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Gattellari M. Back to the Future: Observational Studies and Anticoagulant Selection for Nonvalvular Atrial Fibrillation. Stroke 2024; 55:1171-1173. [PMID: 38511348 DOI: 10.1161/strokeaha.124.046497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Affiliation(s)
- Melina Gattellari
- Department of Neurology, The Royal Prince Alfred Hospital, Camperdown, Australia
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Ebker‐White A, Dinh M, Paver I, Bein K, Tastula K, Gattellari M, Worthington J. Evaluating Stroke Code Activation Pathway in Emergency Departments study. Emerg Med Australas 2022; 34:976-983. [DOI: 10.1111/1742-6723.14032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Anja Ebker‐White
- School of Medicine The University of Notre Dame Australia Sydney New South Wales Australia
- Emergency Department Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Michael Dinh
- Emergency Department Royal Prince Alfred Hospital Sydney New South Wales Australia
- RPA Green Light Institute for Emergency Care, Royal Prince Alfred Hospital, Sydney Local Health District Sydney New South Wales Australia
| | - Ian Paver
- Emergency Department Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Kendall Bein
- Emergency Department Royal Prince Alfred Hospital Sydney New South Wales Australia
- RPA Green Light Institute for Emergency Care, Royal Prince Alfred Hospital, Sydney Local Health District Sydney New South Wales Australia
| | - Kylie Tastula
- Department of Neurology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Melina Gattellari
- Department of Neurology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - John Worthington
- Department of Neurology Royal Prince Alfred Hospital Sydney New South Wales Australia
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Denny MC, Gattellari M. Different Strokes for Different Folks: Socioeconomic Disadvantage and Access to Stroke Reperfusion Therapies. Stroke 2022; 53:2317-2319. [PMID: 35579015 DOI: 10.1161/strokeaha.122.039353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Carter Denny
- Department of Neurology, Georgetown University Medical Center and MedStar Health, Washington, DC (M.C.D.)
| | - Melina Gattellari
- Department of Neurology, The Royal Prince Alfred Hospital, Camperdown, Sydney, Australia (M.G.)
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Andrew NE, Kilkenny MF, Sundararajan V, Kim J, Faux SG, Thrift AG, Johnston T, Grimley R, Gattellari M, Katzenellenbogen JM, Dewey HM, Lannin NA, Anderson CS, Cadilhac DA. Hospital Presentations in Long-Term Survivors of Stroke: Causes and Associated Factors in a Linked Data Study. Stroke 2020; 51:3673-3680. [PMID: 33028173 DOI: 10.1161/strokeaha.120.030656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A comprehensive understanding of the long-term impact of stroke assists in health care planning. We aimed to determine changes in rates, causes, and associated factors for hospital presentations among long-term survivors of stroke. METHODS Person-level data from the AuSCR (Australian Stroke Clinical Registry) during 2009 to 2013 were linked with state-based health department emergency department and hospital admission data. The study cohort included adults with first-ever stroke who survived the first 6 months after discharge from hospital. Annualized rates of hospital presentations (nonadmitted emergency department or admission)/person/year were calculated for 1 to 12 months prior, and 7 to 12 months (inclusive) after hospitalization. Multilevel, negative binomial regression was used to identify associated factors after adjustment for prestroke hospital presentations and stratification for perceived impairment status. Perceived impairments to health were defined according to the subscales and visual analog health status scores on the 5-Dimension European Quality of Life Scale. RESULTS There were 7183 adults with acute stroke, 7-month survivors (median age 72 years; 56% male; 81% ischemic, and 42% with impairment at 90-180 days) from 39 hospitals included in this landmark analysis. Annualized presentations/person increased from 0.88 (95% CI, 0.86-0.91) to 1.25 (95% CI, 1.22-1.29) between the prestroke and poststroke periods, with greater rate increases in those with than without perceived impairment (55% versus 26%). Higher presentation rates were most strongly associated with older age (≥85 versus 65 years, incidence rate ratio, 1.52 [95% CI, 1.27-1.82]) and greater comorbidity score (incidence rate ratio, 1.06 [95% CI, 1.02-1.10]), whereas reduced rates were associated with greater social advantage (incidence rate ratio, 0.71 [95% CI, 0.60-0.84]). Poststroke hospital presentations (7-12 months) were most frequently related to recurrent cardiovascular and cerebrovascular events and sequelae of stroke. CONCLUSIONS A large increase in annualized hospital presentation rates after stroke indicates the potential for improved community management and support for this vulnerable patient group.
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Affiliation(s)
- Nadine E Andrew
- Department of Medicine, Peninsula Clinical School, Central Clinical School (N.E.A.), Monash University, VIC, Australia.,Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health (N.E.A., M.F.K., J.K., A.G.T., R.G., D.A.C.), Monash University, VIC, Australia
| | - Monique F Kilkenny
- Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health (N.E.A., M.F.K., J.K., A.G.T., R.G., D.A.C.), Monash University, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, VIC, Australia (M.F.K., J.K., D.A.C.)
| | - Vijaya Sundararajan
- Department of Public Health, School of Psychology and Public Health, College of Science, Health and Engineering, La Trobe University, VIC, Australia (V.S.)
| | - Joosup Kim
- Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health (N.E.A., M.F.K., J.K., A.G.T., R.G., D.A.C.), Monash University, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, VIC, Australia (M.F.K., J.K., D.A.C.)
| | - Steven G Faux
- St Vincent's Hospital, NSW, Australia (S.G.F.).,University of New South Wales, NSW, Australia (S.G.F.)
| | - Amanda G Thrift
- Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health (N.E.A., M.F.K., J.K., A.G.T., R.G., D.A.C.), Monash University, VIC, Australia
| | - Trisha Johnston
- Health Statistics Branch, Queensland Department of Health, QLD, Australia (T.J.)
| | - Rohan Grimley
- Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health (N.E.A., M.F.K., J.K., A.G.T., R.G., D.A.C.), Monash University, VIC, Australia.,School of Medicine, Griffith University, QLD, Australia (R.G.)
| | - Melina Gattellari
- Department of Neurology, Royal Prince Alfred Hospital, NSW, Australia (M.G.)
| | | | - Helen M Dewey
- Eastern Health Clinical School, Monash University, VIC, Australia (H.M.D.)
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School (N.A.L.), Monash University, VIC, Australia
| | - Craig S Anderson
- Royal Prince Alfred Hospital, NSW, Australia (C.S.A.).,The George Institute for Global Health, NSW, Australia (C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, NSW, Australia (C.S.A.).,The George Institute for Global Health at Peking University Health Science Center China (C.S.A.)
| | - Dominique A Cadilhac
- Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health (N.E.A., M.F.K., J.K., A.G.T., R.G., D.A.C.), Monash University, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, VIC, Australia (M.F.K., J.K., D.A.C.)
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Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC Fam Pract 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
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Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
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Gattellari M, Goumas C, Jalaludin B, Worthington J. Measuring stroke outcomes for 74 501 patients using linked administrative data: System-wide estimates and validation of 'home-time' as a surrogate measure of functional status. Int J Clin Pract 2020; 74:e13484. [PMID: 32003055 DOI: 10.1111/ijcp.13484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 01/06/2023] Open
Abstract
AIMS Administrative data offer cost-effective, whole-of-population stroke surveillance yet the lack of validated measures of functional status is a shortcoming. The number of days spent living at home after stroke ('home-time') is a patient-centred outcome that can be objectively ascertained from administrative data. Population-based validation against both severity and outcome measures and for all subtypes is lacking. We aimed to report representative 'home-time' estimates and validate 'home-time' as a surrogate measure of functional status after stroke. METHODS Stroke hospitalisations from a state-wide census in New South Wales, Australia, from January 1, 2005 to March 31, 2014 were linked to prehospital data, poststroke admissions and deaths. We correlated 90-day 'home-time' with Glasgow Coma Scale (GCS) scores, measured upon a patient's initial contact with paramedics and Functional Independence Measure (FIM) scores, measured upon entry to rehabilitation after the acute hospital stroke admission. Negative binomial regressions identified predictors of 'home-time'. RESULTS Patients with stroke (N = 74 501) spent a median of 53 days living at home 90 days after the event. Median 'home-time' was 60 days after ischaemic stroke, 49 days after subarachnoid haemorrhage and 0 days after intracerebral haemorrhage. GCS and FIM scores significantly correlated with 'home-time' (P < .001). Women spent significantly less time at home compared with men after stroke, although being married increased 'home-time' after ischaemic stroke and subarachnoid haemorrhage. CONCLUSIONS These findings underscore the immediate and adverse impact of stroke. 'Home-time' measured using administrative data is a robust, replicable and valid patient-centred outcome enabling inexpensive population-based surveillance and system-wide quality assessment.
