Emergency Health Services (EHS) : demand and service delivery models. monograph 3 : patients’ reasons and perceptions

Executive Summary Emergency health is a critical component of Australia’s health system and emergency departments (EDs) are increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the perspectives of users of both ambulance services and EDs. The research reported here aimed to identify the perspectives of users of emergency health services, both ambulance services and public hospital Emergency Departments and to identify the factors that they took into consideration when exercising their choice of location for acute health care. A cross-sectional survey design was used involving a survey of patients or their carers presenting to the EDs of a stratified sample of eight hospitals. A specific purpose questionnaire was developed based on a novel theoretical model which had been derived from analysis of the literature (Monograph 1). Two survey versions were developed: one for adult patients (self-complete); and one for children (to be completed by parents/guardians). The questionnaires measured perceptions of social support, health status, illness severity, self-efficacy; beliefs and attitudes towards ED and ambulance services; reasons for using these services, and actions taken prior to the service request. The survey was conducted at a stratified sample of eight hospitals representing major cities (four), inner regional (two) and outer regional and remote (two). Due to practical limitations, data were collected for ambulance and ED users within hospital EDs, while patients were waiting for or under treatment. A sample size quota was determined for each ED based on their 2009/10 presentation volumes. The data collection was conducted by four members of the research team and a group of eight interviewers between March and May 2011 (corresponding to autumn season). Of the total of 1608 patients in all eight emergency departments the interviewers were able to approach 1361 (85%) patients and seek their consent to participate in the study. In total, 911 valid surveys were available for analysis (response rate= 67%). These studies demonstrate that patients elected to attend hospital EDs in a considered fashion after weighing up alternatives and there is no evidence of deliberate or ill-informed misuse. • Patients attending ED have high levels of social support and self-efficacy that speak to the considered and purposeful nature of the exercise of choice. • About one third of patients have new conditions while two thirds have chronic illnesses • More than half the attendees (53.1%) had consulted a healthcare professional prior to making the decision. • The decision to seek urgent care at an ED was mostly constructed around the patient’s perception of the urgency and severity of their illness, reinforced by a strong perception that the hospital ED was the correct location for them (better specialised staff, better care for my condition, other options not as suitable). • 33% of the respondent held private hospital insurance but nevertheless attended a public hospital ED. Similarly patients exercised considered and rational judgements in their choice to seek help from the ambulance service. • The decision to call for ambulance assistance was based on a strong perception about the severity of the illness (too severe to use other means of transport) and that other options were not considered appropriate. • The decision also appeared influenced by a perception that the ambulance provided appropriate access to the ED which was considered most appropriate for their particular condition (too severe to go elsewhere, all facilities in one spot, better specialised and better care). • In 43.8% of cases a health care professional advised use of the ambulance. • Only a small number of people perceived that ambulance should be freely available regardless of severity or appropriateness. These findings confirm a growing understanding that the choice of professional emergency health care services is not made lightly but rather made by reasonable people exercising a judgement which is influenced by public awareness of the risks of acute health and which is most often informed by health professionals. It is also made on the basis of a rational weighing up of alternatives and a deliberate and considered choice to seek assistance from a service which the patient perceived was most appropriate to their needs at that time. These findings add weight to dispensing with public perceptions that ED and ambulance congestion is a result of inappropriate choice by patients. The challenge for health services is to better understand the patient’s needs and to design and validate services that meet those needs. The failure of our health system to do so should not be grounds for blaming the patient, claiming inappropriate patient choices.

Identifying team style in soccer using formations learned from spatiotemporal tracking data

To the trained-eye, experts can often identify a team based on their unique style of play due to their movement, passing and interactions. In this paper, we present a method which can accurately determine the identity of a team from spatiotemporal player tracking data. We do this by utilizing a formation descriptor which is found by minimizing the entropy of role-specific occupancy maps. We show how our approach is significantly better at identifying different teams compared to standard measures (i.e., shots, passes etc.). We demonstrate the utility of our approach using an entire season of Prozone player tracking data from a top-tier professional soccer league.

