Implementation of the South Australian Regional Telestroke service is associated with improved care quality and lower stroke mortality: A retrospective cohort study

INTRODUCTION

Stroke in Regional Australia may have worse outcomes due to difficulties accessing optimal care. The South Australian Regional Telestroke service aimed to improve telestroke neurologist access, supported by improved ambulance triage.

OBJECTIVE

To assess stroke care quality and patient mortality pre- and postimplementation of a vascular neurologist-led Telestroke service.

DESIGN

Historically controlled mixed methods cohort study comparing key quality indicators and patient mortality (6 months pre- vs. 18 months postimplementation date [4 June 2018]) at the three major South Australian regional stroke centres. The primary outcome was 13 care quality indicators as a combined composite risk-adjusted score, and the secondary outcome was risk-adjusted mortality at 12-month postadmission.

FINDINGS

On an annualised basis, of 189 patients with stroke, more were admitted postintervention to the regional stroke centres than in the control period (158 [annualised rate 105.3, 95% CI 86.2-127.4] vs. 31 [annualised rate 62.0, 95% CI 47.5-79.5]) Baseline patient characteristics were similar in both periods. Post-implementation, median last-known-well time to presentation (3.5 h [IQR 1.6-17] vs. 2.0 [IQR 1-14]; p = 0.46) and door to needle times (121 min [IQR 97-144] vs. 90 [IQR 75-138]; p = 0.65) were not significantly lower but an improvement in the combined composite quality score was observed (0.069 [95% CI 0.004-0.134; p = 0.04]), reflecting individual improvements in some quality indicators. Mortality at 12-month postimplementation was substantially lower postimplementation (prechange 23% vs. postchange 13% [hazard ratio 0.58 (95% CI 0.44-0.76; p < 0.001)]).

CONCLUSION

Implementation of a South Australian Regional Telestroke service was associated with improved care metrics and lower mortality.

Do we agree or disagree? A systematic review of the application of preference-based instruments in self and proxy reporting of quality of life in older people

PURPOSE

Quality of life is an important person-centred outcome in health and aged care settings. Due to an increasing prevalence of cognitive decline and dementia in ageing populations, a proportion of older people receiving health and aged care services may not be able to reliably assess their own quality of life, highlighting the need for proxy assessment. This systematic review sought to investigate the level of agreement between self and proxy-report of older people's quality of life using established preference-based instruments of quality of life suitable for economic evaluation.

METHODS

A systematic review was conducted following PRISMA guidelines. Eight databases were searched: Web of Science, Scopus, Medline, Econlit, PsychINFO, CINAHL, Ageline and Cochrane Library. Information was extracted on the instruments, population samples (including any cognitive thresholds applied), mean scores, type of proxy, and measures of inter-rater agreement.

RESULTS

A total of 50 studies using eight different preference-based quality of life instruments were identified. Most studies were cross-sectional (72%) with a wide variety of cognitive assessments and thresholds applied to define older participants with cognitive impairment. The most common proxies were family members, mostly spouses. The level of agreement between self and proxy-report was generally poor - irrespective of the instrument applied or type of proxy - with proxy-report generally indicating lower levels of quality of life than self-report. There was some evidence of stronger agreement on more observable quality of life domains e.g., physical health and mobility, relative to less observable domains e.g. emotional well-being. Few studies tracked self and/or proxy-report of quality of life longitudinally.

CONCLUSIONS

More research is needed to develop evidence to inform guidance on self-report versus proxy-report of quality of life for older people receiving health and aged care services. Until then, the collection of both self and proxy reports as complementary measures is indicated.

Consumer engagement in health care policy, research and services: A systematic review and meta-analysis of methods and effects