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Affiliation(s)
- Melina Gattellari
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, The University of New South Wales, Sydney, NSW, Australia
| | - John Worthington
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia
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Gattellari M, Worthington JM. Letter by Gattellari and Worthington Regarding Article, "Deriving a Passive Surveillance Stroke Severity Indicator From Routinely Collected Administrative Data: The PaSSV Indicator". Circ Cardiovasc Qual Outcomes 2020; 13:e006613. [PMID: 32466728 DOI: 10.1161/circoutcomes.120.006613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Melina Gattellari
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - John Mark Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Gattellari M, Goumas C, Jalaludin B, Worthington JM. Population-based stroke surveillance using big data: state-wide epidemiological trends in admissions and mortality in New South Wales, Australia. Neurol Res 2020; 42:587-596. [PMID: 32449879 DOI: 10.1080/01616412.2020.1766860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Epidemiological trends for major causes of death and disability, such as stroke, may be monitored using administrative data to guide public health initiatives and service delivery. METHODS We calculated admissions rates for ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage between 1 January 2005 and December 31st, 2013 and rates of 30-day mortality and 365-day mortality in 30-day survivors to 31 December 2014 for patients aged 15 years or older from New South Wales, Australia. Annual Average Percentage Change in rates was estimated using negative binomial regression. RESULTS Of 81,703 eligible admissions, 64,047 (78.4%) were ischaemic strokes and 13,302 (16.3%) and 4,778 (5.8%) were intracerebral and subarachnoid haemorrhages, respectively. Intracerebral haemorrhage admissions significantly declined by an average of 2.2% annually (95% Confidence Interval = -3.5% to -0.9%) (p < 0.001). Thirty-day mortality rates significantly declined for ischaemic stroke (Average Percentage Change -2.9%, 95% Confidence Interval = -5.2% to -1.0%) (p = 0.004) and subarachnoid haemorrhage (Average Percentage Change = -2.6%, 95% Confidence Interval = -4.8% to -0.2%) (p = 0.04). Mortality at 365-days amongst 30-day survivors of ischaemic stroke and intracerebral haemorrhage was stable over time and increased in subarachnoid haemorrhage (Annual Percentage Change 6.2%, 95% Confidence Interval = -0.1% to 12.8%), although not significantly (p = 0.05). DISCUSSION Improved prevention may have underpinned declining intracerebral haemorrhage rates while survival gains suggest that innovations in care are being successfully translated. Mortality in patients surviving the acute period is unchanged and may be increasing for subarachnoid haemorrhage warranting investment in post-discharge care and secondary prevention.
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Affiliation(s)
- Melina Gattellari
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Department of Neurology, Royal Prince Alfred Hospital , Camperdown (Sydney), Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,School of Public Health, the University of Sydney , Sydney, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District , Liverpool, Sydney, Australia.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - John M Worthington
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Department of Neurology, Royal Prince Alfred Hospital , Camperdown (Sydney), Australia.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia.,South Western Sydney Clinical School, The University of New South Wales , Liverpool, Sydney, Australia
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Gattellari M, Goumas C, Jalaludin B, Worthington J. The impact of disease severity adjustment on hospital standardised mortality ratios: Results from a service-wide analysis of ischaemic stroke admissions using linked pre-hospital, admissions and mortality data. PLoS One 2019; 14:e0216325. [PMID: 31112556 PMCID: PMC6528964 DOI: 10.1371/journal.pone.0216325] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 04/18/2019] [Indexed: 11/19/2022] Open
Abstract
Background Administrative data are used to examine variation in thirty-day mortality across health services in several jurisdictions. Hospital performance measurement may be error-prone as information about disease severity is not typically available in routinely collected data to incorporate into case-mix adjusted analyses. Using ischaemic stroke as a case study, we tested the extent to which accounting for disease severity impacts on hospital performance assessment. Methods We linked all recorded ischaemic stroke admissions between July, 2011 and June, 2014 to death registrations and a measure of stroke severity obtained at first point of patient contact with health services, across New South Wales, Australia’s largest health service jurisdiction. Thirty-day hospital standardised mortality ratios were adjusted for either comorbidities, as is typically done, or for both comorbidities and stroke severity. The impact of stroke severity adjustment on mortality ratios was determined using 95% and 99% control limits applied to funnel plots and by calculating the change in rank order of hospital risk adjusted mortality rates. Results The performance of the stroke severity adjusted model was superior to incorporating comorbidity burden alone (c-statistic = 0.82 versus 0.75; N = 17,700 patients, 176 hospitals). Concordance in outlier classification was 89% and 97% when applying 95% or 99% control limits to funnel plots, respectively. The sensitivity rates of outlier detection using comorbidity adjustment compared with gold-standard severity and comorbidity adjustment was 74% and 83% with 95% and 99% control limits, respectively. Corresponding positive predictive values were 74% and 91%. Hospital rank order of risk adjusted mortality rates shifted between 0 to 22 places with severity adjustment (Median = 4.0, Inter-quartile Range = 2–7). Conclusions Rankings of mortality rates varied widely depending on whether stroke severity was taken into account. Funnel plots yielded largely concordant results irrespective of severity adjustment and may be sufficiently accurate as a screening tool for assessing hospital performance.
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Affiliation(s)
- Melina Gattellari
- Heart and Brain Collaboration, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia
| | - Chris Goumas
- Heart and Brain Collaboration, Ingham Institute for Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
| | - Bin Jalaludin
- Population Health Intelligence, Healthy People and Places Unit; South Western Sydney Local Health District, Liverpool, Sydney, New South Wales, Australia
- School of Public Health, The University of New South Wales, Kensington, Sydney, New South Wales, Australia
| | - John Worthington
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Liverpool, Sydney, New South Wales, Australia
- * E-mail:
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Kilkenny MF, Kim J, Andrew NE, Sundararajan V, Thrift AG, Katzenellenbogen JM, Flack F, Gattellari M, Boyd JH, Anderson P, Lannin N, Sipthorp M, Chen Y, Johnston T, Anderson CS, Middleton S, Donnan GA, Cadilhac DA. Maximising data value and avoiding data waste: a validation study in stroke research. Med J Aust 2018; 210:27-31. [DOI: 10.5694/mja2.12029] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/11/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Monique F Kilkenny
- School of Clinical Sciences at Monash HealthMonash University Melbourne VIC
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
| | - Joosup Kim
- School of Clinical Sciences at Monash HealthMonash University Melbourne VIC
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
| | - Nadine E Andrew
- School of Clinical Sciences at Monash HealthMonash University Melbourne VIC
- Monash University Melbourne VIC
| | | | - Amanda G Thrift
- School of Clinical Sciences at Monash HealthMonash University Melbourne VIC
| | | | - Felicity Flack
- Centre for Data Linkage, Population Health Research NetworkCurtin University Perth WA
| | | | - James H Boyd
- Centre for Data Linkage, Population Health Research NetworkCurtin University Perth WA
| | - Phil Anderson
- Data Linkage UnitAustralian Institute of Health and Welfare Canberra ACT
- University of Canberra Canberra ACT
| | | | - Mark Sipthorp
- Centre for Victorian Data LinkageDepartment of Health and Human Services Melbourne VIC
| | - Ying Chen
- Centre for Victorian Data LinkageDepartment of Health and Human Services Melbourne VIC
| | | | - Craig S Anderson
- The George Institute for Global HealthUniversity of New South Wales Sydney NSW
- Royal Prince Alfred Hospital Sydney NSW
| | - Sandy Middleton
- Nursing Research InstituteSt Vincent's Health Australia (Sydney) and Australian Catholic University Sydney NSW
| | | | - Dominique A Cadilhac
- School of Clinical Sciences at Monash HealthMonash University Melbourne VIC
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
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Andrew N, Kilkenny M, Sundararajan V, Kim J, Thrift A, Johnston T, Grimley R, Gattellari M, Katzenellenbogen J, Lannin N, Boyd J, Flack F, Chen Y, Cadilhac D. Describing hospital utilisation and associated factors following stroke using linked clinical registry and hospital administrative data. Int J Popul Data Sci 2018. [DOI: 10.23889/ijpds.v3i4.865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
IntroductionSurvivors of stroke have complex needs from ongoing disabilities and have increased risk of cardiovascular diseases. The societal costs are therefore substantial. Person-level longitudinal data on the longer-term hospital utilizations of patients with stroke in Australia, and the factors that may influence usage in this setting, are rarely reported.
Objectives and ApproachWe used person-level linkages between the Australian Stroke Clinical Registry (AuSCR: 2009-2013) and hospital admission and Emergency Department (ED) data from four states to examine determinants of hospital utilisation following stroke. The index event was the first event recorded in AuSCR. The rate of hospital contacts/person/year was calculated from contacts 30-365 days post-discharge. Disability was determined from responses to EQ-5D-3L data collected at 90-180 days post-stroke. Comorbidities were identified using ICD-10 discharge diagnosis codes (5 year look back including the index event). Negative binomial regression was used adjusting for patient clustering by hospital and pre-stroke contacts and stratified by disability.
ResultsAmong 10,082 adults with acute stroke (55% male, median age 74 years, 81% ischaemic, 14% hemorrhagic, 5% undetermined, 44% with disability) from 39 hospitals, 57% had a hospital admission or ED contact in the first 30-365 days post-hospital discharge, with median contacts/person/year post-stroke of 1.09 (Q1, Q3: 0, 3.27) compared to a pre-contact rate of 0 (Q1, Q3: 0, 2.18). The strongest associations with subsequent hospital contacts were prior contacts (IRR:1.10, 95%CI:1.07, 1.13), not able to walk on admission (stroke severity) (IRR:1.19, 95%CI 1.07, 1.31) and having a higher comorbidity index score (IRR:1.18, 95%CI:1.14, 1.22). Within stratified cohorts younger age was associated with increased contacts in those with disability (
Conclusion/ImplicationsIn a large linked cohort of patients we have demonstrated the substantial ongoing burden that stroke imposes on hospital systems, particularly regarding survivors with other comorbidities and younger survivors with disability. Knowledge of disability and comorbidity burden may assist with targeting community and hospital interventions to reduce post-stroke hospital usage.
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Kilkenny M, Kim J, Andrew N, Sundararajan V, Thrift A, Katzenellenbogen J, Flack F, Gattellari M, Boyd J, Anderson P, Lannin N, Sipthorp M, Chen Y, Johnston T. High quality linked data for stroke obtained using non-government clinical registry and routinely collected hospital and death data. Int J Popul Data Sci 2018. [DOI: 10.23889/ijpds.v3i4.781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
IntroductionRecent advances in data linkage infrastructure in Australia mean that data can be linked based on various identifiers across datasets. In a first for Australia, we tested the feasibility of linking data between a clinical quality disease registry with Australian and state government health data across multiple jurisdictions.
Objectives and ApproachTo determine whether high quality linked data for stroke can be obtained using a non-government managed registry (Australian Stroke Clinical Registry, AuSCR), national death registry data (Australian government), and hospital admission and emergency presentation data (state governments) to assess the accuracy of consistent variables across the different datasets. We used a cohort design with probabilistic data linkage to merge patient-level records. Descriptive statistics presented for matching concordance and Cohen’s kappa for concordance across demographic variables. The sensitivity and specificity of in-hospital deaths collected in the AuSCR was assessed against national death registrations.
