Screening for physical activity in family practice - Evaluation of two brief assessment tools

Background: Physical activity (PA) is relevant to the prevention and management of many health conditions in family practice. There is a need for an efficient, reliable, and valid assessment tool to identify patients in need of PA interventions. Methods: Twenty-eight family physicians in three Australian cities assessed the PA of their adult patients during 2004 using either a two- (2Q) or three-question (3Q) assessment. This was administered again approximately 3 days later to evaluate test-retest reliability. Concurrent validity was evaluated by measuring agreement with the Active Australia Questionnaire, and criterion validity by comparison with 7-day Computer Science Applications, Inc. (CSA) accelerometer counts. Results: A total of 509 patients participated, with 428 (84%) completing a repeat assessment, and 415 (82%) accelerometer monitoring. The brief assessments had moderate test-retest reliability (2Q k = 58.0%, 95% confidence interval [CI] = 47.2-68.8%; 3Q k = 55.6%, 95% CI = 43.8-67.4%); fair to moderate concurrent validity (2Q k = 46.7%, 95% CI = 35.657.9%; 3Q k = 38.7%, 95% CI = 26.4-51.1%); and poor to fair criterion validity (2Q k = 18.2%, 95% CI = 3.9-32.6%; 3Q k = 24.3%, 95% CI = 11.6-36.9%) for identifying patients as sufficiently active. A four-level scale of PA derived from the PA assessments was significantly correlated with accelerometer minutes (2Q rho = 0.39, 95% CI = 0.28-0.49; 3Q rho = 0.31, 95% CI = 0.18-0.43). Physicians reported that the assessments took I to 2 minutes to complete. Conclusions: Both PA assessments were feasible to use in family practice, and were suitable for identifying the least active patients. The 2Q assessment was preferred by clinicians and may be most appropriate for dissemination.

Evaluation of the Western Australian Department of Health telehealth project

In 1999, the Department of Health in Western Australia began a telehealth project, which finished in 2004. The 75 videoconferencing sites funded by the project were part of a total state-wide videoconference network of 104 sites. During the period from January 2002 to December 2003, a total of 3266 consultations, case reviews and patient education sessions took place. Clinical use grew to 30% of all telehealth activity. Educational use was approximately 40% (1416 sessions) and management use was about 30% (1031 sessions). The average overhead cost per telehealth session across all regions and usage types was $A192. Meaningful comparisons of the results of the present study with other public health providers were difficult, because many of the available Websites on telehealth were out of date. Despite the successful use of telehealth to deliver clinical services in Western Australia, sustaining the effort in the post-project phase will present significant challenges.

Change in woolgrower profits from adopting staple strength-enhancing management strategies

Wool tenderness is a significant problem in Australia, especially in areas where sheep graze under highly seasonal conditions. In this study, a profit function model is specified, estimated and simulated to assess the economic impact of staple strength-enhancing research on the profits of Australian woolgrowers. The model is based on a number of fundamental characteristics of the Australian wool industry and the staple-strength enhancing technology being assessed. The model consists of a system of demand and supply equations that are specified in terms of effective, rather than actual, prices. The interrelationships between the inputs and outputs are allowed for in the model in a manner that is consistent with theoretical restrictions. The adoption of the new feed management strategy results in a 4.4% increase in the expected profits of Australian wool producers in the short-run, and a 2.2% increase in expected profits in the long-run.

Development and evaluation of the Clinician Suicide Risk Assessment Checklist

This paper describes the development and evaluation of a new instrument – the Clinician Suicide Risk Assessment Checklist (CSRAC). The instrument assesses the clinician’s competency in three areas: clinical interviewing, assessment of specific suicide risk factors, and formulating a management plan. A draft checklist was constructed by integrating information from 1) literature review 2) expert clinician focus group and 3) consultation with experts. It was utilised in a simulated clinical scenario with clinician trainees and a trained actor in order to test for inter-rater agreement. Agreement was calculated and the checklist was re-drafted with the aim of maximising agreement. A second phase of simulated clinical scenarios was then conducted and inter-rater agreement was calculated for the revised checklist. In the first phase of the study, 18 of 35 items had inadequate inter-rater agreement (60%>), while in the second phase, using the revised version, only 3 of 39 items failed to achieve adequate inter-rater agreement. Further evidence of reliability and validity are required. Continued development of the CSRAC will be necessary before it can be utilised to assess the effectiveness of risk assessment training programs.

