Rural-Urban Variation in Time to Diagnosis and Treatment of Colorectal or Breast Cancer in Victoria, Australia

Background: Rural-urban disparities in cancer outcomes are found in many countries, though these vary by cancer type. In Victoria, Australia, survival is poorer for rural patients with colorectal cancer, but not breast cancer. Delayed diagnosis and treatment may contribute to disparities, but previous studies have not compared the timeliness of rural and urban pathways to treatment of these common cancers. Aim: We investigated whether time to diagnosis and treatment differed for rural and urban patients with colorectal or breast cancer in Victoria, Australia. Methods: Population-based, cross-sectional surveys examining events and dates on the pathway to treatment completed by patients aged ≥ 40 and approached within six months of diagnosis, their general practitioner (GP) and specialist. Data were collected from 2013 to 2014 as part of the International Cancer Benchmarking Partnership, Module 4. Six intervals were explored: patient (symptom to presentation), primary care (presentation to referral), diagnostic (presentation/screening to diagnosis), treatment (diagnosis to treatment), health system (presentation to treatment) and total intervals (symptom/screening to treatment). Rural-urban differences were examined for each cancer using quantile regression (50th, 75th and 90th percentiles) models including age, gender, health insurance and socioeconomic status. Results: 433 colorectal (48% rural) and 489 breast (42% rural) patients, 621 GPs and 370 specialists completed surveys. Compared with urban patients, symptomatic colorectal cancer patients from rural areas had a significantly longer total interval at all percentiles: 50th (18 days longer, 95% confidence interval (CI): 9-27), 75th (53, 95% CI: 47-59) 90th (44, 95% CI: 40-48). These patients also had longer health system intervals, ranging 7-85 days longer. This appeared mostly due to longer diagnostic intervals (range: 6-54 days longer). Results were similar when including screen-detected cases. In contrast, breast cancer intervals were similar for rural and urban patients, except the patient interval, which was shorter for rural patients. Conclusion: Consistent with variation in survival, we found longer total and diagnostic intervals for rural compared with urban patients with colorectal cancer, but not breast cancer. The lack of rural-urban differences observed for breast cancer suggest that inequities in the timeliness of colorectal cancer pathways can be ameliorated, and may improve clinical outcomes. Indeed, based on previous research, delays observed in this study could result in stage progression and hence reduced survival. From our results, interventions targeting the time from presentation to colorectal cancer diagnosis in rural populations should be pursued. Countries seeking to understand cancer disparities in their local context may also consider using a pathways approach to identify possible targets for policy intervention.

A National Priority: Improving Outcomes for Aboriginal and Torres Strait Islander People With Cancer Through an Optimal Care Pathway

Background and context: Cancer survival rates in Australia are among the best in the world, yet Aboriginal and Torres Strait Islander (indigenous) people continue to experience disparities in the distribution and burden of cancer, and unwarranted variations in outcomes. Indigenous Australians are 40% more likely to die of cancer than non-Indigenous Australians. Cancer Australia developed the National Aboriginal and Torres Strait Islander Cancer Framework (the framework), which identified 7 national priorities to address disparities in cancer outcomes experienced by indigenous Australians. An ongoing collaboration with indigenous Australians was integral to developing this shared agenda. Priority 5 in the framework highlights the need to ensure indigenous Australians affected by cancer receive optimal and culturally appropriate treatment, services, and supportive and palliative care. Aim: To improve cancer outcomes for indigenous Australians through the development and national endorsement of a population-specific Optimal Care Pathway (OCP) to guide the delivery of consistent, safe, high-quality, culturally appropriate and evidence-based care. Strategy/Tactics: Cancer Australia formed a partnership with the Victorian Department of Health and Human Services (DHHS) to address Priority 5 and develop the OCP. The approach to development was underpinned by Cancer Australia's Model of Engagement for Aboriginal and Torres Strait Islander People and guided by the national Leadership Group on Aboriginal and Torres Strait Islander Cancer Control (Leadership Group). Program/Policy process: Cancer Australia, in collaboration with DHHS: • reviewed experiences of care and the framework's comprehensive evidence base • developed a draft OCP to complement tumor-specific pathways • facilitated an Expert Working Group, comprising indigenous health sector leaders and consumers to refine and validate the draft OCP • undertook national public consultation, including with the indigenous health sector and community, health professionals and professional colleges • received an indication of support to proceed to endorsement from the Leadership Group. Outcomes: The first population-specific OCP for Aboriginal and Torres Strait Islander people with cancer received national endorsement. It will guide the delivery of consistent, safe, high-quality, culturally appropriate and evidence-based care. What was learned: Key elements of optimal care include: addressing the cultural appropriateness of the healthcare environment; improving cross-cultural communication; relationship building with local community; optimizing health literacy; recognition of men's and women's business; and the need to use culturally appropriate resources. The national priority in the framework informed and unified high-level direction, which was integral to effective OCP development and endorsement. The evidence-based, step-wise development approach contributed to its relevance, utility and quality.

Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

OBJECTIVES

Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework.

DESIGN

Single centre, randomised controlled, two-arm trial.

SETTING

Elective surgery PAC in a Brisbane-based tertiary hospital.

PARTICIPANTS

400 adults scheduled for elective surgery were randomised to intervention or control.

INTERVENTION

A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers.

OUTCOME MEASURES

Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing.

RESULTS

There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29).

