Anti-cholinergic load, health care utilization, and survival in people with advanced cancer: a pilot study.

INTRODUCTION: Anti-cholinergic medications have been associated with increased risks of cognitive impairment, premature mortality and increased risk of hospitalisation. Anti-cholinergic load associated with medication increases as death approaches in those with advanced cancer, yet little is known about associated adverse outcomes in this setting. METHODS: A substudy of 112 participants in a randomised control trial who had cancer and an Australia modified Karnofsky Performance Scale (AKPS) score (AKPS) of 60 or above, explored survival and health service utilisation; with anti-cholinergic load calculated using the Clinician Rated Anti-cholinergic Scale (modified version) longitudinally to death. A standardised starting point for prospectively calculating survival was an AKPS of 60 or above. RESULTS: Baseline entry to the sub-study was a mean 62 +/- 81 days (median 37, range 1-588) days before death (survival), with mean of 4.8 (median 3, SD 4.18, range 1 - 24) study assessments in this time period. Participants spent 22% of time as an inpatient. There was no significant association between anti-cholinergic score and time spent as an inpatient (adjusted for survival time) (p = 0.94); or survival time. DISCUSSION: No association between anti-cholinergic load and survival or time spent as an inpatient was seen. Future studies need to include cognitively impaired populations where the risks of symptomatic deterioration may be more substantial.

Capitalism, the state and health care in the age of austerity:A Marxist analysis

The capacity to provide satisfactory nursing care is being increasingly compromised by current trajectories of healthcare funding and governance. The purpose of this paper is to examine how well Marxist theories of the state and its relationship with capital can explain these trajectories in this period of ever-increasing austerity. Following a brief history of the current crisis, it examines empirically the effects of the crisis, and of the current trajectory of capitalism in general, upon the funding and organization of the UK and US healthcare systems. The deleterious effect of growing income inequalities to the health of the population are also addressed. Marx’s writings on the state and its relation to the capitalist class were fragmentary, and historically and geographically specific. From them, we can extract three theoretical variants: the instrumentalist theory of the state, where the state has no autonomy from capital; the abdication theory, whereby capital abstains from direct political power and relies on the state to serve its interests; and the class-balance theory of the state, whereby the struggle between two opposed classes allows the state to assert itself. Discussion of modern Marxist interpretations include Poulantzas’s structuralist abdication theory and Miliband’s instrumentalist theory. It is concluded that, despite the pluralism of electoral democracies, the bourgeoisie do have an overweening influence upon the state. The bourgeoisie’s ownership of the means of production provides the foundation for its influence because the state is obliged to rely on it to manage the supply of goods and services and the creation of wealth. That power is further reinforced by the infiltration of the bourgeoisie into the organs of state. The level of influence has accelerated rapidly over recent decades. One of the consequences of this has been that healthcare systems have become rich pickings for the evermore confident bourgeoisie.

Primary health care. Neoliberal continuities in “person-centered care”

This paper analyzes the document on primary health care (PHC) published by the World Health Organization (WHO) in 2008, held to mark the thirtieth anniversary of the Declaration of Alma-Ata on PHC (1). Objective: to investigate in depth the assumptions outlined in the report, in order to problematize the notion of APS and universal access to health that are made in this proposal. Methodology: using documentary analysis examines the health proposal prepared by the international body and subjected to criticism from the following areas: a) conception of health as aright or as a service. b) Criteria commodified healthcare. Results: emphasize the permanence of a neoliberal perspective on the proposals WHO health reform in this document, which needs to be discussed in contexts where neoliberalism was intense processes of inequality and exclusion, as in the case of Latin America.

An `upside-down` view of rural health care

Access to high quality health care services plays an important part in the health of rural communities and individuals. This fact is reflected in efforts by governments to improve the quality of such services through better targeting of funds and more efficient management of services. In Australia, the difficulties experienced by rural communities in attracting and retaining doctors has long been recognized as a contributing factor to the relatively higher levels of morbidity and mortality in rural areas. However, this paper, based on a study of two small rural communities in Australia, suggests that resolving the health problems of rural communities will require more than simply increasing the quality and accessibility of health services. Health and well-being in such communities relates as much to the sense of community cohesion as it does to the direct provision of medical services. Over recent years, that cohesion has diminished, undermined in part by government policies that have fuelled an exodus from small rural communities to urban areas. Until governments begin to take an 'upside-down' perspective, focusing on building healthy communities rather than simply on building hospitals to make communities healthy, the disadvantages faced by rural people will continue to be exacerbated.

