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Coe A, Gunn J, Allnutt Z, Kaylor-Hughes C. Understanding Australian general practice patients' decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach. BMJ Open 2024; 14:e078179. [PMID: 38355180 PMCID: PMC10868251 DOI: 10.1136/bmjopen-2023-078179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES To evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying the mechanisms of the approach and (3) describing what contexts are associated with antidepressant tapering. DESIGN This mixed methods study was informed by the principles of realist evaluation and was conducted in the first 3 months of participation in the WiserAD randomised control trial. SETTING General practice, Victoria, Australia. PARTICIPANTS 13 antidepressant users from general practice participating in the WiserAD trial for antidepressant deprescribing. INTERVENTION A patient-facing, web-based structured support tool that consists of a personalised tapering schedule, an action plan for managing withdrawal symptoms, a daily mood, sleep and activity tracker and mental health nurse support. PRIMARY/SECONDARY OUTCOME MEASURES The outcomes of the study were revealed on data analysis as per a realist evaluation approach which tests and refines an initial programme theory. RESULTS The contexts of learnt coping skills, knowledge and perceptions of antidepressants and feeling well were evident. Outcomes were intention to commence, initiation of deprescribing and successful completion of deprescribing. Key mechanisms for antidepressant deprescribing were (1) initiation of the deprescribing discussion; (2) patient self-efficacy; (3) provision of structured guidance; (4) coaching; (5) mood, sleep and activity tracking and (6) feelings of safety during the tapering period. CONCLUSIONS The WiserAD approach to antidepressant deprescribing supported participants to commence and/or complete tapering. The refined programme theory presents the WiserAD pragmatic framework for the application of antidepressant deprescribing in clinical practice. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05355025; ACTRN12622000567729; ISRCTN11562922; Pre-results.
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Affiliation(s)
- Amy Coe
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Jane Gunn
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Zoe Allnutt
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Catherine Kaylor-Hughes
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
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Missirlian M, Firdaouss M, Richou M, Hernandez C, Gargiulo L, Bucalossi J, Brun C, Corre Y, Delmas E, Greuner H, Guillermin B, Gunn J, Hatchressian J, Jalageas R, Li Q, Lipa M, Lozano M, Luo G, Pocheau C, Roche H, Tsitrone E, Vignal N, Wang W, Saille A, Zago B. Manufacturing, testing and installation of the full tungsten actively cooled ITER-like divertor in the WEST tokamak. Fusion Engineering and Design 2023. [DOI: 10.1016/j.fusengdes.2023.113683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Saya S, Chondros P, Abela A, Mihalopolous C, Chatterton ML, Gunn J, Chen TF, Polasek TM, Dettmann E, Brooks R, King M, Spencer L, Alphonse P, Milton S, Ramsay G, Siviour Z, Liew J, Ly P, Thoenig M, Seychell R, La Rocca F, Hesson LB, Mejias N, Sivertsen T, Galea MA, Bousman C, Emery J. The PRESIDE (PhaRmacogEnomicS In DEpression) Trial: a double-blind randomised controlled trial of pharmacogenomic-informed prescribing of antidepressants on depression outcomes in patients with major depressive disorder in primary care. Trials 2023; 24:342. [PMID: 37208772 DOI: 10.1186/s13063-023-07361-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/06/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND The evidence for the clinical utility of pharmacogenomic (PGx) testing is growing, and guidelines exist for the use of PGx testing to inform prescribing of 13 antidepressants. Although previous randomised controlled trials of PGx testing for antidepressant prescribing have shown an association with remission of depression in clinical psychiatric settings, few trials have focused on the primary care setting, where most antidepressant prescribing occurs. METHODS The PRESIDE Trial is a stratified double-blinded randomised controlled superiority trial that aims to evaluate the impact of a PGx-informed antidepressant prescribing report (compared with standard prescribing using the Australian Therapeutic Guidelines) on depressive symptoms after 12 weeks, when delivered in primary care. Six hundred seventy-two patients aged 18-65 years of general practitioners (GPs) in Victoria with moderate to severe depressive symptoms, measured using the Patient Health Questionnaire-9 (PHQ-9), will be randomly allocated 1:1 to each arm using a computer-generated sequence. Participants and GPs will be blinded to the study arm. The primary outcome is a difference between arms in the change of depressive symptoms, measured using the PHQ-9 after 12 weeks. Secondary outcomes include a difference between the arms in change in PHQ-9 score at 4, 8 and 26 weeks, proportion in remission at 12 weeks, a change in side effect profile of antidepressant medications, adherence to antidepressant medications, change in quality of life and cost-effectiveness of the intervention. DISCUSSION This trial will provide evidence as to whether PGx-informed antidepressant prescribing is clinically efficacious and cost-effective. It will inform national and international policy and guidelines about the use of PGx to select antidepressants for people with moderate to severe depressive symptoms presenting in primary care. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry ACTRN12621000181808. Registered on 22 February 2021.
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Affiliation(s)
- Sibel Saya
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia.
| | - Patty Chondros
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Anastasia Abela
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Cathrine Mihalopolous
- School of Public Health and Preventive Medicine, Monash University Health Economics Group, Monash University, Melbourne, VIC, Australia
| | - Mary Lou Chatterton
- School of Public Health and Preventive Medicine, Monash University Health Economics Group, Monash University, Melbourne, VIC, Australia
| | - Jane Gunn
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Timothy F Chen
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, 2006, Australia
| | - Thomas M Polasek
- , Certara, Princeton, NJ, USA
- Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Elise Dettmann
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Rachel Brooks
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Michelle King
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Luke Spencer
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Pavithran Alphonse
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Shakira Milton
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Georgia Ramsay
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Zoe Siviour
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Jamie Liew
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Philip Ly
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Matthew Thoenig
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Raushaan Seychell
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Floriana La Rocca
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - Luke B Hesson
- Genetics Department, Douglass Hanly Moir Pathology, Sonic Healthcare, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine, UNSW Sydney, Randwick, NSW, Australia
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | | | - Terri Sivertsen
- Genetics Department, Douglass Hanly Moir Pathology, Sonic Healthcare, Sydney, NSW, Australia
| | - Melanie Anne Galea
- Genetics Department, Douglass Hanly Moir Pathology, Sonic Healthcare, Sydney, NSW, Australia
| | - Chad Bousman
- Department of Medical Genetics, University of Calgary, Calgary, AB, Canada
| | - Jon Emery
- Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Centre for Cancer Research, University of Melbourne, Melbourne, Australia
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Mavragani A, Gunn J, Kaylor-Hughes C. General Practice Patients' Experiences and Perceptions of the WiserAD Structured Web-Based Support Tool for Antidepressant Deprescribing: Protocol for a Mixed Methods Case Study With Realist Evaluation. JMIR Res Protoc 2022; 11:e42526. [PMID: 36580362 PMCID: PMC9837708 DOI: 10.2196/42526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/24/2022] [Accepted: 12/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Research suggests that the rapid increase in worldwide antidepressant use is mainly due to a rise in long-term and potentially inappropriate use. It has been suggested that 1 in 3 antidepressant users among general practice patients are no longer experiencing clinical benefits from their medication and should commence deprescribing. However there are many barriers to antidepressant deprescribing for both patients and clinicians, which adds to the complex nature of reducing or ceasing the medication. As such, antidepressant deprescribing does not routinely occur in clinical practice. Evidence-based supports and interventions for safe and successful antidepressant deprescribing are needed to assist patients and their doctors. Interventions should also include an understanding of how an intervention works, why it works, and whom it is for. OBJECTIVE This study aims to evaluate how the WiserAD approach to antidepressant deprescribing works, whom it is for, and the underlying circumstances by (1) examining the experiences and perceptions of WiserAD among antidepressant users, (2) identifying the underlying mechanisms of the WiserAD approach to antidepressant deprescribing, and (3) describing in what contexts and to what extent the underlying mechanisms of WiserAD are suited for antidepressant users. METHODS A mixed methods case study with realist evaluation will be conducted among participants in the WiserAD randomized controlled trial for antidepressant deprescribing. Quantitative data will be obtained from up to 12 participants from the intervention and control arms at baseline and 3-month follow-up. Baseline data will be used to characterize the sample using descriptive statistics. Paired samples t tests will also be performed to compare responses between baseline and 3-month follow-up for participant self-management, skills, confidence and knowledge, beliefs about medicines, current emotional health, and well-being symptoms. Qualitative data from the same participants will be collected via narrative interview at 3-month follow-up. Quantitative and qualitative data will be converged to form a "case," and analysis will be conducted within each case with comparisons made across multiple cases. RESULTS Recruitment of participants commenced in October 2022 and will be completed by March 2023. Analysis will be completed by June 2023. CONCLUSIONS To our knowledge, this will be the first realist evaluation of an antidepressant deprescribing intervention in general practice. Findings from this evaluation may assist in the implementation of the WiserAD approach to antidepressant deprescribing in routine clinical practice. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/42526.
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Affiliation(s)
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Australia
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Maeker J, Nichols J, Donovan D, Grosjean A, Gunn J, Fedorczak N, Guillemaut C, Klepper C, Unterberg E, Easley D, Team WEST. OEDGE modeling of far-SOL tungsten impurity sources and screening in WEST. Nuclear Materials and Energy 2022. [DOI: 10.1016/j.nme.2022.101309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Eratne D, Janelidze S, Malpas CB, Loi S, Walterfang M, Merritt A, Diouf I, Blennow K, Zetterberg H, Cilia B, Wannan C, Bousman C, Everall I, Zalesky A, Jayaram M, Thomas N, Berkovic SF, Hansson O, Velakoulis D, Pantelis C, Santillo A, Stehmann C, Cadwallader C, Fowler C, Ravanfar P, Farrand S, Keem M, Kang M, Watson R, Yassi N, Kaylor-Hughes C, Kanaan R, Perucca P, Vivash L, Ali R, O’Brien TJ, Masters CL, Collins S, Kelso W, Evans A, King A, Kwan P, Gunn J, Goranitis I, Pan T, Lewis C, Kalincik T. Plasma neurofilament light chain protein is not increased in treatment-resistant schizophrenia and first-degree relatives. Aust N Z J Psychiatry 2022; 56:1295-1305. [PMID: 35179048 DOI: 10.1177/00048674211058684] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Schizophrenia, a complex psychiatric disorder, is often associated with cognitive, neurological and neuroimaging abnormalities. The processes underlying these abnormalities, and whether a subset of people with schizophrenia have a neuroprogressive or neurodegenerative component to schizophrenia, remain largely unknown. Examining fluid biomarkers of diverse types of neuronal damage could increase our understanding of these processes, as well as potentially provide clinically useful biomarkers, for example with assisting with differentiation from progressive neurodegenerative disorders such as Alzheimer and frontotemporal dementias. METHODS This study measured plasma neurofilament light chain protein (NfL) using ultrasensitive Simoa technology, to investigate the degree of neuronal injury in a well-characterised cohort of people with treatment-resistant schizophrenia on clozapine (n = 82), compared to first-degree relatives (an at-risk group, n = 37), people with schizophrenia not treated with clozapine (n = 13), and age- and sex-matched controls (n = 59). RESULTS We found no differences in NfL levels between treatment-resistant schizophrenia (mean NfL, M = 6.3 pg/mL, 95% confidence interval: [5.5, 7.2]), first-degree relatives (siblings, M = 6.7 pg/mL, 95% confidence interval: [5.2, 8.2]; parents, M after adjusting for age = 6.7 pg/mL, 95% confidence interval: [4.7, 8.8]), controls (M = 5.8 pg/mL, 95% confidence interval: [5.3, 6.3]) and not treated with clozapine (M = 4.9 pg/mL, 95% confidence interval: [4.0, 5.8]). Exploratory, hypothesis-generating analyses found weak correlations in treatment-resistant schizophrenia, between NfL and clozapine levels (Spearman's r = 0.258, 95% confidence interval: [0.034, 0.457]), dyslipidaemia (r = 0.280, 95% confidence interval: [0.064, 0.470]) and a negative correlation with weight (r = -0.305, 95% confidence interval: [-0.504, -0.076]). CONCLUSION Treatment-resistant schizophrenia does not appear to be associated with neuronal, particularly axonal degeneration. Further studies are warranted to investigate the utility of NfL to differentiate treatment-resistant schizophrenia from neurodegenerative disorders such as behavioural variant frontotemporal dementia, and to explore NfL in other stages of schizophrenia such as the prodome and first episode.
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Affiliation(s)
- Dhamidhu Eratne
- Neuropsychiatry, The Royal Melbourne Hospital, Parkville, VIC, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Shorena Janelidze
- Clinical Memory Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Charles B Malpas
- Clinical Outcomes Research Unit (CORe), Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Samantha Loi
- Neuropsychiatry, The Royal Melbourne Hospital, Parkville, VIC, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Mark Walterfang
- Neuropsychiatry, The Royal Melbourne Hospital, Parkville, VIC, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Antonia Merritt
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Ibrahima Diouf
- Clinical Outcomes Research Unit (CORe), Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, University of Gothenburg, Mölndal, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, University of Gothenburg, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute, University College London (UCL), London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Brandon Cilia
- The University of Melbourne, Parkville, VIC, Australia
| | - Cassandra Wannan
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Chad Bousman
- Departments of Medical Genetics, Psychiatry, and Physiology & Pharmacology, University of Calgary, Calgary, AB, Canada
| | - Ian Everall
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Andrew Zalesky
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Mahesh Jayaram
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia.,Mid West Area Mental Health Service, Melbourne Health, Sunshine, VIC, Australia
| | - Naveen Thomas
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia.,Mid West Area Mental Health Service, Melbourne Health, Sunshine, VIC, Australia
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia
| | - Oskar Hansson
- Clinical Memory Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Dennis Velakoulis
- Neuropsychiatry, The Royal Melbourne Hospital, Parkville, VIC, Australia.,Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
| | - Christos Pantelis
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia.,Mid West Area Mental Health Service, Melbourne Health, Sunshine, VIC, Australia
| | - Alexander Santillo
- Clinical Memory Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Chatterton ML, Harris M, Burgess P, Fletcher S, Spittal MJ, Faller J, Palmer VJ, Chondros P, Bassilios B, Pirkis J, Gunn J, Mihalopoulos C. Economic evaluation of a Decision Support Tool to guide intensity of mental health care in general practice: the Link-me pragmatic randomised controlled trial. BMC Prim Care 2022; 23:236. [PMID: 36109694 PMCID: PMC9479277 DOI: 10.1186/s12875-022-01839-z] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 08/26/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
This paper reports on the cost-effectiveness evaluation of Link-me – a digitally supported, systematic approach to triaging care for depression and anxiety in primary care that uses a patient-completed Decision Support Tool (DST).
