Application of Geographic Modeling Techniques to Quantify Spatial Access to Health Services Before and After an Acute Cardiac Event: The Cardiac ARIA Project

Background: Access to cardiac services is essential for appropriate implementation of evidence-based therapies to improve outcomes. The Cardiac Accessibility and Remoteness Index for Australia (Cardiac ARIA) aimed to derive an objective, geographic measure reflecting access to cardiac services. Methods: An expert panel defined an evidence-based clinical pathway. Using Geographic Information Systems (GIS), a numeric/alpha index was developed at two points along the continuum of care. The acute category (numeric) measured the time from the emergency call to arrival at an appropriate medical facility via road ambulance. The aftercare category (alpha) measured access to four basic services (family doctor, pharmacy, cardiac rehabilitation, and pathology services) when a patient returned to their community. Results: The numeric index ranged from 1 (access to principle referral center with cardiac catheterization service ≤ 1 hour) to 8 (no ambulance service, > 3 hours to medical facility, air transport required). The alphabetic index ranged from A (all 4 services available within 1 hour drive-time) to E (no services available within 1 hour). 13.9 million (71%) Australians resided within Cardiac ARIA 1A locations (hospital with cardiac catheterization laboratory and all aftercare within 1 hour). Those outside Cardiac 1A were over-represented by people aged over 65 years (32%) and Indigenous people (60%). Conclusion: The Cardiac ARIA index demonstrated substantial inequity in access to cardiac services in Australia. This methodology can be used to inform cardiology health service planning and the methodology could be applied to other common disease states within other regions of the world.

How do the learning outcomes of students compare in units with different levels of practical work? A comparative study about the relation between Problem-­Based Learning and assessment approaches

The literature supporting the notion that active, student-centered learning is superior to passive, teacher-centered instruction is encyclopedic (Bonwell & Eison, 1991; Bruning, Schraw, & Ronning, 1999; Haile, 1997a, 1997b, 1998; Johnson, Johnson, & Smith, 1999). Previous action research demonstrated that introducing a learning activity in class improved the learning outcomes of students (Mejias, 2010). People acquire knowledge and skills through practice and reflection, not by watching and listening to others telling them how to do something. In this context, this project aims to find more insights about the level of interactivity in the curriculum a class should have and its alignment with assessment so the intended learning outcomes (ILOs) are achieved. In this project, interactivity is implemented in the form of problem- based learning (PBL). I present the argument that a more continuous formative feedback when implemented with the correct amount of PBL stimulates student engagement bringing enormous benefits to student learning. Different levels of practical work (PBL) were implemented together with two different assessment approaches in two subjects. The outcomes were measured using qualitative and quantitative data to evaluate the levels of student engagement and satisfaction in the terms of ILOs.

Peer supporters for cardiac patients with diabetes : a randomised controlled trial

Aims: To determine whether incorporation of patient peer supporters in a Cardiac-Diabetes Self-Management Program (Peer-CDSMP) led to greater improvement in self-efficacy, knowledge and self-management behaviour in the intervention group compared to a control group. Background: Promoting improved self-management for those with diabetes and a cardiac condition is enhanced by raising motivation and providing a model. Peer support from former patients who are able to successfully manage similar conditions could enhance patient motivation to achieve better health outcomes and provide a model of how such management can be achieved. While studies on peer support have demonstrated the potential of peers in promoting self-management, none have examined the impact on patients with two comorbidities. Methods: A randomised controlled trial was used to develop and evaluate the effectiveness of the Peer-CDSMP from August 2009 to December 2010. Thirty cardiac patients with type 2 diabetes were recruited. The study commenced in an acute hospital, follow up at participants’ homes in Brisbane Australia. Results: While both the control and intervention groups had improved self-care behaviour, self-efficacy and knowledge, the improvement in knowledge was significantly greater for the intervention group. Conclusions: Significant improvement in knowledge was achieved for the intervention group. Absence of significant improvements in self-efficacy and self-care behaviour represents an inconclusive effect; further studies with larger sample sizes are recommended.