ResultsThere were 16,214 registrants in the study cohort. Their identifiers in the AuSCR from 2009-2013 were linked with death, emergency department and hospital discharge data from April 2004 to December 2016. In total, 99% of the AuSCR registrants were linked to one or more datasets; 98\% were linked with emergency presentation (80%) and/or admission (95%) data. Linkage to national death registrations identified 4,183 death; 1440 of these were identified as in-hospital deaths in both data sets demonstrating that in-hospital death classification in AuSCR had a 98.7% sensitivity and 99.6% specificity. Concordance between common demographic variables was excellent (kappa 0.84 for aboriginal status and kappa 0.99 for sex).
Conclusion/ImplicationsThe majority of AuSCR registrants were accurately linked to the Australian and state government datasets. Linkage quality was excellent and there was high concordance between common variables. The ability to reliably merge the datasets assures future comprehensive analyses of stroke care, ongoing health care resource utilisation and patient outcomes.
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Worthington JM, Goumas C, Jalaludin B, Gattellari M. Decreasing Risk of Fatal Subarachnoid Hemorrhage and Other Epidemiological Trends in the Era of Coiling Implementation in Australia. Front Neurol 2017; 8:424. [PMID: 28912747 PMCID: PMC5583507 DOI: 10.3389/fneur.2017.00424] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 08/07/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Subarachnoid hemorrhage (SAH) is associated with a high risk of mortality and disability in survivors. We examined the epidemiology and burden of SAH in our population during a time services were re-organized to facilitate access to evidence-based endovascular coiling and neurosurgical care. METHODS SAH hospitalizations from 2001 to 2009, in New South Wales, Australia, were linked to death registrations to June 30, 2010. We assessed the variability of admission rates, fatal SAH rates and case fatality over time and according to patient demographic characteristics. RESULTS There were 4,945 eligible patients admitted to hospital with SAH. The risk of fatal SAH significantly decreased by 2.7% on average per year (95% CI = 0.3-4.9%). Case fatality at 2, 30, 90, and 365 days significantly declined over time. The average annual percentage reduction in mortality ranged from 4.4% for 30-day mortality (95% CI -6.1 to -2.7) (P < 0.001) to 4.7% for mortality within 2 days (-7.1 to -2.2) (P < 0.001) (Table 3). Three percent of patients received coiling at the start of the study period, increasing to 28% at the end (P-value for trend <0.001). Females were significantly more likely to be hospitalized for a SAH compared to males [incident rate ratio (IRR) = 1.33, 95% CI = 1.23-1.44] (P < 0.001) and to die from SAH (IRR = 1.40, 95% CI = 1.24-1.59) (P < 0.001). People born in South-East Asia and the Oceania region had a significantly increased risk of SAH, while the risk of fatal SAH was greater in South-East and North-East Asian born residents. People residing in areas of least disadvantage had the lowest risk of hospitalization (IRR = 0.83, 95% CI = 0.74-0.92) and also the lowest risk of fatal SAH (0.81, 95% CI = 0.66-1.00) (P < 0.001 and P = 0.003, respectively). For every 100 SAH admissions, 20 and 15 might be avoided in males and females, respectively, if the risk of SAH in our population equated to that of the most socio-economically advantaged. CONCLUSION Our study reports reductions in mortality risk in SAH corresponding to identifiable changes in health service delivery and evolving treatments such as coiling. Addressing inequities in SAH risk and mortality may require the targeting of prevalent and modifiable risk factors to improve population outcomes.
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Affiliation(s)
- John Mark Worthington
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,South Western Sydney Clinical School UNSW, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Melina Gattellari
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
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14
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Worthington JM, Gattellari M, Goumas C, Jalaludin B. Differentiating Incident from Recurrent Stroke Using Administrative Data: The Impact of Varying Lengths of Look-Back Periods on the Risk of Misclassification. Neuroepidemiology 2017. [PMID: 28637036 DOI: 10.1159/000478016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Administrative data are widely used to monitor epidemiological trends in stroke and outcomes; yet there is scant empirical guidance on how to best differentiate incident from recurrent stroke. METHODS We identified all hospital admissions in New South Wales, Australia, with a principal stroke diagnosis from July 1, 2013 to June 30, 2014, linked to 12 years of previous admissions. We calculated the proportion of cases identified with a prior stroke to determine the number of years of look-back required to minimise misclassification of incident and recurrent strokes. RESULTS Using the maximum available look-back period of 12 years, 1,171 out of 8,364 eligible stroke cases (14.0%) had a stroke history. A 1-year look-back period identified only 25.1% of these patients and 1 in 10 stroke cases were misclassified as incident. With a 10-year clearance period, less than 1 in 100 stroke cases were misclassified as incident. The risk of misclassification was lower in patients younger than 65 years and in those with haemorrhagic stroke. CONCLUSION Hospital administrative data sets linked to prior admissions can be used to distinguish recurrent from incident stroke. The risk of misclassifying recurrent stroke cases as incident events is negligible with a look-back period of 10 years.
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Affiliation(s)
- John Mark Worthington
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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15
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Andrew NE, Sundararajan V, Thrift AG, Kilkenny MF, Katzenellenbogen J, Flack F, Gattellari M, Boyd JH, Anderson P, Grabsch B, Lannin NA, Johnston T, Chen Y, Cadilhac DA. Addressing the challenges of cross-jurisdictional data linkage between a national clinical quality registry and government-held health data. Aust N Z J Public Health 2016; 40:436-442. [DOI: 10.1111/1753-6405.12576] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 04/01/2016] [Accepted: 05/01/2016] [Indexed: 01/12/2023] Open
Affiliation(s)
- Nadine E. Andrew
- Stroke & Ageing Research, School of Clinical Sciences at Monash Health; Monash University; Victoria
| | - Vijaya Sundararajan
- Department of Medicine, St. Vincent's Hospital; Melbourne University; Victoria
| | - Amanda G. Thrift
- Stroke & Ageing Research, School of Clinical Sciences at Monash Health; Monash University; Victoria
| | - Monique F. Kilkenny
- Stroke & Ageing Research, School of Clinical Sciences at Monash Health; Monash University; Victoria
- Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria
| | - Judith Katzenellenbogen
- Western Australian Centre for Rural Health; The University of Western Australia
- Telethon Kids Institute; The University of Western Australia
| | - Felicity Flack
- Telethon Kids Institute; The University of Western Australia
| | - Melina Gattellari
- South Western Sydney Clinical School; University of New South Wales
- Ingham Institute for Applied Medical Research; New South Wales
| | - James H. Boyd
- Population Health Research Network Centre for Data Linkage, Centre for Population Health Research; Curtin University; Western Australia
| | - Phil Anderson
- Data Linkage Unit, Australian Institute of Health and Welfare; Australian Capital Territory
- Faculty of Health; University of Canberra, Australian Capital Territory
| | - Brenda Grabsch
- Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria
| | - Natasha A. Lannin
- School of Allied Health, College of Science, Health and Engineering; La Trobe University; Victoria
| | | | - Ying Chen
- Victorian Data Linkages; Department of Health and Human Services; Victoria
| | - Dominique A. Cadilhac
- Stroke & Ageing Research, School of Clinical Sciences at Monash Health; Monash University; Victoria
- Florey Institute of Neuroscience and Mental Health; Heidelberg Victoria
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16
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Abstract
Background A recent systematic review of epidemiological studies reported intracerebral hemorrhage (ICH) incidence and mortality as unchanged over time; however, comparisons between studies conducted in different health services obscure assessment of trends. We explored trends in ICH rates in a large, representative population in New South Wales, Australia's most populous state (≈7.3 million). Methods and Results Adult hospitalizations with a principal ICH diagnosis from 2001 to 2009 were linked to death registrations through to June 30, 2010. Trends for overall, fatal, and nonfatal ICH rates within 30 days and fatal rates for 30‐day survivors at 365 days were calculated. There were 11 332 ICH patient admissions meeting eligibility criteria, yielding a crude hospitalization rate of 25.2 per 100 000 (age‐standardized rate: 17.2). Age‐ and sex‐adjusted overall rates significantly declined by an average of 1.6% per year (P=0.03). Fatal ICH declined by an average of 2.6% per year (P=0.004). For 30‐day survivors, a nonsignificant decline of 2.3% per year in fatal ICH at 365 days was estimated (P=0.17). Male sex and birth in the Oceania region and Asia were associated with an increased ICH risk, although this depended on age. Approximately 12% of ICH admissions would be prevented if the socioeconomic circumstances of the population equated with those of the least disadvantaged. Conclusions Overall and fatal ICH rates have fallen in this large Australian population. Improvements in cardiovascular prevention and acute care may explain declining rates. There was no evidence of an increase in devastated survivors because the longer term mortality of 30‐day survivors has not increased over time.
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Affiliation(s)
- Melina Gattellari
- Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia (M.G., C.G., J.W.) School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia (M.G.)
| | - Chris Goumas
- Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia (M.G., C.G., J.W.) South Western Sydney Clinical School, The University of New South Wales, Liverpool, Australia (C.G., J.W.)
| | - John Worthington
- Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia (M.G., C.G., J.W.) South Western Sydney Clinical School, The University of New South Wales, Liverpool, Australia (C.G., J.W.)