Methods
The economic evaluation was conducted alongside a parallel, stratified individually randomised controlled trial (RCT) comparing prognosis-matched care to usual care at six- and 12-month follow-up. Twenty-three general practices in three Australian Primary Health Networks recruited 1,671 adults (aged 18 – 75 years), predicted by the DST to have minimal/mild or severe depressive or anxiety symptoms in three months. The minimal/mild prognostic group was referred to low intensity services. Participants screened in the severe prognostic group were offered high intensity care navigation, a model of care coordination. The outcome measures included in this evaluation were health sector costs (including development and delivery of the DST, care navigation and other healthcare services used) and societal costs (health sector costs plus lost productivity), psychological distress [Kessler Psychological Distress Scale (K10)] and quality adjusted life years (QALYs) derived from the EuroQol 5-dimension quality of life questionnaire with Australian general population preference weights applied. Costs were valued in 2018–19 Australian dollars (A$).
Results
Across all participants, the health sector incremental cost-effectiveness ratio (ICER) of Link-me per point decrease in K10 at six months was estimated at $1,082 (95% CI $391 to $6,204) increasing to $2,371 (95% CI $191 to Dominated) at 12 months. From a societal perspective, the ICER was estimated at $1,257/K10 point decrease (95% CI Dominant to Dominated) at six months, decreasing to $1,217 (95% CI Dominant to Dominated) at 12 months. No significant differences in QALYs were detected between trial arms and the intervention was dominated (less effective, more costly) based on the cost/QALY ICER.
Conclusions
The Link-me approach to stepped mental health care would not be considered cost-effective utilising a cost/QALY outcome metric commonly adopted by health technology assessment agencies. Rather, Link-me showed a trend toward cost-effectiveness by providing improvement in mental health symptoms, measured by the K10, at an additional cost.
Trial registration
Australian and New Zealand Clinical Trials Registry, ANZCTRN 12617001333303.
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Taylor AK, Palmer VJ, Davidson S, Fletcher S, Gunn J. Patient reported self-help strategies and the perceived benefits for managing sub-threshold depressive symptoms: A nested qualitative study of Australian primary care attendees. Health Soc Care Community 2022; 30:e2097-e2108. [PMID: 34766664 DOI: 10.1111/hsc.13646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/20/2021] [Accepted: 10/27/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Subthreshold depression is common in primary care, but there is little information about the self-help strategies that patients use and the perceived benefits of these. AIM This study sought to elicit the self-help strategies that primary care attendees identified as beneficial for the self-management of subthreshold depressive symptoms and the implications for general practitioners. METHOD Semi-structured telephone interviews were conducted with 14 people (April-May 2017) from the Target-D randomised controlled trial (RCT). Target-D investigated whether using a patient-centred clinical prediction tool and an e-health platform to match mental health management options to prognosis was beneficial for improving depressive symptoms at 3 months compared to usual care. Interviews were thematically analysed to identify self-help strategies and their perceived benefits. RESULTS Four overarching domains for the self-management strategies were identified: social, cognitive, behavioural and restorative. Interviewees reported using strategies across multiple domains, which included undertaking enjoyable, immersive activities, that provided relief from automatic negative thoughts and had a perceived cognitive benefit. Differences in the perceived sense of agency were noted around the self-regulation of mood, which indicated more explicit direction to patient-identified self-help management strategies by general practitioners for some may be of benefit in routine care. CONCLUSION Some of the reported self-management strategies aligned with evidence-based approaches such as physical activity and mindfulness for mental health symptom management. These findings can inform low-intensity interventions within stepped care models for mental health in primary care, social prescribing models and, help to guide the management of patients by GPs for subthreshold depression.
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Affiliation(s)
- Anna Kathryn Taylor
- School of Medicine, Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Victoria J Palmer
- The ALIVE National Centre for Mental Health Research Translation, The Department of General Practice, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- The Department of General Practice, Melbourne Medical School, The Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sandra Davidson
- The Department of General Practice, Melbourne Medical School, The Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Susan Fletcher
- The Department of General Practice, Melbourne Medical School, The Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Gunn
- The ALIVE National Centre for Mental Health Research Translation, The Department of General Practice, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- The Department of General Practice, Melbourne Medical School, The Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Godbee K, Guccione L, Palmer VJ, Gunn J, Lautenschlager N, Francis JJ. Dementia Risk Reduction in Primary Care: A Scoping Review of Clinical Guidelines Using a Behavioral Specificity Framework. J Alzheimers Dis 2022; 89:789-802. [DOI: 10.3233/jad-220382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Primary care practitioners are being called upon to work with their patients to reduce dementia risk. However, it is unclear who should do what with whom, when, and under what circumstances. Objective: This scoping review aimed to identify clinical guidelines for dementia risk reduction (DRR) in primary care settings, synthesize the guidelines into actionable behaviors, and appraise the guidelines for specificity. Methods: Terms related to “dementia”, “guidelines”, and “risk reduction” were entered into two academic databases and two web search engines. Guidelines were included if they referred specifically to clinical practices for healthcare professionals for primary prevention of dementia. Included guidelines were analyzed using a directed content analysis method, underpinned by the Action-Actor-Context-Target-Time framework for specifying behavior. Results: Sixteen guidelines were included in the analysis. Together, the guidelines recommended six distinct clusters of actions for DRR. These were to 1) invite patients to discuss DRR, 2) identify patients with risk factors for dementia, 3) discuss DRR, 4) manage dementia risk factors, 5) signpost to additional support, and 6) follow up. Guidelines recommended various actors, contexts, targets, and times for performing these actions. Together, guidelines lacked specificity and were at times contradictory. Conclusion: Currently available guidelines allow various approaches to promoting DRR in primary care. Primary care teams are advised to draw on the results of the review to decide which actions to undertake and the locally appropriate actors, contexts, targets, and times for these actions. Documenting these decisions in more specific, local guidelines for promoting DRR should facilitate implementation.
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Affiliation(s)
- Kali Godbee
- Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Lisa Guccione
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department on Oncology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Victoria J. Palmer
- Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- The ALIVE National Centre for Mental Health Research Translation, University of Melbourne, Melbourne, Australia
| | - Jane Gunn
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- The ALIVE National Centre for Mental Health Research Translation, University of Melbourne, Melbourne, Australia
| | - Nicola Lautenschlager
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- The ALIVE National Centre for Mental Health Research Translation, University of Melbourne, Melbourne, Australia
| | - Jill J. Francis
- Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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O'Keefe D, Gunn J, Ryan K, Djordjevic F, Kerr P, Gold J, Elsum I, Layton C, Chan K, Dietze P, Higgs P, Doyle J, Stoové MA, Hellard M, Pedrana AE. Exploring hepatitis C virus testing and treatment engagement over time in Melbourne, Australia: a study protocol for a longitudinal cohort study (EC-Experience Cohort study). BMJ Open 2022; 12:e057618. [PMID: 34983773 PMCID: PMC8728403 DOI: 10.1136/bmjopen-2021-057618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/16/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The advent of direct acting antiviral therapy for hepatitis C virus (HCV) means the elimination of HCV is possible but requires sustained effort to achieve. Between 2016 and 2019, 44% of those living with HCV were treated in Australia. However, treatment uptake has declined significantly. In Australia, people who inject drugs (PWID) are the population most at risk of HCV acquisition. Eliminating HCV in Australia will require nuanced understanding of the barriers to HCV treatment experienced by PWID and tailored interventions to address these barriers. The EC-Experience Cohort study aims to explore the barriers and enablers reported by PWID to engagement in HCV care. METHODS AND ANALYSIS The EC-Experience Cohort study is a prospective cohort of PWID, established in Melbourne, Australia in 2018. Participants are assigned into three study groups: (1) those not currently engaged in HCV testing; (2) those diagnosed with HCV but not currently engaged in treatment and (3) those completed treatment. Participants complete a total of four interviews every 6 months across an 18-month study period. Predictors of experience of key outcome events along the HCV care cascade will be explored over time. ETHICS AND DISSEMINATION Ethical approval for the EC-Experience Cohort study was obtained by the Alfred Hospital Ethics Committee in Melbourne, Australia (Project Number: HREC/16/Alfred/164). All eligible participants are assessed for capacity to consent and partake in a thorough informed consent process. Results from the EC-Experience Cohort study will be disseminated via national and international scientific and public health conferences and peer-reviewed journal publications. Data from the EC-Experience Cohort study will improve the current understanding of the barriers to HCV care for PWID and guide the tailoring of service provision for specific subgroups. Understanding the barriers and how to increase engagement in care of PWID is critical to achieve HCV elimination goals.
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Affiliation(s)
- Daniel O'Keefe
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - J Gunn
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Kathleen Ryan
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Filip Djordjevic
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Phoebe Kerr
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Judy Gold
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Imogen Elsum
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Chloe Layton
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Kico Chan
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Paul Dietze
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
- Department of Public Health, La Trobe University, Bundoora, Victoria, Australia
| | - Joseph Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark A Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
- Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - A E Pedrana
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
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11
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Godbee K, Farrow M, Bindoff A, Gunn J, Lautenschlager N, Palmer V. Implementing dementia risk reduction in primary care: views of enrollees in the Preventing Dementia Massive Open Online Course. Aust J Prim Health 2021; 27:479-484. [PMID: 34818511 DOI: 10.1071/py21122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/28/2021] [Indexed: 12/28/2022]
Abstract
There is a push for greater promotion of dementia risk reduction (DRR) by primary care practitioners (PCPs). The aims of this study were to understand the views of non-medically trained Australian contributors in a Massive Open Online Course (MOOC) about dementia prevention regarding the role of PCPs in promoting DRR and to consider the implications of those views for developing implementation strategies. Discussion board posts of MOOC enrollees were analysed regarding the actions that organisations, communities and/or governments should take to help people work towards DRR. Of the 1641 eligible contributors to the discussion, 160 (10%) indicated that PCPs had a role in promoting DRR. This subset of participants particularly wanted earlier identification of risk by PCPs and a discussion about DRR. Some participants thought PCPs did not currently prioritise DRR, lacked knowledge about DRR and faced Medicare and resource restrictions to promoting DRR. We suggest that PCPs need: better publicity for their role in promoting DRR; to prioritise DRR; knowledge about DRR; and to take advantage of existing opportunities to promote DRR quickly. The findings of this study should be considered when attempting to implement DRR guidelines in primary care.
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Affiliation(s)
- Kali Godbee
- Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic., Australia; and Corresponding author.
| | - Maree Farrow
- Wicking Dementia Research and Education Centre, The University of Tasmania, Hobart, Tas., Australia
| | - Aidan Bindoff
- Wicking Dementia Research and Education Centre, The University of Tasmania, Hobart, Tas., Australia
| | - Jane Gunn
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic., Australia
| | - Nicola Lautenschlager
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic., Australia
| | - Victoria Palmer
- Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Vic., Australia
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12
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Thuraisingam S, Chondros P, Dowsey MM, Spelman T, Garies S, Choong PF, Gunn J, Manski-Nankervis JA. Assessing the suitability of general practice electronic health records for clinical prediction model development: a data quality assessment. BMC Med Inform Decis Mak 2021; 21:297. [PMID: 34717599 PMCID: PMC8557028 DOI: 10.1186/s12911-021-01669-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of general practice electronic health records (EHRs) for research purposes is in its infancy in Australia. Given these data were collected for clinical purposes, questions remain around data quality and whether these data are suitable for use in prediction model development. In this study we assess the quality of data recorded in 201,462 patient EHRs from 483 Australian general practices to determine its usefulness in the development of a clinical prediction model for total knee replacement (TKR) surgery in patients with osteoarthritis (OA). METHODS Variables to be used in model development were assessed for completeness and plausibility. Accuracy for the outcome and competing risk were assessed through record level linkage with two gold standard national registries, Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and National Death Index (NDI). The validity of the EHR data was tested using participant characteristics from the 2014-15 Australian National Health Survey (NHS). RESULTS There were substantial missing data for body mass index and weight gain between early adulthood and middle age. TKR and death were recorded with good accuracy, however, year of TKR, year of death and side of TKR were poorly recorded. Patient characteristics recorded in the EHR were comparable to participant characteristics from the NHS, except for OA medication and metastatic solid tumour. CONCLUSIONS In this study, data relating to the outcome, competing risk and two predictors were unfit for prediction model development. This study highlights the need for more accurate and complete recording of patient data within EHRs if these data are to be used to develop clinical prediction models. Data linkage with other gold standard data sets/registries may in the meantime help overcome some of the current data quality challenges in general practice EHRs when developing prediction models.
