Advance Care Planning in palliative care : a systematic literature review of the contextual factors influencing its uptake 2008-2012

Background: Advance Care Planning is an iterative process of discussion, decision-making and documentation about end-of-life care. Advance Care Planning is highly relevant in palliative care due to intersecting clinical needs. To enhance the implementation of Advance Care Planning, the contextual factors influencing its uptake need to be better understood. Aim: To identify the contextual factors influencing the uptake of Advance Care Planning in palliative care as published between January 2008 and December 2012. Methods: Databases were systematically searched for studies about Advance Care Planning in palliative care published between January 2008 and December 2012. This yielded 27 eligible studies, which were appraised using National Institute of Health and Care Excellence Quality Appraisal Checklists. Iterative thematic synthesis was used to group results. Results: Factors associated with greater uptake included older age, a college degree, a diagnosis of cancer, greater functional impairment, being white, greater understanding of poor prognosis and receiving or working in specialist palliative care. Barriers included having non-malignant diagnoses, having dependent children, being African American, and uncertainty about Advance Care Planning and its legal status. Individuals’ previous illness experiences, preferences and attitudes also influenced their participation. Conclusion: Factors influencing the uptake of Advance Care Planning in palliative care are complex and multifaceted reflecting the diverse and often competing needs of patients, health professionals, legislature and health systems. Large population-based studies of palliative care patients are required to develop the sound theoretical and empirical foundation needed to improve uptake of Advance Care Planning in this setting.

The automation of radiotherapy treatment planning assessment

Aim The assessment of treatment plans is an important component in the education of radiation therapists. The establishment of a grade for a plan is currently based on subjective assessment of a range of criteria. The automation of assessment could provide a number of advantages including faster feedback, reduced chance of human error, and simpler aggregation of past results. Method A collection of treatments planned by a cohort of 27 second year radiation therapy students were selected for quantitative evaluation. Treatment sites included the bladder, cervix, larynx, parotid and prostate, although only the larynx plans had been assessed in detail. The plans were designed with the Pinnacle system and exported using the DICOM framework. Assessment criteria included beam arrangement optimisation, volume contouring, target dose coverage and homogeneity, and organ-at-risk sparing. The in-house Treatment and Dose Assessor (TADA) software1 was evaluated for suitability in assisting with the quantitative assessment of these plans. Dose volume data were exported in per-student and per-structure data tables, along with beam complexity metrics, dose volume histograms, and reports on naming conventions. Results The treatment plans were exported and processed using TADA, with the processing of all 27 plans for each treatment site taking less than two minutes. Naming conventions were successfully checked against a reference protocol. Significant variations between student plans were found. Correlation with assessment feedback was established for the larynx plans. Conclusion The data generated could be used to inform the selection of future assessment criteria, monitor student development, and provide useful feedback to the students. The provision of objective, quantitative evaluations of plan quality would be a valuable addition to not only radiotherapy education programmes but also for staff development and potentially credentialing methods. New functionality within TADA developed for this work could be applied clinically to, for example, evaluate protocol compliance.

Understanding causal relationships between the built and social environment, health and associated behaviours and risk factors

