Showing papers by "Grant Russell published in 2019"

Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial

Abstract: We evaluated the effectiveness of an interdisciplinary, primary care-based model of care for chronic obstructive pulmonary disease (COPD).A cluster randomised controlled trial was conducted in 43 general practices in Australia. Adults with a history of smoking and/or COPD, aged ≥40 years with two or more clinic visits in the previous year were enrolled following spirometric confirmation of COPD. The model of care comprised smoking cessation support, home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase). Main outcomes included changes in St George's Respiratory Questionnaire (SGRQ) score, COPD Assessment Test (CAT), dyspnoea, smoking abstinence and lung function at 6 and 12 months.We identified 272 participants with COPD (157 intervention, 115 usual care); 49 (31%) out of 157 completed both HMR and HomeBase. Intention-to-treat analysis showed no statistically significant difference in change in SGRQ at 6 months (adjusted between-group difference 2.45 favouring intervention, 95% CI -0.89-5.79). Per protocol analyses showed clinically and statistically significant improvements in SGRQ in those receiving the full intervention compared to usual care (difference 5.22, 95% CI 0.19-10.25). No statistically significant differences were observed in change in CAT, dyspnoea, smoking abstinence or lung function.No significant evidence was found for the effectiveness of this interdisciplinary model of care for COPD in primary care over usual care. Low uptake was a limitation.

Improving access to primary healthcare for vulnerable populations in Australia and Canada: protocol for a mixed-method evaluation of six complex interventions

Abstract: Introduction Access to primary healthcare (PHC) has a fundamental influence on health outcomes, particularly for members of vulnerable populations. Innovative Models Promoting Access-to-Care Transformation (IMPACT) is a 5-year research programme built on community-academic partnerships. IMPACT aims to design, implement and evaluate organisational innovations to improve access to appropriate PHC for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three Australian states (New South Wales, Victoria and South Australia) and three Canadian provinces (Ontario, Quebec and Alberta) used a common approach to implement six different interventions. This paper describes the protocol to evaluate the processes, outcomes and scalability of these organisational innovations. Methods and analysis The evaluation will use a convergent mixed-methods design involving longitudinal (pre and post) analysis of the six interventions. Study participants include vulnerable populations, PHC practices, their clinicians and administrative staff, service providers in other health or social service organisations, intervention staff and members of the LIP teams. Data were collected prior to and 3–6 months after the interventions and included interviews with members of the LIPs, organisational process data, document analysis and tools collecting the cost of components of the intervention. Assessment of impacts on individuals and organisations will rely on surveys and semistructured interviews (and, in some settings, direct observation) of participating patients, providers and PHC practices. Ethics and dissemination The IMPACT research programme received initial ethics approval from St Mary’s Hospital (Montreal) SMHC #13–30. The interventions received a range of other ethics approvals across the six jurisdictions. Dissemination of the findings should generate a deeper understanding of the ways in which system-level organisational innovations can improve access to PHC for vulnerable populations and new knowledge concerning improvements in PHC delivery in health service utilisation.

The association of migration experiences on the self-rated health status among adult humanitarian refugees to Australia: an analysis of a longitudinal cohort study

Abstract: Refugees are potentially at an increased risk for health problems due to their past and current migration experiences. How migration factors shape refugee health is not well understood. We examined the association between migration factors and the self-rated general health of adult humanitarian refugees living in Australia. We analyzed the first three waves of data from the ‘Building A New Life In Australia’ longitudinal survey of 2399 humanitarian refugees resettled in Australia. The study outcome was self-rated health measured by the 36-Item Short Form Health Survey. Predictors were migration process and resettlement factors. We used generalized linear mixed models to investigate the relationship between predictor and outcome variables. Poor general health persisted among this refugee population at high levels throughout the three-year follow-up. At baseline, 35.7% (95% CI: 33.8–37.7%) of the study population reported poorer general health. Female gender, increasing age and post-migration financial stressors were positively associated with poorer general health. Having a university degree and absence of chronic health conditions were seemingly protective against declining general health (OR: 0.50; 95% CI: 0.65–1.81 and OR: 0.15, 95% CI: 0.09–1.04, respectively). Our results show that there is persisting high prevalence of poorer general health among adult refugees across the initial years of resettlement in Australia. This finding suggests unmet health needs which may be compounded by the challenges of resettlement in a new society, highlighting the need for increased clinical awareness of this sustained health burden to help inform and prepare refugee health care and settlement service providers.