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Affiliation(s)
- Sharmala Thuraisingam
- Department of Surgery, University of Melbourne, 29 Regent Street, Fitzroy, VIC 3065 Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Parkville, VIC 3010 Australia
| | - Patty Chondros
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Parkville, VIC 3010 Australia
| | - Michelle M. Dowsey
- Department of Surgery, University of Melbourne, 29 Regent Street, Fitzroy, VIC 3065 Australia
| | - Tim Spelman
- Department of Surgery, University of Melbourne, 29 Regent Street, Fitzroy, VIC 3065 Australia
- Karolinska Institute, Solnavagen 1, 171 77 Solna, Sweden
| | - Stephanie Garies
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Alberta, T2N 4N1 Canada
| | - Peter F. Choong
- Department of Surgery, University of Melbourne, 29 Regent Street, Fitzroy, VIC 3065 Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Parkville, VIC 3010 Australia
- Faculty of Medicine Dentistry & Health Sciences, University of Melbourne, Alan Gilbert Building, Level 2, Carlton, VIC 3053 Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Parkville, VIC 3010 Australia
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Abstract
OBJECTIVE To identify and characterise activities for deprescribing used in general practice and to map the identified activities to pioneering principles of deprescribing. SETTING Primary care. DATA SOURCES Medline, EMBASE (Ovid), CINAHL, Australian New Zealand Clinical Trials Registry (ANZCTR), Clinicaltrials.gov, ISRCTN registry, OpenGrey, Annals of Family Medicine, BMC Family Practice, Family Practice and British Journal of General Practice (BJGP) from inception to the end of June 2021. STUDY SELECTION Included studies were original research (randomised controlled trial, quasi-experimental, cohort study, qualitative and case studies), protocol papers and protocol registrations. DATA EXTRACTION Screening and data extraction was completed by one reviewer; 10% of the studies were independently reviewed by a second reviewer. Coding of full-text articles in NVivo was conducted and mapped to five deprescribing principles. RESULTS Fifty studies were included. The most frequently used activities were identification of appropriate patients for deprescribing (76%), patient education (50%), general practitioners (GP) education (48%), and development and use of a tapering schedule (38%). Six activities did not align with the five deprescribing principles. As such, two principles (engage practice staff in education and appropriate identification of patients, and provide feedback to staff about deprescribing occurrences within the practice) were added. CONCLUSION Activities and guiding principles for deprescribing should be paired together to provide an accessible and comprehensive guide to deprescribing by GPs. The addition of two principles suggests that practice staff and practice management teams may play an instrumental role in sustaining deprescribing processes within clinical practice. Future research is required to determine the most of effective activities to use within each principle and by whom.
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Affiliation(s)
- Amy Coe
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Susan Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Murray
- Primary Care and Population Health, University College London, London, UK
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
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Manski-Nankervis JA, Alexander K, Biezen R, Jones J, Hunter B, Emery J, Lumsden N, Boyle D, Gunn J, McMorrow R, Prictor M, Taylor M, Hallinan C, Chondros P, Janus E, McIntosh J, Nelson C. Towards optimising chronic kidney disease detection and management in primary care: Underlying theory and protocol for technology development using an Integrated Knowledge Translation approach. Health Informatics J 2021; 27:14604582211008227. [PMID: 33853414 DOI: 10.1177/14604582211008227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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
Worldwide, Chronic Kidney Disease (CKD), directly or indirectly, causes more than 2.4 million deaths annually with symptoms generally presenting late in the disease course. Clinical guidelines support the early identification and treatment of CKD to delay progression and improve clinical outcomes. This paper reports the protocol for the codesign, implementation and evaluation of a technological platform called Future Health Today (FHT), a software program that aims to optimise early detection and management of CKD in general practice. FHT aims to optimise clinical decision making and reduce practice variation by translating evidence into practice in real time and as a part of quality improvement activities. This protocol describes the co-design and plans for implementation and evaluation of FHT in two general practices invited to test the prototype over 12 months. Service design thinking has informed the design phase and mixed methods will evaluate outcomes following implementation of FHT. Through systematic application of co-design with service users, clinicians and digital technologists, FHT attempts to avoid the pitfalls of past studies that have failed to accommodate the complex requirements and dynamics that can arise between researchers and service users and improve chronic disease management through use of health information technology.
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Affiliation(s)
| | | | | | - Julia Jones
- Department of Nephrology, Western Health, Australia.,Western Health Chronic Disease Alliance, Australia.,University of Melbourne, Australia
| | | | | | - Natalie Lumsden
- Department of Nephrology, Western Health, Australia.,Western Health Chronic Disease Alliance, Australia
| | | | | | | | | | | | | | | | - Edward Janus
- Western Health Chronic Disease Alliance, Australia.,University of Melbourne, Australia.,General Internal Medicine Unit, Western Health, Australia
| | | | - Craig Nelson
- Department of Nephrology, Western Health, Australia.,Western Health Chronic Disease Alliance, Australia.,University of Melbourne, Australia
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15
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Schmauch E, Linna-Kuosmanen S, Galani K, Kang K, Adsera C, Park Y, Hollmen M, Gunn J, Kiviniemi T, Garcia-Cardena G, Kellis M. Single-cell transcriptional and epigenomic dissection of human heart in health and coronary artery disease reveals cell-type-specific driver genes and pathways. Atherosclerosis 2021. [DOI: 10.1016/j.atherosclerosis.2021.06.156] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ekawati FM, Emilia O, Gunn J, Licqurish S, Lau P. Challenging the status quo: results of an acceptability and feasibility study of hypertensive disorders of pregnancy (HDP) management pathways in Indonesian primary care. BMC Pregnancy Childbirth 2021; 21:507. [PMID: 34261428 PMCID: PMC8278644 DOI: 10.1186/s12884-021-03970-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 06/25/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are the leading cause of maternal mortality in Indonesia. Focused HDP management pathways for Indonesian primary care practice have been developed from a consensus development process. However, the acceptability and feasibility of the pathways in practice have not been explored. This study reports on the implementation process of the pathways to determine their acceptability and feasibility in Indonesian practice. METHODS The pathways were implemented in three public primary care clinics (Puskesmas) in Yogyakarta province for a month, guided by implementation science frameworks of Medical Research Council (MRC) and the Practical Robust Implementation and Sustainability Model (PRISM). The participating providers (general practitioners (GPs), midwives, and nurses) were asked to use recommendations in the pathways for a month. The pathway implementation evaluations were then conducted using clinical audits and a triangulation of observations, focus groups (FGs), and interviews with all of the participants. Clinical audit data were analysed descriptively, and qualitative data were analysed using a mix of the inductive-deductive approach of thematic analysis. RESULTS A total of 50 primary care providers, four obstetricians, a maternal division officer in the local health office and 61 patients agreed to participate, and 48 of the recruited participants participated in evaluation FGs or interviews. All of the providers in the Puskesmas attempted to apply recommendations from the pathways to various degrees, mainly adopting preeclampsia risk factor screenings and HDP monitoring. The participants expressed that the recommendations empowered their practice when it came to HDP management. However, their practices were challenged by professional boundaries and hierarchical barriers among health care professionals, limited clinical resources, and regulations from the local health office. Suggestions for future scale-up studies were also mentioned, such as involving champion obstetricians and providing more patient education toolkits. CONCLUSION The HDP management pathways are acceptable and feasible in Indonesian primary care. A further scale-up study is desired and can be initiated with investigations to minimise the implementation challenges and enhance the pathways' value in primary care practice.
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Affiliation(s)
- Fitriana Murriya Ekawati
- Department of Family and Community Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia.
- Department of General Practice, University of Melbourne, Parkville, Victoria, Australia.
| | - Ova Emilia
- Department of Obstetrics and Gynaecology, Universitas Gadjah Mada/Sardjito Hospital, Yogyakarta, Indonesia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Parkville, Victoria, Australia
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Parkville, Victoria, Australia
- Department of General Practice, Western Sydney University, New South Wales, Australia
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Ekawati FM, Licqurish S, Gunn J, Brennecke S, Lau P. Hypertensive disorders of pregnancy (HDP) management pathways: results of a Delphi survey to contextualise international recommendations for Indonesian primary care settings. BMC Pregnancy Childbirth 2021; 21:269. [PMID: 33794799 PMCID: PMC8017638 DOI: 10.1186/s12884-021-03735-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/02/2020] [Accepted: 03/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background Hypertensive disorders of pregnancy (HDP) are a significant contributor to the high maternal mortality rate in Indonesia. At the moment, limited guidelines are available to assist primary care providers in managing HDP cases. A previous review of 16 international HDP guidelines has identified opportunities for improving HDP management in Indonesian primary care, but it has not determined the suitability of the recommendations in practice. This study aims to achieve consensus among the experts regarding the recommendations suitability and to develop HDP pathways in Indonesian primary care. Methods Maternal health experts, including GPs, midwives, nurses, medical specialists and health policy researchers from Indonesia and overseas were recruited for the study. They participated in a consensus development process that applied a mix of quantitative and qualitative questions in three Delphi survey rounds. At the first and second-round survey, the participants were asked to rate their agreement on whether each of 125 statements about HDP and HDP management is appropriate for use in Indonesian primary care settings. The third-round survey presented the drafts of HDP pathways and sought participants’ agreement and further suggestions. The participants’ agreement scores were calculated with a statement needing a minimum of 70% agreement to be included in the HDP pathways. The participants’ responses and suggestions to the free text questions were analysed thematically. Results A total of 52 participants were included, with 48, 45 and 37 of them completing the first, second and third round of the survey respectively. Consensus was reached for 115 of the 125 statements on HDP definition, screening, management and long-term follow-up. Agreement scores for the statements ranged from 70.8–100.0%, and potential implementation barriers of the pathways were identified. Drafts of HDP management pathways were also agreed upon and received suggestions from the participants. Conclusions Most evidence-based management recommendations achieved consensus and were included in the developed HDP management pathways, which can potentially be implemented in Indonesian settings. Further investigations are needed to explore the acceptability and feasibility of the developed HDP pathways in primary care practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03735-3.
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Affiliation(s)
- Fitriana Murriya Ekawati
- Department of Family and Community Medicine, Universitas Gadjah Mada, Sleman, Yogyakarta, Indonesia. .,Department of General Practice, University of Melbourne, Level 2, 780 Elizabeth Street, Melbourne, Victoria, 3000, Australia.
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Level 2, 780 Elizabeth Street, Melbourne, Victoria, 3000, Australia
| | - Shaun Brennecke
- University of Melbourne Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Victoria, Australia.,Pregnancy Research Centre, Department of Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Level 2, 780 Elizabeth Street, Melbourne, Victoria, 3000, Australia
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18
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Fletcher S, Spittal MJ, Chondros P, Palmer VJ, Chatterton ML, Densley K, Potiriadis M, Harris M, Bassilios B, Burgess P, Mihalopoulos C, Pirkis J, Gunn J. Clinical efficacy of a Decision Support Tool (Link-me) to guide intensity of mental health care in primary practice: a pragmatic stratified randomised controlled trial. Lancet Psychiatry 2021; 8:202-214. [PMID: 33571453 DOI: 10.1016/s2215-0366(20)30517-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/06/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The volume and heterogeneity of mental health problems that primary care patients present with is a substantial challenge for health systems, and both undertreatment and overtreatment are common. We developed Link-me, a patient-completed Decision Support Tool, to predict severity of depression or anxiety, identify priorities, and recommend interventions. In this study, we aimed to examine if Link-me reduces psychological distress among individuals predicted to have minimal/mild or severe symptoms of anxiety or depression. METHODS In this pragmatic stratified randomised controlled trial, adults aged 18-75 years reporting depressive or anxiety symptoms or use of mental health medication were recruited from 23 general practices in Australia. Participants completed the Decision Support Tool and were classified into three prognostic groups (minimal/mild, moderate, severe), and those in the minimal/mild and severe groups were eligible for inclusion. Participants were individually and randomly assigned (1:1) by a computer-generated allocation sequence to receive either prognosis-matched care (intervention group) or usual care plus attention control (control group). Participants were not blinded but intervention providers were only notified of those allocated to the intervention group. Outcome assessment was blinded. The primary outcome was the difference in the change in scores between the intervention and control group, and within prognostic groups, on the 10-item Kessler Psychological Distress Scale at 6 months post randomisation. The trial was registered on the Australian and New Zealand Clinical Trials Registry, ACTRN12617001333303. OUTCOMES Between Nov 21, 2017, and Oct 31, 2018, 24 616 patients were invited to complete the eligibility screening survey. 1671 of these patients were included and randomly assigned to either the intervention group (n=834) or the control group (n=837). Prognosis-matched care was associated with greater reductions in psychological distress than usual care plus attention control at 6 months (p=0·03), with a standardised mean difference (SMD) of -0·09 (95% CI -0·17 to -0·01). This reduction was also seen in the severe prognostic group (p=0·003), with a SMD of -0·26 (-0·43 to -0·09), but not in the minimal/mild group (p=0·73), with a SMD of 0·04 (-0·17 to 0·24). In the complier average causal effect analysis in the severe prognostic group, differences were larger among those who received some or all aspects of the intervention (SMD range -0·58 to -1·15). No serious adverse effects were recorded. INTERPRETATION Prognosis-based matching of interventions reduces psychological distress in patients with anxiety or depressive symptoms, particularly in those with severe symptoms, and is associated with better outcomes when patients access the recommended treatment. Optimisation of the Link-me approach and implementation into routine practice could help reduce the burden of disease associated with common mental health conditions such as anxiety and depression. FUNDING Australian Government Department of Health.
