Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up

Objective To investigate whether attendance at cardiac rehabilitation (CR) independently predicts all-cause mortality over 14 years and whether there is a dose–response relationship between the proportion of CR sessions attended and long-term mortality.

Design Retrospective cohort study.

Setting CR programmes in Victoria, Australia

Patients The sample comprised 544 men and women eligible for CR following myocardial infarction, coronary artery bypass surgery or percutaneous interventions. Participants were tracked 4 months after hospital discharge to ascertain CR attendance status.

Main outcome measures All-cause mortality at 14 years ascertained through linkage to the Australian National Death Index.

Results In total, 281 (52%) men and women attended at least one CR session. There were few significant differences between non-attenders and attenders. After adjustment for age, sex, diagnosis, employment, diabetes and family history, the mortality risk for non-attenders was 58% greater than for attenders (HR=1.58, 95% CI 1.16 to 2.15). Participants who attended <25% of sessions had a mortality risk more than twice that of participants attending ≥75% of sessions (OR=2.57, 95% CI 1.04 to 6.38). This association was attenuated after adjusting for current smoking (OR=2.06, 95% CI 0.80 to 5.29).

Conclusions This study provides further evidence for the long-term benefits of CR in a contemporary, heterogeneous population. While a dose–response relationship may exist between the number of sessions attended and long-term mortality, this relationship does not occur independently of smoking differences. CR practitioners should encourage smokers to attend CR and provide support for smoking cessation.

A distinct DNA methylation signature defines pediatric pre-B cell acute lymphoblastic leukemia

Pre-B cell acute lymphoblastic leukemia (ALL) is the most prevalent childhood malignancy and remains one of the highest causes of childhood mortality. Despite this, the mechanisms leading to disease remain poorly understood. We asked if recurrent aberrant DNA methylation plays a role in childhood ALL and have defined a genome-scale DNA methylation profile associated with the ETV6-RUNX1 subtype of pediatric ALL. Archival bone marrow smears from 19 children collected at diagnosis and remission were used to derive a disease specific DNA methylation profile. The gene signature was confirmed in an independent cohort of 86 patients. A further 163 patients were analyzed for DNA methylation of a three gene signature. We found that the DNA methylation signature at diagnosis was unique from remission. Fifteen loci were sufficient to discriminate leukemia from disease-free samples and purified CD34+ cells. DNA methylation of these loci was recurrent irrespective of cytogenetic subtype of pre-B cell ALL. We show that recurrent aberrant genomic methylation is a common feature of pre-B ALL, suggesting a shared pathway for disease development. By revealing new DNA methylation markers associated with disease, this study has identified putative targets for development of novel epigenetic-based therapies.

The management of subjective quality of life by short-stay hospital patients: an exploratory study

Background: This study tested the homeostatic model of subjective quality of life in a group of 47 short stay patients as they progressed through the stages of hospitalization for surgery.
Method: Participants completed a questionnaire measuring subjective quality of life, positive and negative affect, self-esteem, optimism and cognitive flexibility, the day prior to admission (T1), two days post-operation (T2) and one week after discharge (T3). Neuroticism and Extroversion were measured at Time 1.
Results: All variables remained stable across the three times, apart from positive affect, which dropped significantly post-operation but returned to its previous level post discharge.
Conclusion: Although the homeostatic model of subjective quality of life was supported at Time 1, the analyses raise doubts about the stability of personality. This finding is consistent with recent discussions of personality.

Heterogeneity of heart failure management programs in Australia

Background: Heart Failure Management Programs (HFMPs) have proven to be cost-effective in minimising recurrent hospitalisations, morbidity and mortality. However, variability between the programs exists which could translate into variable health outcomes.
Objective: To survey the characteristics of HFMPs throughout Australia and to identify potential heterogeneity in their organisation and structure.
Method: Thirty-nine post-discharge HFMPs were identified from a systematic search of the Australian health-care system in 2002. A comprehensive 19-item questionnaire specifically examining characteristics of HFMPs was sent to co-ordinators of identified programs in early 2003.
Results: All participants responded with six institutions (15%) indicating that their HFMP had ceased operations due to a lack of funding. The survey revealed an uneven distribution of the 33 active HFMPs operating throughout Australia. Overall, 4450 post-discharge HF patients (median: 74; IQR: 24–147) were managed via these programs, representing only 11% of the potential caseload for an Australia-wide network of HFMPs. Heterogeneity of these programs existed in respect to the model of care applied within the program (70% applied a home-based program and 18% a specialist HF clinic) and applied interventions (30% of programs had no discharge criteria and 45% of programs prevented nurses administering/titrating medications). Sustained funding was available to only 52% of the active HFMPs.
Conclusion: Inequity of access to HFMPs in Australia is evident in relation to locality and high service demand, further complicated by inadequate funding. Heterogeneity between these programs is substantial. The development of national benchmarks for evidence-based HFMPs is required to address program variability and funding issues to realise their potential to improve health outcomes.

