Australia, health insurers; and persons living with OA. Through the presentations and discussions during the Summit, there was a broad consensus on the OA research priorities across stakeholders and how these can be supported across government, industry, service providers and consumers.

Conclusion

The Australian OA Summit brought consumers, experts and opinion leaders together to identify OA research priorities, to enhance current research efforts by fostering collaboration that offer the greatest potential for alleviating the disease burden.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2455-x) contains supplementary material, which is available to authorized users.

Epidemiology of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis among 1.5 million patients in Australian general practice: NPS MedicineWise MedicineInsight dataset

Background

Previous estimates for the prevalence of musculoskeletal conditions (MSK) and chronic pain in Australia have been based on self-report. We aimed to determine the prevalence and distribution of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis and current consultations for chronic pain among adults attending Australian general practice, and describe their distribution according to sociodemographic characteristics and presence of co-morbidities.

Methods

We investigated 1,501,267 active adult patients (57.6% females; 22.5% ≥65y) evaluated between 2013 and 2016 and included in the MedicineInsight database (a National Prescribing Service MedicineWise program), a large general practice data program that extracts longitudinal de-identified electronic medical record data from ‘active’ patients in over 550 practices. Three main groups of outcomes were investigated: 1) “prevalence” of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies, and/or rheumatoid arthritis between 2000 and 2016; 2) “current” diagnosis/encounter for the same conditions occurring between 2013 and 2016, and; 3) “current” consultations for chronic pain of any type occurring between 2013 and 2016.

Results

The combined “prevalence” of the investigated MSK (diagnosis between 2000 and 2016) among adults attending Australian general practice was 16.8% (95%CI 15.9;17.7) with 21.3% (95%CI 20.2;22.4) of the sample consulting for chronic pain between 2013 and 2016. The investigated MSK with the highest “prevalence” were arthritis (9.5%) and chronic back pain (6.7%). Patients with some of these MSK attended general practices more frequently than those without these conditions (median 2.0 and 1.0 contacts/year, respectively). The “prevalence” of the investigated MSK and “current” consultations for chronic pain increased with age, especially in women, but chronic pain remained stable at 22% for males aged > 40 years. The investigated MSK and chronic pain were more frequent among those in lower socioeconomic groups, veterans, Aboriginal and Torrent Strait Islanders, current and ex-smokers, and patients with chronic obstructive pulmonary disease or heart failure.

Conclusions

The investigated MSK are more frequent among lower socioeconomic groups and the elderly. Based on information collected from adults attending Australian general practices, MedicineInsight provided similar estimates to those obtained from population-based studies, with the advantage of being based on medical diagnosis and including a national sample.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-1941-x) contains supplementary material, which is available to authorized users.

eMAP:CKD: electronic diagnosis and management assistance to primary care in chronic kidney disease

Background

The increasing burden of chronic kidney disease (CKD) underpins the importance for improved early detection and management programs in primary care to delay disease progression and reduce mortality rates. eMAP:CKD is a pilot program for primary care aimed at addressing the gap between current and best practice care for CKD.

Methods

Customized software programs were developed to integrate with primary care electronic health records (EHRs), allowing real-time prompting for CKD risk factor identification, testing, diagnosis and management according to Kidney Health Australia's (KHA) best practice recommendations. Primary care practices also received support from a visiting CKD nurse and education modules. Patient data were analyzed at baseline (150 910 patients) and at 15 months (175 917 patients) following the implementation of the program across 21 primary care practices.

Results

There was improvement in CKD risk factor recognition (29.40 versus 33.84%; P < 0.001) and more complete kidney health tests were performed (3.20 versus 4.30%; P < 0.001). There were more CKD diagnoses entered into the EHR (0.48 versus 1.55%; P < 0.001) and more patients achieved KHA's recommended management targets (P < 0.001).

Conclusion

The eMAP:CKD program has shown an improvement in identification of patients at risk of CKD, appropriate testing and management of these patients, as well as increased documentation of CKD diagnosis entered into the EHRs. We have demonstrated efficacy in overcoming the verified gap between current and best practice in primary care. The success of the pilot program has encouraging implications for use across the primary care community as a whole.

Large-scale survey to estimate the prevalence of disorders for 192 Kennel Club registered breeds

Background

Pedigree or purebred dogs are often stated to have high prevalence of disorders which are commonly assumed to be a consequence of inbreeding and selection for exaggerated features. However, few studies empirically report and rank the prevalence of disorders across breeds although such data are of critical importance in the prioritisation of multiple health concerns, and to provide a baseline against which to explore changes over time. This paper reports an owner survey that gathered disorder information on Kennel Club registered pedigree dogs, regardless of whether these disorders received veterinary care. This study aimed to determine the prevalence of disorders among pedigree dogs overall and, where possible, determine any variation among breeds.

Results

This study included morbidity data on 43,005 live dogs registered with the Kennel Club. Just under two thirds of live dogs had no reported diseases/conditions. The most prevalent diseases/conditions overall were lipoma (4.3%; 95% confidence interval 4.13-4.52%), skin (cutaneous) cyst (3.1%; 2.94-3.27%) and hypersensitivity (allergic) skin disorder (2.7%; 2.52-2.82%). For the most common disorders in the most represented breeds, 90 significant differences between the within breed prevalence and the overall prevalence are reported.

Conclusion

The results from this study have added vital epidemiological data on disorders in UK dogs. It is anticipated that these results will contribute to the forthcoming Breed Health & Conservation Plans, a Kennel Club initiative aiming to assist in the identification and prioritisation of breeding selection objectives for health and provide advice to breeders/owners regarding steps that may be taken to minimise the risk of the disease/disorders. Future breed-specific studies are recommended to report more precise prevalence estimates within more breeds.

Electronic supplementary material

The online version of this article (doi:10.1186/s40575-017-0047-3) contains supplementary material, which is available to authorized users.

Time Trends in the Family Physician Management of Insomnia: The Australian Experience (2000-2015)

STUDY OBJECTIVES

To evaluate changes in rates of family physician (FP) management of insomnia in Australia from 2000-2015.

METHODS

The Bettering the Evaluation And Care of Health (BEACH) program is a nationally representative cross-sectional survey of 1,000 newly randomly sampled family physicians' activity in Australia per year, who each record details of 100 consecutive patient encounters. This provided records of approximately 100,000 encounters each year. We identified all encounters with patients older than 15 years where insomnia or difficulty sleeping was managed and assessed trends in these encounters from 2000-2015.

RESULTS

There was no change in the management rate of insomnia from 2000-2007 (1.54 per 100 encounters [95% confidence interval [CI]: 1.49-1.58]). This rate was lower from 2008-2015 (1.31 per 100 encounters [95% CI: 1.27-1.35]). There was no change in FP management: pharmacotherapy was used in approximately 90% of encounters; nonpharmacological advice was given at approximately 20%; and onward referral at approximately 1% of encounters. Prescription of temazepam changed from 54.6 [95% CI: 51.4-57.9] per 100 insomnia problems in 2000-2001 to 43.6 [95% CI: 40.1-47.0] in 2014-2015, whereas zolpidem increased steadily from introduction in 2000 to 14.6 [95% CI: 12.2-17.1] per 100 insomnia problems in 2006-2007, and then decreased to 7.3 [95% CI: 5.4-9.2] by 2014-2015.

CONCLUSIONS

Insomnia management frequency decreased after 2007 in conjunction with ecologically associated Australian media reporting of adverse effects linked to zolpidem use. Australian FPs remain reliant on pharmacotherapy for the management of insomnia.

The association between gastroesophageal reflux disease with sleep quality, depression, and anxiety in a cohort study of Australian men

BACKGROUND AND AIM

Previous clinical studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) with anxiety and depression; however, few population-based studies have controlled for sleep disorders. The current study aimed to assess the relationship between GERD and anxiety, depression, and sleep disorders in a community-based sample of Australian men.