To assess the effects of consumer engagement in health care policy, research and services. We updated a review published in 2006 and 2009 and revised the previous search strategies for key databases (The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; PsycINFO; CINAHL; Web of Science) up to February 2020. Selection criteria included randomised controlled trials assessing consumer engagement in developing health care policy, research, or health services. The International Association for Public Participation, Spectrum of Public Participation was used to identify, describe, compare and analyse consumer engagement. Outcome measures were effects on people; effects on the policy/research/health care services; or process outcomes. We included 23 randomised controlled trials with a moderate or high risk of bias, involving 136,265 participants. Most consumer engagement strategies adopted a consultative approach during the development phase of interventions, targeted to health services. Based on four large cluster-randomised controlled trials, there is evidence that consumer engagement in the development and delivery of health services to enhance the care of pregnant women results in a reduction in neonatal, but not maternal, mortality. From other trials, there is evidence that involving consumers in developing patient information material results in material that is more relevant, readable and understandable for patients, and can improve knowledge. Mixed effects are reported of consumer-engagement on the development and/or implementation of health professional training. There is some evidence that using consumer interviewers instead of staff in satisfaction surveys can have a small influence on the results. There is some evidence that consumers may have a role in identifying a broader range of health care priorities that are complementary to those from professionals. There is some evidence that consumer engagement in monitoring and evaluating health services may impact perceptions of patient safety or quality of life. There is growing evidence from randomised controlled trials of the effects of consumer engagement on the relevance and positive outcomes of health policy, research and services. Health care consumers, providers, researchers and funders should continue to employ evidence-informed consumer engagement in their jurisdictions, with embedded evaluation.

Systematic review registration: PROSPERO CRD42018102595.

Compressive strength after blast of sandwich composite materials

Composite sandwich materials have yet to be widely adopted in the construction of naval vessels despite their excellent strength-to-weight ratio and low radar return. One barrier to their wider use is our limited understanding of their performance when subjected to air blast. This paper focuses on this problem and specifically the strength remaining after damage caused during an explosion. Carbon-fibre-reinforced polymer (CFRP) composite skins on a styrene-acrylonitrile (SAN) polymer closed-cell foam core are the primary composite system evaluated. Glass-fibre-reinforced polymer (GFRP) composite skins were also included for comparison in a comparable sandwich configuration. Full-scale blast experiments were conducted, where 1.6×1.3 m sized panels were subjected to blast of a Hopkinson-Cranz scaled distance of 3.02 m kg(-1/3), 100 kg TNT equivalent at a stand-off distance of 14 m. This explosive blast represents a surface blast threat, where the shockwave propagates in air towards the naval vessel. Hopkinson was the first to investigate the characteristics of this explosive air-blast pulse (Hopkinson 1948 Proc. R. Soc. Lond. A 89, 411-413 (doi:10.1098/rspa.1914.0008)). Further analysis is provided on the performance of the CFRP sandwich panel relative to the GFRP sandwich panel when subjected to blast loading through use of high-speed speckle strain mapping. After the blast events, the residual compressive load-bearing capacity is investigated experimentally, using appropriate loading conditions that an in-service vessel may have to sustain. Residual strength testing is well established for post-impact ballistic assessment, but there has been less research performed on the residual strength of sandwich composites after blast.

Age-related changes in EEG power spectra in infants during sevoflurane wash-out

BACKGROUND

Few electroencephalography (EEG) data are available in anaesthetized infants. This study aimed to identify EEG characteristics that might warn of awakening (AW) from sevoflurane anaesthesia in infants.

METHODS

Twenty intubated infants [aged 39-77 weeks post-menstrual age (PMA)] were studied after surgery during sevoflurane wash-out. EEG was recorded at the end of surgery and throughout emergence. Changes in EEG time and frequency domains were described.

RESULTS

At the end of surgery, mean end-tidal sevoflurane concentration was 2.3% (range 1.5-3.5) before wash-out and reduced to 0.3% (0.1-0.6) when AW began. On AW, movement artifacts made signals difficult to interpret. Before awakening, most power was within frequencies ≤4 Hz, but trends over time were variable. Summated power in frequencies between 20 and 70 Hz was almost always <5 µV(2). During anaesthesia, there were two common power spectra: infants >52 weeks PMA had obvious summated power in the frequency range 5-20 Hz (P5-20 Hz) (mean 308, median 320, range 110-542 µV(2)), which decreased before awakening began [mean decrease 252 µV(2) (95% CI 153-351)], whereas younger infants had low P5-20 Hz throughout. P5-20 Hz during anaesthesia increased with age; power in this frequency band of ~100 µV(2) separated infants younger and older than 52 weeks PMA.

CONCLUSIONS

During sevoflurane wash-out, decreasing P5-20 Hz might warn of impending AW in infants >3 months old, but not in younger infants.

Electrophysiological measurements and analysis of nociception in human infants

Pain is an unpleasant sensory and emotional experience. Since infants cannot verbally report their experiences, current methods of pain assessment are based on behavioural and physiological body reactions, such as crying, body movements or changes in facial expression. While these measures demonstrate that infants mount a response following noxious stimulation, they are limited: they are based on activation of subcortical somatic and autonomic motor pathways that may not be reliably linked to central sensory processing in the brain. Knowledge of how the central nervous system responds to noxious events could provide an insight to how nociceptive information and pain is processed in newborns.