Assessing cost-effectiveness in mental health : family interventions for schizophrenia and related conditions

Objective: Existing evidence suggests that family interventions can be effective in reducing relapse rates in schizophrenia and related conditions. Despite this, such interventions are not routinely delivered in Australian mental health services. The objective of the current study is to investigate the incremental cost-effectiveness ratios (ICERs) of introducing three types of family interventions, namely: behavioural family management (BFM); behavioural intervention for families (BIF); and multiple family groups (MFG) into current mental health services in Australia.

Method: The ICER of each of the family interventions is assessed from a health sector perspective, including the government, persons with schizophrenia and their families/carers using a standardized methodology. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted. The second stage involves application of 'second filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using multivariate probabilistic sensitivity analysis.

Results: The most cost-effective intervention, in order of magnitude, is BIF (A$8000 per DALY averted), followed by MFG (A$21 000 per DALY averted) and lastly BFM (A$28 000 per DALY averted). The inclusion of time costs makes BFM more cost-effective than MFG. Variation of discount rate has no effect on conclusions.

Conclusions: All three interventions are considered 'value-for-money' within an Australian context. This conclusion needs to be tempered against the methodological challenge of converting clinical outcomes into a generic economic outcome measure (DALY). Issues surrounding the feasibility of routinely implementing such interventions need to be addressed.

The clinical landscape of critical care: nurses' decision-making

Background. Many studies have tended to explore individual characteristics that impact on nurses' decision-making, despite significant acknowledgement that context is a major determinant in decision-making. The few studies that have examined environmental influences have tended not to study real decisions in the dynamic and complex clinical environment.

Aims. To investigate environmental influences on nurses' real decisions in the critical care setting.

Method. Naturalistic observations and semi-structured interviews were conducted with 18 critical care nurses in private, public and rural hospitals. Observations and interviews were recorded, transcribed verbatim and coded for themes using content analysis.

Results. All clinical decisions were strongly influenced by the context in which the decision was made. Three main environmental influences were identified: the patient situation, resource availability and interpersonal relationships. Time and risk guided all clinical decisions. Nurses established the state of the situation, the time constraints on decisions and the level of risk involved for both patient and nurse.

Conclusions. Decision-making is a manifestation of the landscape and although an increased understanding of the landscape is required, more important is the need to measure the impact of contextual variables on nurses' decision-making in order to improve health care outcomes.

Agreement between adolescent self-report and parent reports of health and well-being: results of an epidemiological study.

Objective To examine parent and adolescent agreement on physical, emotional, mental and social health and well-being in a representative population.
Methodology An epidemiological design was used to obtain parent–child/adolescent dyad data on comparable items and scales of a generic measure of health and well-being, the Child Health Questionnaire (parent/proxy report 50 item, self-report 80 item). Scale analysis included intraclass correlations (ICCs) to examine strength of parent–child associations and independent t-tests for differences between adolescents (with or without an illness). Where there were significant differences in scale scores, analysis of variance and two sample t-tests were used to examine the influence of social, demographic, health concern and school variables. Single items were examined for trends in response categories.
Results 2096 parent–adolescent dyads (adolescent mean age of 15.1 years, males 50%, maternal parent 83.2%, biological parent 93.5%). ICCs were strong. Overall, adolescents reported poorer emotional and social health, and clinically significant differences were observed for perceptions of general health (mean difference 8.1/100), frequency and amount of body pain (5.94/100), experience of mental health (5.14/100), and impact of health on family activities (12.43/100), which widen significantly for adolescents with illness. Social, health and school enjoyment and performance significantly widened parent–child differences.
Conclusions All adolescents were much less optimistic about their health and well-being than their parents, and were only in close agreement on aspects of health and well-being they rated highly. Adolescent reports are more likely to be sensitive to pain, mental health problems, health in general and the impact of their health on family activities.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive–behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness – Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.

Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.

Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.

Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Associations among individual, social, and environmental barriers and children's walking or cycling to school

Purpose. To examine associations among individual, social, and environmental barriers and children's walking or cycling to school.

Design. Exploratory cross-sectional study.

Setting. All eight capital cities in Australia.

Subjects. Parents (N = 720) of school-aged children (4-13 years; 27% response rate 49% parents of boys,).

Measures. Multivariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) for parental reporting of barriers to their children's walking or cycling to school, based on a computer-assisted telephone interview.

