Mixed-initiative decision support for care planning based on clinical practice guidelines

Care Plan On-Line (CPOL) is an intranet based system that supports a “Coordinated Care” model for chronic/complex disease management. CPOL combines provision of solicited and unsolicited advice features based on integration of the electronic medical record (EMR) with its decision support logic. The objective is to support General Practitioners (GPs) in formulating a 12-month care plan of services such that: (a) the plan is proactive and patient-centered; (b) the GP is kept in awareness of project- and diseasespecific clinical practice guidelines; and (c) the support integrates with GP workflow in a natural fashion. A key feature of our approach is to blur the distinction of EMR and decision support by presenting guidelines in layers with the top-most being a problem-oriented presentation of patient status, progressing on through to patient-independent supporting evidence. In conjunction with a degree of automated inclusion of care planning services, the system demonstrates mixed user and software initiative. We describe the CPOL deployment setting, the challenges of guideline-based clinical decision support, our approach to guideline delivery, and the CPOL architecture.

Guidelines for interviewing children during child custody evaluations

This paper offers a brief review of the current literature related to the interviewing of children during child custody evaluations. In particular, the paper highlights several key issues and concerns, and provides a series of recommendations for professionals working in this area. These recommendations (which apply to children aged 3 to 12 years) are organised under the following headings: (a) establish rapport using broad open-ended questions, (b) make the purpose and ground rules of the interview clear to the child, (c) allow the child's perspective be heard without expecting an outright custody preference, (d) demonstrate a willingness to consider all reasonable perspectives or hypotheses about what has occurred, (e) try not to exacerbate the child's stress or guilt, (f) pursue all possible explanations for a child's report, irrespective of whether there are clear signs of “coaching” or contamination, (g) obtain appropriate training in the use of forensic interviewing techniques, and (h) engage in research on the impact of children's participation in custody cases.

How feasible are healthy eating and physical activity for young women?

Objective: This study investigated young women’s perceptions of the feasibility of physical activity and healthy eating behaviours, and how these vary by socioeconomic status, domestic characteristics and weight status. Design: This population-based study used a mailed questionnaire to investigate perceptions of the feasibility of commonly recommended healthy eating and physical activity behaviours among a sample of young women. The feasibility of 29 physical activity behaviours (e.g. relating to frequency, intensity, duration, domain/setting) and 15 healthy eating behaviours (e.g. relating to location/setting, fruit and vegetable intake, fat/sugar intake) was assessed. Height, weight and sociodemographic details were also obtained. Setting: Nation-wide community-based survey. Subjects: A total of 445 women aged 18–32 years selected randomly from the Australian electoral roll. Results: Most women reported that they either were already engaged in many of the healthy eating behaviours or saw these as highly feasible. Many physical activity behaviours, on the other hand, were perceived as less feasible, particularly among women with children and women who were overweight. Conclusions: Health promotion messages and strategies aimed at increasing physical activity and healthy eating are unlikely to succeed unless they take into account perceptions that these behaviours are not feasible. For young women, this may involve promoting more time-effective, flexible ways of achieving recommended physical activity. Messages specifically targeted to women with children, and women who are overweight, are required.

How well do Australian women comply with dietary guidelines?

Objective: To investigate the proportion of middle-aged Australian women meeting national dietary recommendations and its variation according to selected sociodemographic and behavioural characteristics.

Design: This cross-sectional population-based study used a food-frequency questionnaire to investigate dietary patterns and compliance with 13 commonly promoted dietary guidelines among a cohort of middle-aged women participating in the Australian Longitudinal Study on Women's Health.

Setting: Nation-wide community-based survey.

Subjects: A total of 10 561 women aged 50–55 years at the time of the survey in 2001.

Results: Only about one-third of women complied with more than half of the guidelines, and only two women in the entire sample met all 13 guidelines examined. While guidelines for meat/fish/poultry/eggs/nuts/legumes and ‘extra’ foods (e.g. ice cream, chocolate, cakes, potatoes, pizza, hamburgers and wine) were met well, large percentages of women (68–88%) did not meet guidelines relating to the consumption of breads, cereal-based foods and dairy products, and intakes of total and saturated fat and iron. Women working in lower socio-economic status occupations, and women living alone or with people other than a partner and/or children, were at significantly increased risk of not meeting guidelines.

Conclusions: The present results indicate that a large proportion of middle-aged Australian women are not meeting dietary guidelines. Without substantial changes in their diets, and help in making these changes, current national guidelines appear unachievable for many women.

Does successful treatment of constipation or faecal impaction resolve lower urinary tract symptoms? A structured review of the literature

Consensus guidelines advocate the treatment of constipation and faecal impaction in order to improve symptoms of urinary frequency, urgency and urinary incontinence and to promote bladder emptying in the absence of urinary tract obstruction. This structured review of the literature was undertaken to search for and appraise evidence to support or negate the hypothesis of this relationship. The search strategy was comprehensive and identified six relevant studies. Two of these had been conducted on an adult population and four studies involved children with constipation. These studies were appraised for methodological quality. It was found that sample sizes were small and evidence was inconsistent. Variable methods of reporting meant that data were not able to be pooled for meta-analysis.
Based on the limited and conflicting evidence, it is recommended that further research be undertaken to identify any correlation between bowel and bladder function.