METHODS

Participants comprised a subset of 1612 men (mean age: 60.7 years, range: 35-80) who participated in the Men Androgen Inflammation Lifestyle Environment and Stress Study during the years 2001-2012, who had complete GERD measures (Gastresophageal Reflux Disease Questionnaire), and were not taking medications known to impact gastrointestinal function (excluding drugs taken for acid-related disorders). Current depression and anxiety were defined by (i) physician diagnosis, (ii) symptoms of depression (Beck Depression Inventory and Centre for Epidemiological Studies Depression Scale) or anxiety (Generalized Anxiety Disorder-7), and/or current depressive or anxiolytic medication use. Previous depression was indicated by past depressive diagnoses/medication use. Data on sleep quality, daytime sleepiness, and obstructive sleep apnea were collected along with several health, lifestyle, and medical factors, and these were systematically evaluated in both univariate and multivariable analyses.

RESULTS

Overall, 13.7% (n = 221) men had clinically significant GERD symptoms. In the adjusted models, an association between GERD and anxiety (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.0-6.8) and poor sleep quality (OR 1.8; 95% CI 1.2-2.9) was observed; however, no effect was observed for current depression (OR 1.5; 95% CI 0.8-2.7). After removing poor sleep quality from the model, an independent association between current depression (OR 2.6; 95% CI 1.7-3.8) and current anxiety (OR 3.2; 95% CI 1.8-6.0) and GERD was observed, but not for previous depression (OR 1.4; 95% CI 0.7-2.8).

CONCLUSION

In this sample of urban-dwelling men, we observed a strong independent association between GERD, anxiety, and current depression, the latter appearing to be partly mediated by poor sleep quality. Patients presenting with GERD should have concurrent mental health assessments in order to identify potential confounders to the successful management of their symptoms.

Associations between multimorbidity and additional burden for working-age adults with specific forms of musculoskeletal conditions: a cross-sectional study

BACKGROUND

Multiple health conditions are increasingly a problem for adults with musculoskeletal conditions. However, multimorbidity research has focused primarily on the elderly and those with a limited subset of musculoskeletal disorders. We sought to determine whether associations between multimorbidity and additional burden differ with specific forms of musculoskeletal conditions among working-age adults.

METHODS

Data were sourced from a nationally representative Australian survey. Specific musculoskeletal conditions examined were osteoarthritis; inflammatory arthritis; other forms of arthritis or arthropathies; musculoskeletal conditions not elsewhere specified; gout; back pain; soft tissue disorders; or osteoporosis. Multimorbidity was defined as the additional presence of one or more of the Australian National Health Priority Area conditions. Burden was assessed by self-reported measures of: (i) self-rated health (ii) musculoskeletal-related healthcare and medicines utilisation and, (iii) general healthcare utilisation. Associations between multimorbidity and additional health or healthcare utilisation burden among working-age adults (aged 18 - 64 years of age) with specific musculoskeletal conditions were estimated using logistic regression, adjusting for confounders. Interaction terms were fitted to identify whether there were specific musculoskeletal conditions where multimorbidity was more strongly associated with poorer health or greater healthcare utilisation than in the remaining musculoskeletal group.

RESULTS

Among working-age adults, for each of the specified musculoskeletal conditions, multimorbidity was associated with similar, increased likelihood of additional self-rated health burden and certain types of healthcare utilisation. While there were differences in the relationships between multimorbidity and burden for each of the specific musculoskeletal conditions, no one specific musculoskeletal condition appeared to be consistently associated with greater additional health burden in the presence of multimorbidity across the majority of self-rated health burden and healthcare use measures.

CONCLUSIONS

For working-age people with any musculoskeletal conditions examined here, multimorbidity increases self-reported health and healthcare utilisation burden. As no one musculoskeletal condition appears consistently worse off in the presence of multimorbidity, there is a need to better understand and identify strategies that acknowledge and address the additional burden of concomitant conditions for working-age adults with a range of musculoskeletal conditions.

The prevalence of diagnosed chronic conditions and multimorbidity in Australia: A method for estimating population prevalence from general practice patient encounter data

Objectives

To estimate the prevalence of common chronic conditions and multimorbidity among patients at GP encounters and among people in the Australian population. To assess the extent to which use of each individual patient’s GP attendance over the previous year, instead of the average for their age-sex group, affects the precision of national population prevalence estimates of diagnosed chronic conditions.

Design, setting and participants

A sub-study (between November 2012 and March 2016) of the Bettering the Evaluation and Care of Health program, a continuous national study of GP activity. Each of 1,449 GPs provided data for about 30 consecutive patients (total 43,501) indicating for each, number of GP attendances in previous year and all diagnosed chronic conditions, using their knowledge of the patient, patient self-report, and patient's health record.

Results

Hypertension (26.5%) was the most prevalent diagnosed chronic condition among patients surveyed, followed by osteoarthritis (22.7%), hyperlipidaemia (16.6%), depression (16.3%), anxiety (11.9%), gastroesophageal reflux disease (GORD) (11.3%), chronic back pain (9.7%) and Type 2 diabetes (9.6%).

After adjustment, we estimated population prevalence of hypertension as 12.4%, 9.5% osteoarthritis, 8.2% hyperlipidaemia, 8.0% depression, 5.8% anxiety and 5.2% asthma. Estimates were significantly lower than those derived using the previous method.

About half (51.6%) the patients at GP encounters had two or more diagnosed chronic conditions and over one third (37.4%) had three or more. Population estimates were: 25.7% had two or more diagnosed chronic conditions and 15.8% had three or more.

Conclusions

Of the three approaches we have tested to date, this study provides the most accurate method for estimation of population prevalence of chronic conditions using the GP as an expert interviewer, by adjusting for each patient’s reported attendance.

Cross-sectional examination of musculoskeletal conditions and multimorbidity: influence of different thresholds and definitions on prevalence and association estimates

BACKGROUND

Multimorbidity and musculoskeletal conditions create substantial burden for people and health systems. Quantifying the extent of co-occurring conditions is hampered by conceptual heterogeneity, imprecision and/or indecision about how multimorbidity is defined. The purpose of this study is to examine the influence of different ways of operationalising multimorbidity on multimorbidity prevalence rates with a focus on working-age adults with musculoskeletal conditions. Weighted population prevalence rates of multimorbidity among working-age Australians were estimated using data from the National Health Survey. Two nominal thresholds (2+ or 3+ co-occurring conditions) and three operational definitions of multimorbidity (survey-, policy- and research-based) were examined. Using logistic regression, we estimated the association between the prevalence of multimorbidity among persons with musculoskeletal conditions compared to persons with non-musculoskeletal conditions for each definition and threshold combination.

RESULTS

As few as 7.9% of working-age Australians have 2+ conditions using the research-based definition (95% CI 7.4-8.5%), compared to estimates of 15.3% (95% CI 14.3-16.2%) and 61.5% (95% CI 60.3-62.7%). with the policy- and survey-based definitions, respectively. Depending on definition, with the 3+ threshold multimorbidity prevalence ranged from 2.1% (research) to 41.9% (survey). Among the sub-sample with musculoskeletal conditions, multimorbidity with the 2+ threshold ranged from 20.2 to 92.2%; and with 3+ threshold from 5.9 to 75.4%, again lowest with the research-definition and highest with the survey-definition. When compared to any other condition (i.e. non-musculoskeletal conditions), all musculoskeletal conditions were positively associated with multimorbidity, regardless of definition or threshold.

CONCLUSIONS

Depending on definition and threshold, multimorbidity is either rare or endemic in working-age Australians. Irrespective of definition, musculoskeletal conditions are a near-ubiquitous feature of multimorbidity.

How Australian general practitioners engage in discussions about alcohol with their patients: a cross-sectional study

OBJECTIVE

This study aimed to investigate factors that inhibit and facilitate discussion about alcohol between general practitioners (GPs) and patients.

DESIGN

Data analysis from a cross-sectional survey.

