Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.

Examination of social demographic status, disease status, health behaviours and quality of life in older Australians using the theory of planned behaviour model

The increase of life expectancy worldwide during the last three decades has increased age-related disability leading to the risk of loss of quality of life. How to improve quality of life including physical health and mental health for older people and optimize their life potential has become an important health issue. This study used the Theory of Planned Behaviour Model to examine factors influencing health behaviours, and the relationship with quality of life. A cross-sectional mailed survey of 1300 Australians over 50 years was conducted at the beginning of 2009, with 730 completed questionnaires returned (response rate 63%). Preliminary analysis reveals that physiological changes of old age, especially increasing waist circumference and co morbidity was closely related to health status, especially worse physical health summary score. Physical activity was the least adherent behaviour among the respondents compared to eating healthy food and taking medication regularly as prescribed. Increasing number of older people living alone with co morbidity of disease may be the barriers that influence their attitude and self control toward physical activity. A multidisciplinary and integrated approach including hospital and non hospital care is required to provide appropriate services and facilities toward older people.

Quality of cause-of-death reporting using ICD-10 drowning codes : a descriptive study of 69 countries

Background: The systematic collection of high-quality mortality data is a prerequisite in designing relevant drowning prevention programmes. This descriptive study aimed to assess the quality (i.e., level of specificity) of cause-of-death reporting using ICD-10 drowning codes across 69 countries.---------- Methods: World Health Organization (WHO) mortality data were extracted for analysis. The proportion of unintentional drowning deaths coded as unspecified at the 3-character level (ICD-10 code W74) and for which the place of occurrence was unspecified at the 4th character (.9) were calculated for each country as indicators of the quality of cause-of-death reporting.---------- Results: In 32 of the 69 countries studied, the percentage of cases of unintentional drowning coded as unspecified at the 3-character level exceeded 50%, and in 19 countries, this percentage exceeded 80%; in contrast, the percentage was lower than 10% in only 10 countries. In 21 of the 56 countries that report 4-character codes, the percentage of unintentional drowning deaths for which the place of occurrence was unspecified at the 4th character exceeded 50%, and in 15 countries, exceeded 90%; in only 14 countries was this percentage lower than 10%.---------- Conclusion: Despite the introduction of more specific subcategories for drowning in the ICD-10, many countries were found to be failing to report sufficiently specific codes in drowning mortality data submitted to the WHO.

Food insecurity in Brisbane : the single mother’s struggle

Using a feminist reflexive approach this paper reports on interviews with single mother’s in the Brisbane area about their experiences with food shopping and household food security. Preliminary findings suggest that most experience significant stress around the amount of money they have available for food. As the price of food and other costs of living increase, the only budget item that is flexible – groceries - is squeezed tighter. All women expressed a reluctance to ask for help from strangers at agencies instead relying on the support of family and friends to keep them food secure. Sometimes family and friends had no spare resources to help or were not aware of the extent their friend or relative might be struggling. The increased risks of poverty and food insecurity mean many go without as feeding the children takes precedence. The quality of their diets is variable with many reporting on aiming for quantity rather than being concerned with nutritional balance. Exhaustion and stress from being over-committed doing three roles, mother, father and housekeeper was self-identified as a key factor leading to mental health conditions such as depression, burnout and break down. Female single parent households are vulnerable to reducing welfare benefits as children grow or child support changes. Current policy forces single parents out to work but many can only manage part-time work for lower wages and are barely able to cope with this extra burden often resenting the reduction in benefits it brings. Public perceptions, derision and the notions of choice surrounding single parenting leave the cohort divided and silent for fear of reprisals. In my investigation issues arise about welfare policy that keep benefits low and workplace patriarchal power that can contribute to systemic poverty and the widening of the gender gap in poverty. So far analysis suggests a better support system around community food security including some hands on home help services, nutritional information, cooking classes, community gardening and other social capital building activities are needed for these women in order to avoid long-term health problems and help them better care for the next generation.

Brain-derived neurotrophic factor (BDNF) gene : no major impact on antidepressant treatment response

The brain-derived neurotrophic factor (BDNF) has been suggested to play a pivotal role in the aetiology of affective disorders. In order to further clarify the impact of BDNF gene variation on major depression as well as antidepressant treatment response, association of three BDNF polymorphisms [rs7103411, Val66Met (rs6265) and rs7124442] with major depression and antidepressant treatment response was investigated in an overall sample of 268 German patients with major depression and 424 healthy controls. False discovery rate (FDR) was applied to control for multiple testing. Additionally, ten markers in BDNF were tested for association with citalopram outcome in the STAR*D sample. While BDNF was not associated with major depression as a categorical diagnosis, the BDNF rs7124442 TT genotype was significantly related to worse treatment outcome over 6 wk in major depression (p=0.01) particularly in anxious depression (p=0.003) in the German sample. However, BDNF rs7103411 and rs6265 similarly predicted worse treatment response over 6 wk in clinical subtypes of depression such as melancholic depression only (rs7103411: TT