The heel lancing procedure used to extract blood from hospitalised infants offers a unique opportunity to study pain in infancy. In this video we describe how electroencephalography (EEG) and electromyography (EMG) time-locked to this procedure can be used to investigate nociceptive activity in the brain and spinal cord.

This integrative approach to the measurement of infant pain has the potential to pave the way for an effective and sensitive clinical measurement tool.

Risk factors for glaucoma: what do they really mean?

Glaucoma is an insidious eye disease, potentially putting 4% of older Australians at risk of blindness, unless detected sufficiently early for initiation of effective treatment. This paper reports on the strengths of evidence and glaucoma risk factors that can be identified by primary health care providers from a patient's history. A comprehensive search of peer-reviewed databases identified relevant secondary evidence published between 2002 and 2007. Risk factors that could be determined from a patient's history were identified. A novel glaucoma risk factor reference guide was constructed according to evidence strength and level of concern regarding risk of developing glaucoma. The evidence is strong and consistent regarding the risk of developing glaucoma, and elevated intraocular pressure, advancing age, non-Caucasian ethnicity and family history of glaucoma. There is moderate evidence of association with glaucoma, and migraine, eye injury, myopia and long-term use of corticosteroids. There is conflicting evidence for living in a rural location, high blood pressure, diabetes and smoking. Early detection of people at risk of developing glaucoma can be initiated using our risk factor guide coupled with a comprehensive patient history. Timely future assessment and subsequent management strategies for at-risk individuals can then be effectively and efficiently actioned.

Falls are a fact of life for some patients after discharge from a rehabilitation programme

PURPOSE

This paper reports on a 3-month post-discharge falls profile of a cohort of patients discharged home from an acute rehabilitation setting.

METHODS

A consecutively-sampled cohort of consenting patients was prospectively followed for 3 months after discharge from a large Australian metropolitan acute rehabilitation facility. Patients were diagnostically classified by the reason for admission. All patients completed a monthly falls diary. Each month, falls were described by severity, location, frequency and outcome. Patients also completed the World Health Organisation's quality of life (QoL-BREF) at Months 1 and 3.

RESULTS

Almost a third of the study participants fell during the study [105 fallers of 342 total (31%)]. Of these, 21 fell more than once (20%). There were significant differences in falls reported per diagnostic group, including frequency, impact, severity and ability to get up. Irrespective of diagnostic group, fallers had lower QoL scores compared to non-fallers. Both the neurological and orthopaedic trauma groups were most at risk of falling in Months 1 and 3, whereas in Month 2, only the neurological group was most at risk of falling.

CONCLUSION

Falls are a fact of life for some patients during their community rehabilitation phase. Patients from different diagnostic groups have different over-time risk profiles for falling. Thus, there is no 'one-size fits all' solution for falls prevention. This study provides useful data to assist in formulating appropriate falls prevention strategies for recently ill people.

School-based interventions on childhood obesity: a meta-analysis

BACKGROUND

Over the past decade, childhood obesity has been recognized as an increasing health problem worldwide. It is a predictor of obesity during adulthood, which is strongly linked to chronic lifestyle diseases.

PURPOSE

This paper aims to evaluate the effectiveness of school-based programs in the prevention and management of childhood obesity.

METHODS

A comprehensive literature search was undertaken for RCTs and clinical controlled trials on school-based interventions that addressed childhood obesity, published between 1995 and 2007. The papers included for the meta-analysis were those in which ORs or standardized mean differences and their 95% CIs were reported or could be calculated from available data.

RESULTS

Meta-analysis showed that the odds of participants' being overweight and obese in the school-based intervention programs compared with the control arm were significantly protective in the short term (OR=0.74, 95% CI=0.60, 0.92). Interventions that were conducted for more than 1 year had a higher OR of decreasing the prevalence of obesity. However, intervention programs were not effective in decreasing BMI compared with control treatments, with a weighted mean difference of -0.62 (95% CI=-1.39, 0.14).

CONCLUSIONS

This meta-analysis showed that there was convincing evidence that school-based interventions are effective, at least short-term, in reducing the prevalence of childhood obesity. Longer-running programs were more effective than shorter programs.

Integrated GP and allied health care for patients with type 2 diabetes

BACKGROUND

Integrated general practitioner and allied health chronic disease management (CDM) has been supported by Australian Government Medicare initiatives since 2005. Practical ways of implementing CDM have been slow to develop.