SETTING AND PARTICIPANTS

894 GP delegates of a national health seminar series held in five capital cities of Australia in 2014.

MAIN OUTCOME MEASURES

Likelihood of routine alcohol enquiry; self-assessed confidence in assessing and managing alcohol issues in primary healthcare.

RESULTS

Most GPs (87%) reported that they were likely to routinely ask patients about their alcohol consumption and had sufficient skills to manage alcohol issues (74%). Potential barriers to enquiring about alcohol included perceptions that patients are not always honest about alcohol intake (84%) and communication difficulties (44%). 'I usually ask about alcohol' was ranked by 36% as the number one presentation likely to prompt alcohol discussion. Altered liver function test results followed by suspected clinical depression were most frequently ranked in the top three presentations. Suspicious or frequent injuries, frequent requests for sickness certificates and long-term unemployment were ranked in the top three presentations by 20% or less. Confidence in managing alcohol issues independently predicted likelihood to 'routinely ask' about alcohol consumption. Lack of time emerged as the single most important barrier to routinely asking about alcohol. Lack of time was predicted by perceptions of competing health issues in patients, fear of eliciting negative responses and lower confidence in ability to manage alcohol-related issues.

CONCLUSIONS

Improving GPs' confidence and ability to identify, assess and manage at-risk drinking through relevant education may facilitate greater uptake of alcohol-related enquiries in general practice settings. Routine establishment of brief alcohol assessments might improve confidence in managing alcohol issues, reduce the time burden in risk assessment, decrease potential stigma associated with raising alcohol issues and reduce the potential for negative responses from patients.

Prevalence of heart failure in Australia: a systematic review

BACKGROUND

In the absence of a systematic collection of data pertaining to heart failure, summarizing the data available from individual studies provides an opportunity to estimate the burden of heart failure. The present study systematically reviewed the literature to estimate the incidence and prevalence rates of heart failure in Australia.

METHODS

Studies reporting on prevalence or incidence of heart failure published between 1990 and 2015 were identified through a systematic search of Embase, PubMed, Ovid Medline, MeSH, Scopus and websites of the Australian Institute of Health, and Welfare and Australian Bureau of Statistics.

RESULTS

The search yielded a total of 4978 records, of which thirteen met the inclusion criteria. There were no studies reporting on the incidence of heart failure. The prevalence of heart failure in the Australian population ranged between 1.0% and 2.0%, with a significant proportion of cases being previously undiagnosed. The burden of heart failure was higher among Indigenous than non-Indigenous Australians (age-standardized prevalence rate ratio of 1.7). Heart failure was prevalent in women than men, and in rural and remote regions than in the metropolitan and capital territories.

CONCLUSION

This systematic review highlights the limited available data on the epidemiology of heart failure in Australia. Population level studies, using standardized approaches, are needed in order to precisely describe the burden of HF in the population.

Evidence for the low recording of weight status and lifestyle risk factors in the Danish National Registry of Patients, 1999-2012

Background

To examine the prevalence of lifestyle diagnosis codes recorded in the Danish National Registry of Patients (DNRP).

Methods

We identified all hospital contacts in Denmark 1999–2012 with a diagnosis of overweight, obesity, physical inactivity, current tobacco smoking, and/or excessive alcohol consumption. We computed the annual prevalence per 1000 hospital contacts of these diagnoses overall and by baseline characteristics.

Results

Among 56,665,048 hospital contacts, the overall prevalence of recording per 1000 hospital contacts was 4.87 for a diagnosis of obesity, 2.36 for overweight, 2.90 for smoking, 0.39 for excessive alcohol consumption, and 0.47 for physical inactivity. Between 1999 and 2012, marked increases were noted for the prevalence of recorded obesity (30-fold, from 0.26 to 8.02), smoking (26-fold, from 0.18 to 4.88), and overweight (14-fold, from 0.23 to 3.52). Diagnosis coding of excessive alcohol consumption and physical inactivity remained at a very low level. The prevalence of recorded lifestyle risk factors varied substantially according to geographical regions, type of hospital contact, patient age, sex and underlying disease. In 2012, the prevalence of codes for obesity were highest among patients with diabetes (15.64 per 1000), COPD (12.95 per 1000), and congestive heart failure (11.24 per 1000). Codes for smoking were prevalent among patients with COPD (14.11 per 1000), liver disease (12.68 per 1000), and peripheral vascular disease (8.52 per 1000).

Conclusion

Despite increasing prevalence of adverse lifestyle risk factors recorded in the DNRP, the much higher prevalence of similar lifestyle risk factors in health surveys suggests that the completeness of coding in the DNRP remains poor.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2670-9) contains supplementary material, which is available to authorized users.

Residential distance from major urban areas, diabetes and cardiovascular mortality in Australia

BACKGROUND

Living outside major urban centres is associated with increased mortality in the general population but whether having diabetes further impacts on the effects of living outside major urban centres is not known. This study explores the impact of residential location and diabetes on all-cause, ischemic heart disease (IHD) and stroke mortality in Australia.

METHODS

We included 1,101,053 individuals (all ages) with diabetes on the national diabetes register, between 2000 and 2010. Vital statistics were collected by linkage to the death registry. The Accessibility/Remoteness Index of Australia (ARIA+) was used to categorize residences into major urban, inner regional, outer regional and remote areas, according to distance from major service centres. Standardised mortality ratios (SMRs) by ARIA+ are reported.

RESULTS

During follow-up (median 6.7 years), there were 187,761 deaths (46,244 and 12,786 IHD and stroke deaths, respectively). Age-standardized all-cause, stroke and IHD mortality rates increased across ARIA+ categories in diabetes and in the general population. For all outcomes, similar patterns were observed in both sexes and diabetes type, although the rates were higher in males. For all-cause (both sexes, type 1 diabetes (T1DM) and type 2 diabetes (T2DM)), IHD mortality (T2DM only) and stroke mortality (T2DM only), SMRs varied across ARIA+ categories, showing a shallow U-shaped relationship, in which the lowest SMR was in the inner regional or outer regional areas, and the highest SMR in the major urban or remote areas.

CONCLUSION

The effect of diabetes on mortality varied only modestly by location, and the impact of diabetes was greatest in the major urban and remote areas, and least in the inner and outer regional areas.

Web-Based Study of Risk Factors for Pain Exacerbation in Osteoarthritis of the Knee (SPARK-Web): Design and Rationale

Background

Knee osteoarthritis (OA) is the most frequent cause of limited mobility and diminished quality of life. Pain is the main symptom that drives individuals with knee OA to seek medical care and a recognized antecedent to disability and eventually joint replacement. Many persons with symptomatic knee OA experience recurrent pain exacerbations. Knowledge and clarification of risk factors for pain exacerbation may allow those affected to minimize reoccurrence of these episodes.

Objective

The aim of this study is to use a Web-based case-crossover design to identify risk factors for knee pain exacerbations in persons with symptomatic knee OA.

Methods

Web-based case-crossover design is used to study persons with symptomatic knee OA. Participants with knee pain and radiographic knee OA will be recruited and followed for 90 days. Participants will complete an online questionnaire at the baseline and every 10 days thereafter (totaling up to 10 control-period questionnaires); participants will also be asked to report online when they experience an episode of increased knee pain. Pain exacerbation will be defined as an increase in knee pain severity of two points from baseline on a numeric rating scale (NRS 0-10). Physical activity, footwear, knee injury, medication use, climate, psychological factors, and their possible interactions will be assessed as potential triggers for pain exacerbation using conditional logistic regression models.

Results

This project has been funded by the National Health and Medical Research Council (NHMRC). The enrollment for the study has started. So far, 343 participants have been enrolled. The study is expected to be finished in October 2015.

Conclusions

This study will identify risk factors for pain exacerbations in knee OA. The identification and possible modification/elimination of such risk factors will help to prevent the reoccurrence of pain exacerbation episodes and therefore improve knee OA management.