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Affiliation(s)
- Susan Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.
| | - Patty Chondros
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Victoria J Palmer
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Mary Lou Chatterton
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Konstancja Densley
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Maria Potiriadis
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Meredith Harris
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Bridget Bassilios
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Philip Burgess
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Cathrine Mihalopoulos
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Jane Pirkis
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
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Bisson R, Hodille E, Gaspar J, Douai D, Wauters T, Gallo A, Gunn J, Hakola A, Loarer T, Nouailletas R, Morales J, Pégourié B, Reux C, Sabot R, Tsitrone E, Vartanian S, Wang E, Fedorczak N, Brezinsek S. Deuterium and helium outgassing following plasma discharges in WEST: Delayed D outgassing during D-to-He changeover experiments studied with threshold ionization mass spectrometry. Nuclear Materials and Energy 2021. [DOI: 10.1016/j.nme.2020.100885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Urbanczyk G, Fedorczak N, Gunn J, Colas L, Li J, Wang K. Perspective of analogy between heat loads and impurity production in L-mode discharges with ICRH in WEST. Nuclear Materials and Energy 2021. [DOI: 10.1016/j.nme.2021.100925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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21
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Hegarty K, Valpied J, Taft A, Brown SJ, Gold L, Gunn J, O'Doherty L. Two-year follow up of a cluster randomised controlled trial for women experiencing intimate partner violence: effect of screening and family doctor-delivered counselling on quality of life, mental and physical health and abuse exposure. BMJ Open 2020; 10:e034295. [PMID: 33303427 PMCID: PMC7733186 DOI: 10.1136/bmjopen-2019-034295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This was a 2-year follow-up study of a primary care-based counselling intervention (weave) for women experiencing intimate partner violence (IPV). We aimed to assess whether differences in depression found at 12 months (lower depression for intervention than control participants) would be sustained at 24 months and differences in quality in life, general mental and physical health and IPV would emerge. DESIGN Cluster randomised controlled trial. Researchers blinded to allocation. Unit of randomisation: family doctors. SETTING Fifty-two primary care clinics, Victoria, Australia. PARTICIPANTS Baseline: 272 English-speaking, female patients (intervention n=137, doctors=35; control n=135, doctors=37), who screened positive for fear of partner in past 12 months. Twenty-four-month response rates: intervention 59% (81/137), control 63% (85/135). INTERVENTIONS Intervention doctors received training to deliver brief, woman-centred counselling. Intervention patients were invited to receive this counselling (uptake rate: 49%). Control doctors received standard IPV information; delivered usual care. PRIMARY AND SECONDARY OUTCOME MEASURES Twenty-four months primary outcomes: WHO Quality of Life-Bref dimensions, Short-Form Health Survey (SF-12) mental health. SECONDARY OUTCOMES SF-12 physical health and caseness for depression and anxiety (Hospital Anxiety Depression Scale), post-traumatic stress disorder (Check List-Civilian), IPV (Composite Abuse Scale), physical symptoms (≥6 in last month). Data collected through postal survey. Mixed-effects regressions adjusted for location (rural/urban) and clustering. RESULTS No differences detected between groups on quality of life (physical: 1.5, 95% CI -2.9 to 5.9; psychological: -0.2, 95% CI -4.8 to 4.4,; social: -1.4, 95% CI -8.2 to 5.4; environmental: -0.8, 95% CI -4.0 to 2.5), mental health status (-1.6, 95% CI -5.3 to 2.1) or secondary outcomes. Both groups improved on primary outcomes, IPV, anxiety. CONCLUSIONS Intervention was no more effective than usual care in improving 2-year quality of life, mental and physical health and IPV, despite differences in depression at 12 months. Future refinement and testing of type, duration and intensity of primary care IPV interventions is needed. TRIAL REGISTRATION NUMBER ACTRN12608000032358.
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Affiliation(s)
- Kelsey Hegarty
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Family Violence Prevention, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Jodie Valpied
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela Taft
- Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Stephanie Janne Brown
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
- Intergenerational Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Lisa Gold
- School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lorna O'Doherty
- Faculty of Health and Life Sciences, Coventry University, Coventry, West Midlands, UK
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Ishida M, Hulse ES, Mahar RK, Gunn J, Atun R, McPake B, Tenneti N, Anindya K, Armstrong G, Mulcahy P, Carman W, Lee JT. The Joint Effect of Physical Multimorbidity and Mental Health Conditions Among Adults in Australia. Prev Chronic Dis 2020; 17:E157. [PMID: 33301391 PMCID: PMC7769083 DOI: 10.5888/pcd17.200155] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Indexed: 01/03/2023] Open
Abstract
Introduction The prevalence of chronic physical and mental health conditions is rising globally. Little evidence exists on the joint effect of physical and mental health conditions on health care use, work productivity, and health-related quality of life in Australia. Methods We analyzed data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, waves 9 (2009), 13 (2013), and 17 (2017). Economic effects associated with multimorbidity were measured through health service use, work productivity loss, and health-related quality of life. We used generalized estimating equations to assess the effect of the association between physical multimorbidity and mental health conditions and economic outcomes. Results From 2009 through 2017 the prevalence of physical multimorbidity increased from 15.1% to 16.2%, and the prevalence of mental health conditions increased from 11.2% to 17.3%. The number of physical health conditions was associated with the number of health services used (general practitioner visits, incidence rate ratio = 1.41), work productivity loss (labor force participation, adjusted odds ratio = 0.71), and reduced health-related quality of life (SF-6D score: Coefficient = −0.03). These effects were exacerbated by the presence of mental health conditions and low socioeconomic status. Conclusion Having multiple physical health conditions (physical multimorbidity) creates substantial health and financial burdens on individuals, the health system, and society, including increased use of health services, loss of work productivity, and decreased health-related quality of life. The adverse effects of multimorbidity on health, quality of life, and economic well-being are exacerbated by the co-occurrence of mental health conditions and low socioeconomic status.
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Affiliation(s)
- Marie Ishida
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, 333 Exhibition St, Melbourne VIC 3004, Australia.
| | - Emily Sg Hulse
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Robert K Mahar
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Victorian Comprehensive Cancer Centre, University of Melbourne, Melbourne, Australia
| | - Jane Gunn
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Rifat Atun
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Naveen Tenneti
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Kanya Anindya
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Gregory Armstrong
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Patrick Mulcahy
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Will Carman
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - John Tayu Lee
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
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Thuraisingam S, Dowsey M, Manski-Nankervis JA, Spelman T, Choong P, Gunn J, Chondros P. Developing prediction models for total knee replacement surgery in patients with osteoarthritis: Statistical analysis plan. Osteoarthritis and Cartilage Open 2020; 2:100126. [DOI: 10.1016/j.ocarto.2020.100126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/17/2020] [Indexed: 12/16/2022] Open
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24
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Baldwin PA, Sanatkar S, Clarke J, Fletcher S, Gunn J, Wilhelm K, Campbell L, Zwar N, Harris M, Lapsley H, Hadzi-Pavlovic D, Christensen H, Proudfoot J. A Web-Based Mental Health Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The Springboard Trial): 12-Month Outcomes of a Randomized Controlled Trial. J Med Internet Res 2020; 22:e16729. [PMID: 33258790 PMCID: PMC7738252 DOI: 10.2196/16729] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/26/2020] [Accepted: 06/22/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND People with type 2 diabetes mellitus (T2DM) often experience mental health symptoms that exacerbate illness and increase mortality risk. Access to psychological support is low in people with T2DM. Detection of depression is variable in primary care and can be further hampered by mental health stigma. Electronic mental health (eMH) programs may provide an accessible, private, nonstigmatizing mental health solution for this group. OBJECTIVE This study aims to evaluate the efficacy over 12 months of follow-up of an eMH program (myCompass) for improving social and occupational functioning in a community sample of people with T2DM and self-reported mild-to-moderate depressive symptoms. myCompass is a fully automated and self-guided web-based public health program for people with depression or anxiety. The effects of myCompass on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior were also examined. METHODS Adults with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited via online advertisements, community organizations, and general practices. Screening, consent, and self-report questionnaires were administered online. Eligible participants were randomized to receive either myCompass (n=391) or an attention control generic health literacy program (Healthy Lifestyles; n=379) for 8 weeks. At baseline and at 3, 6, and 12 months postintervention, participants completed the Work and Social Adjustment Scale, the Patient Health Questionnaire-9 item, the Diabetes Distress Scale, the Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Glycosylated hemoglobin measurements were obtained at baseline and 6 and 12 months postintervention. RESULTS A total of 38.9% (304/780) of the trial participants completed all postintervention assessments. myCompass users logged in on an average of 6 times and completed an average of 0.29 modules. Healthy Lifestyles users logged in on an average of 4 times and completed an average of 1.37 modules. At baseline, the mean scores on several outcome measures, including the primary outcome of work and social functioning, were close to the normal range, despite a varied and extensive recruitment process. Intention-to-treat analyses revealed slightly greater improvement at 12 months in work and social functioning for the Healthy Lifestyles group relative to the myCompass group. All participants reported equivalent improvements in depression anxiety, diabetes distress, diabetes self-management, and glycemic control across the trial. CONCLUSIONS The Healthy Lifestyles group reported higher ratings of social and occupational functioning than the myCompass group, but no differences were observed for any secondary outcome. Although these findings should be interpreted in light of the near-floor symptom scores at baseline, the trial yields important insights into how people with T2DM might be engaged in eMH programs and the challenges of focusing specifically on mental health. Several avenues emerge for continued investigation into how best to deal with the growing mental health burden in adults with T2DM. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true.
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Affiliation(s)
| | | | | | | | - Jane Gunn
- University of Melbourne, Melbourne, Australia
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Ekawati FM, Emilia O, Gunn J, Licqurish S, Lau P. The elephant in the room: an exploratory study of hypertensive disorders of pregnancy (HDP) management in Indonesian primary care settings. BMC Fam Pract 2020; 21:242. [PMID: 33243157 PMCID: PMC7694432 DOI: 10.1186/s12875-020-01303-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022]
Abstract
Background Indonesia has the highest maternal mortality rate in South East Asia, that a third of the mortality is caused by hypertensive disorders of pregnancy (HDP), including preeclampsia and eclampsia. Research suggests that maternal deaths from HDP are avoidable with appropriate initial management in primary care. However, little is known regarding the exact way HDP management is conducted in Indonesian primary care. This research aims to explore the way HDP management is provided, including its barriers and facilitators in Indonesian primary care settings. Methods This research applied a practical qualitative methodology using interviews with a topic guide. It is guided by the implementation science framework of the Medical Research Council (MRC) framework and Practical Robust Implementation and Sustainability Model (PRISM) to design and evaluate complex healthcare interventions. Primary care key stakeholders from Yogyakarta province were recruited from May–December 2018. The interviews were conducted in face-to-face, telephone, and teleconference interviews. Data from the interviews were analysed thematically using a mix of inductive and deductive approaches. Results A total of 24 participants were interviewed, consisting of four general practitioners, five midwives, three nurses, three obstetricians, a cardiologist, five policymakers and three women with a previous history of HDP. Referrals are the usual management performed for HDP women in primary care and the primary care providers’ practice is challenged by three identified themes: (i) providers’ limited confidence to perform HDP management, (ii) fragmented continuity of care, and (iii) community beliefs. Many participants also desired to have more focused guidance to improve HDP management in primary care practice. Conclusion Even though Indonesian antenatal care and referrals are generally accessible, there are many challenges and fragmentation of HDP management. The most prominent challenge is the primary care providers’ lack of confidence in performing the management and the ‘elephant’ of an urgent need of practice guidelines in primary care that has never been appropriately described in the literature. Further development of an evidence-based primary care-focused guidance will potentially improve primary care providers’ skills to perform optimal HDP management and provide appropriate education to their patients.
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Affiliation(s)
- Fitriana Murriya Ekawati
- Department of Family and Community Medicine, Universitas Gadjah Mada, Level 1, Gedung Radioputro, Jalan Farmako Sekip Utara, Sleman, Indonesia. .,Department of General Practice, University of Melbourne, Level 2&3, 780 Elizabeth St, Melbourne, Victoria, 3000, Australia.
| | - Ova Emilia
- Department of Obstetrics and Gynaecology, Universitas Gadjah Mada/Sardjito Hospital, Jalan Kesehatan No 1, Yogyakarta, Indonesia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Level 2&3, 780 Elizabeth St, Melbourne, Victoria, 3000, Australia
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Level 1, Chancellors Walk, Wellington Road, Clayton, 3800, Victoria, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Level 2&3, 780 Elizabeth St, Melbourne, Victoria, 3000, Australia
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Maaniitty E, Sinisilta S, Jalkanen J, Hollmen M, Biancari F, Gunn J, Jalkanen S, Airaksinen K, Kiviniemi T. Distinct circulating cytokine levels in patients with angiography-proven coronary artery disease compared to disease-free controls. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Systemic inflammation has a critical role in the development of coronary artery disease (CAD). Identification of inflammatory pathways may provide a platform for novel therapeutic approaches.
Purpose
We sought to determine whether there are differences in circulating cytokine profiles between patients with CAD and disease-free controls.
Methods
Study population consisted of 458 patients who underwent diagnostic invasive coronary angiography for clinical indications. Altogether 312 patients had angiographically significant CAD whereas 146 had no angiographically-detected coronary atherosclerosis. We measured the serum concentrations of 48 circulating cytokines.
Results
Patients with CAD had increased levels of interleukin-1 receptor antagonist (IL-1-RA), interleukin-2 receptor alpha (IL-2Rα), IL-3, IL-4, IL-6, IL-9, IL-10, IL-16, IL-17, IL-18, granulocyte-macrophage colony-stimulating factor (GM-CSF), platelet-derived growth factor-BB (PDGF-BB), macrophage inflammatory protein-1-beta (MIP-1-β), tumor necrosis factor-alpha (TNF-α), TNF-β, cutaneous T-cell-attracting chemokine (CTACK), growth regulated oncogene alpha (GRO-α), hepatocyte growth factor (HGF), interferon alpha-2 (IFNα-2), leukemia inhibitory factor (LIF), macrophage colony-stimulating factor (M-CSF), macrophage migration inhibitory factor (MIF), monokine induced by gamma interferon (MIG), beta-nerve growth factor (β-NGF), stem cell factor (SCF) and stromal cell-derived factor 1 alfa (SDF1α). On a logistic multivariate regression model adjusted with age, sex, hypertension and treatment for diabetes, increased levels of IL-4 (p=0.027, OR 1.090), IL-9 (p=0.000, OR 1.013), IL-17 (p=0.011, OR 1.005), CTACK (p=0.008, OR 1.001), MIP-1-β (p=0.004, OR 1.006), GRO-α (p=0.008, OR 1.004), TNF-α (p=0.019, OR 1.011) were independently associated with atherosclerosis.