Shifting intimacies

Our world is literally and figuratively turning to ‘dust’. This work acknowledges decay and renewal and the transitional, cyclical natures of interrelated ecologies. It also suggests advanced levels of degradation potentially beyond reparation. Dust exists both on and beneath the border of our unaided vision. Dust particles are predominantly forms of disintegrating solids that often become the substance or catalyst of future forms. Like many tiny forms, dust is an often unnoticed residue with ‘planet-size consequences’. (Hanna Holmes 2001) The image depicts an ethereal, backlit body, continually circling and morphing, apparently floating, suggesting endless cycles of birth, life and death and inviting differing states of meditation, exploration, stillness and play. This never ending video work is taken from a large-scale interactive/media artwork created during a six-month research residency in England at the Institute of Contemporary Art London and at Vincent Dance Theatre Sheffield in 2006. It was originally presented on a raised floor screen made of pure white sand at the ICA in London (see). The project involved developing new interaction, engagement and image making strategies for media arts practice, drawing on the application of both kinetic and proprioceptive dance/performance knowledges. The work was further informed by ecological network theory that assesses the systemic implications of private and public actions within bounded systems. The creative methodology was primarily practice-led which fomented the particular qualities of imagery, generated through cross-fertilising embodied knowledge of Dance and Media Arts. This was achieved through extensive workshopping undertaken in theatres, working ‘on the floor’ live, with dancers, props, sound and projection. And eventually of course, all this dust must settle. (Holmes 2001, from Dust Jacket) Holmes, H. 2001, The Secret Life of Dust: From the Cosmos to the Kitchen Counter, the Big Consequences of Little Things, p.3

A revisit to Pope's cohort analysis

Gulland's [Gulland, J.A., 1965. Estimation of mortality rates. Annex to Arctic Fisheries Working Group Report (meeting in Hamburg, January 1965). ICES. C.M. 1965, Doc. No. 3 (mimeographed)] virtual population analysis (VPA) is commonly used for studying the dynamics of harvested fish populations. However, it necessitates the solving of a nonlinear equation for the instantaneous rate of fishing mortality of the fish in a population. Pope [Pope, J.G., 1972. An investigation of the accuracy of Virtual Population Analysis using cohort analysis. ICNAF Res. Bull. 9, 65-74. Also available in D.H. Cushing (ed.) (1983), Key Papers on Fish Populations, p. 291-301, IRL Press, Oxford, 405 p.] eliminated this necessity in his cohort analysis by approximating its underlying age- and time-dependent population model. His approximation has since become one of the most commonly used age- and time-dependent fish population models in fisheries science. However, some of its properties are not well understood. For example, many assert that it describes the dynamics of a fish population, from which the catch of fish is taken instantaneously in the middle of the year. Such an assertion has never been proven, nor has its implied instantaneous rate of fishing mortality of the fish of a particular age at a particular time been examined, nor has its implied catch equation been derived from a general catch equation. In this paper, we prove this assertion, examine its implied instantaneous rate of fishing mortality of the fish of a particular age at a particular time, derive its implied catch equation from a general catch equation, and comment on how to structure an age- and time-dependent population model to ensure its internal consistency. This work shows that Gulland's (1965) virtual population analysis and Pope's (1972) cohort analysis lie at the opposite end of a continuous spectrum as a general model for a seasonally occurring fishery; Pope's (1972) approximation implies an infinitely large instantaneous rate of fishing mortality of the fish of a particular age at a particular time in a fishing season of zero length; and its implied catch equation has an undefined instantaneous rate of fishing mortality of the fish in a population, but a well-defined cumulative instantaneous rate of fishing mortality of the fish in the population. This work also highlights a need for a more careful treatment of the times of start and end of a fishing season in fish population models.

Urana subterranean clover (Trifolium subterraneum L. var. subterraneum)

Urana is a hardseeded, moderately early flowering F-5-derived crossbred subterranean clover of var. subterraneum [( Katz. et Morley) Zohary and Heller] developed by the collaborating organisations of the National Annual Pasture Legume Improvement Program. It has been selected for release as a new cultivar on the basis of its high winter and spring herbage production and overall field performance relative to other subterranean clovers of similar maturity. Urana is recommended for sowing in Western Australia, New South Wales, Victoria, South Australia and Queensland. It is best suited to well-drained, moderately acidic soils in areas with a growing season of 5 - 7 months, which extends into mid-October. Urana is suited to phase farming and crop rotations. It has been granted Plant Breeders Rights in Australia.