The Web-Based Osteoarthritis Management Resource My Joint Pain Improves Quality of Care: A Quasi-Experimental Study

Background

Despite the availability of evidence-based guidelines for conservative treatment of osteoarthritis (OA), management is often confined to the use of analgesics and waiting for eventual total joint replacement. This suggests a gap in knowledge for persons with OA regarding the many different treatments available to them.

Objective

Our objective was to evaluate outcomes after usage of a Web-based resource called My Joint Pain that contains tailored, evidence-based information and tools aimed to improve self-management of OA on self-management and change in knowledge.

Methods

A quasi-experimental design was used to evaluate the My Joint Pain website intervention over a 12-month period. The intervention provided participants with general and user-specific information, monthly assessments with validated instruments, and progress-tracking tools. A nationwide convenience sample of 195 participants with self-assessed hip and/or knee OA completed both baseline and 12-month questionnaires (users: n=104; nonusers: n=91). The primary outcome measure was the Health Evaluation Impact Questionnaire (heiQ) to evaluate 8 different domains (health-directed activity, positive and active engagement in life, emotional distress, self-monitoring and insight, constructive attitudes and approaches, skill and technique acquisition, social integration and support, health service navigation) and the secondary outcome measure was the 17-item Osteoarthritis Quality Indicator (OAQI) questionnaire to evaluate the change in appropriateness of care received by participants. Independent t tests were used to compare changes between groups for the heiQ and chi-square tests to identify changes within and between groups from baseline to 12 months for each OAQI item.

Results

Baseline demographics between groups were similar for gender (152/195, 77.9% female), age (mean 60, SD 9 years) and body mass index (mean 31.1, SD 6.8 kg/m²). With the exception of health service navigation, mean effect sizes from all other heiQ domains showed a positive trend for My Joint Pain users compared to the nonusers, although the differences between groups did not reach statistical significance. Within-group changes also showed improvements among the users of the My Joint Pain website for self-management (absolute change score=15%, P=.03), lifestyle (absolute change score=16%, P=.02), and physical activity (absolute change score=11%, P=.04), with no significant improvements for the nonusers. Following 12 months of exposure to the website, there were significant improvements for users compared to nonusers in self-management (absolute change score 15% vs 2%, P=.001) and weight reduction (absolute change scores 3% vs –6%, P=.03) measured on the OAQI.

Conclusions

The My Joint Pain Web resource does not significantly improve overall heiQ, but does improve other important aspects of quality of care in people with hip and/or knee OA. Further work is required to improve engagement with the website and the quality of information delivered in order to provide a greater impact.

The Role of eHealth in Optimizing Preventive Care in the Primary Care Setting

Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world’s morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.

Multimorbidity among people with HIV in regional New South Wales, Australia

Background Multimorbidity is the co-occurrence of more than one chronic health condition in addition to HIV. Higher multimorbidity increases mortality, complexity of care and healthcare costs while decreasing quality of life. The prevalence of and factors associated with multimorbidity among HIV positive patients attending a regional sexual health service are described.

METHODS

A record review of all HIV positive patients attending the service between 1 July 2011 and 30 June 2012 was conducted. Two medical officers reviewed records for chronic health conditions and to rate multimorbidity using the Cumulative Illness Rating Scale (CIRS). Univariate and multivariate linear regression analyses were used to determine factors associated with a higher CIRS score.

RESULTS

One hundred and eighty-nine individuals were included in the study; the mean age was 51.8 years and 92.6% were men. One-quarter (25.4%) had ever been diagnosed with AIDS. Multimorbidity was extremely common, with 54.5% of individuals having two or more chronic health conditions in addition to HIV; the most common being a mental health diagnosis, followed by vascular disease. In multivariate analysis, older age, having ever been diagnosed with AIDS and being on an antiretroviral regimen other than two nucleosides and a non-nucleoside reverse transcriptase inhibitor or protease inhibitor were associated with a higher CIRS score.

CONCLUSION

To the best of our knowledge, this is the first study looking at associations with multimorbidity in the Australian setting. Care models for HIV positive patients should include assessing and managing multimorbidity, particularly in older people and those that have ever been diagnosed with AIDS.

A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Despite the widespread availability of evidence-based clinical guidelines and validated risk predication equations for prevention and management of CVD, their translation into routine practice is limited. We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support, patient risk communication tools, computerised audit and feedback tools, and monthly, peer-ranked performance feedback via a web portal. The intervention was implemented in a cluster randomised controlled trial in 60 primary healthcare services in Australia. Overall, there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals, but it is unclear how this intervention was used in practice and what factors promoted or hindered its use. This information is necessary to optimise intervention impact and maximally implement it in a post-trial context. In this study protocol, we outline our methods to conduct a theory-based, process evaluation of the intervention. Our aims are to understand how, why, and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination.

METHODS/DESIGN

We will conduct four discrete but inter-related studies taking a mixed methods approach. Our quantitative studies will examine (1) the longer term effectiveness of the intervention post-trial, (2) patient and health service level correlates with trial outcomes, and (3) the health economic impact of implementing the intervention at scale. The qualitative studies will (1) identify healthcare provider perspectives on implementation barriers and enablers and (2) use video ethnography and patient semi-structured interviews to understand how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention. We will also assess the costs of implementing the intervention in Australian primary healthcare settings which will inform scale-up considerations.

DISCUSSION

This mixed methods evaluation will provide a detailed understanding of the process of implementing a quality improvement intervention and identify the factors that might influence scalability and sustainability.

TRIALS REGISTRATION

12611000478910.

Out-of-pocket expenditure by Australian seniors with chronic disease: the effect of specific diseases and morbidity clusters

BACKGROUND

Out of pocket expenditure (OOPE) on healthcare is related to the burden of illness and the number of chronic conditions a patient experiences, but the relationship of these costs to particular conditions and groups of conditions is less studied. This study examines the effect on OOPE of various morbidity groupings, and explores the factors associated with a 'heavy financial burden of OOPE' defined by an expenditure of over 10% of equivalised household income on healthcare.

METHODS

Data were collected from 4,574 senior Australians using a stratified sampling procedure by age, rurality and state of residence. Natural clusters of chronic conditions were identified using cluster analysis and clinically relevant clusters based on expert opinion. We undertook logistic regression to model the probability of incurring OOPE, and a heavy financial burden; linear regression to explore the significant factors of OOPE; and two-part models to estimate the marginal effect of factors on OOPE.

RESULTS

The mean OOPE in the previous three months was AU$353; and 14% of respondents experienced a heavy financial burden. Medication and medical service expenses were the major costs. Those who experienced cancer, high blood pressure, diabetes or depression were likely to report higher OOPE. Patients with cancer or diabetes were more likely than others to face a heavy burden of OOPE relative to income. Total number of conditions and some specific conditions predict OOPE but neither the clusters nor pairs of conditions were good predictors of OOPE.

CONCLUSIONS

Total number of conditions and some specific conditions predict both OOPE and heavy financial burden but particular comorbid groupings are not useful in predicting OOPE. Low-income patients pay a higher proportion of income than the well-off as OOPE for healthcare. Interventions targeting those who are likely to face severe financial burdens due to their health could address some of these differences.

Using data from patient interactions in primary care for population level chronic disease surveillance: The Sentinel Practices Data Sourcing (SPDS) project

Background

Population health planning within a health district requires current information on health profiles of the target population. Information obtained during primary care interactions may provide a valuable surveillance system for chronic disease burden. The Sentinel Practices Data Sourcing project aimed to establish a sentinel site surveillance system to obtain a region-specific estimate of the prevalence of chronic diseases and mental health disorders within the Illawarra-Shoalhaven region of New South Wales, Australia.

Methods

In September 2013, de-identified information for all patient interactions within the preceding 24 months was extracted and collated using a computerised chronic disease management program that has been designed for desktop application (Pen Computer Systems Clinical Audit Tool: ^™ (PCS CAT)). Collated patient data included information on all diagnosed pathologies and mental health indicators, clinical variables such as anthropometric measures, and patient demographic variables such as age, sex, geographical location of residence and indigenous status. Age-standardised prevalence of selected health conditions was calculated.

