National health and hospital network for Australia's future : Implications for emergency medicine

The proposals arising from the agreement reached between the Rudd government and the States and Territories (except Western Australia) in April 2010 represent the most fundamental realignment of health responsibilities since the creation of Medicare in 1984. They will change the health system, and the structures that will craft its future direction and design. These proposals will have a significant impact on Emergency Medicine; an impact from not only the system-wide effects of the proposals but also those that derive from the specific recommendations to create an activity-based funding mechanism for EDs, to implement the four hour rule and to develop a performance indicator framework for EDs. The present paper will examine the potential impact of the proposals on Emergency Medicine to inform those who work within the system and to help guide further developments. More work is required to better evaluate the proposals and to guide the design and development of specific reform instruments. Any such efforts should be based upon a proper analysis of the available evidence, and a structured approach to research and development so as to deliver on improved services to the community, and on improved quality and safety of emergency medical care.

Quality of child abuse information for measurement and surveillance : linking hospital and child welfare data

National estimates of the prevalence of child abuse-related injuries are obtained from a variety of sectors including welfare, justice, and health resulting in inconsistent estimates across sectors. The International Classification of Diseases (ICD) is used as the international standard for categorising health data and aggregating data for statistical purposes, though there has been limited validation of the quality, completeness or concordance of these data with other sectors. This research study examined the quality of documentation and coding of child abuse recorded in hospital records in Queensland and the concordance of these data with child welfare records. A retrospective medical record review was used to examine the clinical documentation of over 1000 hospitalised injured children from 20 hospitals in Queensland. A data linkage methodology was used to link these records with records in the child welfare database. Cases were sampled from three sub-groups according to the presence of target ICD codes: Definite abuse, Possible abuse, unintentional injury. Less than 2% of cases coded as being unintentional were recoded after review as being possible abuse, and only 5% of cases coded as possible abuse cases were reclassified as unintentional, though there was greater variation in the classification of cases as definite abuse compared to possible abuse. Concordance of health data with child welfare data varied across patient subgroups. This study will inform the development of strategies to improve the quality, consistency and concordance of information between health and welfare agencies to ensure adequate system responses to children at risk of abuse.

Quality of child abuse information in emergency department injury surveillance data : linking hospital and child welfare data

Emergency departments (EDs) are often the first point of contact with an abused child. Despite legal mandate, the reporting of definite or suspected abusive injury to child safety authorities by ED clinicians varies due to a number of factors including training, access to child safety professionals, departmental culture and a fear of ‘getting it wrong’. This study examined the quality of documentation and coding of child abuse captured by ED based injury surveillance data and ED medical records in the state of Queensland and the concordance of these data with child welfare records. A retrospective medical record review was used to examine the clinical documentation of almost 1000 injured children included in the Queensland Injury Surveillance Unit database (QISU) from 10 hospitals in urban and rural centres. Independent experts re-coded the records based on their review of the notes. A data linkage methodology was then used to link these records with records in the state government’s child welfare database. Cases were sampled from three sub-groups according to the surveillance intent codes: Maltreatment by parent, Undetermined and Unintentional injury. Only 0.1% of cases coded as unintentional injury were recoded to maltreatment by parent, while 1.2% of cases coded as maltreatment by parent were reclassified as unintentional and 5% of cases where the intent was undetermined by the triage nurse were recoded as maltreatment by parent. Quality of documentation varied across type of hospital (tertiary referral centre, children’s, urban, regional and remote). Concordance of health data with child welfare data varied across patient subgroups. Outcomes from this research will guide initiatives to improve the quality of intentional child injury surveillance systems.

The relationship between substrate metabolism, exercise and appetite control : does glycogen availability influence the motivation to eat, energy intake or food choice?

The way in which metabolic fuels are utilised can alter the expression of behaviour in the interests of regulating energy balance and fuel availability. This is consistent with the notion that the regulation of appetite is a psychobiological process, in which physiological mediators act as drivers of behaviour. The glycogenostatic theory suggests that glycogen availability is central in eliciting negative feedback signals to restore energy homeostasis. Due to its limited storage capacity, carbohydrate availability is tightly regulated and its restoration is a high metabolic priority following depletion. It has been proposed that such depletion may act as a biological cue to stimulate compensatory energy intake in an effort to restore availability. Due to the increased energy demand, aerobic exercise may act as a biological cue to trigger compensatory eating as a result of perturbations to muscle and liver glycogen stores. However, studies manipulating glycogen availability over short-term periods (1-3 days) using exercise, diet or both have often produced equivocal findings. There is limited but growing evidence to suggest that carbohydrate balance is involved in the short-term regulation of food intake, with a negative carbohydrate balance having been shown to predict greater ad libitum feeding. Furthermore, a negative carbohydrate balance has been shown to be predictive of weight gain. However, further research is needed to support these findings as the current research in this area is limited. In addition, the specific neural or hormonal signal through which carbohydrate availability could regulate energy intake is at present unknown. Identification of this signal or pathway is imperative if a casual relationship is to be established. Without this, the possibility remains that the associations found between carbohydrate balance and food intake are incidental.