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17
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Lord SJ, Marinovich ML, Patterson JA, Wilcken N, Kiely BE, Gebski V, Crossing S, Roder DM, Gattellari M, Houssami N. Incidence of metastatic breast cancer in an Australian population-based cohort of women with non-metastatic breast cancer at diagnosis. Med J Aust 2012; 196:688-92. [PMID: 22708766 DOI: 10.5694/mja12.10026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer. DESIGN, SETTING AND PARTICIPANTS A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital. MAIN OUTCOME MEASURES 5-year cumulative incidence of MBC; prognostic factors for MBC. RESULTS MBC was recorded within 5 years in 218 of 4137 women with localised node-negative disease (5-year cumulative incidence, 5.3%; 95% CI, 4.6%-6.0%); and 455 of 2507 women with regional disease (5-year cumulative incidence, 18.1%; 95% CI, 16.7%-19.7%). The hazard rate for developing MBC was highest in the second year after the initial diagnosis of breast cancer. Determinants of increased risk of MBC were regional disease at diagnosis, age less than 50 years and living in an area of lower socio-economic status. CONCLUSIONS Our Australian population-based estimates are valuable when communicating average MBC risks to patients and planning clinical services and trials. Women with node-negative disease have a low risk of developing MBC, consistent with outcomes of adjuvant clinical trials. Regional disease at diagnosis remains an important prognostic factor.
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Affiliation(s)
- Sarah J Lord
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW.
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18
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Gattellari M, Worthington JM, Leung DY, Zwar N. Supporting Treatment decision making to Optimise the Prevention of STROKE in Atrial Fibrillation: the STOP STROKE in AF study. Protocol for a cluster randomised controlled trial. Implement Sci 2012; 7:63. [PMID: 22770423 PMCID: PMC3443055 DOI: 10.1186/1748-5908-7-63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 07/06/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke. METHODS The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this 'distance education' program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit. DISCUSSION The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management.
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19
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Abstract
BACKGROUND AND PURPOSE Existing epidemiological studies of Myasthenia Gravis have generally examined small populations. Few national studies have been conducted, and published incidence and prevalence rates vary widely. We report one of the largest national studies of Myasthenia Gravis, and the first incidence and prevalence rates for Australia. METHODS Prescriptions for Pyridostigmine Bromide in 2009 were utilized from a national prescribing database to estimate incidence and the prevalence of symptomatic and treated disease. Crude rates were age-standardized to the WHO world population. We compared standardized rates to recent national studies from Norway and Taiwan. RESULTS In 2009, there were 2574 prevalent cases of symptomatic and treated Myasthenia Gravis, corresponding to an annual crude prevalence rate of 117.1 per 1 million residents. There were 545 incident cases, yielding a crude incidence rate of 24.9 per 1 million residents. The crude incidence in women and men was estimated to be 27.9 and 21.9 per 1 million, respectively. Prevalence and incidence rates were higher in women than men between the ages of 15 and 64 years, and were higher in men than women in those older than 65 years. Rates peaked between the ages of 74 and 84 years, declining thereafter. Standardized incidence was higher in Australia than Norway, but similar to Taiwan (P-values = 0.007 and 1.00, respectively). CONCLUSIONS This first Australian epidemiological study of symptomatic Myasthenia Gravis is one of the largest population-based studies ever reported and supports higher incidence rates for Myasthenia Gravis. Myasthenia Gravis disproportionately affected younger females and older males.
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Affiliation(s)
- M Gattellari
- School of Public Health and Community Medicine, The University of New South Wales and Centre for Research Management, Evidence and Surveillance & Ingham Institute of Applied Medical Research, South Western Sydney Local Health Network, Liverpool, Australia
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20
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Abstract
Background and Purpose—
There is a lack of modern-day data quantifying the effect of transient ischemic attack (TIA) on survival, and recent data do not take into account expected survival.
Methods—
Data for 22 157 adults hospitalized with a TIA from July 1, 2000, to June 30, 2007, in New South Wales, Australia, were linked with registered deaths to June 30, 2009. We estimated survival relative to the age- and sex-matched general population up to 9-years after hospitalization for TIA comparing relative risk of excess death between selected subgroups.
Results—
At 1 year, 91.5% of hospitalized patients with TIA survived compared with 95.0% expected survival in the general population. After 5 years, observed survival was 13.2% lower than expected in relative terms. By 9 years, observed survival was 20% lower than expected. Females had higher relative survival than males (relative risk, 0.79; 95% CI, 0.69–0.90;
P
<0.001). Increasing age was associated with an increasing risk of excess death compared with the age-matched population. Prior hospitalization for stroke (relative risk, 2.63; 95% CI, 1.98–3.49) but not TIA (relative risk, 1.42; 95% CI, 0.86–2.35) significantly increased the risk of excess death. Of all risk factors assessed, congestive heart failure, atrial fibrillation, and prior hospitalization for stroke most strongly impacted survival.
Conclusions—
This study is the first to quantify the long-term effect of hospitalized TIA on relative survival according to age, sex, and medical history. TIA reduces survival by 4% in the first year and by 20% within 9 years. TIA has a minimal effect on mortality in patients <50 years but heralds significant reduction in life expectancy in those >65 years.
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Affiliation(s)
- Melina Gattellari
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
| | - Chris Goumas
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
| | - Frances Garden M. Biost
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
| | - John M. Worthington
- From the School of Public Health and Community Medicine (M.G., C.G., F.G.), The University of New South Wales, Sydney, New South Wales, Australia; Ingham Institute (M.G., J.M.W.), Liverpool, New South Wales, Australia; South Western Sydney Clinical School (J.M.W.), The University of New South Wales, Sydney, New South Wales, Australia; the Department of Neurophysiology (J.M.W.), Liverpool Health Service, Liverpool, New South Wales, Australia; Northern Beaches Stroke Service (J.M.W.), Manly and Mona
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21
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Abstract
BACKGROUND Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps. OBJECTIVES To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes. SEARCH STRATEGY We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles. SELECTION CRITERIA Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons. MAIN RESULTS We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group. AUTHORS' CONCLUSIONS Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.
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Affiliation(s)
- Gerd Flodgren
- Department of Public Health, University of Oxford, Headington, UK
| | - Elena Parmelli
- Department of Oncology, Hematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Gaby Doumit
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia
| | - Mary Ann O’Brien
- School of Rehabilitation Science, Institute for Applied Health Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Canada
| | - Martin P Eccles
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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22
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O'Connell D, Carmichael L, Smith D, Gattellari M, Chambers S, Pinnock C, Slevin T, Ward J. P2-225 Prostate-specific antigen testing awareness and participation in New South Wales, Australia: demographic, lifestyle and health-related factors. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976j.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Gattellari M, Leung DY, Ukoumunne OC, Zwar N, Grimshaw J, Worthington JM. Study protocol: the DESPATCH study: delivering stroke prevention for patients with atrial fibrillation - a cluster randomised controlled trial in primary healthcare. Implement Sci 2011; 6:48. [PMID: 21599901 PMCID: PMC3121604 DOI: 10.1186/1748-5908-6-48] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/20/2011] [Indexed: 12/21/2022] Open
Abstract
Background Compelling evidence shows that appropriate use of anticoagulation in patients with nonvalvular atrial fibrillation reduces the risk of ischaemic stroke by 67% and all-cause mortality by 26%. Despite this evidence, anticoagulation is substantially underused, resulting in avoidable fatal and disabling strokes. Methods DESPATCH is a cluster randomised controlled trial with concealed allocation and blinded outcome assessment designed to evaluate a multifaceted and tailored implementation strategy for improving the uptake of anticoagulation in primary care. We have recruited general practices in South Western Sydney, Australia, and randomly allocated practices to receive the DESPATCH intervention or evidence-based guidelines (control). The intervention comprises specialist decisional support via written feedback about patient-specific cases, three academic detailing sessions (delivered via telephone), practice resources, and evidence-based information. Data for outcome assessment will be obtained from a blinded, independent medical record audit. Our primary endpoint is the proportion of nonvalvular atrial fibrillation patients, over 65 years of age, receiving oral anticoagulation at any time during the 12-month posttest period. Discussion Successful translation of evidence into clinical practice can reduce avoidable stroke, death, and disability due to nonvalvular atrial fibrillation. If successful, DESPATCH will inform public policy, providing quality evidence for an effective implementation strategy to improve management of nonvalvular atrial fibrillation, to close an important evidence-practice gap. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000074392
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
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24
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Gattellari M, Goumas C, Aitken R, Worthington JM. Outcomes for Patients with Ischaemic Stroke and Atrial Fibrillation: The PRISM Study (A Program of Research Informing Stroke Management). Cerebrovasc Dis 2011; 32:370-82. [DOI: 10.1159/000330637] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 05/22/2011] [Indexed: 01/31/2023] Open
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25
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Worthington JM, Gattellari M, Aitken R, Jalaludin B. 8. Effect of large scale stroke unit implementation on one year ischaemic stroke out. J Clin Neurosci 2010. [DOI: 10.1016/j.jocn.2010.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Affiliation(s)
- John M. Worthington
- From Northern Beaches Stroke Service and Department of Neurology, Liverpool Health Service, Liverpool, Sydney, Australia (J.M.W.); Department of Cardiology, Liverpool Health Service, Liverpool, Sydney, Australia (D.Y.L.); Centre for Research, Evidence Management and Surveillance, Division of Population Health, Sydney South West Area Health Service, NSW, Australia (M.G.); The University of New South Wales, Sydney, Australia (J.M.W., M.G., D.Y.L.)
| | - Melina Gattellari
- From Northern Beaches Stroke Service and Department of Neurology, Liverpool Health Service, Liverpool, Sydney, Australia (J.M.W.); Department of Cardiology, Liverpool Health Service, Liverpool, Sydney, Australia (D.Y.L.); Centre for Research, Evidence Management and Surveillance, Division of Population Health, Sydney South West Area Health Service, NSW, Australia (M.G.); The University of New South Wales, Sydney, Australia (J.M.W., M.G., D.Y.L.)
| | - Dominic Y. Leung
- From Northern Beaches Stroke Service and Department of Neurology, Liverpool Health Service, Liverpool, Sydney, Australia (J.M.W.); Department of Cardiology, Liverpool Health Service, Liverpool, Sydney, Australia (D.Y.L.); Centre for Research, Evidence Management and Surveillance, Division of Population Health, Sydney South West Area Health Service, NSW, Australia (M.G.); The University of New South Wales, Sydney, Australia (J.M.W., M.G., D.Y.L.)