Rural nursing and health care reforms : building a social model

This article explores recent shifts in health-care policy and the implications for rural nursing in Australia. Health-care reforms have resulted in the implementation of a 'market forces' ideology, creating tensions between economic imperatives and the need for equity and greater access in rural service delivery. New models of health-service delivery have been developed that have significant implications for the way rural health care is defined, practised and received. The issues surrounding the context of rural nursing practice and service delivery are discussed.

The transition from pediatric to adult health care services for young adults with a disability : an ethical perspective

Young children with disabilities and their carers or parents tend to form a long-term dependent relationship with a paediatrician throughout childhood At some stage when the young person with a disability reaches early adulthood, the relationship is severed This paper draws upon recent research undertaken by the authors that describes the difficulties experienced by young people with disabilities as they go through the transition from paediatric care to adult mainstream health care services. The purpose of this article is to present the argument that the dependent, paternalistic relationship that tends to exist between young people with disabilities (and/or their carers) and paediatricians throughout childhood does not facilitate the successful negotiation of adult mainstream health care services, nor optimally promote the well-being of these young people with disabilities. It is proposed that the promotion of autonomy (or self-determination) via a well planned transition program will increase the likelihood that young adults with disabilities and/or their carers will be empowered to successfully negotiate the current mainstream health care system in Australia, and will enhance the well-being of young adults with disabilities.

Prevention of type 2 diabetes in a primary health care setting interim results from the Greater Green Triangle (GGT) Diabetes Prevention Project

Although clinical trials have shown that lifestyle modifications reduce the risk of type 2 diabetes, translating lessons from trials to primary care remains a challenge. The aim of the study was to evaluate efficacy and feasibility of primary care-based diabetes prevention model with modest resource requirements in rural Australia. Three hundred and eleven subjects with at least a moderate risk of type 2 diabetes participated in a combined dietary and physical activity intervention. Clinical measurements and fasting blood samples were taken at the baseline and after intervention. After 3 months intervention, total (change −3.5%, p < 0.001) and LDL cholesterol (−4.8%, p < 0.001) plasma levels as well as body mass index (−2.5%, p < 0.001), weight (−2.5%, p < 0.001), and waist (−1.6%, p < 0.001) and hip (−2.7%, p < 0.001) circumferences reduced significantly. A borderline reduction was found in triglyceride levels (−4.8%, p = 0.058) while no changes were observed in HDL cholesterol (+0.6%, p = 0.525), glucose (+0.06%, p = 0.386), or systolic (−0.98%, p = 0.095) or diastolic (−1.06%, p = 0.134) blood pressure levels. In conclusion, a lifestyle intervention improved health outcomes – especially obesity and blood lipids – in a population at high risk of developing type 2 diabetes. Our results suggest that the present model is effective and feasible to carry out in primary care settings.

Challenges in health services and health systems research

The relationship between emerging trends in healthcare systems and the consequent research priorities will be explored.

Governments and policy makers in developed countries are increasingly focused on the management of chronic disease, reflecting demographic changes and shifts in the burden of disease. Systems of quality improvement and reward are increasingly based on performance in chronic disease management. There is some evidence that countries with well-developed systems of primary care, such as Australia, achieve better health outcomes at less cost. In the past 15 years, almost all developed countries have undergone some type of health care reform. There has been a major focus on reducing costs; often involving shifting services from secondary to primary care. While there are few international comparisons, most suggest a complex relationship between the strength of primary care within the overall health services system and good performance, particularly with regard to lower costs of care and particularly relevant measures of health.

Aims for 21st century health systems
What, then, are the issues which are shaping contemporary general practice in developed countries? There are several imperatives: Safety, effectiveness, patient-centredness, timeliness, efficiency and equity. A study by the Nuffield Trust (Dargie, 1999) projected the shape of healthcare for the first fifteen years of this century. The study identified six issues that need to be addressed in the process of formulating health systems policies:

• Peoples’ expectations and financial sustainability
• Demography and ageing
• Information and knowledge management
• Scientific advance and new technology
• Workforce education and training
• Systems performance and quality (efficiency, effectiveness, economy
and equity)

Each of these six issues requires innovative thinking and priority setting on the part of the health sector, such as the delivery of health services in new and creative ways. Furthermore, there is a clear need for a finely tuned research, development and evaluation strategies to match these goals.