Introduction: Built environment interventions designed to reduce non-communicable diseases and health inequity, complement urban planning agendas focused on creating more ‘liveable’, compact, pedestrian-friendly, less automobile dependent and more socially inclusive cities.However, what constitutes a ‘liveable’ community is not well defined. Moreover, there appears to be a gap between the concept and delivery of ‘liveable’ communities. The recently funded NHMRC Centre of Research Excellence (CRE) in Healthy Liveable Communities established in early 2014, has defined ‘liveability’ from a social determinants of health perspective. Using purpose-designed multilevel longitudinal data sets, it addresses five themes that address key evidence-base gaps for building healthy and liveable communities. The CRE in Healthy Liveable Communities seeks to generate and exchange new knowledge about: 1) measurement of policy-relevant built environment features associated with leading non-communicable disease risk factors (physical activity, obesity) and health outcomes (cardiovascular disease, diabetes) and mental health; 2) causal relationships and thresholds for built environment interventions using data from longitudinal studies and natural experiments; 3) thresholds for built environment interventions; 4) economic benefits of built environment interventions designed to influence health and wellbeing outcomes; and 5) factors, tools, and interventions that facilitate the translation of research into policy and practice. This evidence is critical to inform future policy and practice in health, land use, and transport planning. Moreover, to ensure policy-relevance and facilitate research translation, the CRE in Healthy Liveable Communities builds upon ongoing, and has established new, multi-sector collaborations with national and state policy-makers and practitioners. The symposium will commence with a brief introduction to embed the research within an Australian health and urban planning context, as well as providing an overall outline of the CRE in Healthy Liveable Communities, its structure and team. Next, an overview of the five research themes will be presented. Following these presentations, the Discussant will consider the implications of the research and opportunities for translation and knowledge exchange. Theme 2 will establish whether and to what extent the neighbourhood environment (built and social) is causally related to physical and mental health and associated behaviours and risk factors. In particular, research conducted as part of this theme will use data from large-scale, longitudinal-multilevel studies (HABITAT, RESIDE, AusDiab) to examine relationships that meet causality criteria via statistical methods such as longitudinal mixed-effect and fixed-effect models, multilevel and structural equation models; analyse data on residential preferences to investigate confounding due to neighbourhood self-selection and to use measurement and analysis tools such as propensity score matching and ‘within-person’ change modelling to address confounding; analyse data about individual-level factors that might confound, mediate or modify relationships between the neighbourhood environment and health and well-being (e.g., psychosocial factors, knowledge, perceptions, attitudes, functional status), and; analyse data on both objective neighbourhood characteristics and residents’ perceptions of these objective features to more accurately assess the relative contribution of objective and perceptual factors to outcomes such as health and well-being, physical activity, active transport, obesity, and sedentary behaviour. At the completion of the Theme 2, we will have demonstrated and applied statistical methods appropriate for determining causality and generated evidence about causal relationships between the neighbourhood environment, health, and related outcomes. This will provide planners and policy makers with a more robust (valid and reliable) basis on which to design healthy communities.

Using qualitative mixed methods to study small health care organizations while maximising trustworthiness and authenticity

Background The primary health care sector delivers the majority of health care in western countries through small, community-based organizations. However, research into these healthcare organizations is limited by the time constraints and pressure facing them, and the concern by staff that research is peripheral to their work. We developed Q-RARA—Qualitative Rapid Appraisal, Rigorous Analysis—to study small, primary health care organizations in a way that is efficient, acceptable to participants and methodologically rigorous. Methods Q-RARA comprises a site visit, semi-structured interviews, structured and unstructured observations, photographs, floor plans, and social scanning data. Data were collected over the course of one day per site and the qualitative analysis was integrated and iterative. Results We found Q-RARA to be acceptable to participants and effective in collecting data on organizational function in multiple sites without disrupting the practice, while maintaining a balance between speed and trustworthiness. Conclusions The Q-RARA approach is capable of providing a richly textured, rigorous understanding of the processes of the primary care practice while also allowing researchers to develop an organizational perspective. For these reasons the approach is recommended for use in small-scale organizations both within and outside the primary health care sector.

The Australian prehospital pandemic risk perception study and an examination of new public health roles in pandemic response for ambulance services

This report is one of a series of products resulting from a National Health and Medical Research Council (NHMRC) Urgent Research Grant – Pandemic Influenza [No 409973]. The research targeted two key aspects of planning and preparedness for a human influenza pandemic, namely:

Cultural safety, diversity and the servicer user and carer movement in mental health research

This study will be of interest to anyone concerned with a critical appraisal of mental health service users’ and carers’ participation in research collaboration and with the potential of the postcolonial paradigm of cultural safety to contribute to the service user research (SUR) movement. The history and nature of the mental health field and its relationship to colonial processes provokes a consideration of whether cultural safety could focus attention on diversity, power imbalance, cultural dominance and structural inequality, identified as barriers and tensions in SUR. We consider these issues in the context of state-driven approaches towards SUR in planning and evaluation and the concurrent rise of the SUR movement in the UK and Australia, societies with an intimate involvement in processes of colonisation. We consider the principles and motivations underlying cultural safety and SUR in the context of the policy agenda informing SUR. We conclude that while both cultural safety and SUR are underpinned by social constructionism constituting similarities in principles and intent, cultural safety has additional dimensions. Hence, we call on researchers to use the explicitly political and self-reflective process of cultural safety to think about and address issues of diversity, power and social justice in research collaboration.