Conclusions
Patients with CAD have distinct circulating cytokine profiles compared to disease-free controls. Based on these findings, certain cytokines may have a pivotal role in the development of atherosclerotic cardiovascular disease and cytokine-mediated pathway appear as a promising target for cardiovascular drug development.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): The Finnish Medical Foundation, Helsinki, Finland; The Finnish Foundation for Cardiovascular Research, Helsinki, Finland
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Affiliation(s)
| | | | - J Jalkanen
- Turku University Hospital, Turku, Finland
| | | | | | - J Gunn
- Turku University Hospital, Turku, Finland
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Geyti C, Christensen KS, Dalsgaard EM, Bech BH, Gunn J, Maindal HT, Sandbaek A. Factors associated with non-initiation of mental healthcare after detection of poor mental health at a scheduled health check: a cohort study. BMJ Open 2020; 10:e037731. [PMID: 33067280 PMCID: PMC7569988 DOI: 10.1136/bmjopen-2020-037731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Poor mental health is an important public health concern, but mental health problems are often under-recognised. Providing feedback to general practitioners (GPs) on their patients' mental health status may improve the identification of cases in need of mental healthcare. OBJECTIVES To investigate the extent of initiation of mental healthcare after identification of poor mental health and to identify factors associated with non-initiation. DESIGN Prospective cohort study with 1-year follow-up. SETTING In a population-based health preventive programme, Check Your Health, we conducted a combined mental and physical health check in Randers Municipality, Denmark, in 2012-2015 in collaboration with local GPs. PARTICIPANTS Participants were 350 individuals aged 30-49 years old with screen-detected poor mental health who had not received mental healthcare within the past year. The cohort was derived from 14 167 randomly selected individuals of whom 52% (n=7348) participated. Mental health was assessed by the mental component summary score of the 12-item Short-Form Health Survey. OUTCOME The outcome was initiation of mental healthcare. Mental healthcare included psychometric testing by GP, talk therapy by GP, contact with a psychologist, contact with a psychiatrist and psychotropic medication. RESULTS Within 1 year, 22% (95% CI 18 to 27) of individuals with screen-detected poor mental health initiated mental healthcare. Among individuals who initiated mental healthcare within follow-up, one in six had visited their GP once or less in the preceding year. Male sex (OR: 0.49 (95% CI 0.28 to 0.86)) and less impaired mental health (OR: 0.93 (95% CI 0.89 to 0.98)) were associated with non-initiation of mental healthcare. We found no overall association between socioeconomic factors and initiating mental healthcare. CONCLUSION Systematic provision of mental health test results to GPs may improve the identification of cases in need of mental healthcare, but does not translate into initiation of mental healthcare. Further research should focus on methods to improve initiation of mental healthcare, especially among men. TRIAL REGISTRATION NUMBER NCT02028195.
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Affiliation(s)
- Christine Geyti
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Research Unit for General Practice, Aarhus, Denmark
| | | | | | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Annelli Sandbaek
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
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Godbee K, Gunn J, Lautenschlager NT, Palmer VJ. Refined conceptual model for implementing dementia risk reduction: incorporating perspectives from Australian general practice. Aust J Prim Health 2020; 26:247-255. [PMID: 32456772 DOI: 10.1071/py19249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/11/2020] [Indexed: 11/23/2022]
Abstract
Dementia is now a global health priority. With no known cure, the best way to reduce the number of people who will be living with dementia is by promoting dementia risk reduction (DRR). However, despite evidence-based guidelines, DRR is not yet routinely promoted in Australian general practice. Previously, we proposed a preliminary conceptual model for implementing DRR in primary care based on our scoping review of practitioners' views. The present study aimed to refine this model for the Australian context by incorporating the current perspectives of Australian general practitioners (GPs) and general practice nurses (GPNs) about DRR. Interviews with 17 GPs and GPNs were analysed using the framework method, underpinned by the Consolidated Framework for Implementation Research (CFIR). We identified 12 barriers to promoting DRR in Australian general practice, along with five facilitators. Using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool to select prioritised implementation strategies from the ERIC project, the findings were incorporated into a refined conceptual model. The refined model points to an implementation intervention that uses educational materials and meetings to reach consensus with GPs and GPNs on the importance of promoting DRR and an appropriate approach. Champion GPs and GPNs should be prepared to drive the agreed implementation forward, and general practices should share successes and lessons learned. This model is a crucial step in bridging the gap between DRR guidelines and routine practice.
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Affiliation(s)
- Kali Godbee
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Vic. 3010, Australia; and Corresponding author.
| | - Jane Gunn
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Vic. 3010, Australia
| | - Nicola T Lautenschlager
- Academic Unit for Psychiatry of Old Age, Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Vic. 3010, Australia; and Aged Persons Mental Health Program, Royal Melbourne Hospital, Royal Park Campus, Building 5, Level 1, 34-54 Poplar Road, Parkville, Vic. 3052, Australia
| | - Victoria J Palmer
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Vic. 3010, Australia
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Davidson SK, Romaniuk H, Chondros P, Dowrick C, Pirkis J, Herrman H, Fletcher S, Gunn J. Antidepressant treatment for primary care patients with depressive symptoms: Data from the diamond longitudinal cohort study. Aust N Z J Psychiatry 2020; 54:367-381. [PMID: 31957463 DOI: 10.1177/0004867419898761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In light of emerging evidence questioning the safety of antidepressants, it is timely to investigate the appropriateness of antidepressant prescribing. This study estimated the prevalence of possible over- and under-treatment with antidepressants among primary care attendees and investigated the factors associated with potentially inappropriate antidepressant use. METHODS In all, 789 adult primary care patients with depressive symptoms were recruited from 30 general practices in Victoria, Australia, in 2005 and followed up every 3 months in 2006 and annually from 2007 to 2011. For this study, we first assessed appropriateness of antidepressant use in 2007 at the 2-year follow-up to enable history of depression to be taken into account, providing 574 (73%) patients with five yearly assessments, resulting in a total of 2870 assessments. We estimated the prevalence of use of antidepressants according to the adapted National Institute for Health and Care Excellence guidelines and used regression analysis to identify factors associated with possible over- and under-treatment. RESULTS In 41% (243/586) of assessments where antidepressants were indicated according to adapted National Institute for Health and Care Excellence guidelines, patients reported not taking them. Conversely in a third (557/1711) of assessments where guideline criteria were unlikely to be met, participants reported antidepressant use. Being female and chronic physical illness were associated with antidepressant use where guideline criteria were not met, but no factors were associated with not taking antidepressants where guideline criteria were met. CONCLUSIONS Much antidepressant treatment in general practice is for people with minimal or mild symptoms, while people with moderate or severe depressive symptoms may miss out. There is considerable scope for improving depression care through better allocation of antidepressant treatment.
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Affiliation(s)
- Sandra K Davidson
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Carlton, VIC, Australia
| | - Helena Romaniuk
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Carlton, VIC, Australia.,Biostatistics Unit, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Patty Chondros
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Carlton, VIC, Australia
| | - Christopher Dowrick
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jane Pirkis
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, Australia
| | - Helen Herrman
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Susan Fletcher
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Carlton, VIC, Australia
| | - Jane Gunn
- Primary Care Research, Department of General Practice, Melbourne Medical School, The University of Melbourne, Carlton, VIC, Australia
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Ekawati FM, Emilia O, Brennecke S, Gunn J, Licqurish S, Lau P. Opportunities for improving hypertensive disorders of pregnancy (HDP) management in primary care settings: A review of international published guidelines in the context of pregnancy care in Indonesia. Pregnancy Hypertens 2020; 19:195-204. [PMID: 32078932 DOI: 10.1016/j.preghy.2020.01.012] [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] [Received: 07/21/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 10/25/2022]
Abstract
Almost all of global maternal mortality caused by HDP occurs in low to middle-income countries (LMIC). However, limited guidance is available to local primary care practitioners who are usually the main health care providers. This review examined existing international practice guidelines to identify potential practices to improve HDP management in Indonesian primary care settings. We performed structured literature search strategies and snowballing searches in six databases (MEDLINE, Web of Science, EMBASE, CINAHL, Cochrane reviews and Google Scholar) for guidelines that were published between 2007 and 2018 using relevant keywords and phrases of 'guidelines', 'hypertensive disorders of pregnancy' or 'preeclampsia' and 'primary care'. The AGREE II instrument was used to assess quality and reporting of the eligible guidelines. Thematic analysis was performed on all of the guidelines and the results were discussed among the project investigators. Sixteen international practice guidelines or similar management recommendations were reviewed. Almost all of them were partially applicable, with some managements potentially able to be adopted to Indonesian primary care settings. Three main themes for improving HDP management were identified, namely clinical management, care planning, and professional communication. These potential improvements in managing women with HDP in Indonesia may also be relevant in other LMIC. Further contextualisation is required to facilitate their adoption in practice settings.
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Affiliation(s)
- Fitriana Murriya Ekawati
- Department of Family and Community Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia; Department of General Practice, University of Melbourne, Victoria, Australia.
| | - Ova Emilia
- Department of Obstetrics and Gynaecology, Universitas Gadjah Mada/Sardjito Hospital, Yogyakarta, Indonesia
| | - Shaun Brennecke
- Department of Obstetrics and Gynaecology, University of Melbourne/Royal Women's Hospital, Parkville, Victoria, Australia; Pregnancy Research Centre, Department of Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Victoria, Australia
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Victoria, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Victoria, Australia
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Davidson S, Fletcher S, Wadley G, Reavley N, Gunn J, Wade D. A Mobile Phone App to Improve the Mental Health of Taxi Drivers: Single-Arm Feasibility Trial. JMIR Mhealth Uhealth 2020; 8:e13133. [PMID: 31939743 PMCID: PMC6996768 DOI: 10.2196/13133] [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] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/27/2019] [Accepted: 08/19/2019] [Indexed: 12/26/2022] Open
Abstract
Background Psychological distress among taxi drivers is 5 times higher than that in the general population, and more than half of all drivers have experienced 3 or more potentially traumatic events in their lifetime. Nevertheless, help-seeking for mental health problems in this male-dominated, predominately immigrant workforce is low. Mobile technologies have the potential to increase mental health awareness, teach self-help skills, and encourage help-seeking in this hard-to-reach population. Objective This study aimed to assess the feasibility, acceptability, and potential efficacy of Driving to Health, a mobile phone–friendly mental health website app designed for people working as taxi drivers. Methods Drivers (n=46) were recruited from the Melbourne Airport Taxi Holding Yard to participate in a single-arm trial. Self-reported, paper-based assessments were completed at baseline and at 1 month. Feasibility was measured by completion rates, representativeness of study participants, and levels of use. Acceptability was assessed by measuring users’ perception of the quality of the app and anticipated levels of future use. The efficacy of Driving to Health to increase awareness, self-help behaviors, and intentions to seek help was assessed using the user version of the Mobile App Rating Scale (uMARS) and the General Help-Seeking Questionnaire (GHSQ). Psychological symptoms were measured using the short form of the Depression, Anxiety, and Stress Scale (DASS-21). Data were analyzed using complete case analysis. Results In total, 42 participants comprising drivers from 10 different countries of origin, and 14 different languages, completed pre- and poststudy measures (42/46, 91% completion rate). Just under half (45%) of all users used the app more than once with an average visit of 4 min 8 seconds. Responding to the uMARS, 62% (26/42) of the participants said that they would recommend the app to many people. Nearly all (40/42, 95%) participants said that Driving to Health increased awareness of their own mental health; 86% (36/42) said that it increased their mental health knowledge; and 76% (32/42) said that it increased their self-help behaviors. Increases in help-seeking intentions on the GHSQ were not significant, and increases on all 3 scales of DASS-21 were not reliable or meaningful. Conclusions This study suggests that Driving to Health is an acceptable and feasible electronic health intervention for a hard-to-reach population. Our findings also suggest that Driving to Health results in increases in mental health awareness, behaviors, and willingness to seek help.
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Affiliation(s)
- Sandra Davidson
- Department of General Practice, The University of Melbourne, Carlton, Australia
| | - Susan Fletcher
- Department of General Practice, The University of Melbourne, Carlton, Australia
| | - Greg Wadley
- School of Computing and Information Systems, The University of Melbourne, Parkville, Australia
| | - Nicola Reavley
- Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Carlton, Australia
| | - Darryl Wade
- Centre for Posttraumatic Mental Health, Phoenix Australia, Carlton, Australia.,Department of Psychiatry, University of Melbourne, Parkville, Australia
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Kyto V, Sipila J, Pikkarainen E, Rautava P, Gunn J. 2227Limited impact of concomitant coronary artery by-pass grafting on long-term outcomes after surgical aortic valve replacement: a nationwide propensity matched study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
Coronary artery disease is a common comorbidity of aortic stenosis. Addition of coronary artery by-pass grafting (CABG) to surgical aortic valve replacement (SAVR) is viable solution for treating both. Modern era impact of concomitant CABG to long-term outcomes is however inadequately known. We set out to study long-term outcomes of patients with or without CABG added to SAVR.
Methods
Patients (excluding infective endocarditis) aged ≥50 years with isolated first-time SAVR with or without CABG in Finland between 2004–2014 (n=7060) were retrospectively studied using nationwide registries. Propensity score matching (1:1) was used to identify patients with comparable baseline features (n=2188 with and n=2188 without concomitant CABG). Outcomes were 10-year all-cause mortality, stroke, major bleeding and myocardial infarction. Median follow-up was 6.1 years.
Results
In matched population mortality after SAVR was comparable with or without CABG (31.0% vs. 32.7%; HR 1.05; CI 0.93–1.20; p=0.428). However, if CABG was performed solely with venous grafts mortality was higher (35.9%; HR 1.21; CI 1.02–1.43; p=0.030 vs. no-CABG). Myocardial infarction was more common in patients with CABG (13.4% vs. 6.9%; HR 1.62; CI 1.22–2.17; p=0.0008). Occurrence of stroke was comparable with or without CABG (15.1% vs. 13.5%; p=0.933). Rate on any major bleeding was also comparable (20.0% with vs. 21.9% without CABG; p=0.496). Gastrointestinal (8.1% vs. 10.3%; p=0.978) and intracranial bleeds (6.0% vs. 5.5%; p=0.383) were also comparable between study groups.
Conclusions
Matched patients with or without concomitant CABG had comparable long-term mortality, stroke and major bleeding rates after SAVR. Our results suggest that successful concomitant CABG has limited impact on long-term outcomes after SAVR.