Coolamon subterranean clover (Trifolium subterraneum L. var. subterraneum)

Coolamon is a mid-season to late-season flowering F4-derived crossbred subterranean clover of var. subterraneum, developed by the collaborating organisations of the National Annual Pasture Legume Improvement Program. It is a replacement for Junee and has been selected for release on the basis of its greater herbage production and persistence, and its resistance to both known races of clover scorch. Coolamon is recommended for sowing in Western Australia, New South Wales, Victoria, South Australia and Queensland. It is best suited to well-drained, moderately acidic soils in areas with a growing season of 6.5-8 months that extends into November. Coolamon is best suited to phase farming and permanent pasture systems. It can also be used in cropping rotations, but at least 2 years of pasture are required between crops. Coolamon has been granted Plant Breeders Rights in Australia.

Izmir subterranean clover (Trifolium subterraneum L. var. subterraneum)

Izmir is a hardseeded, early flowering, subterranean clover of var. subterraneum (Katz. et Morley) Zohary and Heller collected from Turkey and developed by the collaborating organisations of the National Annual Pasture Legume Improvement Program. It is a more hardseeded replacement for Nungarin and best suited to well-drained, moderately acidic soils in areas with a growing season of less than 4.5 months. Izmir seed production and regeneration densities in 3-year pasture phases were similar to Nungarin in 21 trials across southern Australia, but markedly greater in years following a crop or no seed set. Over all measurements, Izmir produced 10% more winter herbage and 7% more spring herbage than Nungarin. Its greater hardseededness and good seed production, makes it better suited to cropping rotations than Nungarin. Softening of Izmir hard seeds occurs later in the summer–autumn period than Nungarin, giving it slightly greater protection from seed losses following false breaks to the season. Izmir is recommended for sowing in Western Australia, New South Wales, Victoria, South Australia and Queensland. Izmir has been granted Plant Breeders Rights in Australia.

Restorative treatment practices and dentist-related factors

This study aimed at elucidating real-life aspects of restorative treatment practices. In addition, dentists' views and perceptions of and variation in restorative treatment practices with respect to dentist-related factors were evaluated. Reasons for placement and replacement of restoration, material selection, posterior restoration longevity, and the use of local anesthesia were assessed on two cross-sectional data sets. Data from the Helsinki Public Dental Service (PDS) included details on 3057 restorations performed by dentists (n=134) during routine clinical work in 2001. The other PDS data from Vantaa were based on 205 patient records of young adults containing information on 1969 restorations investigated retrospectively from 1994-1996 backwards; 51 dentists performed the restorations. In addition, dentists’ self-reported use of local anesthesia and estimates of restoration longevity were investigated by means of a nationwide questionnaire sent to 592 general dental practitioners selected by systematic sampling from the membership list of the Finnish Dental Association in 2004. All data sets included some background information on dentists such as gender, year of birth or graduation, and working sector. In PDS in 2001, primary caries was the reason for placement of restoration more often among patients aged under 19 years than among older patients (p<0.001). Among patients over 36 years of age, replacements represented the majority. Regarding dentist-related factors, replacements of restorations were made by younger dentists more frequently than by older dentists (p<0.001). In PDS in 1994-1996, the replacement rate of posterior restorations was greater among female dentists than among male dentists (p=0.01), especially for amalgams (p=0.008). The mean age of replaced posterior restoration among young adults was 8.9 (SD 5.2) years for amalgam and 2.4 (SD 1.4) years for tooth-colored restorations, the actual replacement rate for all existing posterior restorations being 7% in PDS in 1994-1996. Of all restorative materials used, a clear majority (69%) were composites in PDS in 2001. Local anesthesia was used in 48% of cases and more frequently for older patients (55%) than for patients aged under 13 years (35%) (p<0.001). Younger dentists more often used local anesthesia for primary restoration than did the older dentists (p<0.001), especially for primary teeth (p=0.005). Working sector had an impact on dentists’ self-reported use of local anesthesia and estimates of restoration longevity; public sector dentists reported using local anesthesia more frequently than private sector dentists for Class II (p=0.04) and for Class III restorations (p=0.01). Private sector dentists gave longer estimates of posterior composite longevity than public sector dentists (p=0.001). In conclusion, restorative treatment practices seem to vary according to patient age and also dentist-related factors. Replacements of restorations are common for adults. For children, clear underuse of local anesthesia prevails.