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27
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Worthington JM, Gattellari M. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:2672-3; author reply 2674-5. [PMID: 20050383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Abstract
Background and Purpose—
In randomized trials, acute stroke units are associated with improved patient outcomes. However, it is unclear whether this evidence can be successfully translated into routine clinical practice. We aimed to determine the effect of a coordinated rollout of funding for 22 stroke units on patient outcomes in Australia.
Methods—
A multicenter observational study was undertaken using health administrative data recording admissions for a primary diagnosis of ischemic stroke from July 2000 to June 2006. Analyses were stratified by hospital type (major principal referral, smaller nonprincipal referral hospitals).
Results—
We analyzed 17 659 admissions for ischemic stroke. Among major principal referral hospitals with acute stroke units, the proportion of admissions resulting in death or discharge to home was unchanged after stroke unit rollout (10.7% vs 10.6% and 44.1% vs 45.0%, respectively;
P
=0.37). In contrast, significant differences in discharge destination were noted across time among smaller nonprincipal referral hospitals (
P
<0.001). Before the rollout of stroke units, 13.8% of admissions to smaller hospitals resulted in a death, decreasing to 10.5% after stroke units were implemented. Discharges to home increased from 38.8% to 44.5%. Discharges to nursing homes decreased from 6.3% to 4.9%. Differences across time remained significant when controlling for patient demographics, comorbidities, indicators of poor prognosis, and clustering of outcomes at hospital level. Improved outcomes were observed across all ages and among patients with indicators for a poor prognosis.
Conclusions—
This multicenter analysis of a large Australian population of hospital stroke admissions demonstrates short-term benefits from implementing stroke units in nonprincipal referral hospitals.
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Affiliation(s)
- Melina Gattellari
- From School of Public Health and Community Medicine (M.G.), The University of New South Wales & Centre for Research, Evidence Management and Surveillance, Division of Population Health, SSWAHS, Liverpool, New South Wales, Australia; Northern Beaches Area Stroke Unit (J.W.), Department of Neurology, Liverpool Health Service, Liverpool, New South Wales, Australia; School of Public Health and Community Medicine (B.J.), The University of New South Wales & Director, Centre for Research, Evidence
| | - John Worthington
- From School of Public Health and Community Medicine (M.G.), The University of New South Wales & Centre for Research, Evidence Management and Surveillance, Division of Population Health, SSWAHS, Liverpool, New South Wales, Australia; Northern Beaches Area Stroke Unit (J.W.), Department of Neurology, Liverpool Health Service, Liverpool, New South Wales, Australia; School of Public Health and Community Medicine (B.J.), The University of New South Wales & Director, Centre for Research, Evidence
| | - Bin Jalaludin
- From School of Public Health and Community Medicine (M.G.), The University of New South Wales & Centre for Research, Evidence Management and Surveillance, Division of Population Health, SSWAHS, Liverpool, New South Wales, Australia; Northern Beaches Area Stroke Unit (J.W.), Department of Neurology, Liverpool Health Service, Liverpool, New South Wales, Australia; School of Public Health and Community Medicine (B.J.), The University of New South Wales & Director, Centre for Research, Evidence
| | - Mohammed Mohsin
- From School of Public Health and Community Medicine (M.G.), The University of New South Wales & Centre for Research, Evidence Management and Surveillance, Division of Population Health, SSWAHS, Liverpool, New South Wales, Australia; Northern Beaches Area Stroke Unit (J.W.), Department of Neurology, Liverpool Health Service, Liverpool, New South Wales, Australia; School of Public Health and Community Medicine (B.J.), The University of New South Wales & Director, Centre for Research, Evidence
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Gattellari M, Worthington JM, Zwar NA, Middleton S. The management of non-valvular atrial fibrillation (NVAF) in Australian general practice: bridging the evidence-practice gap. A national, representative postal survey. BMC Fam Pract 2008; 9:62. [PMID: 19014560 PMCID: PMC2611987 DOI: 10.1186/1471-2296-9-62] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 11/13/2008] [Indexed: 01/15/2023]
Abstract
Background General practitioners (GPs) are ideally placed to bridge the widely noted evidence-practice gap between current management of NVAF and the need to increase anticoagulant use to reduce the risk of fatal and disabling stroke in NVAF. We aimed to identify gaps in current care, and asked GPs to identify potentially useful strategies to overcome barriers to best practice. Methods We obtained contact details for a random sample of 1000 GPs from a national commercial data-base. Randomly selected GPs were mailed a questionnaire after an advance letter. Standardised reminders were administered to enhance response rates. As part of a larger survey assessing GP management of NVAF, we included questions to explore GPs' risk assessment, estimates of stroke risk and GPs' perceptions of the risks and benefits of anticoagulation with warfarin. In addition, we explored GPs' perceived barriers to the wider uptake of anticoagulation, quality control of anticoagulation and their assessment of strategies to assist in managing NVAF. Results 596 out of 924 eligible GPs responded (64.4% response rate). The majority of GPs recognised that the benefits of warfarin outweighed the risks for three case scenarios in which warfarin is recommended according to Australian guidelines. In response to a hypothetical case scenario describing a patient with a supratherapeutic INR level of 5, 41.4% of the 596 GPs (n = 247) and 22.0% (n = 131) would be "highly likely" or "likely", respectively, to cease warfarin therapy and resume at a lower dose when INR levels are within therapeutic range. Only 27.9% (n = 166/596) would reassess the patient's INR levels within one day of recording the supratherapeutic INR. Patient contraindications to warfarin was reported to "usually" or "always" apply to the patients of 40.6% (n = 242/596) of GPs when considering whether or not to prescribe warfarin. Patient refusal to take warfarin "usually" or "always" applied to the patients of 22.3% (n = 133/596) of GPs. When asked to indicate the usefulness of strategies to assist in managing NVAF, the majority of GPs (89.1%, n = 531/596) reported that they would find patient educational resources outlining the benefits and risks of available treatments "quite useful" or "very useful". Just under two-thirds (65.2%; n = 389/596) reported that they would find point of care INR testing "quite" or "very" useful. An outreach specialist service and training to enable GPs to practice stroke medicine as a special interest were also considered to be "quite" or "very useful" by 61.9% (n = 369/596) GPs. Conclusion This survey identified gaps, based on GP self-report, in the current care of NVAF. GPs themselves have provided guidance on the selection of implementation strategies to bridge these gaps. These results may inform future initiatives designed to reduce the risk of fatal and disabling stroke in NVAF.
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales and Centre for Research Management, Evidence and Surveillance Sydney South West Area Health Service, Liverpool, Australia.
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Abstract
Background and Purpose—
Anticoagulation reduces the risk of stroke in nonvalvular atrial fibrillation yet remains underused. We explored barriers to the use of anticoagulants among Australian family physicians.
Methods—
The authors conducted a representative, national survey.
Results—
Of the 596 (64.4%) eligible family physicians who participated, 15.8% reported having a patient with nonvalvular atrial fibrillation experience an intracranial hemorrhage with anticoagulation and 45.8% had a patient with known nonvalvular atrial fibrillation experience a stroke without anticoagulation. When presented with a patient at “very high risk” of stroke, only 45.6% of family physicians selected warfarin in the presence of a minor falls risk and 17.1% would anticoagulate if the patient had a treated peptic ulcer. Family physicians with less decisional conflict and longer-standing practices were more likely to endorse anticoagulation.
Conclusion—
Strategies to optimize the management of nonvalvular atrial fibrillation should address psychological barriers to using anticoagulation.
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Affiliation(s)
- Melina Gattellari
- From the School of Public Health and Community Medicine (M.G.), The University of New South Wales and the Centre for Research Management, Evidence and Surveillance, Sydney South West Area Health Service, Liverpool, Australia; Sydney South West Area Health Service and Stroke and Neurology Services (J.W.), Northern Beaches Hospitals, Liverpool; the School of Public Health and Community Medicine (N.Z.), The University of New South Wales, and the GP Unit, Fairfield, Sydney South West Area Health
| | - John Worthington
- From the School of Public Health and Community Medicine (M.G.), The University of New South Wales and the Centre for Research Management, Evidence and Surveillance, Sydney South West Area Health Service, Liverpool, Australia; Sydney South West Area Health Service and Stroke and Neurology Services (J.W.), Northern Beaches Hospitals, Liverpool; the School of Public Health and Community Medicine (N.Z.), The University of New South Wales, and the GP Unit, Fairfield, Sydney South West Area Health
| | - Nicholas Zwar
- From the School of Public Health and Community Medicine (M.G.), The University of New South Wales and the Centre for Research Management, Evidence and Surveillance, Sydney South West Area Health Service, Liverpool, Australia; Sydney South West Area Health Service and Stroke and Neurology Services (J.W.), Northern Beaches Hospitals, Liverpool; the School of Public Health and Community Medicine (N.Z.), The University of New South Wales, and the GP Unit, Fairfield, Sydney South West Area Health
| | - Sandy Middleton
- From the School of Public Health and Community Medicine (M.G.), The University of New South Wales and the Centre for Research Management, Evidence and Surveillance, Sydney South West Area Health Service, Liverpool, Australia; Sydney South West Area Health Service and Stroke and Neurology Services (J.W.), Northern Beaches Hospitals, Liverpool; the School of Public Health and Community Medicine (N.Z.), The University of New South Wales, and the GP Unit, Fairfield, Sydney South West Area Health
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Davey C, White V, Gattellari M, Ward JE. Reconciling population benefits and women's individual autonomy in mammographic screening: in-depth interviews to explore women's views about ‘informed choice’. Aust N Z J Public Health 2007; 29:69-77. [PMID: 15782876 DOI: 10.1111/j.1467-842x.2005.tb00752.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore women's reactions to 'informed choice' in mammographic screening. SETTING AND METHODS Telephone interviews with a convenience sample of 106 women aged 45-70 years recruited from general practices in Sydney. RESULTS Many (42%) women preferred an active role in decision-making. Respondents had low scores for 'uncertainty' and 'factors contributing to uncertainty' in response to explicit questions about the decision to have mammographic screening. Yet respondents indicated significantly greater willingness to have a test when the benefit of a 'new' screening test for breast cancer was expressed as relative risk reduction (RRR) (88%) than either absolute risk reduction (ARR) (78%) (McNemar's test: chi(2)1=7.14, p=0.013) or all-cause mortality (53%) (McNemar's test: chi(2)1=35.1, p<0.01). Significantly more respondents considered information about ARR 'new' to them (65%) compared with RRR information (30%) (McNemar's test: chi(2)1=25.83, p<0.01). CONCLUSIONS As mammographic screening exposes well women to potential harms for an overall population benefit, it is challenging to ensure 'informed choice'. Our results suggest women will likely appreciate individual consultations as the context in which to share complex information that women in our study agreed they need to know about mammographic screening. Our results also demonstrate that women's willingness as individuals to participate in mammographic screening is influenced by 'framing effect'. Hence, the quantitative content of decision aids to promote 'informed choice' must be comprehensive and balanced.