Results

Of the 52 general practices within the 6 major Statistical Local Areas (SLAs) of the health district that met the inclusion criteria, 17 consented to participate in the study, yielding data on n = 152,767 patients, and representing 39.7% of the regional population. Higher than national average estimates were found for the age-adjusted prevalence of chronic diseases such as obesity/overweight (65.9% vs 63.4%), hypertension (11.9% vs 10.4%) and anxiety disorders (5.0% vs 3.8%), but a lower than national average age-adjusted prevalence of asthma (8.0% vs 10.2%) was also identified.

Conclusions

This proof-of-concept study has demonstrated that the scope of data collected during patient visits to their general practitioners (GPs), facilitated through the Medicare-funded primary health care system in Australia, provides an opportunity for monitoring of chronic disease prevalence and its associated risk factors at the local level. Selection of sentinel sites that are representative of the population being served will facilitate an accurate and region-specific system for the purpose of population health planning at the primary care level.

Encouraging general practitioners to complete the four-year-old Healthy Kids Check and provide healthy eating and physical activity messages

OBJECTIVE

To describe the impact of a training and support intervention to encourage completion of the Healthy Kids Check (HKC) by general practitioners (GP) or practice nurses (PN) and provision of brief advice on diet and physical activity.

METHODS

The intervention (June 2008 to July 2010) was delivered by Divisions of General Practice (DGP) in the Hunter New England (HNE) region of NSW, Australia, to members in 300 practices. Intervention impact was evaluated using Medicare data on the number of HKCs completed and a post-intervention telephone survey of randomly selected parents in HNE and rest of NSW.

RESULTS

Training reached 31% of GPs (n∼ 216/700) and 71% of PNs (n∼320/450); 31% of four-year-olds received a HKC in HNE compared to 15% in NSW; 27% of HNE parents (n=162) reported a GP or PN had provided advice during their child's vaccinations visit compared to 15% of parents (n=154) in NSW (p=0.002). There was no significant difference in proportion of children who had weight or height assessed (55.6% in HNE and 54.6% in NSW).

CONCLUSIONS

Boosting HKC claims and healthy eating and physical activity messages in general practice is feasible. More intensive strategies are required if obesity prevention and management benefits are to be achieved.

IMPLICATIONS

General practice is an important but under-utilised source of advice for parents and data for policy makers on childhood obesity in Australia.

A telephone-supported cardiovascular lifestyle programme (CLIP) for lipid reduction and weight loss in general practice patients: a randomised controlled pilot trial

OBJECTIVE

To evaluate a primary prevention care model using telephone support delivered through an existing health call centre to general practitioner-referred patients at risk of developing CVD, using objective measures of CVD risk reduction and weight loss.

DESIGN

Participants were randomised into two groups: (i) those receiving a telephone-supported comprehensive lifestyle intervention programme (CLIP: written structured diet and exercise advice, plus seven telephone sessions with the Heart Foundation Health Information Service); and (ii) those receiving usual care from their general practitioner (control: written general lifestyle advice). Fasting plasma lipids, blood pressure, weight, waist circumference and height were assessed on general practice premises by a practice nurse at Weeks 0 and 12.

SETTING

Two general practices in Adelaide, South Australia.

SUBJECTS

Forty-nine men and women aged 48·0 (sd 5·88) years identified by their general practitioner as being at future risk of CVD (BMI = 33·13 (sd 5·39) kg/m2; LDL cholesterol (LDL-C) = 2·66 (sd 0·92) mmol/l).

RESULTS

CLIP participants demonstrated significantly greater reductions in LDL-C (estimated mean (EM) = 1·98 (se 0·17) mmol/l) and total cholesterol (EM = 3·61 (se 0·21) mmol/l) at Week 12 when compared with the control group (EM = 3·23 (se 0·18) mmol/l and EM = 4·77 (se 0·22) mmol/l, respectively). There were no significant treatment effects for systolic blood pressure (F(1,45) = 0·28, P = 0·60), diastolic blood pressure (F(1,43) = 0·52, P = 0·47), weight (F(1,42) = 3·63, P = 0·063) or waist circumference (F(1,43) = 0·32, P = 0·577).

CONCLUSIONS

In general practice patients, delivering CLIP through an existing telephone health service is effective in achieving reductions in LDL-C and total cholesterol. While CLIP may have potential for wider implementation to support primary prevention of CVD, longer-term cost-effectiveness data are warranted.

Multimorbidity and comorbidity of chronic diseases among the senior Australians: prevalence and patterns

Understanding patterns and identifying common clusters of chronic diseases may help policymakers, researchers, and clinicians to understand the needs of the care process better and potentially save both provider and patient time and cost. However, only limited research has been conducted in this area, and ambiguity remains as those limited previous studies used different approaches to identify common clusters and findings may vary with approaches. This study estimates the prevalence of common chronic diseases and examines co-occurrence of diseases using four approaches: (i) identification of the most occurring pairs and triplets of comorbid diseases; performing (ii) cluster analysis of diseases, (iii) principal component analysis, and (iv) latent class analysis. Data were collected using a questionnaire mailed to a cross-sectional sample of senior Australians, with 4574 responses. Eighty-two percent of respondents reported having at least one chronic disease and over 52% reported having at least two chronic diseases. Respondents suffering from any chronic diseases had an average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified: (i) asthma, bronchitis, arthritis, osteoporosis and depression; (ii) high blood pressure and diabetes; and (iii) cancer, with heart disease and stroke either making a separate group or "attaching" themselves to different groups in different analyses. The groups were largely consistent across the approaches. Stability and sensitivity analyses also supported the consistency of the groups. The consistency of the findings suggests there is co-occurrence of diseases beyond chance, and patterns of co-occurrence are important for clinicians, patients, policymakers and researchers. Further studies are needed to provide a strong evidence base to identify comorbid groups which would benefit from appropriate guidelines for the care and management of patients with particular disease clusters.

Multimorbidity in patients attending 2 Australian primary care practices

PURPOSE

Multiple chronic conditions in a single patient can be a challenging health burden. We aimed to examine patterns and prevalence of multimorbidity among patients attending 2 large Australian primary care practices and to estimate disease severity burden using the Cumulative Illness Rating Scale (CIRS).

METHODS

Using published CIRS guidelines and a disease severity index calculated for each individual, we extracted data from the medical records of all 7,247 patients (58.5% female) seen over 6 months in 2008 who were rated for chronic conditions across 14 anatomical domains.

RESULTS

Fifty-two percent of patients had multimorbidity in 2 or more CIRS domains, ranging from 20.6% if younger than 25 years, 43.7% if aged 25 to 44 years, 75.5% if aged 45 to 64 years, 87.5% if aged 65 to 74 years, and 97.1% if aged 75 years and older. Using a cutoff of 3 or more CIRS domains, 34.5% had multimorbidity ranging from 4.8% if younger than 25 years, 22.3% if aged 25 to 44 years, 56.1% if aged 45 to 64 years, 74.6% if aged 65 to 74 years, and 92.0% if aged 75 years and older. Musculoskeletal, singularly or in combination with others, was the commonest morbidity domain. The moderate severity index category increased with increasing age.

CONCLUSIONS

Multimorbidity is a significant problem in men and women across all age-groups, and the moderate severity index increases with age. The musculoskeletal domain was most commonly affected. Mild and moderate severity index categories may underrepresent disease burden. Severity burden assessment in the primary care setting needs to take into account the severity index, as well as levels of domain severity within the index categories.

The influence of perceived stress on the onset of arthritis in women: findings from the Australian Longitudinal Study on women's health

BACKGROUND

Psychosocial factors are considered as risk factors for some chronic diseases. A paucity of research exists surrounding the role of perceived stress in arthritis onset.

PURPOSE

Perceived stress as a risk factor for arthritis development was explored in an ageing cohort of Australian women.