Acknowledgement/Funding
Finnish Cardiac Society, Finnish Cultural Foundation, Governmental VTR-funding
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Affiliation(s)
- V Kyto
- Turku University Hospital, Turku, Finland
| | - J Sipila
- North Karelia Central Hospital, Joensuu, Finland
| | | | | | - J Gunn
- Turku University Hospital, Turku, Finland
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O'Brien P, Bunzli S, Ayton D, Dowsey MM, Gunn J, Manski-Nankervis JA. What are the patient factors that impact on decisions to progress to total knee replacement? A qualitative study involving patients with knee osteoarthritis. BMJ Open 2019; 9:e031310. [PMID: 31551388 PMCID: PMC6773346 DOI: 10.1136/bmjopen-2019-031310] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES General practitioners (GPs) are often the first health professionals to assess patients with osteoarthritis (OA). Despite clinical guideline recommendations for non-surgical intervention as first-line therapies, the most frequent referral from a GP for a person with knee OA is to an orthopaedic surgeon. The aim of our study was to explore patient factors that impact on the decision to progress to total knee replacement (TKR), including the experience of patients in general practice, their perceptions of their condition, and their access and use of community-based allied health interventions. DESIGN Qualitative investigation using semi-structured interviews. The Candidacy framework was selected as a lens to examine the factors driving healthcare access. Data were analysed using a thematic analysis approach. Codes identified in the data were mapped to the seven Candidacy domains. Themes corresponding to each domain were described. SETTING A public hospital in Melbourne, Australia. PARTICIPANTS 27 patients with knee OA who were on a waiting list to undergo TKR. RESULTS Ten themes described factors influencing access and use of non-surgical interventions and decision-making for undergoing TKR: (1) History of knee problems, change in symptoms; (2) Physical and psychosocial functioning (Identification of Candidacy); (3) GP and social networks as information sources, access to care (Navigation); (4) Referral pathways (Permeability of services); (5) Communication of impact (Appearances at health services); (6) GP-Surgeon as the predominant referral pathway (Adjudications); (7) Physical activity as painful; (8) Beliefs about effectiveness of non-surgical interventions (Offers and resistance); (9) Familiarity with local system; and (10) Availability (Operating conditions and local production of Candidacy). CONCLUSIONS Using the Candidacy framework to analyse patients' experiences when deciding to progress to TKR highlighted missed opportunities in general practice to orient patients to first try non-surgical interventions. Patients with knee OA also require improved support to navigate allied health services.
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Affiliation(s)
- Penny O'Brien
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - Samantha Bunzli
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Michelle M Dowsey
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
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Sanatkar S, Baldwin P, Clarke J, Fletcher S, Gunn J, Wilhelm K, Campbell L, Zwar N, Harris M, Lapsley H, Hadzi-Pavlovic D, Christensen H, Proudfoot J. The influence of personality on trajectories of distress, health and functioning in mild-to-moderately depressed adults with type 2 diabetes. PSYCHOL HEALTH MED 2019; 25:296-308. [PMID: 31537118 DOI: 10.1080/13548506.2019.1668567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Identification of mental health risk is important for optimising diabetes care in type 2 diabetes mellitus (T2DM). Personality is linked to diabetes health and may assist detection of individuals with T2DM most at risk of chronic mental health difficulties. This study examined the moderator effect of personality factors on changes in psychological distress and functioning in adults with T2DM and mild-to-moderate depressive symptoms across a 12-month period. Data were obtained from participants in a randomised controlled trial of adults with T2DM. Participants completed measures of depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), general functioning (Work and Social Adjustment Scale), diabetes distress (Diabetes Distress Scale), and diabetes self-management (Self-Management Profile for Type 2 Diabetes) at baseline, 3-, 6- and 12-months. Glycaemic control (HbA1c) was measured at baseline, 6- and 12-months. Two hundred trial completers agreed to complete a personality inventory (Big Five Inventory). Low neuroticism was linked with reduced depression, anxiety, functional impairment and diabetes distress over the year. High extraversion was associated with decreased anxiety and functional impairment. High conscientiousness was linked to increased healthy eating. No personality trait moderated HbA1c levels. Personality screening may help identify mental health risk and guide medical carer approach in T2DM patients.
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Affiliation(s)
- Samineh Sanatkar
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Peter Baldwin
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Janine Clarke
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Susan Fletcher
- Department of General Practice, University of Melbourne, Victoria, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Victoria, Australia
| | - Kay Wilhelm
- School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Lesley Campbell
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, Australia
| | - Nick Zwar
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, UNSW Sydney, Sydney, Australia
| | - Helen Lapsley
- School of Psychiatry, UNSW Sydney, Sydney, Australia
| | | | - Helen Christensen
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Judith Proudfoot
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
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Zun PS, Narracott AJ, Chiastra C, Gunn J, Hoekstra AG. Location-Specific Comparison Between a 3D In-Stent Restenosis Model and Micro-CT and Histology Data from Porcine In Vivo Experiments. Cardiovasc Eng Technol 2019; 10:568-582. [PMID: 31531821 PMCID: PMC6863796 DOI: 10.1007/s13239-019-00431-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 09/07/2019] [Indexed: 11/25/2022]
Abstract
Background Coronary artery restenosis is an important side effect of percutaneous coronary intervention. Computational models can be used to better understand this process. We report on an approach for validation of an in silico 3D model of in-stent restenosis in porcine coronary arteries and illustrate this approach by comparing the modelling results to in vivo data for 14 and 28 days post-stenting. Methods This multiscale model includes single-scale models for stent deployment, blood flow and tissue growth in the stented vessel, including smooth muscle cell (SMC) proliferation and extracellular matrix (ECM) production. The validation procedure uses data from porcine in vivo experiments, by simulating stent deployment using stent geometry obtained from micro computed tomography (micro-CT) of the stented vessel and directly comparing the simulation results of neointimal growth to histological sections taken at the same locations. Results Metrics for comparison are per-strut neointimal thickness and per-section neointimal area. The neointimal area predicted by the model demonstrates a good agreement with the detailed experimental data. For 14 days post-stenting the relative neointimal area, averaged over all vessel sections considered, was 20 ± 3% in vivo and 22 ± 4% in silico. For 28 days, the area was 42 ± 3% in vivo and 41 ± 3% in silico. Conclusions The approach presented here provides a very detailed, location-specific, validation methodology for in silico restenosis models. The model was able to closely match both histology datasets with a single set of parameters. Good agreement was obtained for both the overall amount of neointima produced and the local distribution. It should be noted that including vessel curvature and ECM production in the model was paramount to obtain a good agreement with the experimental data. Electronic supplementary material The online version of this article (10.1007/s13239-019-00431-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- P S Zun
- Institute for Informatics, Faculty of Science, University of Amsterdam, Amsterdam, The Netherlands.
- Biomechanics Laboratory, Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands.
- National Center for Cognitive Technologies, ITMO University, Saint Petersburg, Russia.
| | - A J Narracott
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - C Chiastra
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
- PoliToBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - J Gunn
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Insigneo Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - A G Hoekstra
- Institute for Informatics, Faculty of Science, University of Amsterdam, Amsterdam, The Netherlands
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Palmer VJ, Weavell W, Callander R, Piper D, Richard L, Maher L, Boyd H, Herrman H, Furler J, Gunn J, Iedema R, Robert G. The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement. Med Humanit 2019; 45:247-257. [PMID: 29954854 PMCID: PMC6818522 DOI: 10.1136/medhum-2017-011398] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 05/23/2023]
Abstract
Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist-the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an 'explanatory theoretical model of change' that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities-narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome. TRIAL REGISTRATION NUMBER: The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results).
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Affiliation(s)
- Victoria Jane Palmer
- The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Wayne Weavell
- The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Callander
- The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Donella Piper
- Business School, University of New England, Armidale, New South Wales, Australia
| | - Lauralie Richard
- The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
- Department of General Practice and Rural Health, Dunedin School of Medicine, The University of Otago, Dunedin, New Zealand
| | - Lynne Maher
- Ko Awatea, Health System Innovation and Improvement, Counties Manukau Health, Auckland, New Zealand
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Hilary Boyd
- Strategy, Participation and Improvement Group, Auckland District Health Board, Auckland, New Zealand
| | - Helen Herrman
- Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Furler
- The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jane Gunn
- The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rick Iedema
- Centre for Team Based Practice and Learning in Health Care, Health Schools, King's College London, London, UK
| | - Glenn Robert
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
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Helminen O, Kytö V, Kauppila JH, Gunn J, Lagergren J, Sihvo E. Population-based study of anastomotic stricture rates after minimally invasive and open oesophagectomy for cancer. BJS Open 2019; 3:634-640. [PMID: 31592081 PMCID: PMC6773660 DOI: 10.1002/bjs5.50176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/16/2019] [Accepted: 04/01/2019] [Indexed: 12/19/2022] Open
Abstract
Background The population‐based incidence of anastomotic stricture after minimally invasive oesophagectomy (MIO) and open oesophagectomy (OO) is not known. The aim of this study was to compare rates of anastomotic stricture requiring dilatation after the two approaches in an unselected cohort using nationwide data from Finland and Sweden. Methods All patients who had MIO or OO for oesophageal cancer between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. Outcomes were the overall rate of anastomotic stricture and need for single or repeated (3 or more) dilatations for stricture within the first year after surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95 per cent confidence intervals, adjusted for age, sex, co‐morbidity, histology, stage, year, country, hospital volume, length of hospital stay and readmissions. Results Some 239 patients underwent MIO and 1430 had an open procedure. The incidence of strictures requiring one dilatation was 16·7 per cent, and that for strictures requiring three or more dilatations was 6·6 per cent. The HR for strictures requiring one dilatation was not increased after MIO compared with that after OO (HR 1·19, 95 per cent c.i. 0·66 to 2·12), but was threefold higher for repeated dilatations (HR 3·25, 1·43 to 7·36). Of 18 strictures following MIO, 14 (78 per cent) occurred during the first 2 years after initiating this approach. Conclusion The need for endoscopic anastomotic dilatation after oesophagectomy was common, and the need for repeated dilatation was higher after MIO than following OO. The increased risk after MIO may reflect a learning curve.
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Affiliation(s)
- O Helminen
- Department of Surgery Central Finland Central Hospital Jyväskylä Finland.,Cancer and Translational Medicine Research Unit, Medical Research Centre Oulu University of Oulu Oulu Finland.,Department of Surgery Oulu University Hospital Oulu Finland
| | - V Kytö
- Heart Centre Turku University Hospital Turku Finland.,Research Centre of Applied and Preventive Cardiovascular Medicine University of Turku Turku Finland
| | - J H Kauppila
- Cancer and Translational Medicine Research Unit, Medical Research Centre Oulu University of Oulu Oulu Finland.,Department of Surgery Oulu University Hospital Oulu Finland.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet Karolinska University Hospital Stockholm Sweden
| | - J Gunn
- Heart Centre Turku University Hospital Turku Finland.,Department of Surgery, Faculty of Medicine University of Turku Turku Finland
| | - J Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet Karolinska University Hospital Stockholm Sweden.,School of Cancer and Pharmaceutical Sciences King's College London London UK.,Guy's and St Thomas' NHS Foundation Trust London UK
| | - E Sihvo
- Department of Surgery Central Finland Central Hospital Jyväskylä Finland
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Fletcher S, Clarke J, Sanatkar S, Baldwin P, Gunn J, Zwar N, Campbell L, Wilhelm K, Harris M, Lapsley H, Hadzi-Pavlovic D, Proudfoot J. Recruiting to a Randomized Controlled Trial of a Web-Based Program for People With Type 2 Diabetes and Depression: Lessons Learned at the Intersection of e-Mental Health and Primary Care. J Med Internet Res 2019; 21:e12793. [PMID: 31127718 PMCID: PMC6555119 DOI: 10.2196/12793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/18/2019] [Accepted: 03/24/2019] [Indexed: 12/25/2022] Open
Abstract
Background E-mental health (eMH) interventions are now widely available and they have the potential to revolutionize the way that health care is delivered. As most health care is currently delivered by primary care, there is enormous potential for eMH interventions to support, or in some cases substitute, services currently delivered face to face in the community setting. However, randomized trials of eMH interventions have tended to recruit participants using online recruitment methods. Consequently, it is difficult to know whether participants who are recruited online differ from those who attend primary care. Objective This paper aimed to document the experience of recruiting to an eMH trial through primary care and compare the characteristics of participants recruited through this and other recruitment methods. Methods Recruitment to the SpringboarD randomized controlled trial was initially focused on general practices in 2 states of Australia. Over 15 months, we employed a comprehensive approach to engaging practice staff and supporting them to recruit patients, including face-to-face site visits, regular contact via telephone and trial newsletters, and development of a Web-based patient registration portal. Nevertheless, it became apparent that these efforts would not yield the required sample size, and we therefore supplemented recruitment through national online advertising and promoted the study through existing networks. Baseline characteristics of participants recruited to the trial through general practice, online, or other sources were compared using the analysis of variance and chi square tests. Results Between November 2015 and October 2017, 780 people enrolled in SpringboarD, of whom 740 provided information on the recruitment source. Of these, only 24 were recruited through general practice, whereas 520 were recruited online and 196 through existing networks. Key barriers to general practice recruitment included perceived mismatch between trial design and diabetes population, prioritization of acute health issues, and disruptions posed by events at the practice and community level. Participants recruited through the 3 different approaches differed in age, gender, employment status, depressive symptoms, and diabetes distress, with online participants being distinguished from those recruited through general practice or other sources. However, most differences reached only a small effect size and are unlikely to be of clinical importance. Conclusions Time, labor, and cost-intensive efforts did not translate into successful recruitment through general practice in this instance, with barriers identified at several different levels. Online recruitment yielded more participants, who were broadly similar to those recruited via general practice.