The impact of an integrated diabetes and kidney service on patients, primary and specialist health professionals in Australia: A qualitative study.

Abstract: Background To address guideline-practice gaps and improve management of patients with both diabetes and chronic kidney disease (CKD), we involved patients, health professionals and patient advocacy groups in the co-design and implementation of an integrated diabetes-kidney service. Objective In this study, we explored the experiences of patients and health-care providers, within this integrated diabetes and kidney service. Methods 5 focus groups and 2 semi-structured interviews were conducted amongst attending patients, referring primary health professionals, and attending specialist health professionals. Maximal variation sampling was used for both patients and referring primary health professionals to ensure an equal representation of males and females, and patients of different CKD stages. All discussions were audiotaped and transcribed verbatim, before being thematically analysed independently by 2 researchers. Results The mean age (SD) for specialist health professionals, primary care professionals and patients who participated was 45 (11), 44 (15) and 68 (5) years with men being 50%, 80% and 76% of the participants respectively. Key strengths of the diabetes and kidney service were noted to be better integration of care and a perception of improved health and management of health. Whilst some aspects of access such as time between referral and initial appointment and having fewer appointments improved, other aspects such as in-clinic waiting times and parking remained problematic. Specialist health professionals noted that health professional education could be improved. Patient self-management was also noted by to be an issue with some patients requesting more information and some health professionals expressing difficulty in empowering some patients. Conclusions Health professionals and patients reported that a co-designed integrated diabetes kidney service improved integration of care and improved health and management of health. However, some aspects of the process of care, health professional education and patient self-management remained challenging.

Mindfulness-based lifestyle programs for the self-management of Parkinson's disease in Australia.

Abstract: Despite emerging evidence suggesting positive outcomes of mindfulness training for the self-management of other neurodegenerative diseases, limited research has explored its effect on the self-management of Parkinson's disease (PD). We aimed to characterize the experiences of individuals participating in a facilitated, group mindfulness-based lifestyle program for community living adults with Stage 2 PD and explore how the program influenced beliefs about self-management of their disease. Our longitudinal qualitative study was embedded within a randomized controlled trial exploring the impact of a 6-week mindfulness-based lifestyle program on patient-reported function. The study was set in Melbourne, Australia in 2012-2013. We conducted semi-structured interviews with participants before, immediately after, and 6 months following participation in the program. Sixteen participants were interviewed prior to commencing the program. Of these, 12 were interviewed shortly after its conclusion, and 9 interviewed at 6 months. Prior to the program, participants felt a lack of control over their illness. A desire for control and a need for alternative tools for managing the progression of PD motivated many to engage with the program. Following the program, where participants experienced an increase in mindfulness, many became more accepting of disease progression and reported improved social relationships and self-confidence in managing their disease. Mindfulness-based lifestyle programs have the potential for increasing both participants' sense of control over their reactions to disease symptoms as well as social connectedness. Community-based mindfulness training may provide participants with tools for self-managing a number of the consequences of Stage 2 PD.

Health service brokerage to improve primary care access for populations experiencing vulnerability or disadvantage: a systematic review and realist synthesis