Evaluation of Melanotaenia duboulayi (Atheriniformes : Melanotaeniidae), Hypseleotris galii (Perciformes : Eleotridae), and larvicide Vectolex (R) WG (Bacillus sphaericus) for integrated control of Culex annulirostris

Australian freshwater fish species Melanotaenia duboulayi and Hypseleotris galii were selected for a small plot field evaluation of an integrated pest management strategy using native fish and VectoLex® WG (Bacillus sphaericus) for the control of Culex annulirostris Skuse, the principal freshwater vector of arbovirus Ross River virus in Australia. When tested alone, the level of control afforded by M. duboulayi and H. galii was highly dependent on the prerelease density of mosquito larvae; and even when stocking rates as high as 10 g per pond (>30 kg/ha) were used, larval abundance was too high to attain adequate control from fish alone. In contrast, treatment with VectoLex WG at 500 g/ha resulted in 100% mortality of Cx. annulirostris immatures, but no residual activity was evident. The delayed reduction of Cx. annulirostris immatures in ponds stocked with fish alone, and the recolonization by Cx. annulirostris in ponds after treatment with B. sphaericus, did not occur when both treatments were combined.

Evaluation of NHMRC funded research completed in 1992, 1997 and 2003: gains in knowledge, health and wealth

Objective: To report on strategies for, and outcomes of, evaluation of knowledge (publications), health and wealth (commercial) gains from medical research funded by the Australian Government through the National Health and Medical Research Council (NHMRC). Design and methods: End-of-grant reports submitted by researchers within 6 months of completion of NHMRC funded project grants which terminated in 2003 were used to capture self-reported publication number, health and wealth gains. Self-reported gains were also examined in retrospective surveys of grants completed in 1992 and 1997 and awards primarily supporting people (“people awards”) held between 1992 and 2002. Results: The response rate for the 1992 sample was too low for meaningful analysis. The mean number of publications per grant in the basic biomedical, clinical and health services research areas was very similar in 1997 and 2003. The publication output for population health was somewhat higher in the 2003 than in the 1997 analysis. For grants completed in 1997, 24% (31/131) affected clinical practice; 14% (18/131) public health practice; 9% (12/131) health policy; and 41% (54/131) had commercial potential with 20% (26/131) resulting in patents. Most respondents (89%) agreed that NHMRC people awards improved their career prospects. Interpretation is limited by the relatively low response rates (50% or less). Conclusions: A mechanism has been developed for ongoing assessment of NHMRC funded research. This process will improve accountability to the community and to government, and refine current funding mechanisms to most efficiently deliver health and economic returns for Australia.

Risk stratification of patients with chronic kidney disease: Results of screening strategies incorporating clinical risk scoring and dobutamine stress echocardiography

Background Cardiac disease is the principal cause of death in patients with chronic kidney disease (CKD). Ischemia at dobutamine stress echocardiography (DSE) is associated with adverse events in these patients. We sought the efficacy of combining clinical risk evaluation with DSE. Methods We allocated 244 patients with CKD (mean age 54 years, 140 men, 169 dialysis-dependent at baseline) into low- and high-risk groups based on two disease-specific scores and the Framingham risk model. All underwent DSE and were further stratified according to DSE results. Patients were followed over 20 +/- 14 months for events (death, myocardial infarction, acute coronary syndrome). Results There were 49 deaths and 32 cardiac events. Using the different clinical scores, allocation of high risk varied from 34% to 79% of patients, and 39% to 50% of high-risk patients had an abnormal DSE. In the high-risk groups, depending on the clinical score chosen, 25% to 44% with an abnormal DSE had a cardiac event, compared with 8% to 22% with a.normal DSE. Cardiac events occurred in 2.0%, 3.1 %, and 9.7% of the low-risk patients, using the two disease-specific and Framingham scores, respectively, and DSE results did not add to risk evaluation in this subgroup. Independent DSE predictors of cardiac events were a lower resting diastolic blood pressure, angina during the test, and the combination of ischemia with resting left ventricular dysfunction. Conclusion In CKD patients, high-risk findings by DSE can predict outcome. A stepwise strategy of combining clinical risk scores with DSE for CAD screening in CKD reduces the number of tests required and identifies a high-risk subgroup among whom DSE results more effectively stratify high and low risk.