Rationale and design of the national benchmarking and evidence-based national clinical guidelines for chronic heart failure management programs study

OBJECTIVES: The National Benchmarks and Evidence-Based National Clinical Guidelines for Heart Failure Management Programs Study is a national, multicenter study designed to determine the nature, range, and effect of interventions applied by chronic heart failure management programs (CHF-MPs) throughout Australia on patient outcomes. Its primary objective is to use these data to develop national benchmarks and evidence-based clinical guidelines and optimize their cost-effective application by reducing quality and outcome variability. DATA SOURCES/STUDY SETTING: Primary data will be collected from CHF-MP coordinators and CHF patients enrolled in these programs on a national basis. Secondary outcome data will be collected from a national morbidity record and from patients' medical records. STUDY DESIGN: Stage I of the study involves a prospective clinical audit of all CHF-MPs throughout Australia (n = 45) to determine the extent of variability in programs currently. Stage II is a prospective cross-sectional survey design enrolling 1,500 patients (average of 40 patients per program) to firstly determine the typical profile of patients being managed via a CHF-MP in Australia and, secondly, the subsequent morbidity and mortality during the 6-month follow-up. Outcome data will be subject to multivariate analysis to determine the key components of care in this regard. All study data will be then examined in the final stage of the study (III) to develop national benchmarks for the application and auditing of CHF-MPs in Australia. CONCLUSION: Variability in patient outcomes is a product of heterogeneity among CHF-MPs. The development of national benchmarks will minimize such heterogeneity and will provide a greater level of evidence for their cost-effective application.

Prediction of alcohol-related harm from controlled drinking stragegies and alcohol consumption trajectories

Aims To establish predictors of age 21 alcohol-related harm from prior drinking patterns, current levels of alcohol consumption and use of controlled drinking strategies.
Participants One thousand, five hundred and ninety-six students recruited from an initial sample of 3300 during their final year of high school in 1993.
Design Longitudinal follow-up across five waves of data collection.
Setting Post high school in Victoria, Australia.
Measurements Self-administered surveys examining a range of health behaviours, including alcohol consumption patterns and related behaviour.
Findings Drinking behaviours at age 21 were found to be strongly predicted by drinking trajectories established through the transition from high school. Multivariate regression analysis revealed that alcohol-related harms at age 21 were reduced where current levels of alcohol use fell within limits recommended in Australian national guidelines. After controlling for this effect it was found that the range of strategies employed by participants to control alcohol use maintained a small protective influence. Post-high-school drinking trajectories continued to demonstrate a significant effect after controlling for current behaviours. Findings revealed that over one quarter of males and females drank alcohol, but on a less-than-weekly basis. This pattern of alcohol use demonstrated considerable stability through the post-school transition and was associated with a low level of subsequent harm at age 21.
Conclusions Future research should investigate whether encouraging more Australian adolescents to drink alcohol on a less-than-weekly basis may be a practical intervention target for reducing alcohol-related harms.

Developing national physical activity guidelines for Australians

The process and outcome of developing National Physical Activity Guidelines for Australians is described. The guidelines provide a means of incorporating new data on physical activity into public health education.

Prediction of alcohol-related harm from controlled drinking strategies and alcohol consumption trajectories

Aims To establish predictors of age 21 alcohol-related harm from prior drinking patterns, current levels of alcohol consumption and use of controlled drinking strategies.

Participants One thousand, five hundred and ninety-six students recruited from an initial sample of 3300 during their final year of high school in 1993.

Design Longitudinal follow-up across five waves of data collection.

Setting Post high school in Victoria, Australia.

Measurements Self-administered surveys examining a range of health behaviours, including alcohol consumption patterns and related behaviour.

Findings Drinking behaviours at age 21 were found to be strongly predicted by drinking trajectories established through the transition from high school. Multivariate regression analysis revealed that alcohol-related harms at age 21 were reduced where current levels of alcohol use fell within limits recommended in Australian national guidelines. After controlling for this effect it was found that the range of strategies employed by participants to control alcohol use maintained a small protective influence. Post-high-school drinking trajectories continued to demonstrate a significant effect after controlling for current behaviours. Findings revealed that over one quarter of males and females drank alcohol, but on a less-than-weekly basis. This pattern of alcohol use demonstrated considerable stability through the post-school transition and was associated with a low level of subsequent harm at age 21.

Conclusions Future research should investigate whether encouraging more Australian adolescents to drink alcohol on a less-than-weekly basis may be a practical intervention target for reducing alcohol-related harms.

An investigation of the development of navigation design guidelines for online educational applications delivery to a primary school audience

Despite growing interest in educational websites for children, there has been surprisingly little research conducted into the design of websites intended for a younger audience. This research aims to determine how the design principles identified in the extant body of literature, might be fused with the development practices currently employed within a focus organisation (case study organisation), to synthesise and partially validate a set of website navigation design guidelines for use when developing website navigation for primary school students, between the ages of nine and twelve years.

A review of critical information infrastructure protection within IT security guidelines

This research takes the form of a review and looks at the current advisories offered to informationl security professionals in Ihe area of critical information infrastructure protection A critical information infrastructure protection mode! is also presented along with a critical review of some of lhe recent formal guidance that has been offered. The Critical lnformation Infrastructure Protection - Risk Analysis-Methodology (CIlP-RAM) is then offered as a solution to the lack of information and advice.