Genotyping for genetic association studies: Methods and applications

In this thesis, two separate single nucleotide polymorphism (SNP) genotyping techniques were set up at the Finnish Genome Center, pooled genotyping was evaluated as a screening method for large-scale association studies, and finally, the former approaches were used to identify genetic factors predisposing to two distinct complex diseases by utilizing large epidemiological cohorts and also taking environmental factors into account. The first genotyping platform was based on traditional but improved restriction-fragment-length-polymorphism (RFLP) utilizing 384-microtiter well plates, multiplexing, small reaction volumes (5 µl), and automated genotype calling. We participated in the development of the second genotyping method, based on single nucleotide primer extension (SNuPeTM by Amersham Biosciences), by carrying out the alpha- and beta tests for the chemistry and the allele-calling software. Both techniques proved to be accurate, reliable, and suitable for projects with thousands of samples and tens of markers. Pooled genotyping (genotyping of pooled instead of individual DNA samples) was evaluated with Sequenom s MassArray MALDI-TOF, in addition to SNuPeTM and PCR-RFLP techniques. We used MassArray mainly as a point of comparison, because it is known to be well suited for pooled genotyping. All three methods were shown to be accurate, the standard deviations between measurements being 0.017 for the MassArray, 0.022 for the PCR-RFLP, and 0.026 for the SNuPeTM. The largest source of error in the process of pooled genotyping was shown to be the volumetric error, i.e., the preparation of pools. We also demonstrated that it would have been possible to narrow down the genetic locus underlying congenital chloride diarrhea (CLD), an autosomal recessive disorder, by using the pooling technique instead of genotyping individual samples. Although the approach seems to be well suited for traditional case-control studies, it is difficult to apply if any kind of stratification based on environmental factors is needed. Therefore we chose to continue with individual genotyping in the following association studies. Samples in the two separate large epidemiological cohorts were genotyped with the PCR-RFLP and SNuPeTM techniques. The first of these association studies concerned various pregnancy complications among 100,000 consecutive pregnancies in Finland, of which we genotyped 2292 patients and controls, in addition to a population sample of 644 blood donors, with 7 polymorphisms in the potentially thrombotic genes. In this thesis, the analysis of a sub-study of pregnancy-related venous thromboses was included. We showed that the impact of factor V Leiden polymorphism on pregnancy-related venous thrombosis, but not the other tested polymorphisms, was fairly large (odds ratio 11.6; 95% CI 3.6-33.6), and increased multiplicatively when combined with other risk factors such as obesity or advanced age. Owing to our study design, we were also able to estimate the risks at the population level. The second epidemiological cohort was the Helsinki Birth Cohort of men and women who were born during 1924-1933 in Helsinki. The aim was to identify genetic factors that might modify the well known link between small birth size and adult metabolic diseases, such as type 2 diabetes and impaired glucose tolerance. Among ~500 individuals with detailed birth measurements and current metabolic profile, we found that an insertion/deletion polymorphism of the angiotensin converting enzyme (ACE) gene was associated with the duration of gestation, and weight and length at birth. Interestingly, the ACE insertion allele was also associated with higher indices of insulin secretion (p=0.0004) in adult life, but only among individuals who were born small (those among the lowest third of birth weight). Likewise, low birth weight was associated with higher indices of insulin secretion (p=0.003), but only among carriers of the ACE insertion allele. The association with birth measurements was also found with a common haplotype of the glucocorticoid receptor (GR) gene. Furthermore, the association between short length at birth and adult impaired glucose tolerance was confined to carriers of this haplotype (p=0.007). These associations exemplify the interaction between environmental factors and genotype, which, possibly due to altered gene expression, predisposes to complex metabolic diseases. Indeed, we showed that the common GR gene haplotype associated with reduced mRNA expression in thymus of three individuals (p=0.0002).