CONCLUSIONS

Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.

TRIAL REGISTRATION

Registered with ANZCTR-ACTR Number ACTRN12609000426280.

A system for recording individualized behavioral data in a token program

A data matrix system used to record and summarize individual behavioral data is described. The major characteristics of the system are: (1) it provides a place to record and summarize all patient token exchanges, whether for standard contingencies or for idiosyncratic behavior; (2) it serves as a record and summary for time samples observed during a 24-hr period and as a record of reliability data on time sample measures; (3) it provides a place where the new token balance for each patient can be calculated and recorded for use the next day; (4) it provides for calculation of an individual patient's token balance at any given moment; and (5) it is a permanent record of each patient's daily participation in the program and documents progress in terms of his economic status as well as in changes in critical target behaviors.

Association between lung function and disability in African-Americans

BACKGROUND

Impaired lung function is independently associated with higher rates of disability; however, few studies have examined the extent to which this relationship varies by sex. Because men are less likely to have disability, it is expected that the relationship between lung function and disability will be greater among women.

METHODS

Logistic regression models were specified to examine the relationship between lung function and disability in 689 African-American men and women participating in the Carolina African American Twin Study of Aging. Disability was defined as difficulty in performing at least one of seven basic activities of daily living. Impaired lung function was defined as per cent of predicted peak expiratory flow (PEF) <80.

RESULTS

Accounting for demographic and health-related characteristics, women who had impaired lung function had a higher odds (OR 1.77; 95% CI 1.02 to 3.06) of being disabled than those with normal lung function. Impaired lung function was unrelated to disability in men.

CONCLUSION

Lung function appears to vary by sex in this sample of African-Americans. Furthermore, among women, lung function should be considered as an important indicator of health. Every effort should be made to improve lung function in African-Americans, but interventions and health promoting strategies may need to be sex specific.

Notification of patients with acute flaccid paralysis since certification of Australia as polio-free

OBJECTIVE

Surveillance of patients presenting with acute flaccid paralysis (AFP) is the World Health Organization (WHO) recommended method for the detection of incident cases of poliovirus infection. Australia was certified free of circulating poliovirus in 2000 but is required to continue AFP surveillance until global certification. Although Australia reached the WHO nominated surveillance target in 2000 and 2001, it was not reached in 2002. Notification rates between states have been variable. We aim to investigate the difference in notification rates by state to determine whether different rates reflect different patterns of disease or different approaches to reporting.

METHODS

Notification rates were reviewed by state for the years 1997-2002. The completeness of case ascertainment was reviewed from published studies. Key informants described differences in AFP reporting in states with consistent differences in notification rates.

RESULTS

Australia achieved 75% of the WHO surveillance target for AFP cases between 1997 and 1999 and 98% between 2000 and 2002. After 2000, Queensland achieved 150% of its target while Victoria achieved less than 50%. New South Wales reached its target over the entire 6 years but other states and territories were not as consistent. Although the formal process for AFP reporting is uniform throughout Australia, many differences in approach were identified between Victoria and Queensland.

CONCLUSION

Maintaining AFP surveillance at the required WHO standard will be more likely in Australia if the populous states are able to notify cases at the same rate as Queensland (since 2000) and New South Wales (in general).

Origins of individual differences in episodic memory in the oldest-old: a population-based study of identical and same-sex fraternal twins aged 80 and older

The relative importance of genetic and environmental influences on episodic memory in very late life was studied using a quantitative genetic approach. Identical (n = 125) and same-sex fraternal (n = 157) twin pairs, aged 80 and older (mean age = 83.3; SD = 3.1) and without a diagnosis of dementia were tested with seven memory measures: (1-2) Digit Span Forward and Backwards, (3) Prose Recall, (4) Thurstone's picture memory test, and the Memory in Reality (MIR) test, including the subtasks of (5) free recall, (6) recognition, and (7) relocation. Heritabilities, estimated by structural equation modeling, ranged from .04 to .49. The digit span backward test showed the highest heritability (h2 = .49), while heritabilities were typically lower for the long-term memory measures. The results demonstrate genetic influences on memory in the oldest-old, but suggest that the magnitude of these effects differs across memory measures.

Genetic and environmental influences on functional age: a twin study

Twin analyses were conducted to determine the relative influence of genetic and environmental factors on functional aging. As part of the ongoing Minnesota Twin Study of Adult Development and Aging (MTSADA), measures of 30 demographic, cognitive, physiological, personality, and behavioral variables were available from 140 monozygotic twin pairs and 97 dizygotic twin pairs ranging in age from 27 to 88 years. Functional age was based on a general linear regression model with chronological age as the dependent variable. Stepwise regression determined the subset of variables by MTSADA providing the best prediction of chronological age. Factor analysis of these 12 variables resulted in three factors: physiological measures, cognitive abilities, and processing speed. When entered into, a regression equation, the three factors accounted for 66% of the variance in chronological age. Analysis of twin similarity for components of functional age suggested the relative influence of genetic and environmental factors varies greatly for different components of functional aging. In addition, the genetic and shared environmental influences on the three components were common to all three, while the nonshared environmental influences were specific to each component.

A normative sample using the Loong Computerized Tapping Program

This article provides results of a comparison between the Halstead-Reitan tapper and a 1988 computerized tapping program by Loong. Care should be taken in using the computerized tapper in diagnosis or assessment.