Defining dual diagnosis : a qualitative study of the views of health care workers

Background: 'Dual diagnosis' is the term of choice in many countries to describe clients with co-occurring mental health and alcohol and other drug (AOD) issues. However, it is not known if its meaning is consistently represented within and across health care services. This uncertainty has significant implications for referral, consultation and research.
Aim: To obtain information about the way that different health care professionals understand the term 'dual diagnosis'.
Method: Twenty-nine health care workers across five service types (medical, mental health, AOD, dual diagnosis and community health) in Victoria, Australia were interviewed about their understanding of the term 'dual diagnosis'.
Results: The findings indicated that service providers working in AOD and Mental Health had a shared general understanding of what was meant by 'dual diagnosis', despite uncertainties about more specific inclusion criteria. In contrast, medical and community health staff lacked a similar shared understanding, and were more likely to recommend change, but offered no consensus on alternatives.
Conclusion: The results indicate that while the term 'dual diagnosis' has value in efficiently directing attention to the complexity of treatment issues, health practitioners cannot assume it will convey the intended meaning outside mental health or AOD services. Clear articulation of the intended definition may be a necessary requirement in wider health care communication.

Health care provider and consumer understandings of cultural safety and cultural competency in health care : an Australian study

There is increasing recognition in Australia that racial and ethnic minority groups experience significant disparities in health and health care compared with the average population and that the Australian health care system needs to be more responsive to the health and care needs of these groups. The paper presents the findings of a year long study that explored what providers and recipients of health care know and understand about the nature and implications of providing culturally safe and competent health care to minority racial and ethnic groups in Victoria, Australia. Analysis of the data obtained from interviewing 145 participants recruited from over 17 different organizational sites revealed a paucity of knowledge and understanding of this issue and the need for a new approach to redress the status quo.

Effects of financial disadvantage on use and non-use of after hours care in Australia

Policy addressing the provision of primary care after hours (AH) is currently in flux because of concerns about equity of access and cost. In this study we examine the effects of socioeconomic disadvantage on access to AH care and episodes of not seeking AH care when needed among users and non-users of AH care. The effects of health on these relationships were also explored. The total sample consisted of 5538 users of AH care and 891 non-users of AH care who were randomly selected for telephone interviews. Factors determining AH care included accessibility that is structural barriers to use of care such as distance and transport, as well as affordability and availability. Logistic regression was used to determine the impact of financial disadvantage on episodes of not seeking AH care. Barriers to use of AH care and household health were subsequently added to the models to assess their impact. The results suggested that there were inequities in access to AH care but these were a function of barriers to AH care use rather than financial disadvantage per se. Accessibility and availability were significant barriers to use of AH clinics among both user and non-user samples. Affordability was only a significant barrier among users of AH care. The study suggests that policy aimed at reducing these barriers may effectively address inequities in AH care but that to be optimally effective policy change would also need to be accompanied by changes in consumer awareness.

An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context

Cultural safety has been promoted by its New Zealand proponents as an effective process for managing cultural risk in health care and improving the cultural responsiveness of mainstream health services when delivering care to culturally diverse populations. Its effectiveness in this regard has not, however, been comprehensively investigated. A key purpose of this study was to explore and describe what is known and understood about the notion of cultural safety and its possible application to and in Australian health care domains. Findings from the study indicate that the notion of cultural safety is conceptually problematic, poorly understood, and underresearched and, unless substantially revised, cannot be meaningfully applied to the cultural context of Australia.

Investigating people management issues in a third sector health care organisation - an inductive approach

Objective : To explain use of inductive convergent interviewing to generate the perceived critical people management issues, as perceived by staff, as a prelude to longitudinal surveys in a third sector health care organisation.

Design : Convergent interviewing is a qualitative technique that addresses research topics that lack theoretical underpinning and is an inductive, flexible, evolving research approach. The key issues converged after six rounds of interviews as well as a further round to ensure that all of the common people management issues had been generated.