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Affiliation(s)
- Claire Davey
- Centre for Behavioural Research in Cancer, The Cancer Council Victoria
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Abstract
BACKGROUND Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one innovative method that holds promise as a strategy to bridge evidence-practice gaps. OBJECTIVES To assess the effectiveness of the use of local opinion leaders in improving the behaviour of health care professionals and patient outcomes. SEARCH STRATEGY We searched MEDLINE, Health Star, SIGLE and the Cochrane Effective Practice and Organisation of Care Group Trials Register. We did not apply date restrictions to our search strategy. Searches were last updated in February 2005. In addition, we searched reference lists of all potential studies that were identified. SELECTION CRITERIA Studies eligible for inclusion were randomized controlled trials that used objective measures of performance/provider behaviour and/or patient health outcomes. DATA COLLECTION AND ANALYSIS Two reviewers extracted data from each study and assessed its methodological quality. We calculated the absolute difference in the risk of 'non-compliance' with desired practice, adjusting for baseline levels of non-compliance where these data were available. MAIN RESULTS Twelve studies met our eligibility criteria. The adjusted absolute risk difference of non-compliance with desired practice varied from -6% (favouring control) to +25% (favouring opinion leader intervention). Overall, the median adjusted risk difference (ARD) was 0.10 representing a 10% absolute decrease in non-compliance in the intervention group. AUTHORS' CONCLUSIONS The use of local opinion leaders can successfully promote evidence-based practice. However the feasibility of its widespread use remains uncertain.
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Affiliation(s)
- G Doumit
- Ottawa Hospital, Department of General Surgery, Ottawa, Ontario, Canada.
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Abstract
BACKGROUND To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and 'non-treatment' options. A survey was conducted to determine patients' recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA). METHODS A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA. RESULTS A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001). CONCLUSIONS Patients recalled discussions with their surgeon about short-term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.
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Affiliation(s)
- Sandy Middleton
- School of Nursing (NSW), ACU National, Sydney, New South Wales, Australia.
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Gattellari M, Donnelly N, Taylor N, Meerkin M, Hirst G, Ward JE. Does 'peer coaching' increase GP capacity to promote informed decision making about PSA screening? A cluster randomised trial. Fam Pract 2005; 22:253-65. [PMID: 15824055 DOI: 10.1093/fampra/cmi028] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Very little effort has been directed to enable GPs to better informed decisions about PSA screening among their male patients. OBJECTIVES To evaluate an innovative programme designed to enhance GPs' capacity to promote informed decision making by male patients about PSA screening. METHODS The study design was a cluster randomised controlled trial set in New South Wales, Australia's most populous state. 277 GPs were recruited through a major pathology laboratory. The interventions were three telephone-administered 'peer coaching' sessions integrated with educational resources for GPs and patients and the main outcome measures were: GP knowledge; perceptions of patient involvement in informed decision making; GPs' own decisional conflict; and perceptions of medicolegal risk. RESULTS Compared with GPs allocated to the control group, GPs allocated to our intervention gained significantly greater knowledge about PSA screening and related information [Mean 6.1 out of 7; 95% confidence interval (CI) = 5.9-6.3 versus 4.8; 95% CI = 4.6-5.0; P < 0.001]. They were less likely to agree that patients should remain passive when making decisions about PSA screening [Odds ratio (OR) = 0.11; 95% CI = 0.04-0.31; P < 0.001]. They perceived less medicolegal risk when not acceding to an 'uninformed' patient request for a PSA test (OR = 0.31; 95% CI 0.19-0.51). They also demonstrated lower levels of personal decisional conflict about the PSA screening (Mean 25.4; 95% CI 24.5-26.3 versus 27.8; 95% CI 26.6-29.0; P = 0.0002). CONCLUSION A 'peer coaching' programme, supplemented by education materials, holds promise as a strategy to equip GPs to facilitate informed decision making amongst their patients.
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, University of New South Wales and Centre for Research, Evidence Management and Serveillance, South Western Sydney Area Health Service, Liverpool, NSW 1871, Australia.
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Abstract
RATIONALE, AIMS AND OBJECTIVES Now that active involvement by patients in their health care is widely endorsed, valid and reliable methods for determining preferences for involvement in treatment decision making are essential. Relatively little methodological work has been conducted to compare and contrast their reliability and validity. Available single-item measures exist to determine preferences, ranging from 'menu-based' questions to simpler Likert-type scales. METHODS Within a larger community survey of 514 men aged 50-70 years in Sydney, Australia, we compared two measures to assess their preferences for involvement in medical decision making. Using the 'menu-based' Control Preference Scale (CPS), men were classified as preferring to be either 'passive' or 'active' during decision making or to share ('shared') with their doctors on an equal basis. Men also were classified as preferring to be either 'passive' or 'active' according to a Likert-scale measure. RESULTS Agreement between the two measures was 'poor' (kappa=0.19). While 24.9% of participants were classified as preferring a 'passive' role in treatment decision making according to the CPS, almost half (47.9%) were so classified according to Arora and McHorney's measure. In the absence of a 'shared' response option on the Arora and McHorney measure, 45.3% of men classified as preferring a 'shared role' on the CPS were instead categorized as 'passive' using Arora and McHorney's measure. Predictors of preferring a 'passive' role also differed, depending on the measure employed. Only occupational skill level predicted men's preferences for a 'passive' role when measured by the CPS [odds ratio (OR)=1.67; 95% CI 1.09-2.55] (P=0.02). For the Arora and McHorney's measure of preferences for involvement, men were significantly more likely to prefer a 'passive' role if they were older [adjusted odds ratio (AOR)=1.06, 95% CI 1.02-1.09] (P=0.001), currently smoking (AOR=1.86, 95% CI 1.09-3.17) (P=0.02) and had higher chance health locus of control scores (AOR=1.26; 95% CI 1.01-1.56) (P=0.04). Having been employed or previously employed in an occupation of a lower skill level was also significantly and independently predictive of a passive role (AOR=2.35, 95% CI 1.57-3.50) (P<0.001). CONCLUSIONS Single-item measures of decisional preferences have poor convergent validity. Characteristics associated with preference classifications also differ, depending upon the measures used. These results suggest that research efforts should be directed towards developing psychometrically robust measures to determine decisional preferences.
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, Department of General Practice, The University of New South Wales, and Division of Population Health, South-western Sydney Area Health Service, Liverpool, Australia.
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Gattellari M, Ward JE. A community-based randomised controlled trial of three different educational resources for men about prostate cancer screening. Patient Educ Couns 2005; 57:168-82. [PMID: 15911190 DOI: 10.1016/j.pec.2004.05.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2003] [Revised: 04/14/2004] [Accepted: 05/14/2004] [Indexed: 05/02/2023]
Abstract
Randomised evaluations of resources to facilitate informed decisions about prostate cancer screening are rarely conducted. In this study, 421 men recruited from the community were randomly allocated to receive a leaflet (n = 140) or one of two resources meeting criteria for a decision-aid: a video (n = 141) or an evidence-based booklet, developed by the authors (n = 140). Men in all three groups demonstrated significant increases in knowledge scores from pre to post-test. Scores were significantly higher at post-test amongst those who had received our evidence-based booklet compared with men who received the leaflet or video (P < 0.001). Scores were significantly modified by men's preferences for decisional control (P = 0.002). Decisional conflict was significantly lower amongst men receiving the evidence-based booklet (P = 0.038). Men receiving the evidence-based booklet also were less likely to accept a recommendation by a GP to undergo prostate-specific-antigen (PSA) screening (P = 0.003). Men require detailed information about the pros and cons of PSA screening in order to make an informed decision. Resources are not equivalent in achieving these outcomes.
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Affiliation(s)
- Melina Gattellari
- Department of General Practice, School of Public Health and Community Medicine, University of New South Wales, Liverpool, NSW 1871, Australia.