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Affiliation(s)
- Susan Fletcher
- Department of General Practice, University of Melbourne, Carlton, Australia
| | - Janine Clarke
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, Australia
| | - Samineh Sanatkar
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, Australia
| | - Peter Baldwin
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Carlton, Australia
| | - Nick Zwar
- School of Medicine, University of Woollongong, Woollongong, Australia
| | - Lesley Campbell
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, Australia
| | - Kay Wilhelm
- School of Psychiatry, University of New South Wales Sydney, Sydney, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales Sydney, Sydney, Australia
| | - Helen Lapsley
- School of Psychiatry, University of New South Wales Sydney, Sydney, Australia
| | | | - Judy Proudfoot
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, University of New South Wales Sydney, Sydney, Australia
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Clarke J, Sanatkar S, Baldwin PA, Fletcher S, Gunn J, Wilhelm K, Campbell L, Zwar N, Harris M, Lapsley H, Hadzi-Pavlovic D, Christensen H, Proudfoot J. A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial. J Med Internet Res 2019; 21:e12246. [PMID: 31115345 PMCID: PMC6548532 DOI: 10.2196/12246] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression. Objective The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined. Methods Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Results myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement. Conclusions Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true (Archived by WebCite at http://www.webcitation.org/7850eg8pi)
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Affiliation(s)
- Janine Clarke
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Samineh Sanatkar
- School of Psychiatry, UNSW Sydney, Sydney, Australia.,The Black Dog Institute, Sydney, Australia
| | - Peter Andrew Baldwin
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Susan Fletcher
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Kay Wilhelm
- School of Psychiatry, UNSW Sydney, Sydney, Australia
| | - Lesley Campbell
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, Australia
| | - Nicholas Zwar
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, UNSW Sydney, Sydney, Australia
| | - Helen Lapsley
- School of Psychiatry, UNSW Sydney, Sydney, Australia
| | | | | | - Judy Proudfoot
- Black Dog Institute, Sydney, Australia.,School of Psychiatry, UNSW Sydney, Sydney, Australia
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Plana-Ripoll O, Pedersen CB, Holtz Y, Benros ME, Dalsgaard S, de Jonge P, Fan CC, Degenhardt L, Ganna A, Greve AN, Gunn J, Iburg KM, Kessing LV, Lee BK, Lim CCW, Mors O, Nordentoft M, Prior A, Roest AM, Saha S, Schork A, Scott JG, Scott KM, Stedman T, Sørensen HJ, Werge T, Whiteford HA, Laursen TM, Agerbo E, Kessler RC, Mortensen PB, McGrath JJ. Exploring Comorbidity Within Mental Disorders Among a Danish National Population. JAMA Psychiatry 2019; 76:259-270. [PMID: 30649197 PMCID: PMC6439836 DOI: 10.1001/jamapsychiatry.2018.3658] [Citation(s) in RCA: 311] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Individuals with mental disorders often develop comorbidity over time. Past studies of comorbidity have often restricted analyses to a subset of disorders and few studies have provided absolute risks of later comorbidity. OBJECTIVES To undertake a comprehensive study of comorbidity within mental disorders, by providing temporally ordered age- and sex-specific pairwise estimates between the major groups of mental disorders, and to develop an interactive website to visualize all results and guide future research and clinical practice. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study included all individuals born in Denmark between January 1, 1900, and December 31, 2015, and living in the country between January 1, 2000, and December 31, 2016. The analyses were conducted between June 2017 and May 2018. MAIN OUTCOMES AND MEASURES Danish health registers were used to identify mental disorders, which were examined within the broad 10-level International Statistical Classification of Diseases and Related Health Problems, 10th Revision, subchapter groups (eg, codes F00-F09 and F10-F19). For each temporally ordered pair of disorders, overall and lagged hazard ratios and 95% CIs were calculated using Cox proportional hazards regression models. Absolute risks were estimated using competing risks survival analyses. Estimates for each sex were generated. RESULTS A total of 5 940 778 persons were included in this study (2 958 293 men and 2 982 485 women; mean [SD] age at beginning of follow-up, 32.1 [25.4] years). They were followed up for 83.9 million person-years. All mental disorders were associated with an increased risk of all other mental disorders when adjusting for sex, age, and calendar time (hazard ratios ranging from 2.0 [95% CI, 1.7-2.4] for prior intellectual disabilities and later eating disorders to 48.6 [95% CI, 46.6-50.7] for prior developmental disorders and later intellectual disabilities). The hazard ratios were temporally patterned, with higher estimates during the first year after the onset of the first disorder, but with persistently elevated rates during the entire observation period. Some disorders were associated with substantial absolute risks of developing specific later disorders (eg, 30.6% [95% CI, 29.3%-32.0%] of men and 38.4% [95% CI, 37.5%-39.4%] of women with a diagnosis of mood disorders before age 20 years developed neurotic disorders within the following 5 years). CONCLUSIONS AND RELEVANCE Comorbidity within mental disorders is pervasive, and the risk persists over time. This study provides disorder-, sex-, and age-specific relative and absolute risks of the comorbidity of mental disorders. Web-based interactive data visualization tools are provided for clinical utility.
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Affiliation(s)
- Oleguer Plana-Ripoll
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
| | - Carsten Bøcker Pedersen
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
| | - Yan Holtz
- Queensland Brain Institute, University of Queensland, St Lucia, Queensland, Australia
| | - Michael E. Benros
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Dalsgaard
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - Peter de Jonge
- Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, Groningen, the Netherlands,Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, the Netherlands
| | - Chun Chieh Fan
- Department of Cognitive Science, University of California San Diego, La Jolla,Center for Multimodal Imaging and Genetics, School of Medicine, University of California San Diego, La Jolla
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrea Ganna
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, Massachusetts,Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston
| | - Aja Neergaard Greve
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Psychosis Research Unit, Aarhus University Hospital Risskov, Risskov, Denmark
| | - Jane Gunn
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Lars Vedel Kessing
- Copenhagen Affective Disorder Research Centre, Psychiatric Centre Copenhagen, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brian K. Lee
- Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Carmen C. W. Lim
- Queensland Brain Institute, University of Queensland, St Lucia, Queensland, Australia,Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Queensland, Australia
| | - Ole Mors
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Psychosis Research Unit, Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - Merete Nordentoft
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anders Prior
- Research Unit for General Practice, Aarhus, Denmark
| | - Annelieke M. Roest
- Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, Groningen, the Netherlands,Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, the Netherlands
| | - Sukanta Saha
- Queensland Brain Institute, University of Queensland, St Lucia, Queensland, Australia,Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Queensland, Australia
| | - Andrew Schork
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Institute of Biological Psychiatry, Copenhagen Mental Health Services, Copenhagen, Denmark
| | - James G. Scott
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Queensland, Australia,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia,Metro North Mental Health, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Kate M. Scott
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Terry Stedman
- West Moreton Division of Mental Health and Specialised Services, Archerfield, Queensland, Australia
| | - Holger J. Sørensen
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Mental Health Centre Copenhagen, Hellerup, Denmark,Faculty of Health Sciences, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Werge
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Institute of Biological Psychiatry, MHC Sct. Hans, Mental Health Services Copenhagen, Roskilde, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Harvey A. Whiteford
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Queensland, Australia,School of Public Health, University of Queensland, St Lucia, Queensland, Australia
| | - Thomas Munk Laursen
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - Esben Agerbo
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Preben Bo Mortensen
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark,Centre for Integrated Register-based Research at Aarhus University, Aarhus, Denmark
| | - John J. McGrath
- National Centre for Register-based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark,Queensland Brain Institute, University of Queensland, St Lucia, Queensland, Australia,Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Queensland, Australia
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Fletcher S, Chondros P, Palmer VJ, Chatterton ML, Spittal MJ, Mihalopoulos C, Wood A, Harris M, Burgess P, Bassilios B, Pirkis J, Gunn J. Link-me: Protocol for a randomised controlled trial of a systematic approach to stepped mental health care in primary care. Contemp Clin Trials 2019; 78:63-75. [PMID: 30593884 DOI: 10.1016/j.cct.2018.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/12/2018] [Accepted: 12/25/2018] [Indexed: 11/16/2022]
Abstract
Primary care in Australia is undergoing significant reform, with a particular focus on cost-effective tailoring of mental health care to individual needs. Link-me is testing whether a patient-completed Decision Support Tool (DST), which predicts future severity of depression and anxiety symptoms and triages individuals into care accordingly, is clinically effective and cost-effective relative to usual care. The trial is set in general practices, with English-speaking patients invited to complete eligibility screening in their general practitioner's waiting room. Eligible and consenting patients will then complete the DST assessment and are randomised and stratified according to predicted symptom severity. Participants allocated to the intervention arm will receive feedback on DST responses, select treatment priorities, assess motivation to change, and receive a severity-matched treatment recommendation (information about and links to low intensity services for those with mild symptoms, or assistance from a specially trained health professional (care navigator) for those with severe symptoms). All patients allocated to the comparison arm will receive usual GP care plus attention control. Primary (psychological distress) and secondary (depression, anxiety, quality of life, days out of role) outcomes will be assessed at 6 and 12 months. Differences in outcome means between trial arms both across and within symptom severity group will be examined using intention-to-treat analyses. Within trial and modelled economic evaluations will be conducted to determine the value for money of credentials of Link-me. Findings will be reported to the Federal Government to inform how mental health services across Australia are funded and delivered in the future.
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Affiliation(s)
- Susan Fletcher
- The Department of General Practice, Melbourne Medical School, University of Melbourne.
| | - Patty Chondros
- The Department of General Practice, Melbourne Medical School, University of Melbourne
| | - Victoria J Palmer
- The Department of General Practice, Melbourne Medical School, University of Melbourne
| | | | - Matthew J Spittal
- Melbourne School of Population and Global Health, University of Melbourne
| | | | - Anna Wood
- The Department of General Practice, Melbourne Medical School, University of Melbourne
| | | | | | - Bridget Bassilios
- Melbourne School of Population and Global Health, University of Melbourne
| | - Jane Pirkis
- Melbourne School of Population and Global Health, University of Melbourne
| | - Jane Gunn
- The Department of General Practice, Melbourne Medical School, University of Melbourne
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42
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Heffernan M, Andrews G, Fiatarone Singh MA, Valenzuela M, Anstey KJ, Maeder AJ, McNeil J, Jorm L, Lautenschlager NT, Sachdev PS, Ginige JA, Hobbs MJ, Boulamatsis C, Chau T, Cobiac L, Cox KL, Daniel K, Flood VM, Guerrero Y, Gunn J, Jain N, Kochan NA, Lampit A, Mavros Y, Meiklejohn J, Noble Y, O’Leary F, Radd-Vagenas S, Walton CC, Brodaty H. Maintain Your Brain: Protocol of a 3-Year Randomized Controlled Trial of a Personalized Multi-Modal Digital Health Intervention to Prevent Cognitive Decline Among Community Dwelling 55 to 77 Year Olds. J Alzheimers Dis 2019; 70:S221-S237. [PMID: 30475762 PMCID: PMC6700632 DOI: 10.3233/jad-180572] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Maintain Your Brain (MYB) is a randomized controlled trial of an online multi-modal lifestyle intervention targeting modifiable dementia risk factors with its primary aim being to reduce cognitive decline in an older age cohort. METHODS MYB aims to recruit 8,500 non-demented community dwelling 55 to 77 year olds from the Sax Institute's 45 and Up Study in New South Wales, Australia. Participants will be screened for risk factors related to four modules that comprise the MYB intervention: physical activity, nutrition, mental health, and cognitive training. Targeting risk factors will enable interventions to be personalized so that participants receive the most appropriate modules. MYB will run for three years and up to four modules will be delivered sequentially each quarter during year one. Upon completing a module, participants will continue to receive less frequent booster activities for their eligible modules (except for the mental health module) until the end of the trial. DISCUSSION MYB will be the largest internet-based trial to attempt to prevent cognitive decline and potentially dementia. If successful, MYB will provide a model for not just effective intervention among older adults, but an intervention that is scalable for broad use.