The introduction of an interactive teaching and learning activity (TLA) in class and its relationship to students’ learning-outcomes

In the university education arena, it is becoming apparent that traditional methods of conducting classes are not the most effective ways to achieve desired learning outcomes. The traditional class/method involves the instructor verbalizing information for passive, note-taking students who are assumed to be empty receptacles waiting to be filled with knowledge. This method is limited in its effectiveness, as the flow of information is usually only in one direction. Furthermore, “It has been demonstrated that students in many cases can recite and apply formulas in numerical problems, but the actual meaning and understanding of the concept behind the formula is not acquired (Crouch & Mazur)”. It is apparent that memorization is the main technique present in this approach. A more effective method of teaching involves increasing the students’ level of activity during, and hence their involvement in the learning process. This technique stimulates self- learning and assists in keeping these students’ levels of concentration more uniform. In this work, I am therefore interested in studying the influence of a particular TLA on students’ learning-outcomes. I want to foster high-level understanding and critical thinking skills using active learning (Silberman, 1996) techniques. The TLA in question aims to promote self-study by students and to expose them to a situation where their learning-outcomes can be tested. The motivation behind this activity is based on studies which suggest that some sensory modalities are more effective than others. Using various instruments for data collection and by means of a thorough analysis I present evidence of the effectiveness of this action research project which aims to improve my own teaching practices, with the ultimate goal of enhancing student’s learning.

Do perceptions mirror reality? Student perceptions of learning versus grade outcomes

This research addresses whether educators should consider measuring if students have learned what was intended, as recommended by education researchers. Students in an Introductory Marketing subject were asked to complete a voluntary survey rating their own progress on the intended learning outcomes for the course. One hundred and one surveys were completed by students in the second-last teaching week of the semester. Student identification numbers were used to link student perceptions with their grade outcomes. Regression analysis was used to ascertain whether student perceptions of their progress on the intended learning outcomes for the course could be used to predict their grades. While the results were significant, student perceptions of their progress on learning outcomes were a poor predictor of grade outcomes. The results of this study suggest that student perceptions may not mirror the reality. These results are somewhat surprising and future research examining the degree of change in the learning outcomes perceived by students is warranted. This will further contribute to decisions surrounding whether educators should measure if students have learned what was intended.

‘Show Me Your Wiki and I’ll Show you Mine’: Using Online Interactive Media to Improve Academic Writing and Research in a Public Health Under-Graduate Cohort

The number of Internet users in Australia has been steadily increasing, with over 10.9 million people currently subscribed to an internet provider (ABS, 2011). Over the past year, the most avid users of the Internet were 15 – 24 year olds, with approximately 95% accessing the internet on a regular basis (ABS, Social Trends, 2011). While the internet has been described as fundamental to higher education students, social and leisure internet tools are also increasingly being used by these students to generate and maintain their social and professional networks and interactions (Duffy & Bruns 2006). Rapid technological advancements have enabled greater and faster access to information for learning and education (Hemmi et al, 2009; Glassman and Kang, 2011). As such, we sought to integrate interactive, online social media into the assessment profile of a Public Health undergraduate cohort at the Queensland University of Technology (QUT). The aim of this exercise was to engage students to both develop and showcase their research on a range of complex, contemporary health issues within the online forum of Wikispaces (http://www.wikispaces.com/) for review and critique by their peers. We applied Bandura’s Social Learning Theory (SLT) to analyse the interactive processes from which students developed deeper and more sustained learning, and via which their overall academic writing standards were raised. This paper outlines the assessment task, and the students’ feedback on their learning outcomes in relation to the Attentional, Retentional, Motor Reproduction, and Motivational Processes outlined by Bandura in SLT. We conceptualise the findings in a theoretical model, and discuss the implications for this approach within the broader tertiary environment.