Genetic influences on handedness: data from 25,732 Australian and Dutch twin families

Handedness refers to a consistent asymmetry in skill or preferential use between the hands and is related to lateralization within the brain of other functions such as language. Previous twin studies of handedness have yielded inconsistent results resulting from a general lack of statistical power to find significant effects. Here we present analyses from a large international collaborative study of handedness (assessed by writing/drawing or self report) in Australian and Dutch twins and their siblings (54,270 individuals from 25,732 families). Maximum likelihood analyses incorporating the effects of known covariates (sex, year of birth and birth weight) revealed no evidence of hormonal transfer, mirror imaging or twin specific effects. There were also no differences in prevalence between zygosity groups or between twins and their singleton siblings. Consistent with previous meta-analyses, additive genetic effects accounted for about a quarter (23.64%) of the variance (95%CI 20.17, 27.09%) with the remainder accounted for by non-shared environmental influences. The implications of these findings for handedness both as a primary phenotype and as a covariate in linkage and association analyses are discussed.

Finding genes for economically important traits: Brahman cattle puberty.

Age at puberty is an important component of reproductive performance in beef cattle production systems. Brahman cattle are typically late-pubertal relative to Bos taurus cattle and so it is of economic relevance to select for early age at puberty. To assist selection and elucidate the genes underlying puberty, we performed a genome-wide association study (GWAS) using the BovineSNP50 chip (similar to 54 000 polymorphisms) in Brahman bulls (n = 1105) and heifers (n = 843) and where the heifers were previously analysed in a different study. In a new attempt to generate unbiased estimates of single-nucleotide polymorphism (SNP) effects and proportion of variance explained by each SNP, the available data were halved on the basis of year and month of birth into a calibration and validation set. The traits that defined age at puberty were, in heifers, the age at which the first corpus luteum was detected (AGECL, h(2) = 0.56 +/- 0.11) and in bulls, the age at a scrotal circumference of 26 cm (AGE26, h(2) = 0.78 +/- 0.10). At puberty, heifers were on average older (751 +/- 142 days) than bulls (555 +/- 101 days), but AGECL and AGE26 were genetically correlated (r = 0.20 +/- 0.10). There were 134 SNPs associated with AGECL and 146 SNPs associated with AGE26 (P < 0.0001). From these SNPs, 32 (similar to 22%) were associated (P < 0.0001) with both traits. These top 32 SNPs were all located on Chromosome BTA 14, between 21.95 Mb and 28.4 Mb. These results suggest that the genes located in that region of BTA 14 play a role in pubertal development in Brahman cattle. There are many annotated genes underlying this region of BTA 14 and these are the subject of current research. Further, we identified a region on Chromosome X where markers were associated (P < 1.00E-8) with AGE26, but not with AGECL. Information about specific genes and markers add value to our understanding of puberty and potentially contribute to genomic selection. Therefore, identifying these genes contributing to genetic variation in AGECL and AGE26 can assist with the selection for early onset of puberty.

Hans Friedrich Kayser Collection 1877-1893

Photocopies of birth certificate (1877) and release from citizenship certificate (1893), Berlin.

Evaluating pasture species for less fertile soils in a subtropical aseasonal low rainfall zone

Grasses, legumes, saltbushes and herbs were evaluated at 6 sites in southern inland Queensland to identify potential pasture and forage plants for use on marginal cropping soils. The region experiences summer heat waves and severe winter frosts. Emphasis was on perennial plants, and native species were included. Seedlings were transplanted into the unfertilized fields in either summer or autumn to suit the growing season of plants, and watered to ensure estab-lishment. Summer-growing grasses were the most successful group, while cool season-growing perennials mostly failed. Summer legumes were disappointing, with Stylosanthes scabra and Indigofera schimperi performing best. Some lines such as I. schimperi and the Eragrostis hybrid cv. Cochise were assessed as potential weeds owing to low animal acceptance. Native Rhynchosia minima grew well at some sites and deserves more study. Cenchrus ciliaris was always easy to establish and produced the highest yields. Persistence of some Digitaria and Bothriochloa species, Eragrostis curvula and Fingerhuthia africana at specific sites was encouraging, but potential weediness needs careful assessment. Standard species were identified to represent the main forage types, such as Austrostipa scabra for cool season-growing grasses, for incorporation into future trials with new genetic materials. The early field testing protocol used should be considered for use elsewhere, if unreliable rainfall poses a high risk of establishment failure from scarce seed.