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Gattellari M, Ward JE. Will men attribute fault to their GP for adverse effects arising from controversial screening tests? An Australian study using scenarios about PSA screening. J Med Screen 2005; 11:165-9. [PMID: 15563771 DOI: 10.1258/0969141042467386] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine men's attribution of fault for adverse consequences of prostate-specific antigen (PSA) screening. SETTING Representative, population-based sample recruited from Sydney, Australia (n=405). METHODS Telephone interview to assess reactions to two scenarios: Scenario 1, depicting a GP who dismisses an opportunity to order a PSA test (missed diagnosis); and Scenario 2, depicting a GP who recommends PSA screening to a patient who then experiences adverse outcomes from treatment of his prostate cancer (iatrogenic consequences). RESULTS Two-thirds of participants (66.9%) ascribed fault to the GP in Scenario 1. Men in fair or poor health (adjusted odds ratio [AOR] 1.81; 95% confidence interval [CI] 1.04-3.12; p=0.03) and those with better knowledge about PSA screening (AOR 0.98; 95% CI 0.97-0.99; p=0.002) were significantly and independently more likely to ascribe fault in Scenario 1. By contrast, only 15.8% of participants ascribed responsibility to the GP in Scenario 2. Older men (AOR 1.05; 95% CI 1.00-1.10; p=0.04) and those with higher levels of decisional conflict (AOR 1.19; 95% CI 1.04-1.37; p=0.01) were significantly and independently more likely to ascribe responsibility. CONCLUSION Public education could better target men's tendency to ascribe fault to GPs when they miss an opportunity to diagnose prostate cancer early through PSA screening, even though the corollary of potential iatrogenic consequences is perceived as less blameworthy. As decisional conflict and knowledge were found to predict attribution of fault, evidence-based information may reduce the medicolegal volatility of this controversy.
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, Department of General Practice, University of New South Wales and Division of Population Health, South Western Sydney Area Health Service, LIVERPOOL NSW 1871, Australia.
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Gattellari M, Ward JE. Men's reactions to disclosed and undisclosed opportunistic PSA screening for prostate cancer. Med J Aust 2005; 182:386-9. [PMID: 15850434 DOI: 10.5694/j.1326-5377.2005.tb06756.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2004] [Accepted: 02/07/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the degree to which men considered it appropriate for general practitioners to order prostate-specific antigen (PSA) testing if the testing was either "disclosed" or "undisclosed" to the patient. DESIGN Telephone-administered survey conducted in June to October 2000. PARTICIPANTS 514 men aged 50-70 years, identified by random selection of households from the Sydney Electronic White Pages phone directory. METHODS We developed two hypothetical scenarios. Each scenario described a GP ordering a PSA test for a male patient at the same time as other pathology tests were ordered. In Scenario 1, the GP's intention to order a PSA test was disclosed to the patient ("disclosed"). In Scenario 2, the GP did not tell the patient a PSA test was being ordered ("undisclosed"). For each scenario, men reported the degree to which they perceived screening to be "appropriate". We also recorded demographic characteristics, health status and health locus of control, and administered a 14-question knowledge test about prostate cancer and PSA screening. RESULTS Over 90% of men stated that "disclosed" PSA screening was either "appropriate" or "very appropriate". Significantly fewer (44.9%) rated "undisclosed" screening as appropriate/very appropriate (P < 0.001). While the skewed distribution of responses to Scenario 1 precluded multivariate analysis to determine predictors, men rejecting "undisclosed" PSA screening (Scenario 2) were more likely to be younger (adjusted odds ratio [AOR], 0.97; 95% CI, 0.94-1.00; P = 0.03); to have better knowledge of the issues (AOR, 1.01; 95% CI, 1.00-1.03; P = 0.02); and to be single (AOR, 0.62; 95% CI, 0.41-0.94; P = 0.02). CONCLUSIONS Many men consider that inclusion of PSA screening within a battery of pathology tests without disclosure to the patient is unacceptable. Educating men about the pros and cons of screening may alter their support of opportunistic screening and thus enhance community expectations of "informed participation".
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, University of New South Wales, Locked Bag 7008, Liverpool, NSW 1871, Australia.
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Gattellari M, Ward JE. Does a deadline improve men's participation in self-administered health surveys? A randomized controlled trial in general practice. J Public Health (Oxf) 2004; 26:384-7. [PMID: 15598859 DOI: 10.1093/pubmed/fdh177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Self-administered questionnaires are commonly used in experimental studies to elicit quality of life or other outcomes. Hence, achieving an acceptable level of follow-up from patients is critical to minimizing bias. Many methods for maximizing follow-up remain untested. It is also unclear what level of follow-up is required to prevent bias being introduced. METHODS We recruited 246 men from general practice surgeries in Sydney, Australia. These 246 men were randomized to receive a covering letter with their follow-up questionnaire either advising of a deadline to reply (Deadline, n = 126) or a standard letter without a deadline (No Deadline, n = 120). Four standardized reminder prompts subsequently were administered. We calculated interim response rates and the final proportion of follow-up questionnaires received according to group. We also compared scores on two main outcomes, namely, knowledge and decisional conflict at each time when reminder prompts were administered. RESULTS One hundred and twelve (88.9%) men in the Deadline group returned their follow-up questionnaires compared with 102 (85.0%) men in the No Deadline group. This difference was not statistically significant [odds ratio = 1.41, 95% confidence interval (CI) = 0.67-2.99; p = 0.36]. Time to response also was not significantly affected by cover letter received (hazard ratio = 0.96; 95% CI = 0.73-1.25; p = 0.76). Results of the original RCT were similar in terms of direction and effect size at all times irrespective of when reminder prompts were administered. CONCLUSION The addition of a deadline adds no further impact in improving response rates from male patients compared with an unspecified letter. Despite the accepted wisdom that higher response protects against bias, differences in outcomes were consistent throughout the post-test data collection period.
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Affiliation(s)
- M Gattellari
- School of Public Health and Community Medicine, University of New South Wales & Centre for Research, Evidence, Management and Surveillance, South Western Sydney Area Health Service, Australia.
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Abstract
OBJECTIVE We explored the influence of different but factual scenarios about prostate-specific antigen (PSA) screening on men's interest in having PSA screening to detect early prostate cancer. DESIGN Cross-sectional, representative community survey. SETTING AND PARTICIPANTS A total of 514 men (89% response fraction) aged 50-70 years randomly selected from a telephone directory database in Sydney, Australia. MAIN VARIABLES STUDIED Demographic, health and psychological variables. MAIN OUTCOME VARIABLES Interest in undergoing screening in response to five unspecified scenarios and, elsewhere in our interview, a specified scenario in which PSA screening was mentioned explicitly. RESULTS When presented with a scenario describing a lack of evidence underpinning the efficacy of screening for an unspecified cancer, 61.2% of men reported that they 'probably' or 'definitely' wanted to undergo screening for an unspecified cancer. Similar proportions reported that they 'probably' or 'definitely' wanted to undergo screening even at the risk of unmasking indolent cancer (60.9%) or without expert consensus about the value of screening (62.8%). Greatest interest in screening was elicited in that scenario describing life-time risk of dying from prostate cancer (72.6%) (P < 0.001). Significantly fewer indicated they would 'probably' or 'definitely' want to undergo screening for a cancer for which there was uncertainty about treatment efficacy and known side-effects (46.1%) (P < 0.001). Increasing age was a consistent predictor of positive interest in screening. When asked later in our survey specifically about PSA screening, 68.1%'probably' or definitely' wanted PSA screening. CONCLUSION Public health policy makers need to ensure that men are provided with the scope of medical evidence germane to prostate cancer screening and treatment, thereby potentially improving prostate cancer screening decisions.
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Affiliation(s)
- Melina Gattellari
- Department of General Practice, School of Public Health and Community Medicine, University of New South Wales, Liverpool, Australia.
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Cooney A, Gattellari M, Donnelly N, Ward J. Impact of national guidelines about the management of colorectal cancer on Australian surgeons' awareness of evidence: a pre/post survey. Colorectal Dis 2004; 6:418-27. [PMID: 15521929 DOI: 10.1111/j.1463-1318.2004.00710.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the immediate impact of national evidence-based guidelines about colorectal cancer on Australian surgeons' self-reported practice and their deficits in awareness of scientific evidence underpinning clinical management practices. DESIGN Pre/post evaluation, comprising preguidelines survey (November 1998) and postguidelines survey (February 2001). METHODS One hundred and fourteen Australian surgeons returned postguidelines surveys, of whom 103 (90%) agreed to matching of their pre- and postguidelines responses. National distribution of the CRC guidelines occurred in November 1999. Over the ensuing year, dissemination strategies included seminars, presentations at conferences and journal articles. The main outcome measures used were changes in awareness of evidence for each of 23 clinical recommendations, changes in overall awareness score (maximum possible 23), changes in subscore for nine items for which evidence was compelling and predictors of change. RESULTS Of those surgeons followed up, 95% were aware of the guidelines and 32% had read them in detail. Only 47% recalled the consumer version. The three most highly rated topics in the guidelines were: high-risk familial syndromes (45%); screening based on family history of colorectal cancer (40%); population screening for colorectal cancer (25%). Compared with baseline, there was a modest improvement in the mean overall awareness score (P = 0.02). Paired analyses of awareness of the evidence for each of 23 individual topics revealed significant improvement only in five. For two, awareness significantly decreased. CONCLUSIONS Our pre/post findings are not inconsistent with the expectation that dissemination of the CRC guidelines has had some short-term impact. However, definitive evidence acquired through more rigorously designed controlled trials will be needed to determine first, whether surgical practice has changed and, second, whether implementation of the CRC guidelines or some other secular event caused such change.