METHODS

This study focused on 12,202 women from the 1946-1951 cohort who completed the Australian Longitudinal Study on Women's Health surveys in 2001, 2004 and 2007. Longitudinal associations were modelled, with and without a time lag.

RESULTS

Findings from the multivariate time lag modelling, excluding women with persistent joint pain, revealed that perceived stress predicted the onset of arthritis, with women experiencing minimal and moderate/high stress levels having a 1.7 and 2.4 times greater odds of developing arthritis 3 years later, respectively (p's < 0.001).

CONCLUSION

Chronically perceiving life as stressful is detrimental to future health. The findings provide support for perceived stress to be considered alongside other modifiable risk factors.

Quality of life impact of cardiovascular and affective conditions among older residents from urban and rural communities

Background

The demographic, health and contextual factors associated with quality of life impairment are investigated in older persons from New South Wales, Australia. We examine the impact of cardiovascular and affective conditions on impairment and the potential moderating influence of comorbidity and remoteness.

Methods

Data from persons aged 55 and over were drawn from two community cohorts sampling from across urban to very remote areas. Hierarchical linear regressions were used to assess: 1) the impact of cardiovascular and affective conditions on physical and psychological quality of life impairment; and 2) any influence of remoteness on these effects (N = 4364). Remoteness was geocoded to participants at the postal code level. Secondary data sources were used to examine the social capital and health service accessibility correlates of remoteness.

Results

Physical impairment was consistently associated with increased age, male gender, lower education, being unmarried, retirement, stroke, heart attack/angina, depression/anxiety, diabetes, hypertension, current obesity and low social support. Psychological impairment was consistently associated with lower age, being unmarried, stroke, heart attack/angina, depression/anxiety and low social support. Remoteness tended to be associated with lower psychological impairment, largely reflecting overall urban versus rural differences. The impacts of cardiovascular and affective conditions on quality of life were not influenced by remoteness. Social capital increased and health service accessibility decreased with remoteness, though no differences between outer-regional and remote/very remote areas were observed. Trends suggested that social capital was associated with lower psychological impairment and that the influence of cardiovascular conditions and social capital on psychological impairment was greater for persons with a history of affective conditions. The beneficial impact of social capital in reducing psychological impairment was more marked for those experiencing financial difficulty.

Conclusions

Cardiovascular and affective conditions are key determinants of physical and psychological impairment. Persons affected by physical-psychological comorbidity experience greater psychological impairment. Social capital is associated with community remoteness and may ameliorate the psychological impairment associated with affective disorders and financial difficulties. The use of classifications of remoteness that are sensitive to social and health service accessibility determinants of health may better inform future investigations into the impact of context on quality of life outcomes.

Comparisons of multi-morbidity in family practice--issues and biases

BACKGROUND

As the population ages, practice and policy need to be guided by accurate estimates of chronic disease burden in primary care.

OBJECTIVE

To produce a preliminary set of methodological considerations for cross-sectional and retrospective cohort studies of multi-morbidity in primary care using three studies as examples. Prevalence rate results from the three studies were re-estimated using identical age-sex groups.

METHODS

We compared the methods and results of three separate studies in primary care: (i) patients in the Saguenay region of Quebec, Canada (2005); (ii) a substudy of the BEACH (Bettering the Evaluation and Care of Health) programme in Australia (2008); and (iii) the DELPHI (Deliver Primary Health Care Information) project in South-western Ontario, Canada (2009). Areas where the methods of multi-morbidity studies may differ were identified. The percentage of patients with two or more chronic conditions was compared by age-sex groups.

RESULTS

Multi-morbidity prevalence varied by as much as 61%, where reported prevalence was 95% among females aged 45-64 in the Saguenay study, 46% in the BEACH substudy and 34% in the DELPHI study. Several aspects of the methods and study designs were identified as differing among the studies, including the sampling of frequent attenders, sampling period, source of data, and both the definition and count of chronic conditions.

CONCLUSIONS

Understanding the differences among the methods used to produce prevalence data on multi-morbidity in primary care can help explain the varying results. Standardization of methods would allow for more valid inter-study comparisons.

Gastro oesophageal reflux disease (GORD)-related symptoms and its association with mood and anxiety disorders and psychological symptomology: a population-based study in women

BACKGROUND

Psychopathology seems to play a role in reflux pathogenesis and vice versa, yet few population-based studies have systematically investigated the association between gastro-oesophageal reflux disease (GORD) and psychopathology. We thus aimed to investigate the relationship between GORD-related symptoms and psychological symptomatology, as well as clinically diagnosed mood and anxiety disorders in a randomly selected, population-based sample of adult women.

METHODS

This study examined data collected from 1084 women aged 20-93 yr participating in the Geelong Osteoporosis Study. Mood and anxiety disorders were identified using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID-I/NP), and psychological symptomatology was assessed using the General Health Questionnaire (GHQ-12). GORD-related symptoms were self-reported and confirmed by medication use where possible and lifestyle factors were documented.

RESULTS

Current psychological symptomatology and mood disorder were associated with increased odds of concurrent GORD-related symptoms (adjusted OR 2.1, 95% CI 1.3-3.5, and OR 3.0, 95% CI 1.7-5.6, respectively). Current anxiety disorder also tended to be associated with increased odds of current GORD-related symptoms (p = 0.1). Lifetime mood disorder was associated with a 1.6-fold increased odds of lifetime GORD-related symptoms (adjusted OR 1.6, 95% CI 1.1-2.4) and lifetime anxiety disorder was associated with a 4-fold increased odds of lifetime GORD-related symptoms in obese but not non-obese participants (obese, age-adjusted OR 4.0, 95% CI 1.8-9.0).

CONCLUSIONS

These results indicate that psychological symptomatology, mood and anxiety disorders are positively associated with GORD-related symptoms. Acknowledging this common comorbidity may facilitate recognition and treatment, and opens new questions as to the pathways and mechanisms of the association.

Prevalence of chronic conditions in Australia

OBJECTIVES

To estimate prevalence of chronic conditions among patients seeing a general practitioner (GP), patients attending general practice at least once in a year, and the Australian population.

DESIGN SETTING AND PARTICIPANTS

A sub-study of the BEACH (Bettering the Evaluation and Care of Health) program, a continuous national study of general practice activity conducted between July 2008 and May 2009. Each of 290 GPs provided data for about 30 consecutive patients (total 8,707) indicating diagnosed chronic conditions, using their knowledge of the patient, patient self-report, and patient's health record.

MAIN OUTCOME MEASURES

Estimates of prevalence of chronic conditions among patients surveyed, adjusted prevalence in patients who attended general practice at least once that year, and national population prevalence.

RESULTS

Two-thirds (66.3%) of patients surveyed had at least one chronic condition: most prevalent being hypertension (26.6%), hyperlipidaemia (18.5%), osteoarthritis (17.8%), depression (13.7%), gastro-oesophageal reflux disease (11.6%), asthma (9.5%) and Type 2 diabetes (8.3%). For patients who attended general practice at least once, we estimated 58.8% had at least one chronic condition. After further adjustment we estimated 50.8% of the Australian population had at least one chronic condition: hypertension (17.4%), hyperlipidaemia (12.7%), osteoarthritis (11.1%), depression (10.5%) and asthma (8.0%) being most prevalent.

CONCLUSIONS

This study used GPs to gather information from their knowledge, the patient, and health records, to provide prevalence estimates that overcome weaknesses of studies using patient self-report or health record audit alone. Our results facilitate examination of primary care resource use in management of chronic conditions and measurement of prevalence of multimorbidity in Australia.