The evolving landscape of natural resource planning and governance in Australia

Australia’s governance of land and natural resources involves multiple polycentric domains of decision-making from global through to local levels. Although certainly complex, these arrangements have not necessarily translated into better decision-making or better environmental outcomes as evidenced by the growing concerns over the health and future of the Great Barrier Reef, (GBR). However within this system, arrangements for natural resource management (NRM) and reef water quality, which both use Australia’s integrated regional NRM model, have showed signs of improving decision-making and environmental outcomes in the GBR. In this paper we describe the latest evolutions in the governance and planning for natural resource use and management in Australia. We begin by reviewing the experience with first generation NRM as published in major audits and evaluations. As our primary interest is the health and future of the GBR, we then consider the impact of changes of second generation planning and governance outcomes in Queensland. We find that first generation plans, although developed under a relatively cohesive governance context, faced substantial problems in target setting, implementation, monitoring and review. Despite this, they were able to progress improvements in water quality in the Great Barrier Reef Regions. Second generation plans, currently being developed, face an even greater risk of failure due to the lack of bilateralism and cross-sectoral cooperation across the NRM governance system. The findings highlight the critical need to re-build and enhance the regional NRM model for NRM planning to have a positive impact on environmental outcomes in the GBR.

Discovering future disaster management capability needs using scenario planning

In recent years disaster risk reduction efforts have focused on disturbances ranging from climate variability, seismic hazards, geo-political instability and public and animal health crises. These factors combined with uncertainty derived from inter-dependencies within and across systems of critical infrastructure create significant problems of governance for the private and public sector alike. The potential for rapid spread of impacts, geographically and virtually, can render a comprehensive understanding of disaster response and recovery needs and risk mitigation issues beyond the grasp of competent authority. Because of such cascading effects communities and governments at local and state-levels are unlikely to face single incidents but rather series of systemic impacts: often appearing concurrently. A further point to note is that both natural and technological hazards can act directly on socio-technical systems as well as being propagated by them: as network events. Such events have been categorised as ‘outside of the box,’ ‘too fast,’ and ‘too strange’ (Lagadec, 2004). Emergent complexities in linked systems can make disaster effects difficult to anticipate and recovery efforts difficult to plan for. Beyond the uncertainties of real world disasters, that might be called familiar or even regular, can we safely assume that the generic capability we use now will suit future disaster contexts? This paper presents initial scoping of research funded by the Bushfire and Natural Hazards Cooperative Research Centre seeking to define future capability needs of disaster management organisations. It explores challenges to anticipating the needs of representative agencies and groups active in before, during and after phases of emergency and disaster situations using capability deficit assessments and scenario assessment.

Advance care planning in stroke: Influence of time on engagement in the process

Purpose Individuals who experience stroke have a higher likelihood of subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, engaging in the process of advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, and the extent to which stroke HCPs engage in conversations around planning for such events. In this study, we sought to understand how the process of ACP unfolded between HCPs and patients post-stroke. Patients and methods Using grounded theory (GT) methodology, we engaged in direct observation of HCP and patient interactions on an acute stroke unit and two stroke rehabilitation units. Using semi-structured interviews, 14 patients and four HCPs were interviewed directly about the ACP process. Results We found that open and continual ACP conversations were not taking place, patients experienced an apparent lack of urgency to engage in ACP, and HCPs were uncomfortable initiating ACP conversations due to the sensitive nature of the topic. Conclusion In this study, we identified lack of engagement in ACP post-stroke, attributable to patient and HCP factors. This encourages us to look further into the process of ACP in order to develop open communication between the patient with stroke, their families, and stroke HCPs.