METHODS

An integrated CDM program for patients with type 2 diabetes was piloted in 2006 by Central Northern Adelaide Health Service (South Australia), in conjunction with four divisions of general practice. Health providers included GPs, practice nurses, credentialed diabetes educators, dieticians and podiatrists. Eligible patients with Medicare approved Team Care Arrangements (TCAs) received allied health care for the Medicare Plus rebate only. This article reports on GP and staff perspectives of the processes, and the effectiveness and sustainability of the pilot.

RESULTS

Chronic disease management improved with integrated health care, reflected by appropriate allied health referrals and better quality TCAs, interprofessional communication, and patient satisfaction.

DISCUSSION

There are benefits for interested GPs, their staff, co-located allied health providers and diabetic patients if integrated multidisciplinary care is provided in the manner of this Enhanced Primary Care CDM model.

Case-mix fails to explain variation in mastectomy rates: management of screen-detected breast cancer in a UK region 1997-2003

Wide variation in the surgical management of breast cancer exists at hospital, regional, national and international level. To demonstrate whether variation in surgical practice observed at aggregate level between breast units persists following adjustment for case-mix, individual patient-level data from the Trent Breast Screening Programme Quality Assurance database (1997–2003) was analysed. Expected case-mix adjusted mastectomy rates were derived by logistic regression using the variables tumour size, site and grade, patient age and year of presentation, employing the region's overall case-mix adjusted practice as the reference population. The region's 11 breast screening units detected 5109 (3989 invasive) surgically managed primary breast cancers over the 6-year period. A total of 1828 mastectomies (Mx) were performed (Mx rate 35.8%, 95% confidence interval: 34.5–37.1%). Significant variation in mastectomy rates were observed between units (range 25–45%, P<0.0001), and persists following case-mix adjustment (P<0.0001). Two-fold variation in observed to expected unit mastectomy rate coefficient is demonstrated overall (range 0.66–1.36), increasing to almost four-fold variation in cancers less than 15 mm diameter (range 0.55–1.95). Significant variation in surgery for screen-detected primary breast cancer is not explained by case-mix. Further research is required to investigate potential patient and professional causative factors.

An audit of current clinical practice in the management of osteoporosis in Nottingham

BACKGROUND

Osteoporosis is now recognized by the World Health Organization and the Department of Health as a major public health problem. In 1994, the Advisory Group on Osteoporosis (AGO), set up by the Department of Health, recommended that Health Authorities and general practitioner fundholders should purchase bone densitometry services for the management of osteoporosis. The aims of this study were to assess the criteria for requests for bone densitometry from primary care in comparison with the AGO recommendations and to compare the numbers of patients referred with a low-trauma osteoporotic fracture with the expected number of fractures in the Nottingham area.

METHODS

Patient referral data and requests for bone densitometry were collected by case note review of all new patients referred to the Nottingham Osteoporosis Clinic over a 12 month period and then compared with the AGO recommendations. The patients referred with a history of a low-trauma fracture were then compared with the expected incidence of fractures, calculated using age-sex-specific fracture incidence data applied to the Nottingham population Census statistics.

RESULTS

A total of 413 patients were referred to the Osteoporosis Clinic for bone densitometry. Almost two-thirds of the patients had no clinical indicators for requests for scanning, in comparison with the AGO recommendations. Seventy-seven patients were referred with vertebral fracture, 12 hip, 20 colles and 26 other fractures. Using age-sex-specific fracture incidence data applied to the Nottingham population Census statistics, it was estimated that the expected incidence of hip fractures would be 812, distal forearm fractures 514 and vertebral fractures presenting to clinical attention 625. This represents 1.5 per cent of the total hip fractures, 3.9 per cent distal forearm and 12.3 per cent vertebral actually presenting to the Osteoporosis Clinic.

CONCLUSION

Bone densitometry was requested in up to 60 per cent of the patients with no clinical risk factors to warrant bone densitometry. Osteoporosis-related fractures remain unrecognized in clinical practice. The majority of patients do not receive specialist assessment despite being at high risk of future fracture. Further steps are necessary to educate health care professionals in primary and secondary care, but more importantly, to direct services more proactively in those at high risk of future fracture.