Cancer incidence, mortality, and pregnancy outcome among women treated for cervical intraepithelial neoplasia

Cervical cancer develops through precursor lesions, i.e. cervical intraepithelialneoplasms (CIN). These can be detected and treated before progression to invasive cancer. The major risk factor for developing cervical cancer or CIN is persistent or recurrent infection with high-risk human papilloma virus (hrHPV). Other associated risk factors include low socioeconomic status, smoking, sexually transmitted infections, and high number of sexual partners, and these risk factors can predispose to some other cancers, excess mortality, and reproductive health complications as well. The aim was to study long-term cancer incidence, mortality, and reproductive health outcomes among women treated for CIN. Based on the results, we could evaluate the efficacy and safety of CIN treatment practices and estimate the role of the risk factors of CIN patients for cancer incidence, mortality, and reproductive health. We collected a cohort of 7 599 women treated for CIN at Helsinki University Central Hospital from 1974 to 2001. Information about their cancer incidence, cause of death, birth of children and other reproductive endpoints, and socio-economic status were gathered through registerlinkages to the Finnish Cancer Registry, Finnish Population Registry, and Statistics Finland. Depending on the endpoints in question, the women treated were compared to the general population, to themselves, or to an age- and municipality-matched reference cohort. Cervical cancer incidence was increased after treatment of CIN for at least 20 years, regardless of the grade of histology at treatment. Compared to all of the colposcopically guided methods, cold knife conization (CKC) was the least effective method of treatment in terms of later CIN 3 or cervical cancer incidence. In addition to cervical cancer, incidence of other HPV-related anogenital cancers was increased among those treated, as was the incidence of lung cancer and other smoking-related cancers. Mortality from cervical cancer among the women treated was not statistically significantly elevated, and after adjustment for socio-economic status, the hazard ratio (HR) was 1.0. In fact, the excess mortality among those treated was mainly due to increased mortality from other cancers, especially from lung cancer. In terms of post-treatment fertility, the CIN treatments seem to be safe: The women had more deliveries, and their incidence of pregnancy was similar before and after treatment. Incidence of extra-uterine pregnancies and induced abortions was elevated among the treated both before and after treatment. Thus this elevation did not occur because they were treated rather to a great extent was due to the other known risk factors these women had in excess, i.e. sexually transmitted infections. The purpose of any cancer preventive activity is to reduce cancer incidence and mortality. In Finland, cervical cancer is a rare disease and death from it even rarer, mostly due to the effective screening program. Despite this, the women treated are at increased risk for cancer; not just for cervical cancer. They must be followed up carefully and for a long period of time; general health education, especially cessation of smoking, is crucial in the management process, as well as interventions towards proper use of birth control such as condoms.

Associations between personality traits and sleep quality and quantity in young adults

This thesis examines the associations between personality traits and sleep quantity and quality in young adults. Additionally the possible effects of birth status on these associations are examined. The data used in this thesis is part of a birth cohort study (Helsinki Study of Very Low Birth Weight Adults). The personality traits are based on the five-factor model of personality. The sleep quantity and quality are based on actigraphy assessments. Four hypothesis were made about the personality and sleep associations: (1) neuroticism is related to a lesser quality of sleep, (2) there will be more significant associations between personality traits and sleep quality than between personality traits and sleep quantity, (3) the Very Low Birth Weight (VLBW) as well as, (4) the Small for Gestational Age (SGA) status will affect the associations. Linear regressions were used to study the associations between personality traits and sleep quality and quantity. Whenever an association was significant, it was tested whether this association was moderated first, by the VLBW and second, by the SGA status of the participant. The results were mostly in line with previous research especially demonstrating the negative association between neuroticism and the quality of sleep and suggesting that vulnerability to stress decreases sleep quality. Also it was found that agreeableness and conscientiousness were associated with better sleep quality and extraversion was associated with lower sleep quantity. In addition SGA status moderated the personality and sleep associations. It is proposed that there are two factors behind the interaction. First, prenatally developing mechanisms have an effect on the development of sleep as well as personality. Second, differences in the postnatal environment, for instance the parenting practices, can account for this finding. Future research could focus especially on what kind of prenatal disturbances SGA infants have in the development of mechanisms related to sleep and personality. Also focusing on the differences in parental interaction might shed more light on the results.