Peer mentoring for radiotherapy planning skills development: A pilot study

Introduction: This study aimed to determine the potential role and guidelines for implementation of skill-based peer mentoring for radiotherapy planning education. Methods: After four weekly mentoring sessions, both Year 3 mentors (n=9) and Year 2 mentees (n=9) were invited to complete a short online questionnaire relating to the impact of the initiative. The tool contained a mixture of Likert-style questions concerning student enjoyment and perceived usefulness of the initiative as well as more qualitative open questions that gathered perceptions of the peer mentoring process, implementation methods and potential future scope. Results: Several key discussion themes related to benefits to each stakeholder group, challenges arising, improvements and potential future directions. There were high levels of enjoyment and perceived value of the mentoring from both sides with 100% of the 18 respondents enjoying the experience. The informal format encouraged further learning, while mentors reported acquisition of valuable skills and gains in knowledge. Conclusions: Peer mentoring has a valuable and enjoyable role to play in radiotherapy planning training and helps consolidate theoretical understanding for experienced students. An informal approach allows for students to adopt the most appropriate mentoring model for their needs while providing them with a free space to engender additional discussion.

Planning for pandemics: Lessons from the past decade

It is now 10 years since the disease we now know as SARS-severe acute respiratory syndrome-caused more than 700 deaths around the world and made more than 8,000 people ill. More recently, in 2009 the global community experienced the first influenza pandemic of the 21st century-the 2009 H1N1 influenza pandemic. This paper analyses the major developments in international public health law relating to infectious diseases in the period since SARS and considers their implications for pandemic planning.

Changing travel patterns and journeys to health services in Great Britain 1985-2012: An examination health service utilisation using the National Travel Survey

Background This paper examines changing patterns in the utilisation and geographic access to health services in Great Britain using National Travel Survey data (1985-2012). The National Travel Survey (NTS) is a series of household surveys designed to provide data on personal travel and monitor changes in travel behaviour over time. The utilisation rate was derived using the proportion of journeys made to access health services. Geographic access was analysed by separating the concept into its accessibility and mobility dimensions. Methods Variables from the PSU, households, and individuals datasets were used as explanatory variables. Whereas, variables extracted from the journeys dataset were used as dependent variables to identify patterns of utilisation i.e. the proportion of journeys made by different groups to access health facilities in a particular journey distance or time band or by mode of transport; and geographic access to health services. A binary logistic regression analysis was conducted to identify the utilisation rate over the different time periods between different groups. This analysis shows the Odds Ratios (ORs) for different groups making a trip to utilise health services compared to their respective counterparts. Linear multiple regression analyses were conducted to then identify patterns of change in the accessibility and mobility level. Results Analysis of the data has shown that that journey distances to health facilities were signi fi cantly shorter and also gradually reduced over the period in question for Londoners, females, those without a car or on low incomes, and older people. Although rates of utilisation of health services we re Oral Abstracts / Journal of Transport & Health 2 (2015) S5 – S63 S43 signi fi cantly lower because of longer journey times. These fi ndings indicate that the rate of utilisation of health services largely depends on mobility level although previous research studies have traditionally overlooked the mobility dimension. Conclusions This fi nding, therefore, suggests the need to improve geographic access to services together with an enhanced mobility option for disadvantaged groups in order for them to have improved levels of access to health facilities. This research has also found that the volume of car trips to health services also increased steadily over the period 1985-2012 while all other modes accounted for a smaller number of trips. However, it is dif fi cult to conclude from this research whether this increase in the volume of car trips was due to a lack of alternative transport or due to an increase in the level of car-ownership.

Dieting and non-dieting: Socio-cognitive determinants and associations with nutrition and health status indicators

Dieting and non-dieting are two contrasting approaches to the management of overweight/obesity, but less is known about why people follow non-dieting approaches and how these approaches are associated with health and nutrition status indicators. This thesis enables a greater understanding of why dieting and non-dieting approaches are adopted and provides insight into whether one approach is more favourably associated with nutrition and health status indicators. The findings of this thesis will be useful for clinicians who wish to encourage dieting or non-dieting approaches in their clients and for researchers wishing to understand how best to address overweight and obesity.