Incremental cost-effectiveness of exercise echocardiography vs. SPECT imaging for the evaluation of stable chest pain

Aims Technological advances in cardiac imaging have led to dramatic increases in test utilization and consumption of a growing proportion of cardiovascular healthcare costs. The opportunity costs of strategies favouring exercise echocardiography or SPECT imaging have been incompletely evaluated. Methods and results We examined prognosis and cost-effectiveness of exercise echocardiography (n=4884) vs. SPECT (n=4637) imaging in stable, intermediate risk, chest pain patients. Ischaemia extent was defined as the number of vascular territories with echocardiographic wall motion or SPECT perfusion abnormalities. Cox proportional hazard models were employed to assess time to cardiac death or myocardial infarction (MI). Total cardiovascular costs were summed (discounted and inflation-corrected) throughout follow-up. A cost-effectiveness ratio = 2% annual event risk), SPECT ischaemia was associated with earlier and greater utilization of coronary revascularization (P < 0.0001) resulting in an incremental cost-effectiveness ratio of $32 381/LYS. Conclusion Health care policies aimed at allocating limited resources can be effectively guided by applying clinical and economic outcomes evidence. A strategy aimed at cost-effective testing would support using echocardiography in low-risk patients with suspected coronary disease, whereas those higher risk patients benefit from referral to SPECT imaging.

Extent and economic effect of heat loads on dairy cattle production in Australia

Objective To investigate the extent of heat load problems, caused by the combination of excessive temperature and humidity, in Holstein-Friesian cows in Australia. Also, to outline how milk production losses and consequent costs from this can be estimated and minimised. Procedures Long-term meteorological data for Australia were analysed to determine the distribution of hot conditions over space and time. Fifteen dairy production regions were identified for higher-resolution data analysis. Both the raw meteorological data and their integration into a temperature-humidity thermal index were compiled onto a computer program. This mapping software displays the distribution of climatic patterns, both Australia-wide and within the selected dairying regions. Graphical displays of the variation in historical records for 200 locations in the 15 dairying regions are also available. As a separate study, production data from research stations, on-farm trials and milk factory records were statistically analysed and correlated with the climatic indices, to estimate production losses due to hot conditions. Results Both milk yields and milk constituents declined with increases in the temperature-humidity index. The onset and rate of this decline are dependent on a number of factors, including location, level of production, adaptation, and management regime. These results have been integrated into a farm-level economic analysis for managers of dairy properties. Conclusion By considering the historical patterns of hot conditions over time and space, along with expected production losses, managers of dairy farms can now conduct an economic evaluation of investment strategies to alleviate heat loads. These strategies include the provision of sprinklers, shade structures, or combinations of these.

Evaluation of the effectiveness of enrichment for a group of captive squirrel monkeys (Saimiri sciureus) using time-lapse recording and instantaneous scan sampling

One aim of providing enrichment to captive animals is to promote the expression of behavioural patterns similar to their wild conspecifics. We evaluated the effectiveness of four types of simple feeding enrichment, using surveillance cameras to record the behaviour of 11 captive squirrel monkeys housed in a single enclosure at Alma Park Zoo in Brisbane, Australia. The enrichment involved differences in presentation (whole/chopped) and distribution (localised/scattered) of fruit and vegetables that were part of the normal diet of these animals. Distinguishing between individual squirrel monkeys was not possible from the videos, so Instantaneous Scan Sampling was used to record the numbers of animals performing particular behaviours every 15 minutes over the 24 hour period as well as every 5 minutes for the hour following provision of enrichment. This provided an estimation of the percentage of time spent by the group in various activities. As a result of the enrichment, the activity budget of the group more closely approximated that of wild squirrel monkeys. However on a number of occasions where the enrichment required the squirrel monkeys to work to obtain their food (whole fruit and vegetables), a number of individuals became aggressive towards the zookeepers. This result highlights the variation in responses of individual animals towards enrichment and indicates that in enclosures with large numbers of animals, the response of each individual should be evaluated in addition to the overall benefit of the enrichment for the group. Furthermore, this variation also suggests that it may be beneficial to provide the animals with choices of enrichment as opposed to providing single forms of enrichment that may only be effective for a proportion of the animals in the enclosure, and may even result in undesirable responses from some individuals.