Search

BACKGROUND: A consistent gap exists between evidence-based guideline recommendations and clinical practice across all medical disciplines, including nephrology. This study aims to explore nephrologists' perspectives on guidelines and elicit their perspectives on the effects of guidelines on clinical decisions. METHODS: Semistructured face-to-face interviews were undertaken with 19 nephrologists from a variety of clinical settings across Australia. Participants were asked about their views of clinical practice guidelines in nephrology, both local (Caring for Australasians With Renal Impairment [CARI]) and international, and their opinions of other factors that shape their decision making. Interviews were recorded, transcribed, and analyzed qualitatively. RESULTS: 4 major themes were identified. First, overall, the nephrologists interviewed trusted the CARI guideline process and output. Second, guidelines served a variety of purposes, providing a good summary of evidence, a foundation for practice, an educational resource, and justification for funding requests to policy makers, as well as promoting patient adherence to treatment. Third, guidelines were only one input into decision making. Other inputs included individual patient quality of life and circumstances, opinion leaders, peers, nephrologists' own experiences, the regulation and subsidy framework for drugs and devices, policies and work practices of the local unit, and other sources of evidence. Fourth, guideline uptake varied. Factors that favored the use of guidelines included having a strong evidence base, being current, including specific targets and an explicit treatment algorithm, being sent frequent reminders, and having local peer support for implementation and the necessary personnel and other resources for effective implementation. CONCLUSIONS: Evidence-based guidelines appear to impact strongly on clinical decision making of Australian nephrologists, but are only one input. Improvements in the evidence that underpins guidelines and improvements in the content and formatting of guidelines are likely to make them more influential on decision making. Trust in the guideline groups' processes is a prerequisite for implementation. [ABSTRACT FROM AUTHOR]

Evidence-based clinical practice guidelines have been a major development in nephrology internationally, but it is uncertain how the nephrology community regards these guidelines. This study aimed to determine the views of nephrologists on the content and effects of their local guidelines (Caring for Australasians with Renal Impairment [CARI]). In 2006, a self-administered survey was distributed to all Australian and New Zealand nephrologists. Seven questions were repeated from a similar survey in 2002. A total of 211 nephrologists (70% of practicing nephrologists) responded. More than 90% agreed that the CARI guidelines were a useful summary of evidence, and nearly 60% reported that the guidelines had significantly influenced their practice. The proportion of nephrologists reporting that the guidelines had improved patient outcomes increased from 14% in 2002 to 38% in 2006. The proportion of nephrologists indicating that the guidelines did not match the best available evidence decreased from 30% in 2002 to 8% in 2006. Older age and male sex showed some associations with a less favorable response for some domains. The CARI approach of rigorous evidence-based guidelines has been shown to be a successful model of guideline production. Almost all nephrologists regarded the CARI guidelines as useful evidence summaries, although only one-third believed that the guidelines affected health outcomes. Attitudes to the guidelines have become more favorable over time; this may reflect changes in the CARI process or attitudinal changes to evidence among nephrologists. Evaluation by the end user is fundamental to ensuring the applicability of guidelines in clinical practice in the future. Copyright © 2009 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

Study Objectives: Insomnia is a highly prevalent and debilitating disorder. Cognitive behavioral therapy for insomnia (CBTi) is the recommended 'fist line' treatment, but is accessed by a minority of people with insomnia. This paper describes a system-level implementation program to improve access to CBTi in Australia to inform CBTi implementation in other locations., Methods: From 2019 to 2023, we conducted a program of work to promote sustained change in access to CBTi in Australia. Three distinct phases included 1) Scoping and mapping barriers to CBTi access, 2) Analysis and synthesis of barriers and facilitators to devise change goals, and 3) Structured promotion and coordination of change. We used a system-level approach, knowledge brokerage, and co-design, and drew on qualitative, quantitative, and implementation science methods., Results: We identified barriers to CBTi access from the perspectives of people with insomnia, primary care clinicians, and the health system. A stakeholder advisory committee was convened to co-design change goals, identify modifiable barriers, devise program logic and drive change strategies. We commenced a program to promote system-level change in CBTi access via; improved awareness and education of insomnia among primary care clinicians, self-guided interventions, and advocating to Government for additional CBTi funding mechanisms., Conclusions: This implementation program made significant progress toward improving access to CBTi in Australia. Ongoing work is required to continue this program, as long-term system-level change requires significant and sustained time, effort and resources from multiple stakeholders. This program may be used to inform CBTi implementation activities in other locations., (© 2024 American Academy of Sleep Medicine.)