General Practitioners' perceptions of their role in cancer care and factors which influence this role

Effective cancer care depends on inter-sectoral and inter-professional communication. General Practitioners (GPs) play a pivotal role in managing the health of most Australians, but their role in cancer care is unclear. This qualitative study explored GPs' views of this role and factors influencing their engagement with cancer care. Twelve metropolitan and non-metropolitan GPs in Queensland, Australia, were recruited between April and May 2008, and three focus groups and one interview were conducted using open-ended questions. The transcripts were analysed thematically. The first theme, GPs' perceptions of their role, comprised subthemes corresponding to four phases of the trajectory. The second theme, Enhancing GPs' involvement in ongoing cancer care, comprised subthemes regarding enhanced communication and clarification of roles and expectations. GPs' role in cancer care fluctuates between active advocacy during diagnosis and palliation, and ambivalent redundancy in between. The role is influenced by socioeconomic, clinical and geographical factors, patients' expectations and GPs' motivation. Not all participants wanted an enhanced role in cancer care, but all valued better specialist-GP communication. Role clarification is needed, together with greater mutual trust between GPs and specialists. Key needs included accessible competency training and mentoring for doctors unfamiliar with the system. Existing system barriers and workforce pressures in general practice must be addressed to improve the sharing of cancer care. Only one metropolitan focus group was conducted, so saturation of themes may not have been reached. The challenges of providing cancer care in busy metropolitan practices are multiplied in non-metropolitan settings with less accessible resources and where distance affects specialist communication. Non-metropolitan GPs learn from experience how to overcome referral and communication challenges. While the GPs identified solutions to their concerns, the role can be daunting. GPs are motivated to provide long-term care for their patients, but need to be acknowledged and supported by the health system.

Monitoring the prevalence of chronic conditions: which data should we use?

Background

Chronic diseases are an increasing threat to people’s health and to the sustainability of health organisations. Despite the need for routine monitoring systems to assess the impact of chronicity in the population and its evolution over time, currently no single source of information has been identified as suitable for this purpose. Our objective was to describe the prevalence of various chronic conditions estimated using routine data recorded by health professionals: diagnoses on hospital discharge abstracts, and primary care prescriptions and diagnoses.

Methods

The ICD-9-CM codes for diagnoses and Anatomical Therapeutic Chemical (ATC) codes for prescriptions were collected for all patients in the Basque Country over 14 years of age (n=1,964,337) for a 12-month period. We employed a range of different inputs: hospital diagnoses, primary care diagnoses, primary care prescriptions and combinations thereof. Data were collapsed into the morbidity groups specified by the Johns Hopkins Adjusted Clinical Groups (ACGs) Case-Mix System. We estimated the prevalence of 12 chronic conditions, comparing the results obtained using the different data sources with each other and also with those of the Basque Health Interview Survey (ESCAV). Using the different combinations of inputs, Standardized Morbidity Ratios (SMRs) for the considered diseases were calculated for the list of patients of each general practitioner. The variances of the SMRs were used as a measure of the dispersion of the data and were compared using the Brown-Forsythe test.

Results

The prevalences calculated using prescription data were higher than those obtained from diagnoses and those from the ESCAV, with two exceptions: malignant neoplasm and migraine. The variances of the SMRs obtained from the combination of all the data sources (hospital diagnoses, and primary care prescriptions and diagnoses) were significantly lower than those using only diagnoses.

Conclusions

The estimated prevalence of chronic diseases varies considerably depending of the source(s) of information used. Given that administrative databases compile data registered for other purposes, the estimations obtained must be considered with caution. In a context of increasingly widespread computerisation of patient medical records, the complementary use of a range of sources may be a feasible option for the routine monitoring of the prevalence of chronic diseases.

The relative importance of psychosocial factors in arthritis: findings from 10,509 Australian women

OBJECTIVE

To determine the relative importance of psychosocial factors in arthritis diagnosis in an ageing cohort of Australian women.

METHODS

This study focused on 10,509 women from the 1946-1951 cohort who responded to questions on arthritis in the fifth mailed population-based survey of the Australian Longitudinal Study on Women's Health conducted in 2007.

RESULTS

Arthritis was characterised by widespread psychosocial concerns, particularly relating to chronic stress and poor mental health. Univariate analyses revealed that in comparison to women without stress, women with moderate/high stress levels had a 2.5-fold increase in reporting arthritis. Experiencing ongoing negative interpersonal life events concerning illness of a family member/close friend and relationship difficulties was also associated with a 1.4-fold increase in the reporting of arthritis. Likewise, significantly reduced levels of optimism and perceived social support were noted (all associations p<.001). Psychiatric diagnosis was also associated with a two-fold increase in having arthritis (p<.001). Following adjustment for behavioural, demographic and health-related characteristics, anxiety was the only psychosocial factor associated with arthritis (OR=1.4, 95% CI=1.2, 1.7; p<.001).

CONCLUSION

This study examined, epidemiologically, the relative importance of psychosocial factors in arthritis in an ageing cohort of Australian women. The findings from this population-based study indicate that women with arthritis are more likely to report a range of psychosocial-related problems, particularly with regard to chronic stress perception and anxiety. Longitudinal analyses are required to examine the processes by which stress and psychosocial factors may contribute to arthritis risk and poor adaptation in terms of health-related quality of life.

Supporting health behaviour change in chronic obstructive pulmonary disease with telephone health-mentoring: insights from a qualitative study

Background

Adoption and maintenance of healthy behaviours is pivotal to chronic disease self-management as this influences disease progression and impact. This qualitative study investigated health behaviour changes adopted by participants with moderate or severe chronic obstructive pulmonary disease (COPD) recruited to a randomised controlled study of telephone-delivered health-mentoring.

Methods

Community nurses trained as health-mentors used a patient-centred approach with COPD patients recruited in general practice to facilitate behaviour change, using a framework of health behaviours; ‘SNAPPS’ Smoking, Nutrition, Alcohol, Physical activity, Psychosocial well-being, and Symptom management, through regular phone calls over 12 months. Semi-structured interviews in a purposive sample sought feedback on mentoring and behaviour changes adopted. Interviews were analysed using iterative thematic and interpretative content approaches by two investigators.

Results

Of 90 participants allocated to health-mentoring, 65 (72%) were invited for interview at 12-month follow up. The 44 interviewees, 75% with moderate COPD, had a median of 13 mentor contacts over 12 months, range 5–20. Interviewed participants (n = 44, 55% male, 43% current smokers, 75% moderate COPD) were representative of the total group with a mean age 65 years while 82% had at least one additional co-morbid chronic condition. Telephone delivery was highly acceptable and enabled good rapport. Participants rated ‘being listened to by a caring health professional’ as very valuable. Three participant groups were identified by attitude to health behaviour change: 14 (32%) actively making changes; 18 (41%) open to and making some changes and 12 (27%) more resistant to change. COPD severity or current smoking status was not related to group category. Mentoring increased awareness of COPD effects, helping develop and personalise behaviour change strategies, even by those not actively making changes. Physical activity was targeted by 43 (98%) participants and smoking by 14 (74%) current smokers with 21% reporting quitting. Motivation to maintain changes was increased by mentor support.

Conclusions

Telephone delivery of health-mentoring is feasible and acceptable to people with COPD in primary care. Health behaviours targeted by this population, mostly with moderate disease, were mainly physical activity and smoking reduction or cessation. Health-mentoring increased motivation and assisted people to develop strategies for making and sustaining beneficial change.

Trial registration

ACTR12608000112368

Systematic review of the prevalence of gout and hyperuricaemia in Australia

AIMS

Gout is a growing health problem worldwide especially in affluent countries, such as Australia. Gout and hyperuricaemia are associated with the metabolic syndrome, diabetes mellitus, obesity and hypertension. More importantly, Australia has a growing prevalence of these important health problems. The aim of this study was to systematically review published information regarding the prevalence of gout and hyperuricaemia in Australia.

METHODS

A systematic search was undertaken of the MEDLINE, EMBASE and Web of Science databases, as well as relevant websites for journal articles and reports relating to the prevalence of hyperuricaemia and gout in Australia.

RESULTS

Twenty-five journal articles and five reports were included in the review. Data collected in a standardised way show gout increased in prevalence from 0.5% population prevalence to 1.7% population prevalence from 1968 to 1995/1996. There has been a significant rise in the prevalence of gout in the Australian Aboriginal population from 0% in 1965 to 9.7% in men and 2.9% in women in 2002. Consistent with the rise in gout prevalence, serum uric acid in blood donors has increased from 1959 to 1980 (17% in 30- to 40-year-old men).