Factors that affect health outcomes in adults with type 2 diabetes : a cross-sectional study

Background: Factors that individually influence blood sugar control, health-related quality of life, and diabetes self-care behaviors have been widely investigated; however, most previous diabetes studies have not tested an integrated association between a series of factors and multiple health outcomes. ---------- Objectives: The purposes of this study are to identify risk factors and protective factors and to examine the impact of risk factors and protective factors on adaptive outcomes in people with type 2 diabetes.---------- Design: A descriptive correlational design was used to examine a theoretical model of risk factors, protective factors, and adaptive outcomes.---------- Settings: This study was conducted at the endocrine outpatient departments of three hospitals in Taiwan. Participants A convenience sample of 334 adults with type 2 diabetes aged 40 and over.---------- Methods: Data were collected by a self-reported questionnaire and physiological examination. Using the structural equation modeling technique, measurement and structural regression models were tested.---------- Results: Age and life events reflected the construct of risk factors. The construct of protective factors was explained by diabetes symptoms, coping strategy, and social support. The construct of adaptive outcomes comprised HbA1c, health-related quality of life, and self-care behaviors. Protective factors had a significant direct effect on adaptive outcomes (β = 0.68, p < 0.001); however, risk factors did not predict adaptive outcomes (β = − 0.48, p = 0.118).---------- Conclusions: Identifying and managing risk factors and protective factors are an integral part of diabetes care. This theoretical model provides a better understanding of how risk factors and protective factors work together to influence multiple adaptive outcomes in people living with type 2 diabetes.

The Australian Palliative Care Outcomes Collaboration (PCOC) : measuring the quality and outcomes of palliative care on a routine basis

Australia is leading the way in establishing a national system (the Palliative Care Outcomes Collaboration – PCOC) to measure the outcomes and quality of specialist palliative care services and to benchmark services across the country. This article reports on analysis of data collected routinely at point-of-care on 5939 patients treated by the first fifty one services that voluntarily joined PCOC. By March 2009, 111 services have agreed to join PCOC, representing more than 70% of services and more than 80% of specialist palliative care patients nationally. All states and territories are involved in this unique process that has involved extensive consultation and infrastructure and close collaboration between health services and researchers. The challenges of dealing with wide variation in outcomes and practice and the progress achieved to date are described. PCOC is aiming to improve understanding of the reasons for variations in clinical outcomes between specialist palliative care patients and differences in service outcomes as a critical step in an ongoing process to improve both service quality and patient outcomes. What is known about the topic? Governments internationally are grappling with how best to provide care for people with life limiting illnesses and how best to measure the outcomes and quality of that care. There is little international evidence on how to measure the quality and outcomes of palliative care on a routine basis. What does this paper add? The Palliative Care Outcomes Collaboration (PCOC) is the first effort internationally to measure the outcomes and quality of specialist palliative care services and to benchmark services on a national basis through an independent third party. What are the implications for practitioners? If outcomes and quality are to be measured on a consistent national basis, standard clinical assessment tools that are used as part of everyday clinical practice are necessary.

Estimating the cost of health care–associated infections : mind your p’s and q’s

Monetary valuations of the economic cost of health care–associated infections (HAIs) are important for decision making and should be estimated accurately. Erroneously high estimates of costs, designed to jolt decision makers into action, may do more harm than good in the struggle to attract funding for infection control. Expectations among policy makers might be raised, and then they are disappointed when the reduction in the number of HAIs does not yield the anticipated cost saving. For this article, we critically review the field and discuss 3 questions. Why measure the cost of an HAI? What outcome should be used to measure the cost of an HAI? What is the best method for making this measurement? The aim is to encourage researchers to collect and then disseminate information that accurately guides decisions about the economic value of expanding or changing current infection control activities.