Objectives: Our objective is to assess the potential contribution of the Australian Government's mobile smartphone tracing app (COVIDSafe) to the sustained control of coronavirus disease 2019 (COVID-19)., Study Type: Development and analysis of a system dynamics model., Methods: To define the pandemic context and specify model-building parameters, we searched for literature on COVID-19, its epidemiology in Australia, case finding processes, and factors that might affect community acceptance of the COVIDSafe smartphone app for contact tracing. We then developed a system dynamics model of COVID-19 based on a modified susceptible-exposed-infected-recovered compartmental model structure, using initial pandemic data and published information on virus behaviour to determine parameter values. We applied the model to examine factors influencing the projected trends: the extent of viral testing, community participation in social distancing, and the level of uptake of the COVIDSafe app., Results: Modelling suggests that a second COVID-19 wave will occur if social distancing declines (i.e. if the average number of contacts made by each individual each day increases) and the rate of testing declines. The timing and size of the second wave will depend on the rate of decrease in social distancing and the decline in testing rates. At the app uptake level of approximately 27% (current at 20 May 2020), with a monthly 50% reduction in social distancing (i.e. the average number of contacts per day doubling every 30 days until they reach pre-social distancing rates) and a 5% decline in testing, the app would reduce the projected total number of new cases during April-December 2020 by one-quarter. If uptake reaches the possible maximum of 61%, the reduction could be more than half., Conclusions: Maintenance of a large-scale testing regimen for COVID-19 and widespread community practice of social distancing are vital. The COVIDSafe smartphone app has the potential to be an important adjunct to testing and social distancing. Depending on the level of community uptake of the app, it could have a significant mitigating effect on a second wave of COVID-19 in Australia., Competing Interests: None declared.

Objectives: To determine whether recruitment of rural students and uptake of extended rural placements are associated with students' expressed intentions to undertake rural internships and students' acceptance of rural internships after finishing medical school, and to compare any associations., Design, Setting and Participants: Longitudinal study of three successive cohorts (commencing 2005, 2006, 2007) of medical students in the Sydney Medical Program (SMP), University of Sydney, New South Wales, using responses to self-administered questionnaires upon entry to and exit from the Sydney Medical School and data recorded in rolls., Main Outcome Measures: Students' expressed intentions to undertake rural internships, and their acceptance of rural internships after finishing medical school., Results: Data from 448 students were included. The proportion of students preferring a rural career dropped from 20.7% (79/382) to 12.5% (54/433) between entry into and exit from the SMP. A total of 98 students took extended rural placements. Ultimately, 8.1% (35/434) accepted a rural internship, although 14.5% (60/415) had indicated a first preference for a rural post. Students who had undertaken an extended rural placement were more than three times as likely as those with rural backgrounds to express a first preference for a rural internship (23.9% v 7.7%; χ(2) = 7.04; P = 0.008) and more than twice as likely to accept a rural internship (21.3% v 9.9%; χ(2) = 3.85; P = 0.05)., Conclusion: For the three cohorts studied, rural clinical training through extended placements in rural clinical schools had a stronger association than rural background with a preference for, and acceptance of, rural internship.

Aim: Renal nurses in Australia and New Zealand are critical to the care of patients with chronic kidney disease (CKD), especially those on dialysis. We aimed to obtain the opinions of renal nurses in Australia and New Zealand on the Caring for Australasians with Renal Impairment (CARI) Guidelines., Methods: A self-administered survey was distributed to all members of the professional organisation for renal nurses (Renal Society of Australasia) in 2006. The results were compared with those from a similar survey in 2002 and an identical 2006 survey of Australian and New Zealand nephrologists., Results: Of the 173 respondents, more than 95% considered the Guidelines to be a good synthesis of the available evidence, 80% indicated that the Guidelines had significantly influenced their practice and 86% considered that the Guidelines had improved patient outcomes. Older respondents were less likely to perceive that the Guidelines had improved patient outcomes, and renal nurse educators were more likely to consider that the Guidelines were based on the best available evidence than other respondents. Respondents were generally more positive about the Guidelines in 2006 than in 2002. Although nephrologists were generally positive about the CARI Guidelines, renal nurses were more positive, especially regarding the effect of the Guidelines on practice and the improvement in health outcomes., Conclusion: Australian and New Zealand renal nurses valued the CARI Guidelines highly, used them in practice and considered that they led to improved patient outcomes. Positive responses towards the Guidelines increased between 2002 and 2006.