Abstract: Individuals experiencing disadvantage or marginalisation often face difficulty accessing primary health care. Overcoming access barriers is important for improving the health of these populations. Brokers can empower and enable people to access resources; however, their role in increasing access to health services has not been well-defined or researched in the literature. This review aims to identify whether a health service broker working with health and social service providers in the community can (a) identify individuals experiencing vulnerability who may benefit from improved access to quality primary care, and (b) link these individuals with an appropriate primary care provider for enduring, appropriate primary care. Six databases were searched for studies published between January 2008 and August 2015 that evaluated a health service broker intervention linking adults experiencing vulnerability to primary care. Relevant websites were also searched. Included studies were analysed using candidacy theory and a realist matrix was developed to identify mechanisms that may have contributed to changes in response to the interventions in different contexts. Eleven studies were included in the review. Of the eight studies judged to provide detailed description of the programs, the interventions predominately addressed two domains of candidacy (identification of candidacy and navigation), with limited applicability to the third and fourth dimensions (permeability of services and appearances at health services). Six of the eight studies were judged to have successfully linked their target group to primary care. The majority of the interventions focused on assisting patients to reach services and did not look at ways that providers or health services could alter the way they deliver care to improve access. While specific mechanisms behind the interventions could not be identified, it is suggested that individual advocacy may be a key element in the success of these types of interventions. The interventions were found to address some dimensions of candidacy, with health service brokers able to help people to identify their need for care and to access, navigate and interact with services. More consideration should be given to the influence of providers on patient candidacy, rather than placing the onus on patients.

Preventive Evidence into Practice: what factors matter in a facilitation intervention to prevent vascular disease in family practice?

Abstract: A perennial challenge of primary care quality improvement is to establish why interventions work in some circumstances, but not others. This study aimed to identify factors explaining variations in the impact on clinical practice of a facilitation led vascular health intervention in Australian family practice. Our mixed methods study was embedded within a cluster randomised controlled trial of a facilitation intervention designed to increase the uptake of evidence-based prevention of vascular disease in family practices. The study was set in four Australian states using eight of the study’s 16 intervention practices. Facilitators worked with intervention practices to develop and implement improvements in preventive care informed by a vascular risk factor audit. We constructed case studies of each practice’s “intervention narrative” from semi-structured interviews with clinicians, facilitators and other staff, practice observation, and document analysis of facilitator diaries. The intervention narratives were combined with pre- and post-intervention audit data to generate typologies of practice responses to the intervention. We found substantial variability between practices in the changes made to vascular risk recording. Context (i.e. practice size), adaptive reserve (i.e. interpersonal relationships, manager and nurse involvement), and occasional data idiosyncrasies interacted to influence this variability. The findings emphasise the importance of tailoring facilitation interventions to practice size, clinician engagement and, critically, the organisation of, and relationships between, the members of the practice team. The trial was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTR N12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

Clinical Characteristics Of Patients With Asthma COPD Overlap (ACO) In Australian Primary Care

Abstract: Purpose Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices. Patients and methods Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George's Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone. Results Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p<0.001), but no difference was found in post-bronchodilator spirometry. Demographic and clinical characteristics, dyspnoea, quality of life, comorbidities and treatment prescribed did not differ significantly between groups. Conclusion This is the first study describing the clinical characteristics of ACO patients in Australian general practices. Our finding of lower pre-bronchodilator lung function in the ACO group compared to those with COPD reinforces the importance of spirometry in primary care to inform management. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Patient-reported barriers and outcomes associated with poor glycaemic and blood pressure control in co-morbid diabetes and chronic kidney disease.

Abstract: Aims In patients with comorbid diabetes and chronic kidney disease, the extent to which patient-reported barriers to health-care and patient reported outcomes influence the quality of health care is not well established. This study explored the association between patient-reported barriers to health-care, patient activation, quality of life and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets. Methods This cross-sectional study recruited adults with diabetes and CKD (eGFR 20 to Results 199 patients, mean age 68.7 (SD 9.6), 70.4% male and 90.0% with type 2 diabetes were studied. Poor glycaemic control was associated with increased odds of patient reported “poor family support” (OR 4.90; 95% CI 1.80 to 13.32, p 0.05). Conclusions Specific patient-reported barriers, lack of patient perceived family and primary care physician support, are associated with increased odds of poor glycaemic and blood pressure control respectively. Interventions addressing these barriers may improve treatment target attainment.

Providing person-centred care for people with multiple chronic conditions: protocol for a qualitative study incorporating client and staff perspectives.