Up the e-learning curve : ensuring quality online education within an Australian university

The paper describes the implementation of a project within Australian Catholic University designed to launch the Faculties into online education in a manner which ensured quality in all aspects of the teaching-learning experiences of academics and students. Key elements of the strategic approach adopted by the project leaders, including the involvement of a specialist commercial provider of web-based delivery systems as a partner in the project, mechanisms to support the initiative through the first stages, careful choice of the programs offered online, and staff development matched to the emerging needs of those involved in the teaching of courses, are described. Challenges encountered in the implementation process, and the factors which assisted in overcoming these problems are identified. The paper draws upon this experience to raise some important issues relevant to the successful introduction of online education as an integral component of the teaching repertoire of Faculties.

A new approach to assessing Malaysian contractor satisfaction levels

The extent of poor project outcomes is a recurring issue for construction industries worldwide. One of the main causes of these and project failure seems to be the inability of contractors to provide a high level of service quality to the project team. In Malaysia, design failures have also been identified as a further contributory factor. To overcome this, different types of subjective performance measurement have been progressively developed. These approaches are typically concerned with client satisfaction, customer satisfaction, home buyer satisfaction and occupant satisfaction, but very seldom consider contractor satisfaction. This paper examines the implications of this, and what is involved in developing satisfaction measures based on contractor perception instead of the typical sole concern with client performance. As a result, other attributes such as participants’ performance, business performance, project performance, external factors and contractor characteristics are also examined. Several potential attributes are derived from interviews among Malaysian contractors, namely: performance (direct attributes) and contractor characteristics (indirect attributes) that possibly influence contractor satisfaction levels. These attributes are then developed to improve the existing conceptual framework. The developed framework is expected to help the project team in performing projects more efficiently, maintaining service quality and improving relationships between participants. In addition, the findings of the paper should assist contractors enhance competitiveness, improve their image and create more job opportunities in the future.

Service quality in the Malaysian fast food industry : an examination using DINESERV

This study addresses calls in the literature for the external validation of Western-based marketing concepts and theory in the East. Using DINESERV, the relationships between service quality, overall service quality perceptions, customer satisfaction, and repurchase intentions in the Malaysian fast food industry are examined. A questionnaire was administered to Malaysian fast food consumers at a large university, resulting in findings that support the five-dimensional nature of DINESERV and three of four proposed hypotheses. This study contributes to knowledge of service quality in developing countries and is the first to examine DINESERV in the Malaysian fast food industry.

Social Participation of Community Dwelling Stroke Survivors [Published Abstract: From the Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Conference 2009]

Disability following a stroke can impose various restrictions on patients’ attempts at participating in life roles. The measurement of social participation, for instance, is important in estimating recovery and assessing quality of care at the community level. Thus, the identification of factors influencing social participation is essential in developing effective measures for promoting the reintegration of stroke survivors into the community. Data were collected from 188 stroke survivors (mean age 71.7 years) 12 months after discharge from a stroke rehabilitation hospital. Of these survivors, 128 (61 %) had suffered a first ever stroke, and 81 (43 %) had a right hemisphere lesion. Most (n = 156, 83 %) were living in their own home, though 32 (17 %) were living in residential care facilities. Path analysis was used to test a hypothesized model of participation restriction which included the direct and indirect effects between social, psychological and physical outcomes and demographic variables. Participation restriction was the dependent variable. Exogenous independent variables were age, functional ability, living arrangement and gender. Endogenous independent variables were depressive symptoms, state self-esteem and social support satisfaction. The path coefficients showed functional ability having the largest direct effect on participation restriction. The results also showed that more depressive symptoms, low state self-esteem, female gender, older age and living in a residential care facility had a direct effect on participation restriction. The explanatory variables accounted for 71% of the variance in explaining participation restriction. Prediction models have empirical and practical applications such as suggesting important factors to be considered in promoting stroke recovery. The findings suggest that interventions offered over the course of rehabilitation should be aimed at improving functional ability and promoting psychological aspects of recovery. These are likely to enhance stroke survivors resume or maximize their social participation so that they may fulfill productive and positive life roles.

Anxiety among high school students in India : comparisons across gender, school type, social strata, and perceptions of quality time with parents

The broad objective of the study was to better understand anxiety among adolescents in Kolkata city, India. Specifically, the study compared anxiety across gender, school type, socio-economic background and mothers’ employment status. The study also examined adolescents’ perceptions of quality time with their parents. A group of 460 adolescents (220 boys and 240 girls), aged 13-17 years were recruited to participate in the study via a multi-stage sampling technique. The data were collected using a self-report semi-structured questionnaire and a standardized psychological test, the State-Trait Anxiety Inventory. Results show that anxiety was prevalent in the sample with 20.1% of boys and 17.9% of girls found to be suffering from high anxiety. More boys were anxious than girls (p<0.01). Adolescents from Bengali medium schools were more anxious than adolescents from English medium schools (p<0.01). Adolescents belonging to the middle class (middle socio-economic group) suffered more anxiety than those from both high and low socio-economic groups (p<0.01). Adolescents with working mothers were found to be more anxious (p<0.01). Results also show that a substantial proportion of the adolescents perceived they did not receive quality time from fathers (32.1%) and mothers (21.3%). A large number of them also did not feel comfortable to share their personal issues with their parents (60.0% for fathers and 40.0% for mothers).