CONCLUSIONS

The rate of gout and hyperuricaemia in Australia is high in relation to comparable countries and is increasing. The prevalence of gout in elderly male Australians is second only to New Zealand, which has the highest reported rate in the world. Further research on Aboriginal and Torres Strait Islander gout and hyperuricaemia is required as a result of the lack of contemporary data.

Prevalence and determinants of frequent gastroesophageal reflux symptoms in the Australian community

Frequent gastroesophageal reflux (GER) causes chronic inflammation and damages esophageal mucosa, which can lead to Barrett's esophagus. It has also been consistently found to be a strong risk factor for esophageal adenocarcinoma. The prevalence of GER appears to vary; however, population-based Australian studies investigating the symptoms are limited. This study aimed to estimate the population prevalence and identify the determinants of frequent GER symptoms in the Australian population. Self-reported information on the frequency of reflux symptoms were collected from 1,580 adults from a population register. We estimated age- and sex-standardized prevalence of occasional (<weekly) and frequent (≥weekly) GER symptoms in the Australian population. We also estimated adjusted prevalence ratios (PR) for GER symptoms associated with demographic and lifestyle characteristics. The standardized prevalences of GER symptoms were 10.4% and 38.3% for frequent and occasional symptoms, respectively. Compared with participants with body mass index <25, those with body mass index ≥35 had almost 90% higher prevalence of frequent GER symptoms (PR 1.89; 95% confidence interval [CI] 1.13-3.16). Similarly, the prevalence of frequent GER symptoms was significantly higher among regular users of aspirin or other non-steroidal anti-inflammatory drugs than never users (PR 1.71; 95%CI 1.08-3.16) and regular consumers of medium to well-done barbecued meat (PR 1.75; 95%CI 1.10-2.80) or fried food (PR 2.69; 95%CI 1.66-4.35). The prevalence of frequent GER symptoms was significantly lowered with regular physical activity (PR 0.46; 95%CI 0.32-0.66) and Helicobacter pylori infection (PR 0.53; 95%CI 0.35-0.80). We found no evidence that frequent GER symptoms were associated with smoking, alcohol, spicy food, or coffee consumption. Our results confirm that GER symptoms are common and that frequent GER symptoms are associated with a range of modifiable lifestyle factors.

Cardiovascular risk management in chronic kidney disease in general practice (the AusHEART study)

BACKGROUND

Chronic kidney disease (CKD) is common and increasing in prevalence. Adverse outcomes of CKD can be prevented through early detection and treatment. There is limited data on the awareness of CKD and the quality of care offered to patients with CKD in the primary care setting. The objectives of this study were to assess the prevalence, general practitioner (GP) awareness and extent of current evidence-practice gaps in the management of CKD in Australian primary care.

METHODS

The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster stratified, cross-sectional survey among 322 GPs. Each GP was asked to provide data for 15-20 consecutive patients (age ≥ 55 years) who presented between April and June, 2008. The main outcome measures were CKD prevalence based on proteinuria and decreased estimated glomerular filtration rate. Evidence-practice gaps in management of patients with CKD were identified.

RESULTS

Among a total of 4966 patients with kidney function test data, 1845 (37%) had abnormal kidney function. Of the 1312 patients with abnormal kidney function known to the GP at the time of visit, only 235 were correctly identified as having CKD. GPs under-estimated cardiovascular (CV) risks in patients with CKD when compared with the prevailing guidelines at the time of survey and the recent national guidelines, particularly in later stages of CKD. Among CKD patients not prescribed blood pressure-lowering agents or lipid-lowering agents, treatment was indicated as per relevant guidelines in 51 and 46%, respectively. For CKD patients who were already prescribed blood pressure-lowering and lipid-lowering agents, 61 and 50%, respectively, did not meet the treatment targets recommended by the relevant guidelines.

CONCLUSIONS

CKD is common, significantly under-recognized and under-treated in primary care. Effort to increase awareness and provide opportunities for improved screening and assessment should improve the management and outcome of these patients at high risk of CV disease.

The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review

OBJECTIVE

To understand the differences in prevalence and incidence estimates of osteoarthritis (OA), according to case definition, in knee, hip and hand joints.

METHOD

A systematic review was carried out in PUBMED and SCOPUS databases comprising the date of publication period from January 1995 to February 2011. We attempted to summarise data on the incidence and prevalence of OA according to different methods of assessment: self-reported, radiographic and symptomatic OA (clinical plus radiographic). Prevalence estimates were combined through meta-analysis and between-study heterogeneity was quantified.

RESULTS

Seventy-two papers were reviewed (nine on incidence and 63 on prevalence). Higher OA prevalences are seen when radiographic OA definition was used for all age groups. Prevalence meta-analysis showed high heterogeneity between studies even in each specific joint and using the same OA definition. Although the knee is the most studied joint, the highest OA prevalence estimates were found in hand joints. OA of the knee tends to be more prevalent in women than in men independently of the OA definition used, but no gender differences were found in hip and hand OA. Insufficient data for incidence studies didn't allow us to make any comparison according to joint site or OA definition.

CONCLUSIONS

Radiographic case definition of OA presented the highest prevalences. Within each joint site, self-reported and symptomatic OA definitions appear to present similar estimates. The high heterogeneity found in the studies limited further conclusions.

Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice

OBJECTIVES

To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post-bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses.

DESIGN, SETTING AND PARTICIPANTS

General practitioners from practices in Sydney identified eligible patients aged 40-80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients.

MAIN OUTCOME MEASURES

Frequency of COPD diagnosis on spirometry; odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses.

RESULTS

56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years; 49% male). Of these, 257 (57.8%) had post-bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis.

CONCLUSIONS

A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.

The role of assisted self-help in services for alcohol-related disorders

Potentially harmful substance use is common, but many affected people do not receive treatment. Brief face-to-face treatments show impact, as do strategies to assist self-help remotely, by using bibliotherapies, computers or mobile phones. Remotely delivered treatments offer more sustained and multifaceted support than brief interventions, and they show a substantial cost advantage as users increase in number. They may also build skills, confidence and treatment fidelity in providers who use them in sessions. Engagement and retention remain challenges, but electronic treatments show promise in engaging younger populations. Recruitment may be assisted by integration with community campaigns or brief opportunistic interventions. However, routine use of assisted self-help by standard services faces significant challenges. Strategies to optimize adoption are discussed.

Marked increase in proton pump inhibitors use in Australia

OBJECTIVES

To examine the trends in the prescribing of subsidized proton pump inhibitors (PPIs) and histamine receptor antagonists (H2RAs), in the Australian population from 1995 to 2006 to encourage discussion regarding appropriate clinical use. PPIs and H2RAs are the second highest drug cost to the publicly subsidized Pharmaceutical Benefits Scheme (PBS).

DESIGN

Government data on numbers of subsidized scripts, quantity and doses for PPIs and H2RAs were analysed by gender and age, dose and indication.

MAIN OUTCOME MEASURE

Drug utilisation as DDD [defined daily dose]/1000 population/day.

RESULTS

The use of combined PPIs increased by 1318%. Utilisation increased substantially after the relaxation of the subsidized indications for PPIs in 2001. Omeprazole had the largest market share but was substituted by its S-enantiomer esomeprazole after its introduction in 2002. There was considerable use in the elderly with the peak use being in those aged 80 years and over. The utilisation of H2RAs declined 72% over 12 years.

CONCLUSIONS

PPI use has increased substantially, not only due to substitution of H2RAs but to expansion in the overall market. Utilisation does not appear to be commensurate with prevalence of gastro-oesophageal reflux disease (GORD) nor with prescribing guidelines for PPIs, with significant financial costs to patients and PBS. This study encourages clinical discussion regarding quality use of these medicines.