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Affiliation(s)
- A Cooney
- Alcohol and Drug Service, St Vincent's Hospital, Darlinghurst, NSW, Australia
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Abstract
BACKGROUND Antitumour antibiotics are used in the management of metastatic breast cancer. Some of these agents have demonstrated higher tumour response rates than non-antitumour antibiotic regimens, however a survival benefit has not been established in this setting. OBJECTIVES To identify and review the randomised evidence comparing anti-tumour antibiotic containing chemotherapy regimens with regimens not containing an anti-tumour antibiotic in the management of women with metastatic breast cancer. SEARCH STRATEGY The specialised register maintained by the Editorial Base of the Cochrane Breast Cancer Group was searched on 2nd May, 2003 using the codes for "advanced breast cancer" and "chemotherapy". Details of the search strategy and coding applied by the Group to create the register are described in the Group's module on The Cochrane Library. SELECTION CRITERIA Randomised trials comparing anti-tumour antibiotic containing regimens with regimens not containing anti-tumour antibiotics in women with metastatic breast cancer. DATA COLLECTION AND ANALYSIS Data were collected from published trials. Studies were assessed for eligibility and quality, and data were extracted by two independent reviewers. Hazard ratios (HRs) were derived from time-to-event outcomes where possible, and a fixed effect model was used for meta-analysis. Response rates were analysed as dichotomous variables. Quality of life and toxicity data were extracted where present. A primary analysis was conducted for all trials and by class of antitumour antibiotic. MAIN RESULTS Thirty-three trials reporting on 45 treatment comparisons were identified. All trials published results for tumour response and 26 trials published time-to-event data for overall survival. The observed 4084 deaths in 5284 randomised women did not demonstrate a statistically significant difference in survival between regimens that contained antitumour antibiotics and those that did not (HR 0.97, 95% CI 0.91 to 1.03, P = 0.35) and no significant heterogeneity. Antitumour antibiotic regimens were favourably associated with time-to-progression (HR 0.84, 95% CI 0.77 to 0.91) and tumour response rates (odds ratio (OR) 1.34, 95% CI 1.21 to 1.48) although statistically significant heterogeneity was observed for these outcomes. These associations were consistent when the analysis was restricted to the 29 trials that reported on anthracyclines. Patients receiving anthracycline-containing regimens were also more likely to experience toxic events compared to patients receiving non-antitumour antibiotic regimens. No statistically significant difference was observed in any outcome between mitoxantrone-containing and non-antitumour antibiotic-containing regimens. REVIEWERS' CONCLUSIONS Compared to regimens without antitumour antibiotics, regimens that contained these agents showed a statistically significant advantage for tumour response and time to progression in women with metastatic breast cancer but were not associated with an improvement in overall survival. The favourable effect on tumour response and time to progression observed in anthracycline-containing regimens was also associated with greater toxicity.
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Gattellari M, Ward JE. Does evidence-based information about screening for prostate cancer enhance consumer decision-making? A randomised controlled trial. J Med Screen 2004; 10:27-39. [PMID: 12790313 DOI: 10.1258/096914103321610789] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Efforts to educate men about the controversy surrounding prostate cancer screening are well intended but rarely evaluated rigorously. We evaluated an evidence-based (EB) booklet for men designed to promote informed decision-making. We also determined whether men's preference for involvement in decision-making ("passive", "collaborative" or "active") modified its impact. SETTING AND METHODS Men aged 40-70 years were recruited from the practices of 13 local general practitioners (GPs) in Sydney, Australia. They completed a self-administered questionnaire before seeing their GP, who, according to pre-randomised codes, distributed either our EB booklet or conventional information. Post-test questionnaires were mailed to men three days later. Of the 248 eligible men recruited, 214 (86% response rate) returned post-test questionnaires. Knowledge of evidence and of risk of developing and dying from prostate cancer, attitudes, interest in screening for prostate-specific antigen (PSA), worry and decisional conflict were the main outcome measures. RESULTS Compared with those receiving conventional information, men receiving the EB booklet had significantly improved knowledge (50% of items correct, 95% CI 46-53%; vs 45% correct, 95% CI 42-48%) (p = 0.048) and lower levels of decisional conflict (mean 21.6, 95% CI 20.7-22.5; vs mean 24.3, 95% CI 23.4-25.2) (p < 0.001). Interest in PSA screening was significantly reduced in both groups at post-test (p < 0.001). Men preferring a "passive" approach to decision-making gained as much from our EB booklet as those with "active" or "collaborative" preferences. CONCLUSIONS Our findings show the benefits of providing evidence-based information to men about PSA screening. Our EB booklet facilitated informed choice, even among "passive" decision-makers.
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Affiliation(s)
- M Gattellari
- Division of Population Health, South Western Sydney Area Health Service and School of Public Health, University of Sydney, Australia
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Abstract
OBJECTIVE We determined GP and patient variables associated first with men's prior uptake of prostate-specific antigen (PSA) screening and, subsequently, its initiation during an 'index consultation' in Australian general practice. METHODS From the practices of 60 GPs, we recruited a sample of 423 male patients aged 40-70 years. In a waiting room questionnaire completed before their 'index consultation' (retrospective component), men reported their previous PSA screening status. We obtained demographic and clinical data, including the presence of lower urinary tract symptoms (LUTS). Men also were mailed a questionnaire 2 days after their 'index consultation' to ascertain whether the GP had discussed PSA screening (prospective component) for prostate cancer and other behaviours. GPs themselves completed questionnaires eliciting demographic and practice characteristics as well as their propensity to screen and understanding of the evidence about PSA testing. GP and patient study variables were modelled simultaneously in analyses. RESULTS Of those 348 men consulting with their regular GP, 80 (23.0%) reported previously having had a PSA screening test. Men were significantly and independently more likely ever to have had PSA screening if their regular GP reported a propensity to initiate screening [adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) 1.23-4.20; P = 0.009]. GP age also was independently associated with men's PSA screening status [chi-squared (3) P < 0.0001] as was men's age and severity of LUTS (AOR = 2.38, 95% CI 1.58-3.57, P < 0.0001 and AOR = 1.79, 95% CI 1.00-3.19, P = 0.004, respectively). Current smokers were less likely ever to have had a PSA screening test (AOR = 0.34, 95% CI 0.16-0.69; P = 0.003). Discussion of PSA screening in their 'index consultation' was recalled independently more often by older men (AOR = 1.46, 95% CI 1.00-2.13; P = 0.04), those with moderate/severe LUTS (AOR = 1.94, 1.07-3.49; P = 0.04), those whose GP had performed or discussed a cholesterol test (AOR = 2.26, 95% CI 1.03-4.92; P = 0.04) and those whose GP had postgraduate training in family medicine (AOR = 3.13, 95% CI 1.23-8.00; P = 0.02). CONCLUSION In the absence as yet of compelling evidence that PSA screening will prolong life or enhance its quality, our findings identify GP and patient factors that could be targeted to modify PSA screening.
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Affiliation(s)
- Melina Gattellari
- Division of Population Health, South Western Sydney Area Health Service, School of Public Health, University of Sydney, Sydney, Australia
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Gattellari M, Ward JE. Patient education. PSA: pros and cons. Aust Fam Physician 2003; 32:429-30. [PMID: 12833769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Melina Gattellari
- Division of Population Health, South West Sydney Area, Health Service and School of Public Health, University of Sydney, New South Wales
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Abstract
HYPOTHESIS Not all Australian surgeons are aware of the status of the current evidence for the management of colorectal cancer. DESIGN Postal survey of Fellows of the Royal Australasian College of Surgeons. PARTICIPANTS One hundred ninety-five surgeons (127 general surgeons and 68 subspecialist colorectal surgeons) from a response fraction of 89%. MAIN OUTCOME MEASURES Overall awareness score for 23 clinical recommendations and a subscore for 10 of these for which evidence is compelling rather than inconclusive (9 for and 1 against incorporation in clinical practice). RESULTS Although no surgeon indicated the status of the evidence correctly for all 23 items, 61% of respondents correctly identified 12 or more items. Surgeons who practiced in capital cities had significantly higher scores than those who practiced outside cities (beta =.16; B = 1.01; 95% confidence interval [CI], 0.14-1.89; P =.02). Surgeons who had been in practice for relatively more years had significantly lower scores than younger surgeons (beta = -.17; B = -0.059; 95% CI, -0.11 to 0.01; P =.02). Surgeons involved in research had significantly higher scores (beta =.18; B = 1.11; 95% CI, 0.23-1.99; P =.01), as did those respondents who had been involved in guideline development (beta =.18; B = 1.42; 95% CI, 0.24-2.63; P =.02). Subscores showed a significantly greater awareness of compelling evidence (level I or level II) (P<.001). There was no relationship between awareness of the evidence for adjuvant therapy and surgeons' perceptions of the usefulness of guidelines about this aspect of clinical management. CONCLUSIONS Our innovative preguidelines survey has shown that not all surgeons were aware of the evidence underpinning the management of colorectal cancer, affirming the need for guidelines. Predictors of low awareness could be used to target efforts to disseminate and implement guidelines.
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Affiliation(s)
- Jeanette E Ward
- Division of Population Health, Southwestern Sydney Area Health Service, Locked Bag 7008, Liverpool, New South Wales 1780, Australia.
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Cooney A, Donnelly NJ, Gattellari M, Ward JE. Surgeons' views about colorectal cancer screening before and after national guidelines. Med J Aust 2002; 177:278-9. [PMID: 12197831 DOI: 10.5694/j.1326-5377.2002.tb04773.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2002] [Accepted: 07/24/2002] [Indexed: 11/17/2022]
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Abstract
We determined the extent to which Australian patients with incurable cancer are informed of their prognosis and treatment options by their oncologists and are encouraged to participate in treatment decisions. To this end, 118 patients with incurable cancer presenting for an initial consultation with one of nine oncologists in two Sydney teaching hospitals were enrolled in the study. Consultations were audio-taped. We developed a coding system to assess the disclosure of information considered necessary to equip patients to make informed decisions and to evaluate doctor encouragement of patient participation in treatment decision-making. Patient recall, satisfaction, and anxiety and their perceptions of the decision-making process were assessed. Most patients were informed about the aim of cancer treatment (84.7%), that their disease was incurable (74.6%) and about life expectancy (57.6%); 44.1% were presented with an alternative to cancer treatments, such as supportive care, 36.3% were informed how anticancer treatment would affect quality of life, and 29.7% were offered a management choice. Patient understanding was checked in only 10% of consultations. While greater information disclosure did not appear to elevate anxiety levels, greater patient participation in the decision making process was associated with increased anxiety levels ( P=0.0005), which persisted over a 2-week time span. Most patients were well informed, but important gaps remain, especially concerning information about prognosis and alternatives to cancer treatment.
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