The social work & human services workforce : report from a national study of education, training and workforce needs

This report analyses the national curriculum and workforce needs of the social work and human services workforce. Australia’s community and health services are among the fastest growing sectors of employment in the nation but the sustainability of an appropriately qualified workforce is threatened. Yet there is little integration of education and workforce planning for the community services sector. This contrasts markedly with the health services sector, where key stakeholders are collaboratively addressing workforce challenges. Our research confirmed rapid growth in the social work and human services workforce and it also identified: • an undersupply of professionally qualified social work and human service practitioners to meet workforce demand; • the rapid ageing of the workforce with many workers approaching retirement; • limited career and salary structures creating disincentives to retention; • a highly diverse qualification base across the workforce. This diversity is inconsistent with the specialist knowledge and skills required of practitioners in many domains of community service provision. Our study revealed a lack of co-ordination across VET and higher education to meet the educational needs of the social work and human services workforce. Our analysis identified: • strong representation of equity groups in social work and related human service programs, although further participation of these groups is still needed; • the absence of clear articulation pathways between VET and higher education programs due the absence of co-ordination and planning between these sectors; • substantial variation in the content of the diverse range of social work and human service programs, with accredited programs conforming to national standards and some others in social and behavioural sciences lacking any external validation; • financial obstacles and disincentives to social work and human service practitioners in achieving postgraduate level qualifications. We recommend that: • DEEWR identify accredited social work and human services courses as a national education priority (similar to education and nursing). This will help ensure the supply of professional workers to this sector; • VET and higher education providers are encouraged to collaboratively develop clear and accessible educational pathways across the educational sectors; • DEEWR undertake a national workforce analysis and planning processes in collaboration with CSDMAC, and all social and community services stakeholders, to ensure workforce sustainability; and • COAG develop a national regulation framework for the social and community services workforce. This would provide sound accountability systems, and rigorous practice and educational standards necessary for quality service provision. It will also ensure much needed public confidence in this workforce.

Randomised controlled trial of an automated, interactive telephone intervention to improve type 2 diabetes self-management (Telephone-Linked Care Diabetes Project) : study protocol

Background: An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030. For the year 2010, it is estimated that 3.96 million excess deaths in the age group 20-79 years are attributable to diabetes around the world. Self-management is recognised as an integral part of diabetes care. This paper describes the protocol of a randomised controlled trial of an automated interactive telephone system aiming to improve the uptake and maintenance of essential diabetes self-management behaviours. ---------- Methods/Design: A total of 340 individuals with type 2 diabetes will be randomised, either to the routine care arm, or to the intervention arm in which participants receive the Telephone-Linked Care (TLC) Diabetes program in addition to their routine care. The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months. They receive the study handbook and a glucose meter linked to a data uploading device. The TLC system consists of a computer with software designed to provide monitoring, tailored feedback and education on key aspects of diabetes self-management, based on answers voiced or entered during the current or previous conversations. Data collection is conducted at baseline (Time 1), 6-month follow-up (Time 2), and 12-month follow-up (Time 3). The primary outcomes are glycaemic control (HbA1c) and quality of life (Short Form-36 Health Survey version 2). Secondary outcomes include anthropometric measures, blood pressure, blood lipid profile, psychosocial measures as well as measures of diet, physical activity, blood glucose monitoring, foot care and medication taking. Information on utilisation of healthcare services including hospital admissions, medication use and costs is collected. An economic evaluation is also planned.---------- Discussion: Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes. Furthermore, the study will provide insight into the potential for more widespread uptake of automated telehealth interventions, globally.

Incidence, severity and correlates of bicycling injuries in a sample of cyclists in Queensland, Australia

Bicycle injuries, particularly those resulting from single bicycle crashes, are underreported in both police and hospital records. Data on cyclist characteristics and crash circumstances are also often lacking. As a result, the ability to develop comprehensive injury prevention policies is hampered. The aim of this study was to examine the incidence, severity, cyclist characteristics, and crash circumstances associated with cycling injuries in a sample of cyclists in Queensland, Australia. A cross-sectional study of Queensland cyclists was conducted in 2009. Respondents (n=2056) completed an online survey about their cycling experiences, including cycling injuries. Logistic regression modelling was used to examine the associations between demographic and cycling behaviour variables with experiencing cycling injuries in the past year, and, separately, with serious cycling injuries requiring a trip to a hospital. Twenty-seven percent of respondents (n=545) reported injuries, and 6% (n=114) reported serious injuries. In multivariable modelling, reporting an injury was more likely for respondents who had cycled <5 years, compared to ≥10 years (p<0.005); cycled for competition (p=0.01); or experienced harassment from motor vehicle occupants (p<0.001). There were no gender differences in injury incidence, and respondents who cycled for transport did not have an increased risk of injury. Reporting a serious injury was more likely for those whose injury involved other road users (p<0.03). Along with environmental and behavioural approaches for reducing collisions and near-collisions with motor vehicles, interventions that improve the design and maintenance of cycling infrastructure, increase cyclists’ skills, and encourage safe cycling behaviours and bicycle maintenance will also be important for reducing the overall incidence of cycling injuries.