Water sensitive urban design : landscape planning and design to improve water quality in Shijiazhaung and Yueyang

Water quality issues are heavily dependent on land development and management decisions within river and lake catchments or watersheds. Economic benefits of urbanisation may be short‐ lived without cleaner environmental outcomes. However, whole‐of‐catchment thinking is not, as yet, as frequent a consideration in urban planning and development in China as it is in many other countries. Water is predominantly seen as a resource to be ‘owned’ by different jurisdictions and allocated to numerous users, both within a catchment and between catchments. An alternative to this approach is to think of water in the same way as other commodities that must be kept moving through a complex transport system. Water must ultimately arrive at particular destinations in the biosphere, although it travels across a broad landscape and may be held up temporarily at certain places along the way. While water extraction can be heavily controlled, water pollution is far more difficult to regulate. Both have significant impacts on water availability and flows both now and in the future. As Chinese cities strive to improve economic conditions for their citizens, new centres are being rebuilt and environmental valued

Towards universal high quality early childhood education

The Australian Government has committed $970 million over 5 years to fund the expansion of preschool education and has established a National Early Childhood Education Partnership Agreement with States and Territories to achieve universal preschool access by 2013. The Partnership Agreement acknowledges the role of State and Territory Government in preschool education, and different approaches to preschool provision. It also recognises differences in current preschool participation rates across states and territories. This paper offers snapshots of a number of different models of preschool provision, spanning traditional sessional approaches to some integrated and innovative approaches within the long day care context. The paper explores the newer long day care model and offers recommendations for the delivery of preschool education within this different context.

Recent advances in dermal wound healing : biomedical device approaches

Successful repair of wounds and tissues remains a major healthcare and biomedical challenge in the 21st Century. In particular, chronic wounds often lead to loss of functional ability, increased pain and decreased quality of life, and can be a burden on carers and health-system resources. Advanced healing therapies employing biological dressings, skin substitutes, growth factor-based therapies and synthetic a cellular matrices, all of which aim to correct irregular and dysfunctional cellular pathways present in chronic wounds, are becoming more popular. This review focuses on recent advances in biologically inspired devices for would healing and includes a commentary on the challenges facing the regulatory governance of such products.

Autocrine fibroblast growth factor 2 increases the multipotentiality of human adipose-derived mesenchymal stem cells

Multipotent mesenchymal stem cells (MSCs), first identified in the bone marrow, have subsequently been found in many other tissues, including fat, cartilage, muscle, and bone. Adipose tissue has been identified as an alternative to bone marrow as a source for the isolation of MSCs, as it is neither limited in volume nor as invasive in the harvesting. This study compares the multipotentiality of bone marrow-derived mesenchymal stem cells (BMSCs) with that of adipose-derived mesenchymal stem cells (AMSCs) from 12 age- and sex-matched donors. Phenotypically, the cells are very similar, with only three surface markers, CD106, CD146, and HLA-ABC, differentially expressed in the BMSCs. Although colony-forming units-fibroblastic numbers in BMSCs were higher than in AMSCs, the expression of multiple stem cell-related genes, like that of fibroblast growth factor 2 (FGF2), the Wnt pathway effectors FRAT1 and frizzled 1, and other self-renewal markers, was greater in AMSCs. Furthermore, AMSCs displayed enhanced osteogenic and adipogenic potential, whereas BMSCs formed chondrocytes more readily than AMSCs. However, by removing the effects of proliferation from the experiment, AMSCs no longer out-performed BMSCs in their ability to undergo osteogenic and adipogenic differentiation. Inhibition of the FGF2/fibroblast growth factor receptor 1 signaling pathway demonstrated that FGF2 is required for the proliferation of both AMSCs and BMSCs, yet blocking FGF2 signaling had no direct effect on osteogenic differentiation. Disclosure of potential conflicts of interest is found at the end of this article.

A risk-based approach to course quality assurance

A decade ago, Queensland University of Technology (QUT) developed an innovative annual Courses Performance Report, but through incremental change, this report became quite labour-intensive. A new risk-based approach to course quality assurance, that consolidates voluminous data in a simple dashboard, responds to the changing context of the higher education sector. This paper will briefly describe QUT’s context and outline the second phase of implementation of this new approach to course quality assurance. The main components are: Individual Course Reports (ICRs), the Consolidated Courses Performance Report (CCPR), Underperforming Courses Status Update and the Strategic Faculty Courses Update (SFCU). These components together form a parsimonious and strategic annual cycle of reporting and place QUT in a positive position to respond to future sector change