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Affiliation(s)
- Megan Heffernan
- Centre for Healthy Brain Ageing, University of New South Wales, Australia
| | - Gavin Andrews
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales, Australia
| | - Maria A. Fiatarone Singh
- Sydney Medical School, University of Sydney, Australia
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
- Hebrew SeniorLife and Jean Meyer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA USA
| | - Michael Valenzuela
- Sydney Medical School, University of Sydney, Australia
- Brain and Mind Centre, University of Sydney, Australia
| | | | - Anthony J. Maeder
- College of Nursing & Health Sciences, Flinders University, Australia
| | | | - Louisa Jorm
- Centre for Big Data Research in Health, University of New South Wales, Australia
| | - Nicola T. Lautenschlager
- University of Melbourne, Australia
- North Western Mental Health, Melbourne Health, Melbourne, Australia
| | | | | | - Megan J. Hobbs
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales, Australia
| | | | - Tiffany Chau
- Centre for Healthy Brain Ageing, University of New South Wales, Australia
| | | | - Kay L. Cox
- Medical School, University of Western Australia, Perth, Australia
| | - Kenneth Daniel
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Victoria M. Flood
- Faculty of Health Sciences, University of Sydney, Australia
- Western Sydney Local Health District, Westmead Hospital, Australia
| | - Yareni Guerrero
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Nidhi Jain
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Nicole A. Kochan
- Centre for Healthy Brain Ageing, University of New South Wales, Australia
| | - Amit Lampit
- Brain and Mind Centre, University of Sydney, Australia
- University of Melbourne, Australia
| | - Yorgi Mavros
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Jacinda Meiklejohn
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Yian Noble
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Fiona O’Leary
- Nutrition and Dietetics Group, School of Life and Environmental Science, Faculty of Science & The Charles Perkins Centre, University of Sydney, Australia
| | - Sue Radd-Vagenas
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
| | - Courtney C. Walton
- Brain and Mind Centre, University of Sydney, Australia
- School of Psychology, University of Queensland, Melbourne, Australia
| | - Maintain Your Brain Collaborative Team
- Centre for Healthy Brain Ageing, University of New South Wales, Australia
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales, Australia
- Sydney Medical School, University of Sydney, Australia
- Physical Activity, Lifestyle, Ageing and Wellbeing Faculty Research Group, Faculty of Health Sciences, University of Sydney, Australia
- Brain and Mind Centre, University of Sydney, Australia
- School of Psychology, University of New South Wales, Australia
- College of Nursing & Health Sciences, Flinders University, Australia
- Monash University, Australia
- Centre for Big Data Research in Health, University of New South Wales, Australia
- University of Melbourne, Australia
- Western Sydney University, Australia
- CSIRO Health and Biosecurity
- Medical School, University of Western Australia, Perth, Australia
- Faculty of Health Sciences, University of Sydney, Australia
- Western Sydney Local Health District, Westmead Hospital, Australia
- Nutrition and Dietetics Group, School of Life and Environmental Science, Faculty of Science & The Charles Perkins Centre, University of Sydney, Australia
- North Western Mental Health, Melbourne Health, Melbourne, Australia
- Department of General Practice, University of Melbourne, Melbourne, Australia
- School of Psychology, University of Queensland, Melbourne, Australia
- Hebrew SeniorLife and Jean Meyer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA USA
| | - Henry Brodaty
- Centre for Healthy Brain Ageing, University of New South Wales, Australia
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43
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Castellani B, Griffiths F, Rajaram R, Gunn J. Exploring comorbid depression and physical health trajectories: A case-based computational modelling approach. J Eval Clin Pract 2018; 24:1293-1309. [PMID: 30277297 DOI: 10.1111/jep.13042] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 11/30/2022]
Abstract
While comorbid depression/physical health is a major clinical concern, the conventional methods of medicine make it difficult to model the complexities of this relationship. Such challenges include cataloguing multiple trends, developing multiple complex aetiological explanations, and modelling the collective large-scale dynamics of these trends. Using a case-based complexity approach, this study engaged in a richly described case study to demonstrate the utility of computational modelling for primary care research. N = 259 people were subsampled from the Diamond database, one of the largest primary care depression cohort studies worldwide. A global measure of depressive symptoms (PHQ-9) and physical health (PCS-12) were assessed at 3, 6, 9, and 12 months and then annually for a total of 7 years. Eleven trajectories and 2 large-scale collective dynamics were identified, revealing that while depression is comorbid with poor physical health, chronic illness is often low dynamic and not always linked to depression. Also, some of the cases in the unhealthy and oscillator trends remain ill without much chance of improvement. Finally, childhood abuse, partner violence, and negative life events are greater amongst unhealthy trends. Computational modelling offers a major advance for health researchers to account for the diversity of primary care patients and for developing better prognostic models for team-based interdisciplinary care.
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Affiliation(s)
- Brian Castellani
- Department of Sociology, Durham University, Durham, UK.,Department of Psychiatry, Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Frances Griffiths
- Division of Health Sciences, University of Warwick, Coventry, UK.,University of the Witwatersrand, Johannesburg, South Africa
| | - Rajeev Rajaram
- Department of Mathematics, Kent State University, Kent, OH, USA
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Australia
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Gaspar J, Coenen J, Corre Y, Dejarnac R, Firdaouss M, Clairet F, Gunn J, Iglesias D, Komm M, Krieger K, Matthews G, Pitts R, Silburn S. Heat flux analysis of Type-I ELM impact on a sloped, protruding surface in the JET bulk tungsten divertor. Nuclear Materials and Energy 2018. [DOI: 10.1016/j.nme.2018.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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45
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Hocking JS, Temple-Smith M, Guy R, Donovan B, Braat S, Law M, Gunn J, Regan D, Vaisey A, Bulfone L, Kaldor J, Fairley CK, Low N. Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial. Lancet 2018; 392:1413-1422. [PMID: 30343857 DOI: 10.1016/s0140-6736(18)31816-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [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: 06/30/2018] [Revised: 07/20/2018] [Accepted: 07/30/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Screening young adults who are sexually active for genital Chlamydia trachomatis infection is promoted in several high-income countries, but its effectiveness at the population level is highly debated. We aimed to investigate the effects of opportunistic chlamydia testing in primary care on the estimated chlamydia prevalence in the population aged 16-29 years in Australia. METHODS We did a cluster-randomised controlled trial. Clusters were rural towns with a minimum of 500 women and men aged 16-29 years and no more than six primary care clinics. We randomly allocated each cluster using a computer-generated minimisation algorithm to receive a multifaceted, clinic-based chlamydia testing intervention or to continue usual care. The intervention included computerised reminders to test patients, an education package, payments for chlamydia testing, and feedback on testing rates. The primary outcome was chlamydia prevalence, estimated before randomisation (survey 1) and at the end of the trial (survey 2) in patients aged 16-29 years who attended the clinics. Analyses were done by intention to treat. General practitioners and clinic staff were aware of group allocation, whereas patients and laboratory staff who performed the chlamydia tests were not. This trial was completed on Dec 31, 2015, and is registered (ACTRN12610000297022). FINDINGS Between Dec 14, 2010, and Sept 14, 2015, 26 clusters (63 clinics) received the chlamydia testing intervention and 26 (67 clinics) continued usual care. Over a mean duration of 3·1 years (SD 0·3), 93 828 young adults attended intervention clinics and 86 527 attended control clinics. The estimated chlamydia prevalence decreased from 5·0% (95% CI 3·8 to 6·2) at survey 1 to 3·4% (2·7 to 4·1) at survey 2 in the intervention clusters (difference -1·6%, 95% CI -2·9 to -0·3) and from 4·6% (95% CI 3·5 to 5·7) at survey 1 to 3·4% (2·4 to 4·5) at survey 2 in the control clusters (difference -1·1%, -2·7 to 0·5). The unadjusted odds ratio for the difference between intervention and control clusters was 0·9 (95% CI 0·5 to 1·5). INTERPRETATION These findings, in conjunction with evidence about the feasibility of sustained uptake of opportunistic testing in primary care, indicate that sizeable reductions in chlamydia prevalence might not be achievable. FUNDING Australian Government Department of Health, National Health and Medical Research Council, Victorian Department of Health and Human Services, and New South Wales Ministry of Health.
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Affiliation(s)
- Jane S Hocking
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.
| | | | - Rebecca Guy
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Basil Donovan
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Sydney Sexual Health Centre, Sydney, NSW, Australia
| | - Sabine Braat
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew Law
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - David Regan
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Alaina Vaisey
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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46
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Yeung A, Hocking J, Guy R, Fairley CK, Smith K, Vaisey A, Donovan B, Imrie J, Gunn J, Temple-Smith M. 'It Opened My Eyes'-examining the impact of a multifaceted chlamydia testing intervention on general practitioners using Normalization Process Theory. Fam Pract 2018; 35:626-632. [PMID: 29608672 DOI: 10.1093/fampra/cmy011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chlamydia is the most common notifiable sexually transmissible infection in Australia. Left untreated, it can develop into pelvic inflammatory disease and infertility. The majority of notifications come from general practice and it is ideally situated to test young Australians. OBJECTIVES The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) was a multifaceted intervention that aimed to reduce chlamydia prevalence by increasing testing in 16- to 29-year-olds attending general practice. GPs were interviewed to describe the effectiveness of the ACCEPt intervention in integrating chlamydia testing into routine practice using Normalization Process Theory (NPT). METHODS GPs were purposively selected based on age, gender, geographic location and size of practice at baseline and midpoint. Interview data were analysed regarding the intervention components and results were interpreted using NPT. RESULTS A total of 44 GPs at baseline and 24 at midpoint were interviewed. Most GPs reported offering a test based on age at midpoint versus offering a test based on symptoms or patient request at baseline. Quarterly feedback was the most significant ACCEPt component for facilitating a chlamydia test. CONCLUSIONS The ACCEPt intervention has been able to moderately normalize chlamydia testing among GPs, although the components had varying levels of effectiveness. NPT can demonstrate the effective implementation of an intervention in general practice and has been valuable in understanding which components are essential and which components can be improved upon.
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Affiliation(s)
- Anna Yeung
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jane Hocking
- Sexual Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Rebecca Guy
- Sexual Health Program, Kirby Institute, University of New South Wales, Sydney, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Kirsty Smith
- Sexual Health Program, Kirby Institute, University of New South Wales, Sydney, Australia
| | - Alaina Vaisey
- Sexual Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Basil Donovan
- Sexual Health Program, Kirby Institute, University of New South Wales, Sydney, Australia.,Sydney Sexual Health Centre, Sydney, Australia
| | - John Imrie
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa
| | - Jane Gunn
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Melbourne, Australia
| | - Meredith Temple-Smith
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Melbourne, Australia
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Parker W, Gosling R, Churton A, Parviz Y, Iqbal J, Heppenstall J, Teare D, Gunn J. P28 DOES MILD CORONARY ARTERY ATHEROSCLEROSIS PROGRESS AT SERIAL ANGIOGRAPHY? Cardiovasc Res 2018. [DOI: 10.1093/cvr/cvy216.031] [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: 11/13/2022] Open
Affiliation(s)
- W Parker
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - R Gosling
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A Churton
- University of Birmingham Medical School, Birmingham, UK
| | - Y Parviz
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J Iqbal
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J Heppenstall
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - D Teare
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - J Gunn
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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48
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Pond D, Mate K, Stocks N, Gunn J, Disler P, Magin P, Marley J, Paterson N, Horton G, Goode S, Weaver N, Brodaty H. Effectiveness of a peer-mediated educational intervention in improving general practitioner diagnostic assessment and management of dementia: a cluster randomised controlled trial. BMJ Open 2018; 8:e021125. [PMID: 30121596 PMCID: PMC6104761 DOI: 10.1136/bmjopen-2017-021125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Test effectiveness of an educational intervention for general practitioners (GPs) on quality of life and depression outcomes for patients. DESIGN Double-blind, cluster randomised controlled trial. SETTING General practices in Australia between 2007 and 2010. PARTICIPANTS General practices were randomly allocated to the waitlist (n=37) or intervention (n=66) group, in a ratio of 1:2. A total of 2030 (1478 intervention; 552 waitlist) community-dwelling participants aged 75 years or older were recruited via 168 GPs (113 intervention; 55 waitlist). INTERVENTIONS A practice-based academic detailing intervention led by a peer educator that included: (1) training in use of the GP assessment of cognition dementia screening instrument; (2) training in diagnosis and management based on Royal Australian College of General Practitioners Dementia Guidelines; (3) addressing GPs' barriers to dementia diagnosis; and (4) a business case outlining a cost-effective dementia assessment approach. OUTCOME MEASURES Primary outcome measures were patient quality of life and depression; secondary outcome measures were: (1) sensitivity and specificity of GP identification of dementia; (2) referral to medical specialists and/or support services; (3) patient satisfaction with care; and (4) carer quality of life, depression and satisfaction with care. RESULTS The educational intervention had no significant effect on patient quality of life or depression scores after 12 months. There were however improvements in secondary outcome measures including sensitivity of GP judgement of dementia (p=0.002; OR 6.0, 95% CI 1.92 to 18.73), satisfaction with GP communication for all patients (p=0.024; mean difference 2.1, 95% CI 0.27 to 3.93) and for patients with dementia (p=0.007; mean difference 7.44, 95% CI 2.02 to 12.86) and enablement of carers (p=0.0185; mean difference 24.77, 95% CI 4.15 to 45.40). CONCLUSION Practice-based academic detailing did not improve patient quality of life or depression scores but did improve detection of dementia in primary care and patient satisfaction with GP communication. TRIAL REGISTRATION NUMBER ACTRN12607000117415; Pre-results.
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Affiliation(s)
- Dimity Pond
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Karen Mate
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Disler
- School of Rural Health, Monash University, Bendigo, Victoria, Australia
| | - Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - John Marley
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Nerida Paterson
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Graeme Horton
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Susan Goode
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration and the Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
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49
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Levesque JF, O'Dowd JJM, Ní Shé ÉM, Weenink JW, Gunn J. Moving regional health services planning and management to a population-based approach: implementation of the Regional Operating Model (ROM) in Victoria, Australia. Aust J Prim Health 2018; 24:PY17151. [PMID: 30086821 DOI: 10.1071/py17151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 05/03/2018] [Indexed: 11/23/2022]
Abstract
Various jurisdictions are moving towards population-based approaches to plan and manage healthcare services. The evidence on the implementation of these models remains limited. The aim of this study is to evaluate the effect of a regional operating model (ROM) on internal functioning and stakeholder engagement of a regional office. Semi-structured interviews and focus groups with staff members and stakeholders of the North West Metropolitan Regional office in Victoria, Australia, were conducted. Overall, the ROM was perceived as relevant to staff and stakeholders. However, creating shared objectives and priorities across a range of organisations remained a challenge. Area-based planning and management is seen as simplifying management of contracts; however, reservations were expressed about moving from specialist to more generalist approaches. A clearer articulation of the knowledge, skills and competencies required by staff would further support the implementation of the model. The ROM provides a platform for public services and stakeholders to discuss, negotiate and deliver on shared outcomes at the regional level. It provides an integrated managerial platform to improve service delivery and avoid narrow programmatic approaches.
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50
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Sinisilta S, Hollmen M, Gunn J, Ruohonen I, Jalkanen J, Airaksinen J, Jalkanen S, Kiviniemi T. P1656Circulating cytokines predict atrial fibrillation in patients undergoing open-heart coronary bypass. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1656] [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: 11/14/2022] Open
Affiliation(s)
- S Sinisilta
- Turku University Hospital, Heart Center, Turku, Finland
| | - M Hollmen
- University of Turku, MediCity Research Laboratory, Turku, Finland
| | - J Gunn
- Turku University Hospital, Heart Center, Turku, Finland
| | - I Ruohonen
- Turku University Hospital, Heart Center, Turku, Finland
| | - J Jalkanen
- University of Turku, MediCity Research Laboratory, Turku, Finland
| | - J Airaksinen
- Turku University Hospital, Heart Center, Turku, Finland
| | - S Jalkanen
- University of Turku, MediCity Research Laboratory, Turku, Finland
| | - T Kiviniemi
- Turku University Hospital, Heart Center, Turku, Finland
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