Abstract: Introduction Chronic conditions are associated with over one-third of potentially avoidable hospitalisations. Integrated care programmes aim to help people with chronic conditions to self-manage their health, thus avoiding hospital admissions. While founded on principles of person-centred care, the experiences of people with multiple chronic conditions in integrated care programmes are not widely known. Our study will explore how person-centred care is incorporated into an integrated care programme for people with multiple chronic conditions. Methods and analysis This is a qualitative phenomenological study being conducted from March 2018 to June 2019, in a large metropolitan health service in Melbourne, Australia. Participants will be programme clients (and/or their carers) and staff working in the programme. We will interview staff about their experiences of the programme. Recruited staff will assist with recruitment of clients who recently completed an episode of care, to participate in a semistructured interview in their home. We will also analyse the medical records of interviewed clients, and observe outpatient clinics connected to the programme, based on the findings of the interviews. We will analyse all data using thematic analysis, with overarching themes representing staff and client perspectives of person-centred care. Ethics and dissemination Ethical approval was granted by Monash Health (HREC/18/MonH/33) and Monash University (12260) Human Research Ethics Committees. Our study will provide a comprehensive exploration of person-centred care in an integrated care programme. It will add information to person-centred care literature on participants’ perceptions of what works and why, including barriers and enablers to person-centred care in a complex environment. Findings of this study will be disseminated via publications, conferences and presentations to the health service participants.

The OPTIMISE project: Protocol for a mixed methods, pragmatic, quasi-experimental trial to improve primary care delivery to refugees in Australia

Abstract: Australia is one of many nations struggling with the challenges of delivering quality primary health care (PHC) to increasing numbers of refugees. The OPTIMISE project represents a collaboration between 12 organisations to generate a model of integrated refugee PHC suitable for uptake throughout Australia. This paper describes the methodology of one component; an outreach practice facilitation intervention, directed towards improving the quality of PHC received by refugees in Australian general practices. Our mixed methods study will use a cluster stepped wedge randomised controlled trial design set in 3 urban regions of high refugee resettlement in Australia. The intervention was build upon regional partnerships of policy advisors, clinicians, academics and health service managers. Following a regional needs assessment, the partnerships reached consensus on four core areas for intervention in general practice (GP): recording of refugee status; using interpreters; conducting comprehensive health assessments; and referring to refugee specialised services. Refugee health staff trained in outreach practice facilitation techniques will work with GP clinics to modify practice routines relating to the four core areas. 36 general practice clinics with no prior involvement in a refugee health focused practice facilitation will be randomly allocated into early and late intervention groups. The primary outcome will be changes in number of claims for Medical Benefit Service reimbursed comprehensive health assessments among patients identified as being from a refugee background. Changes in practice performance for this and 3 secondary outcomes will be evaluated using multilevel mixed effects models. Baseline data collection will comprise (i) pre-intervention provider survey; (ii) two surveys documenting each practices’ structure and approaches to delivery of care to refugees. De-identified medical record data will be collected at baseline, at the end of the intervention and 6 and 12 months following completion. OPTIMISE will test whether a regionally oriented practice facilitation initiative can improve the quality of PHC delivered to refugees. Findings have the potential to influence policy and practice in broader primary care settings. Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 , 05/12/2018, Retrospectively registered. Protocol Version 1, 21/08/2017.

An investigation into the association of pre- and post-migration experiences on the self-rated health status among new resettled adult humanitarian refugees to Australia: a protocol for a mixed methods study.

Abstract: Refugees are one of the most vulnerable groups in our society. They are at risk of poor physical and mental health outcomes, much of this attributed to traumatic events prior to migration and the additional risk factors refugees face in the host nations. However, how migration factors shape the health of resettling refugees is not well understood. This study uses a mixed methods approach to examine how pre- and post-migration factors shape the self-rated health of resettling adult refugees in an effort to address the current knowledge gap. This study will use a sequential explanatory mixed method study design. We begin by analyzing resettlement and health data from the ‘Building a New Life In Australia’ longitudinal study of humanitarian refugees resettled in Australia to identify significant associations between migration factors and refugee health. Then, a series of semi-structured interviews with resettled refugees will further explore the lived experiences of refugees with respect to the relationship between migration and refugee health. Finally, we will integrate both sets of findings to develop a detailed understanding of how and why migratory factors contribute to refugee health during resettlement. There is a paucity of studies that examine the multidimensional nature of refugee health during resettlement and as a result, little is understood about their resettlement health needs. This information is required to inform existing or new resettlement interventions to help promote or improve refugee health. To overcome these limitations in the research knowledge, this study will use a mixture of study methods to illustrate the complex and multifaceted determinants of refugee health during resettlement in Australia.

