Public use and perceptions of emergency departments: A population survey

Objectives To inform demand management strategies aimed at reducing congestion in EDs by: (i) identifying public use of EDs, decision-making and reasons; and (ii) measuring acceptance of alternative care models. Methods A cross-sectional telephone survey of a random sample of Queensland population aged 18 years or older residing in a dwelling unit in Queensland that could be contacted on a land-based telephone service was conducted. One person per household was selected according to a predetermined algorithm to ensure sex and regional balance were interviewed. The main outcome measures were: ED use, attitudes towards ED staff and services, and alternative models of care. Results The final sample included a total of 1256 respondents (response rate = 40.3%). Twenty-one per cent attended EDs in the preceding 12 months. The decision to attend was made by patients (51%), health and medical professionals (31%), and others (18%). The main reasons included perceived severity of the illness (47%), unavailability of alternative services (26%) and better care (11%). Most respondents agreed with more flexible care models of service delivery including incentives for general practitioners (90%), private health insurance coverage for ED use (89%), and enhanced roles for paramedics and nurses. Conclusions Main reason for attending ED is perceived severity of illness, followed by lack of alternative care. The majority of both consumers and the public are in favour of more flexible care models. However, further research is necessary to detail those alternatives and to test and validate their effectiveness.

Qualitative study of patients' choice between public and private hospital emergency departments

Objective The aim of this study was to gather patients' perceptions regarding their choice between public and private hospital EDs for those who hold private health insurance. The findings of this study will contribute to knowledge regarding patients' decision-making processes and therefore may contribute to the development of evidence based public policies. Methods An in-depth semi-structured guide was used to interview participants at public and private hospital EDs. Questions sought to identify the issues that were considered by the participants to decide to attend that hospital ED, previous ED experience, expectations of ED services and perceived benefits and barriers to accessing services. Interviews were audio recorded, transcribed verbatim and analysed using content and thematic approaches. Results Four core themes emerged: prior good experience with the hospital, perceived quality of care, perceived waiting times and perceived costs that may explain patients' choice. Patients' choice between public and private EDs can be explained by the interaction of these core themes. The principal issues appear to be concern for gap payments at private hospital ED and waiting times at public hospital ED. Conclusions Patients who choose to attend public EDs appear to value financial concern over waiting time; those who choose to attend private EDs appear to value waiting time ahead of financial concerns.

Assessing infant exposure to persistent organic pollutants via dietary intake in Australia

Persistent organic pollutants (POPs) including polybrominated diphenyl ethers (PBDEs); organochlorine pesticides (OCPs); and polychlorinated biphenyls (PCBs) persist in the environment, bioaccumulate, and pose a risk of causing adverse human health effects. Typically, exposure assessments undertaken by modeling existing intake data underestimate the concentrations of these chemicals in infants. This study aimed to determine concentrations of POPs in infant foods, assess exposure via dietary intake and compare this to historical exposure. Fruit purees, meat and vegetables, dairy desserts, cereals and jelly foods (n = 33) purchased in 2013 in Brisbane, Australia were analyzed. For OCPs and PCBs, concentrations ranged up to 95 pg/g fw and for PBDEs up to 32 pg/g fw with most analytes below the limit of detection. Daily intake is dependent on type and quantity of foods consumed. Consumption of a 140 g meal would result in intake ranging from 0 to 4.2 ng/day, 4.4 ng/day and 13.3 ng/day, for OCPs, PBDEs and PCBs, respectively. PBDEs were detected in 3/33 samples, OCPs in 9/33 samples and PCBs in 13/33 samples. Results from this study indicate exposure for infants via dietary (in contrast to dust and breast milk) intake in Australia contribute only a minor component to total exposure.

Use of pooled samples to assess human exposure to parabens, benzophenone-3 and triclosan in Queensland, Australia

Parabens, benzophenone-3 and triclosan are common ingredients used as preservatives, ultraviolet radiation filters and antimicrobial agents, respectively. Human exposure occurs through consumption of processed food and use of cosmetics and consumer products. The aim of this study was to provide a preliminary characterisation of exposure to selected personal care product chemicals in the general Australian population. De-identified urine specimens stratified by age and sex were obtained from a community-based pathology laboratory and pooled (n= 24 pools of 100). Concentrations of free and total (sum of free plus conjugated) species of methyl, ethyl, propyl and butyl paraben, benzophenone-3 and triclosan were quantified using isotope dilution tandem mass spectrometry; with geometric means 232, 33.5, 60.6, 4.32, 61.5 and 87.7. ng/mL, respectively. Age was inversely associated with paraben concentration, and females had concentrations approximately two times higher than males. Total paraben and benzophenone-3 concentrations are significantly higher than reported worldwide, and the average triclosan concentration was more than one order of magnitude higher than in many other populations. This study provides the first data on exposure of the general Australian population to a range of common personal care product chemical ingredients, which appears to be prevalent and warrants further investigation.