Acceptability of cognitive-behaviour therapy via the Internet for cessation of benzodiazepine use

Introduction and Aims: Long-term use of benzodiazepines remains common, and conveys significant risk. Providing psychological intervention in association with gradual dose reduction increases cessation rates above dose reduction alone, but appropriate psychological support is difficult to obtain. This study was undertaken to assess the outcomes of an uncontrolled case series of an internet-based cognitive-behaviour therapy (I-CBT) for benzodiazepine cessation. Design and Method: Users of benzodiazepines for > 3 months who wanted to reduce or cease benzodiazepines participated in the trial. They completed online assessments and accessed 13 newsletters on managing withdrawal symptoms and developing alternate ways to cope with life events. Therapist assistance was provided by email. Follow-up was at 3 and 6 months and feedback was obtained via comments and emails. Results: Program ratings and emailed comments of the program were positive. Thirty-two people registered for the program and 14 (44%) completed a 6-month follow-up. Of these, 8 (57%) reduced weekly intake by at least half, including 5 (36%) who ceased use. Shorter duration of use and birth outside Australia predicted greater percentage reductions at 3 months, while being partnered and in paid employment predicted reductions at 6 months. Discussion and Conclusion: While results were encouraging, controlled research is required to confirm the efficacy of the program, and engagement of both users and prescribers needs further attention.

Can the Cardiac ARIA Index Improve Cardiac Care for Australia's Indigenous Population?

Background: Timely access to appropriate cardiac care is critical for optimising outcomes. Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services for Australia's 20,387 population locations. Methods: An expert panel defined a single patient care pathway. Using geographic information systems (GIS) the numeric/alpha index was modelled in two phases. The acute phase index (numeric) ranged from 1 (access to tertiary centre with PCI ≤1 h) to 8 (no ambulance service, >3 h to medical facility, air transport required). The aftercare index was modelled into 5 alphabetic categories; A (Access to general practitioner, pharmacy, cardiac rehabilitation, pathology ≤1 h) to E (no services available within 1 h). Results: Approximately 70% or 13.9 million people lived within a CardiacARIAindex category 1A location. Disparity continues in access to category 1A cardiac services for 5.8 million (30%) of all Australians, 60% of Aboriginal and Torres Strait Islander people and 32% of people over 65 years of age. In a cardiac emergency only 40% of the Indigenous population reside within one hour of category 1 hospital. Approximately 30% (81,491 Indigenous persons) are more than one to three hours from basic cardiac services. Conclusion: Geographically, the majority of Australian's have timely access for survival of a cardiac event. The CardiacARIAindex objectively demonstrates that the healthcare system may not be providing for the needs of 60% of Indigenous people residing outside the 1A geographic radius. Innovative clinical practice maybe required to address these disparities.

Where not to have a Heart Attack in Australia!: The Cardiac ARIA Index

Background/aims: Access to appropriate health care following an acute cardiac event is important for positive outcomes. The aim of the Cardiac ARIA index was to derive an objective, comparable, geographic measure reflecting access to cardiac services across Australia. Methods: Geographic Information Systems (GIS) were used to model a numeric-alpha index based on acute management from onset of symptoms to return to the community. Acute time frames have been calculated to include time for ambulance to arrive, assess and load patient, and travel to facility by road 40–80 kph. Results: The acute phase of the index was modelled into five categories: 1 [24/7 percutaneous cardiac intervention (PCI) ≤1 h]; 2 [24/7 PCI 1–3 h, and PCI less than an additional hour to nearest accident and emergency room (A&E)]: 3 [Nearest A&E ≤3 h (no 24/7 PCI within an extra hour)]: 4 [Nearest A&E 3–12 h (no 24/7 PCI within an extra hour)]: 5 [Nearest A&E 12–24 h (no 24/7 PCI within an extra hour)]. Discharge care was modelled into three categories based on time to a cardiac rehabilitation program, retail pharmacy, pathology services, hospital, GP or remote clinic: (A) all services ≤30 min; (B) >30 min and ≤60 min; (C) >60 min. Examples of the index indicate that the majority of population locations within capital cities were category 1A; Alice Springs and Byron Bay were 3A; and the Northern Territory town of Maningrida had minimal access to cardiac services with an index ranking of 5C. Conclusion: The Cardiac ARIA index provides an invaluable tool to inform appropriate strategies for the use of scarce cardiac resources.