Effectiveness of quality incentive payments in general practice (EQuIP-GP): a study protocol for a cluster-randomised trial of an outcomes-based funding model in Australian general practice to improve patient care.

Abstract: In the original publication of this article [1], the first name of the 3rd author is wrong.

Factors associated with successful chronic disease treatment plans for older Australians: Implications for rural and Indigenous Australians

Abstract: Objective: To identify factors associated with having a successful treatment plan for managing chronic conditions. Design: Secondary analysis of the Commonwealth Fund's 2014 International Health Policy Survey. Setting: Australia 2014. Participants: A total of 3310 Australian adults over 55 years old. Main outcome measures: Whether respondents: (i) had a treatment plan for their chronic condition; and (ii) believed that the plan was helpful in managing their condition. Methods: We used multiple logistic regressions to assess the association between individual factors (age, income, remoteness, Australian Aboriginal or Torres Strait Islander status) and patient reports of the outcomes of interest. Results: Most respondents reported having a treatment plan for their chronic condition(s); the majority reported that it was helpful in managing their health. Treatment plan provision was associated with age over 75 years, above-average income, Australian Aboriginal or Torres Strait Islander status and multiple chronic conditions. Plans were less likely for residents of outer regional and remote areas. Indigenous respondents were far less likely than non-Indigenous respondents to report that their treatment plan helped a lot. Respondents with providers who 'always' explained things were far more likely to say that a treatment plan helped. Conclusion: While the patient–provider relationship influenced the perceived success of treatment plans, inequities in treatment plan provision seemed linked with rurality and income. The higher frequency of treatment plans for Indigenous respondents might reflect access to Australian Aboriginal or Torres Strait Islander health checks, while the plan's perceived lack of efficacy suggests a gap in cultural acceptability.

The relationship between discharge medications and falls in post-hospitalised older adults: A 6-month follow-up

Abstract: Objective To identify discharge medications, especially psychotropic medications that are associated with falls, amongst older adults within 6 months following hospitalisation. Methods Negative binomial regression was used to examine relationships between discharge medications and falls in older post-hospitalised adults. Multiple regression that considered falls risk factors at discharge was performed. Results Data for 267 participants showed that discharge medications were not independently associated with falls postdischarge after adjustment for other falls risk factors. Male gender (adjusted incidence rate ratio [95% confidence interval, CI]) 2.15 [1.36-3.40]), higher depression scores (1.14 [1.05-1.25]) and co-morbidity of neurological disease other than stroke (5.98 [3.08-11.60]) were independently associated with an increased rate of falls. Higher depression scores (1.20 [1.11-1.31]) and co-morbidity of cancer (1.97 [1.20-3.25]) were independently associated with an increased rate of injurious falls in the 6 months postdischarge. Conclusion Falls prevention strategies, other than hospital discharge medication management in the postdischarge older adults, warrant investigation.

'Factors affecting services offered to older adults with psychological morbidity: an exploration of health professional attitudes'.

Abstract: Aim: Poor collaboration between the multiple services involved in hospital discharge planning may contribute to suboptimal patient outcomes post discharge. This study aimed to explore clinician (me...

Correction to: Effectiveness of quality incentive payments in general practice (EQuIP-GP): a study protocol for a cluster-randomised trial of an outcomes-based funding model in Australian general practice to improve patient care (BMC health services research (2019) 19 1 (529))

Abstract: In the original publication of this article [1], the first name of the 3rd author is wrong.