Driving performance impairments due to hypovigilance on monotonous roads

Drivers' ability to react to unpredictable events deteriorates when exposed to highly predictable and uneventful driving tasks. Highway design reduces the driving task mainly to a lane-keeping manoeuvre. Such a task is monotonous, providing little stimulation and this contributes to crashes due to inattention. Research has shown that driver's hypovigilance can be assessed with EEG measurements and that driving performance is impaired during prolonged monotonous driving tasks. This paper aims to show that two dimensions of monotony - namely road design and road side variability - decrease vigilance and impair driving performance. This is the first study correlating hypovigilance and driver performance in varied monotonous conditions, particularly on a short time scale (a few seconds). We induced vigilance decrement as assessed with an EEG during a monotonous driving simulator experiment. Road monotony was varied through both road design and road side variability. The driver's decrease in vigilance occurred due to both road design and road scenery monotony and almost independently of the driver's sensation seeking level. Such impairment was also correlated to observable measurements from the driver, the car and the environment. During periods of hypovigilance, the driving performance impairment affected lane positioning, time to lane crossing, blink frequency, heart rate variability and non-specific electrodermal response rates. This work lays the foundation for the development of an in-vehicle device preventing hypovigilance crashes on monotonous roads.

Association between indoor air pollution measurements and respiratory health in women and children in Lao PDR

This article presents the results of a study on the association between measured air pollutants and the respiratory health of resident women and children in Lao PDR, one of the least developed countries in Southeast Asia. The study, commissioned by the World Health Organisation, included PM10, CO and NO2 measurements made inside 181 dwellings in nine districts within two provinces in Lao PDR over a 5- month period (12/05–04/06), and respiratory health information (via questionnaires and peak expiratory flow rate (PEFR) measurements) for all residents in the same dwellings. Adjusted odds ratios were calculated separately for each health outcome using binary logistic regression. There was a strong and consistent positive association between NO2 and CO for almost all questionnaire-based health outcomes for both women and children. Women in dwellings with higher measured NO2 had more than triple of the odds of almost all of the health outcomes, and higher concentrations of NO2 and CO were significantly associated with lower PEFR. This study supports a growing literature confirming the role of indoor air pollution in the burden of respiratory disease in developing countries. The results will directly support changes in health and housing policy in Lao PDR.

Access and Quality of Heart Failure Management Programs in Australia

Background/aim In response to the high burden of disease associated with chronic heart failure (CHF), in particular the high rates of hospital admissions, dedicated CHF management programs (CHF-MP) have been developed. Over the past five years there has been a rapid growth of CHF-MPs in Australia. Given the apparent mismatch between the demand for, and availability of CHF-MPs, this paper has been designed to discuss the accessibility to and quality of current CHF-MPs in Australia. Methods The data presented in this report has been combined from the research of the co-authors, in particular a review of the inequities in access to chronic heart failure which utilised geographical information systems (GIS) and the survey of heterogeneity in quality and service provision in Australian. Results Of the 62 CHF-MPs surveyed in this study 93% (58) centres had been located areas that are rated as Highly Accessible. This result indicated that most of the CHF-MPs have been located in capital cities or large regional cities. Six percent (4 CHF-MPs) had been located in Accessible areas which were country towns or cities. No CHF-MPs had been established outside of cities to service the estimated 72,000 individuals with CHF living in rural and remote areas. 16% of programs recruited NYHA Class I patients and of these 20% lacked confirmation (echocardiogram) of their diagnosis. Conclusion Overall, these data highlight the urgent need to provide equitable access to CHF-MP's. When establishing CHF-MPs consideration of current evidence based models to ensure quality in practice.

“Teaching them a lesson?” : a qualitative exploration of underlying motivations for driver aggression

Aggressive driving is increasingly a concern for drivers in highly motorised countries. However, the role of driver intent in this behaviour is problematic and there is little research on driver cognitions in relation to aggressive driving incidents. In addition, while drivers who admit to behaving aggressively on the road also frequently report being recipients of similar behaviours, little is known about the relationship between perpetration and victimisation or about how road incidents escalate into the more serious events that feature in capture media attention. The current study used qualitative interviews to explore driver cognitions and underlying motivations for aggressive behaviours on the road. A total of 30 drivers aged 18-49 years were interviewed about their experiences with aggressive driving. A key theme identified in responses was driver aggression as an attempt to manage or modify the behaviour of other road users. Two subthemes were identified and appeared related to separate motivations for aggressive responses: ‘teaching them a lesson’ referred to situations where respondents intended to convey criticism or disapproval, usually of unintended behaviours by the other driver, and thus encourage self-correction; and ‘justified retaliation’ which referred to situations where respondents perceived deliberate intent on the part of the other driver and responded aggressively in return. Mildly aggressive driver behaviour appears to be common. Moreover such behaviour has a sufficiently negative impact on other drivers that it may be worth addressing because of its potential for triggering retaliation in kind or escalation of aggression, thus compromising safety.