Personal monitoring of 218Po and 214Po radionuclide deposition onto individuals under normal environmental exposure conditions

Personal dosemeters have been utilized to monitor the deposition of the radon decay products 218Po and 214Po onto individuals under normal environmental exposure conditions. Each detector consists of TASTRAK alpha-sensitive plastic incorporated into an ordinary working wristwatch. Subsequent analysis provides energy discrimination of the detected alpha-particle decays, and allows events from the individual radon decay products 218Po and 214Po, attached to the detector surface, to be uniquely identified. Assuming similar deposition onto skin and detector surfaces, the activity per unit area of deposited radionuclides can be determined for exposed skin. Forty-one personal dosemeters were issued to volunteers selected through the hospital medical physics departments at Reading, Northampton, Exeter and Plymouth. Each volunteer was also issued with a personal radon dosemeter to determine their individual radon exposure. The volunteers wore the two dosemeters simultaneously and continuously for a period of around one month. Correlations were observed between the radon exposure of the individual and the activity per unit area of 218Po and 214Po on the detector surface. From these correlations it can be estimated that at the UK average radon exposure of 20 Bq m(-3), the number of decays/cm2/year on continuously exposed skin surface is between 3500 and 28,000 for 218Po, and between 7000 and 21,000 for 214Po. These results can be combined with theoretical modelling of the dose distribution in the skin to yield the alpha-particle radiation dose to any identified target cells.

Colles' fracture of the wrist as an indicator of underlying osteoporosis in postmenopausal women: a prospective study of bone mineral density and bone turnover rate

Colles' fracture has been shown to be associated with an increased risk of hip fracture. The incidence of low bone mineral density (BMD) and high bone turnover in such patients is uncertain. The aim of this study was to prospectively assess BMD and bone turnover in a cohort of consecutive postmenopausal Colles' fracture patients. BMD (spine, hip and contralateral radius) was measured by dual-energy X-ray absorptiometry (DXA) within 2 weeks of fracture. Bone turnover was assessed within 4 days by measurement of serum osteocalcin, total alkaline phosphatase (TALP), bone-specific alkaline phosphatase (BSAP) and urine hydroxyproline. We recruited 106 (71%) of 149 consecutive patients. Fifty-one per cent of subjects had a history of previous fracture, and 25% a past history of wrist, hip or vertebral body fracture. The incidence of osteoporosis was 21%, 42% and 22% at the spine, hip and radius respectively. Fifty per cent of subjects had osteoporosis of at least one of these sites. When compared with the values expected for their age the patients were found to have higher BMD than expected at the spine, and slightly lower BMD at the hip and distal radius. Patients aged 65 years or less had lower hip BMD than expected from the age-matched normal range (p < 0.01). Osteocalcin and TALP levels did not differ from the normal ranges, but BSAP and hydroxyproline levels were significantly elevated (p < 0.001), with 37% and 25% of patients having levels above the respective normal ranges. We conclude that osteoporosis is common in patients with Colles' fracture; however, in older patients BMD is not lower than would be expected in the normal population. In patients aged 65 years or less BMD is lower than expected at the hip. Bone turnover rate is high in many such patients. Intervention to prevent future fracture would be appropriate in women aged 65 years or less with Colles' fracture.

Current diet does not relate to bone mineral density after the menopause. The Nottingham Early Postmenopausal Intervention Cohort (EPIC) Study Group

The influence of dietary Ca on peak bone mass and on subsequent bone loss is controversial. Despite this an assessment of nutritional status is often included in the clinical evaluation of osteoporosis risk. To assess the value of this we investigated the relationship between current diet and bone mineral density (BMD) in 426 postmenopausal women, aged 45-59 years, who were enrolled into an international multi-centre trial of alendronate for the prevention of postmenopausal osteoporosis. BMD of the lumbar spine and proximal femur was measured on two occasions approximately 2 weeks apart by dual-energy X-ray absorptiometry. Serum osteocalcin was measured by immunoradiometric assay and serum 25-hydroxycholecalciferol by radioimmunoassay. Dietary assessment was performed by analysis of a 3 d unweighted dietary record, using Salford University's Microdiet software. BMD at both the lumbar spine and femoral neck correlated significantly with BMI, age, and average serum osteocalcin concentration. We therefore corrected for these variables in subsequent analyses. Dietary Ca intake ranged from 223 to 2197 mg/d (median 852 mg/d). Neither dietary Ca intake nor any other nutritional variable correlated significantly with BMD. There was a weak, but significant correlation between Ca intake and serum osteocalcin. We conclude that current diet does not correlate with BMD in early postmenopausal women. However, present diet may affect the rate of change of BMD, and this is supported by the finding of a significant relationship between dietary Ca and serum osteocalcin, a marker of bone formation rate.