The global burden of injury: Incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013

Background The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country. Methods Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures. Results In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries. Conclusions Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.

Prospective case review of a global e-health system for doctors in developing countries

The Swinfen Charitable Trust has managed email consultations for doctors in developing countries since 1999. The process was handled manually for the first three years and then subsequently using an automatic message-handling system. We conducted a prospective review of email consultations between referring doctors and consulting specialists during six months of automatic operation (December 2003 to May 2004). During the study period 125 consultations took place. These concerned a wide range of specialties (e.g. orthopaedics 17%, dermatology 16%, obstetrics and gynaecology 11%, radiology 10%). Of these referrals, 33% (41) were for paediatric cases. Consulting specialists, who were based in five countries, were volunteers. Referring doctors were from 24 hospitals in 12 developing countries. The median time from referral to definitive reply was 1.5 days (interquartile range 0.6-4.9). There was an 85% response rate (n = 106) to a survey concerning the value of the consultation to the referring doctor. All the referring doctors who responded made positive comments about the service and half said that it improved their management of the case. The second-opinion consultation system operated by the Swinfen Charitable Trust represents an example of a global e-health system operated for altruistic, rather than commercial, reasons.

Paediatric telecardiology services in Queensland: a review of three years' experience

Videoconferencing at 384 kbit/s for the transmission of echocardiograms has proved useful for the assessment of children with suspected cardiac disease, in regional areas of Queensland. A retrospective review of patient and management outcomes was conducted on cardiac teleconsultations performed at two regional hospitals during the period November 2000 to February 2004, inclusive. There were 106 echo studies. A subset of 72 cardiac teleconsultations performed between May 2001 and February 2004 was reviewed in detail. The median age of patients at the time of consultation was 3 months (range 1 day-17 years). Sixteen per cent of teleconsultations were classified as urgent and were conducted on the same day as referral. Following the videoconference, 90% of patients could be managed locally and reviewed by the paediatrician or visiting paediatric cardiologist during an outreach clinic. Six children (8%) had significant cardiac lesions that were initially managed locally, with subsequent elective transfer at the appropriate time for treatment. Only one child (1%) required urgent transfer to the tertiary centre for specialist care and surgery. Telecardiology was effective in accurately identifying congenital heart disease. Paediatric telecardiology is an evolving modality of assessment and communication, and is likely to result in continued improvements in patient care, patient outcomes and parental satisfaction, in provincial centres removed from the tertiary cardiac centre.

Paediatric outreach services

Paediatric outreach services are provided in Australia and overseas to regional and rural communities. More recently telehealth services have been established to support the delivery of paediatric services and clinical management at distant sites. It is suggested that with the large distances separating centres in Australia that a combination of telehealth clinics and outreach visits may provide the most efficient means of delivering paediatric specialty and subspecialty care to these centres.

Inhibition of 19-kDa C-terminal region of merozoite surface protein-1-specific antibody responses in neonatal pups by maternally derived 19-kDa C-terminal region of merozoite surface protein-1-specific antibodies but not whole parasite-specific antibodies

Immunizing pregnant women with a malaria vaccine is one approach to protecting the mother and her offspring from malaria infection. However, specific maternal Abs generated in response to vaccination and transferred to the fetus may interfere with the infant's ability to respond to the same vaccine. Using a murine model of malaria, we examined the effect of maternal 19-kDa C-terminal region of merozoite surface protein-1 (MSP1(19)) and Plasmodium yoelii Abs on the pups' ability to respond to immunization with MSP1(19). Maternal MSPI,g-specific Abs but not A yoelii-specific Abs inhibited Ab production following MSP1(19) immunization in 2-wk-old pups. This inhibition was correlated with the amount of maternal MSP1(19) Ab present in the pup at the time of immunization and was due to fewer specific B cells. Passively acquired Ab most likely inhibited the development of an Ab response by blocking access to critical B cell epitopes. If a neonate's ability to respond to MSP1(19) vaccination depends on the level of maternal Abs present at the time of vaccination, it may be necessary to delay immunization until Abs specific for the vaccinating Ag have decreased.