Results. Forty-one percent of children walked or cycled to school at least once per week. Multivariable analyses found inverse associations with individual ("child prefers to be driven" [OR = 0.4, 95% CI = 0.3-0.6], "no time in the mornings" [OR 0.5, 95% CI = 0.3-0.8]); social ("worry child will take risk" [OR = 0.6, 95% CI = 0.3-0.9], "no other children to walk with" [OR = 0.7, 95% CI = 0.4-0.99], "no adults to walk with" [OR = 0.6, 95% CI = 0.4-0.9]); and environmental barriers ("too far to walk" [OR = 0.1, 95% CI = 0.0- 0.1], "no direct route" [OR = 0.4, 95% CI = 0.2-0. 7]) and positive associations with "concern child may he injured in a road accident" (OR = 1.9, 95% CI = 1.1-3.1) and active commuting.

Conclusion. Working with parents, schools, and local authorities to improve pedestrian, skills and environments may help to overcome barriers.

Returning to work: exploring the experiences of women with acute coronary syndromes

Aims: The aim of this study was to explore the transition experiences of Australian women in resuming paid employment after an acute coronary syndrome (ACS) event. Background: Until recently cardiovascular research has focused predominantly on men but this is changing and research exploring women’s experiences of ACS has increased. Despite knowing that many women do not resume paid employment following an ACS event, little is known about the experience of those women who do, even though it is understood that returning to the previous level of employment after an ACS event is a positive outcome. Design: An exploratory qualitative approach underpinned by naturalistic inquiry was undertaken. Methods: A purposive sample of seven women who had experienced their first ACS event 12 months ago was selected. Each woman was interviewed using a semi–structured format and their interviews were transcribed verbatim. Thematic analysis of the transcript set and conceptual mapping were employed to formulate key themes. Findings: All women (mean age 52.6 years) resumed paid employment at various stages during their recovery, but reported similar transition processes. Three key themes representing this process were identified: primary motivation; influence through guidance and support; and resuming paid employment. Conclusions: Study findings revealed that these women required substantial support from family, friends and employers, with ongoing guidance from health professionals to return to paid work. The time frames for their return varied and some modified their roles within the workforce to enable them to return to paid work. However, formal cardiac rehabilitation did not appear to have a significant impact on these participants' decisions to return to work. They felt that more information about this decision may have been helpful if given at the time of cardiac rehabilitation.

The impact of Porter's strategy types on the role of market research and customer relationship management

Purpose – This paper seeks to investigate the influence of Porter’s strategy types on the use of customer relationship management (CRM) techniques and traditional market research, against theoretical and empirical evidence that differences in strategy types may result in variation in favoured marketing information sources and procedure.

Design/methodology/approach – Depth interviews generated a series of scale items, which were combined with others derived from the literature in a questionnaire measuring strategy types, the roles of market research, and the characteristics of CRM systems. Responses were obtained from 240 senior marketing managers in Australia, and applied to the testing of five research propositions.

Findings – ANOVA found no differences in CRM usage among the strategy types. Variation was widespread, however, in four roles of traditional market research: enhancing strategic decision making, increasing usability of existing data, presenting plans to senior management, and achieving productivity and political outcomes.

Research limitations/implications – Future researchers using the Porter strategic types should separate “marketing differentiators” from “product differentiators” because they function and compete differently.

Practical implications – All organisations can benefit from CRM systems, but “marketing differentiators” exhibit a relatively higher usage of traditional market research. This is likely to be because they compete by creating softer product differences, while others do so on harder characteristics such as price or product functionality.

Originality/value – This is the first study to use the Porter types to explain differences between the roles and uses of market research and CRM within organisations.

Does gymnastics training inhibit growth of females?

OBJECTIVE: The increasingly dominant performance of smaller-sized female gymnasts and increased magnitude of training beginning at an early age have prompted public and medical concerns, especially from an auxological perspective. The objective of this review is to determine if gymnastics training inhibits growth of females. DATA SOURCES: An extensive research of MedLine (PubMed interface) along with cross-referencing was conducted using the Text and MeSH words "gymnastics" in combination with "growth," "maturation," "body height," "body weight," and "growth plate." Our analysis is limited to English articles only.
STUDY SELECTION: All published studies that included data related to the research questions were included. MAIN RESULTS: Although data from three historical cohort studies indicate that female gymnasts are short even before they begin training, clinical reports and cohort studies do suggest that some female gymnasts experience attenuated growth during training followed by catch-up growth during periods of reduced training or retirement. There is conflicting evidence whether the "catch-up" is complete. There were no studies reporting prevalence or incidence of inadequate growth. Three cohort studies provide evidence of reduced growth but training was not partitioned from other confounding factors in the gymnastics environment. Although there is a paucity of studies examining the link of dietary practices with diminished growth in female gymnasts, a review of related dietary literature indicates the potential for insufficient energy and nutrient intake among female gymnasts.
CONCLUSIONS: Elite level or heavily involved female gymnasts may experience attenuated growth during their years of training and competition followed by catch-up growth during reduced training schedules or the months following retirement. However, a cause-effect relation between gymnastics training and inadequate growth of females has not been demonstrated.