CARDIAC-ARIA: Measuring the Accessibility to Cardiovascular Services in Rural and Remote Australia Via Applied Geographical Spatial Technology (GIS)

Background/aims: Cardiovascular disease (CVD) continues to impose a heavy burden in terms of cost, disability and death in Australia. Recent evidence suggests that increasing remoteness, where cardiac services are scarce, is linked to an increased risk of dying from CVD. Fatal CVD events are reported to be between 20% and 50% higher in rural areas compared to major cities. Method: This project, with its extensive use of Geographic Information Systems (GIS) technology, will rank 11,338 rural and remote population centres to identify geographical ‘hotspots’ where there is likely to be a mismatch between the demand for and actual provision of cardiovascular services. It will, therefore, guide more equitable provision of services to rural and remote communities. Outcomes: The CARDIAC-ARIA project is designed to; map the type and location of cardiovascular services currently available in Australia, relative to the distribution of individuals who currently have symptomatic CVD; determine, by expert panel, what are the minimal requirements for comprehensive cardiovascular health support in metropolitan and rural communities and derive a rating classification based on the Accessibility and Remoteness Index of Australia (ARIA) for each of Australia's 11,338 rural and remote population centres. Conclusion: This unique, innovative and highly collaborative project has the potential to deliver a powerful tool to highlight and combat the burden imposed by cardiovascular disease (CVD) in Australia.

Shikumidukuri vs. one best (no) way! Project and Programme Management for Enterprise Innovation (P2M) : towards a new paradigm?

The purpose of this paper is to investigate the Japanese answer to the 90’s depression by (i). presenting a case study of the framework developed to address the new business challenges and value creation in complex, ambiguous and uncertain environment, i.e., Development of Project and Programme Management for Enterprise Innovation (P2M) and Project Management Association Japan (PMAJ) in Japan; and (ii). Exposing what in our view are the underlying theoretical bases supporting this framework and from this drawing some theoretical lessons learnt which could be helpful to the development of sound PM standards and PM competence model. This theoretical approach is assumed to be useful to transpose the Japanese experience to other analogical contexts and situations.

Book Review: "Mark Considine, Jenny Lewis and Damon Alexander Networks, Innovation and Public Policy : Politicians, Bureaucrats and the Pathways to Change inside Government Houndsmills, UK: Palgrave Macmillan, 2009"

Having wrung the most from workforce and workplace productivity initiaitves, innovation has come to the fore as a key goal and directive for public sector organisations to become more efficient. This clarion call for innovation can be heard all around the world, with public services everywhere taking up the message to develop better, smarter, novel, more innovative processes, programs and policies. In the current push for innovation, networks are considered to be a superior vehicle through which collective knowledge can be shared and leveraged; replacing or at least supplementing the role function previously provided by inventive leaders...

Dose response relationships between physical activity, walking and health-related quality of life in mid-age and older women

Background Although physical activity is associated with health-related quality of life (HRQL), the nature of the dose-response relationship remains unclear. This study examined the concurrent and prospective dose-response relationships between total physical activity (TPA) and (only) walking with HRQL in two age cohorts of women. Methods Participants were 10,698 women born in 1946-1951 and 7,646 born in 1921-1926, who completed three mailed surveys for the Australian Longitudinal Study on Women's Health. They reported weekly TPA minutes (sum of walking, moderate, and vigorous minutes). HRQL was measured with the Medical Outcomes Study Short-Form 36 Health Status Survey (SF-36). Linear mixed models, adjusted for socio-demographic and health-related variables, were used to examine associations between TPA level (none, very low, low, intermediate, sufficient, high, and very high) and SF-36 scores. For women who reported walking as their only physical activity, associations between walking and SF-36 scores were also examined. Results Curvilinear trends were observed between TPA and walking with SF-36 scores. Concurrently, HRQL scores increased significantly with increasing TPA and walking, in both cohorts, with increases less marked above sufficient activity levels. Prospectively, associations were attenuated although significant and meaningful improvements in physical functioning and vitality were observed across most TPA and walking categories above the low category. Conclusion For women in their 50s-80s without clinical depression, greater amounts of TPA are associated with better current and future HRQL, particularly physical functioning and vitality. Even if walking is their only activity, women, particularly those in their 70s-80s, have better health-related quality of life.