Setting : Studies in employee behaviour in the health care industry exist, but there is little in the way of tested models of predictors of such behaviour in third sector organisations in the Australian health care industry. The context is what differentiates this study covering a range of facilities and positions in hospitals and aged care situations within one third sector health care organisation.

Subjects : The study proposed twenty seven extensive interviews over a range of facilities and positions. Twenty one interviewees participated in the final convergent process.

Conclusions : Critical issues included: workload across occupational groups, internal management support, adequate training, the appropriate skill mix in staff, physical risk in work, satisfaction, as well as other issues. These issues confirm the proposition of sector‑ness in health organisations that are multi‑dimensional rather than uni‑dimensional.

Examination of the "all hazards" approach to disaster management as applied to field disaster management and pre-hospital care in Australia

Disasters, emergencies, incidents, and major incidents - they all come back to the same thing regardless of what they are called. The common denominator is that there is loss of life, injury to people and animals and damage and destruction of property. The management of such events relies on four phases: 1. Prevention 2. Preparation 3. Response 4. Recovery Each of these phases is managed in a different way and often by different teams. Here, concentration has been given to phases 2 and 3, with particular emphasis on phase 3, Response. The words used to describe such events are often related to legislation. The terminology is detailed later. However, whatever the description, whenever prevention is not possible, or fails, then the need is to respond. Response is always better when the responders are prepared. Training is a major part of response preparation and this book is designed to assist those in the health industry who need to be ready when something happens. One of the training packages for responders is the Major Incident Medical Management and Support (MIMMS) Course and this work was designed to supplement the manual prepared by Hodgetts and Macway-Jones(87) in the UK. Included is what the health services responder, who may be sent to an event in which the main concern is trauma, should know. Concentration is on the initial response and does not deal in any detail with hospital reaction, the public health aspects, or the mental health support that provides psychological help to victims and responders, and which are also essential parts of disaster management. People, in times of disaster, have always been quick to offer assistance. It is now well recognised however, that the 'enthusiastic amateur', whilst being a well meaning volunteer, isn't always what is needed. All too often such people have made things worse and have sometimes ended up as victims themselves. There is a place now for volunteers and there probably always will be. The big difference is that these people must be well informed, well trained and well practiced if they are to be effective. Fortunately such people and organisations do exist. Without the work of the St John Ambulance, the State Emergency Service, the Rural Fire Service the Red Cross and the Volunteer Rescue Association, to mention only a few, our response to disasters would be far less effective. There is a strong history of individuals being available to help the community in times of crisis. Mostly these people were volunteers but there has also always been the need for a core of professional support. In the recent past, professional support mechanisms have been developed from lessons learned, particularly to situations that need a rapid and well organised response. As lessons are learned from an analysis of events, philosophy and methods have changed. Our present system is not perfect and perhaps never will be. The need for an 'all-hazards approach' makes detailed planning very difficult and so there will probably always be criticisms about the way an event was handled. Hindsight is a wonderful thing, provided we learn from it. That means that this text is certainly not the 'last word' and revisions as we learn from experience will be inevitable. Because the author works primarily in New South Wales, many of the explanations and examples are specific to that state. In Australia disaster response is a State, rather than a Commonwealth, responsibility and consequently, and inevitably, there are differences in management between the states and territories within Australia. With the influence of Emergency Management Australia, these differences are being reduced. This means that across state and territory boundaries, assistance is common and interstate teams can be deployed and assimilated into the response rapidly, safely, effectively and with minimum explanation. This text sets out to increase the understanding of what is required, what is in place and how the processes of response are managed. By way of introduction and background, examples are given of those situations that have occurred, or could happen. Man Made Disasters has been divided into two distinct sections. Those which are related to structures or transport and those related directly to people. The first section, Chapter 3, includes: • Transport accidents involving land, rail, sea or air vehicles. • Collapse of buildings for reasons other than earthquakes or storms. • Industrial accidents, including the release of hazardous substances and nuclear events. A second section dealing with the consequences of the direct actions of people is separated as Chapter 4, entitled 'People Disasters'. Included are: • Crowd incidents involving sports and entertainment venues. • Terrorism From Chapter 4 on, the emphasis is on the Response phase and deals with organisation and response techniques in detail. Finally there is a section on terminology and abbreviations. An appendix details a typical disaster pack content. War, the greatest of all man made disasters is not considered in this text.