Urban area disadvantage and physical activity: a multilevel study in Melbourne, Australia

Objective: To estimate variation between small areas in the levels of walking, cycling, jogging, and swimming and overall physical activity and the importance of area level socioeconomic disadvantage in predicting physical activity participation.

Methods: All census collector districts (CCDs) in the 20 innermost local government areas in metropolitan Melbourne, Australia, were identified and ranked by the percentage of low income households (<$400/week) living in the CCD. Fifty CCDs were randomly selected from the least, middle, and most disadvantaged septiles of the ranked CCDs and 2349 residents (58.7% participation rate) participated in a cross sectional postal survey about physical activity. Multilevel logistic regression (adjusted for extrabinomial variation) was used to estimate area level variation in walking, cycling, jogging, and swimming and in overall physical activity participation, and the importance of area level socioeconomic disadvantage in predicting physical activity participation.

Results: There were significant variations between CCDs in all activities and in overall physical participation in age and sex adjusted models; however, after adjustment for individual SES (income, occupation, education) and area level socioeconomic disadvantage, significant differences remained only for walking (p = 0.004), cycling (p = 0.003), and swimming (p = 0.024). Living in the most socioeconomically disadvantaged areas was associated with a decreased likelihood of jogging and of having overall physical activity levels that were sufficiently active for health; these effects remained after adjustment for individual socioeconomic status (sufficiently active: OR 0.70, 95% CI 0.55 to 0.90 and jogging: OR = 0.69, 95% CI 0.51 to 0.94).

Conclusion: These research findings support the need to focus on improving local environments to increase physical activity participation.

Abbreviations: SES, socioeconomic status; CCD, census collector district

Systematic review of randomised controlled trials of sildenafil (Viagra®) in the treatment of male erectile dysfunction.

Background: Sildenafil (Viagra®), a new oral drug for the treatment of erectile dysfunction, was licensed for use across Europe in 1998. Aim: To examine the effectiveness and safety of sildenafil as an oral treatment for erectile dysfunction. Design of study: Systematic review and meta-analysis.
Setting: All published or unpublished randomised controlled trials comparing sildenafil with a placebo or alternative therapies. Method: Published studies were sought by computerised searches of electronic databases using the keywords ‘sildenafil’ and ‘Viagra’. A hand search was also done of the British Medical Journal, Lancet, Journal of the American
Medical Association, New England Journal of Medicine, British Journal of General Practice, Drug, Inpharma and Scrip. An assessment of quality of all identified studies and data extraction was undertaken independently by two researchers. Results were combined in a meta-analysis where appropriate, using RevMan version 3. Results: Twenty-one trials were identified. All trials showed a statistically significant improvement in erectile or sexual function in patients using sildenafil compared with a placebo. A meta-analysis of 16 trials reporting a global efficacy response showed that men were 3.57 (95% CI = 2.93–4.43) times as likely to have improved erections on sildenafil compared with those on a placebo. The number needed to treat to have one man with improved erections was two. The drug has a relatively safe side-effect profile. Conclusions: Available research shows that sildenafil is an effective treatment for male erectile dysfunction. Many trial participants had some baseline erectile function and it is probable that in clinical practice, where the erectile function tends to be more impaired, the number needed to treat may be higher.

Parsimonious and efficient assessment of health-related quality of life in osteoarthritis research: validation of the Assessment of Quality of Life (AQoL) instrument

Background: The Assessment of Quality of Life (AQoL) utility instrument was psychometrically developed for the general population. This study aimed to explore its potential as an osteoarthritis (OA) outcome measure.

Methods: WOMAC, Lequesne index, SF-36, Visual analogue scales and the AQoL were administered to 222 people with OA. The ability of each questionnaire to detect differences between groups was based on (i) self-rated health (SRH) and, (ii) differences between people on an orthopedic waiting list (WL) vs people with OA in the community (C). Comparisons included effect size, relative efficiency and receiver operator characteristic curves.

Results: All instruments detected differences between groups; however no one instrument exhibited superior efficiency. The AQoL demonstrated strong psychometric properties.

Conclusion: The AQoL has equivalent performance to comparator questionnaires commonly used in OA research and would be a useful adjunct to well-established disease specific scales. The AQoL has important advantages; brevity (12 items), facilitates comparisons between disease groups, and delivers a utility score that can be used in health economic evaluations.