Increased use of emergency services by older people after health screening

Background: evaluation of the 'Keep Well At Home' (KWAH) Project in West London indicated that a programme of screening persons aged 75 and over had not reduced rates of emergency attendances and admissions to hospital. However, coverage of the target population was incomplete. The present analysis addresses 'efficacy'-whether individuals who completed the screening protocol as intended did subsequently use Accident & Emergency (A&E) services less often. Methods: the target population was divided into five groups, depending on whether an individual had completed none, one or both phases of screening, and whether deviations from the protocol related to incomplete coverage or refusal to participate further. We ascertained use of emergency services before screening and for up to 3 years afterwards by linkage of records from KWAH to those of local A&E Departments. Patterns of emergency care were examined as crude races and, via proportional hazards models, after adjustment for available confounders. Results: there was an increase of 51% (95% CI 22-86%) in the crude rate of emergency admissions in the year after first-phase screening compared with the 12 months before assessment. This was most obvious in individuals deemed at high risk who also underwent the second-phase assessment (adjusted hazard ratio relative to individuals not 'at risk'= 2.33; 95% CI 1.59-3.42). Conclusions: the available data do not allow us to distinguish between several possible explanations for the paradoxical increase in use of emergency services. However, what seem to be sensible policies do not necessarily have their intended effects when implemented in practice.

Wireless telemedicine for the delivery of specialist paediatric services to the bedside

A mobile interactive online health system was used to conduct virtual ward rounds at a regional hospital which had no specialist paediatrician. The system was wireless, which allowed telepaediatric services to be delivered direct to the bedside. Between December 2004 and May 2005, 43 virtual ward rounds were coordinated between specialists based in Brisbane and local staff at the Gladstone Hospital. Eighty-six consultations were provided for 64 patients. The most common conditions included asthma (27%), chest infections (12%), gastroenteritis (10%) and urinary tract infections (10%). In the majority of cases, there were partial (67%) or complete changes (11%) in the clinical management of patients. Specialist services were offered by a team of 13 clinicians at the Royal Children's Hospital: 10 general paediatricians, two physiotherapists and one registered nurse. Feedback from all consultants involved in the service and local staff in Gladstone was extremely positive. In 43 videoconference calls there were three technical problems, probably due to an intermittent mains power supply at the regional hospital. There appears to be potential for other rural and regional hospitals to adopt this model of service delivery.

Telemedicine for rural and remote child and youth mental health services

The E-Child and Youth Mental Health Service was designed to provide children and adolescents in Queensland with access to specialist mental health consultations using telemedicine. A project officer provided a single point of contact for referral management and clinic coordination, thereby reducing barriers of access to the service. Over a six-month period from November 2004, 42 point-to-point videoconferences were conducted to nine sites in Queensland. Three multipoint conferences were also conducted. Eleven videoconferences (24%) were arranged for administrative purposes, and 34 (76%) were conducted for the delivery of clinical services (30 patients). The referral and consultation activity suggests an improvement in the capacity of rural and remote mental health service providers to deliver specialist services for children and adolescents.

Delivery of child development services by videoconferencing: a review of four years' experience in Queensland

In 2001 the Child Development Unit (CDU) in Brisbane piloted a series of monthly multidisciplinary case discussions via videoconference in the area of child development. During 2001 two sessions were provided; during 2004 there were 40. The substantial growth in 2004 was due to the expansion of child development services to include special interest group meetings and multipoint case conference meetings. In 2004, a total of 49 h of videoconferencing was conducted. The average session length was 75 min. Education and training sessions were delivered to 32 hospitals and health centres in Queensland and northern New South Wales. The maximum number of sites involved during a single videoconference was 25. The average number of attendees for each videoconference was five per site, including allied health staff, nurses and paediatricians. The delivery of child development services via videoconference has been shown to be useful in Queensland, especially for allied health staff working in regional and remote areas. The growth of the programme indicates its acceptance as a mainstream child development service in Queensland.