Background: Evidence suggests that there is considerable variation in the types of procedures used to treat cancer. This variation may result in suboptimal or cost-ineffective care. The present study examined the variation in surgical treatment of melanoma before the establishment of a Melanoma Network that could promote more uniform high-quality care in New South Wales (NSW). The variations in the use of surgical procedures for melanoma by NSW Area Health Service of patient residence were examined., Methods: Data in the Health Information Exchange of NSW Health collected on procedures carried out on patients with a diagnosis of melanoma in NSW public and private hospitals from 1 July 2001 to 30 June 2002 were examined. Data were aggregated by Area Health Services of patient residence. These data were compared with the numbers of new cases of melanoma notified to the NSW Central Cancer Registry in the same areas in 2001-2002. Excision of skin lesions, skin grafting and numbers and types of lymph node procedures were examined., Results: During the study period, the Central Cancer Registry reported that there were 3085 notifications of melanoma, whereas hospital inpatient data recorded that 6864 procedures were carried out for patients with a melanoma diagnosis in NSW public and private hospitals. Sixty-seven per cent of procedures were carried out in private hospitals. A total of 852 skin grafting procedures were recorded. Of these, 60% were carried out in private hospitals. The average proportion of skin grafts associated with excisions in NSW was 30% (range, 0-53%). Eight hundred and fifty-eight lymph node procedures were recorded for 747 NSW residents. These were biopsies, excisions or both. Forty per cent were carried out in private hospitals. The average proportion of new cases of melanoma associated with a lymph node procedure in NSW was 28% (range, 0-47%)., Conclusion: Most of the inpatient procedures for patients with melanoma were carried out in private hospitals. The proportions of new cases that underwent skin grafting after excision, or underwent lymph node dissection, varied more than fivefold from one Area Health Service to another. This may indicate variations in casemix, variations in clinical practice or both.

This article describes the evolution of community pharmacy in the Australian health system, and assesses its current and potential future contribution to health care. A central theme is the unique extent and accessibility of community pharmacy to the public, with a vast and dispersed infrastructure that is funded by private enterprise. The viability of community pharmacy as a retail trade depends on a diversification of its service roles and retention of its product-supply roles. Initiatives by the pharmacy profession, the pharmacy industry and the Australian Government are likely to give community pharmacy an increasingly prominent place in health promotion and primary, secondary and tertiary prevention, especially in relation to the management of chronic diseases.

Objective: To describe the development of guidelines for the management of Aboriginal health information in NSW. The purpose of the guidelines is to promote the ethical management of Aboriginal health information, with appropriate consideration for cultural factors., Methods: The guidelines were developed collaboratively by the NSW Aboriginal Health Partnership, which comprises NSW Health (the central administrative office, named NSW Department of Health, and the Area Health Services) and the NSW Aboriginal Health and Medical Research Council (AHMRC), the peak body representing member Aboriginal Community Controlled Health Services in NSW. A lengthy and comprehensive consultation process enabled a wide range of interested groups to have input into the guidelines., Results: The project culminated in the production of the NSW Aboriginal Health Information Guidelines, covering the collection, ownership, storage, security, release, usage, interpretation and reporting of information, as well as issues of privacy and confidentiality. The Guidelines formed the basis of a formal Memorandum of Understanding, signed by the NSW Minister for Health, NSW Department of Health and the AHMRC, on 24 August 1998., Conclusions and Implications: The Guidelines make an important contribution to meeting a need for protocols on the collection, ownership and use of Aboriginal health information. Their production reflects successful collaboration between government and Aboriginal Community Controlled Health Services in NSW. Future reviews of the Guidelines will ensure their effectiveness and consistency with Aboriginal community principles.

The rate of transfer of the knowledge gained from health and medical research into evidence-based practice is determined by many factors. Preconditions for the uptake of new evidence are the availability of good evidence, ready access to the evidence, a supportive organisational environment, and effective mechanisms for promoting knowledge uptake. Evidence-based medicine is being promoted in Australia by a body of enthusiastic clinicians, public health practitioners and consumer advocates, supported by initiatives from national, State and local healthcare services and professional bodies. The short to medium term future of evidence-based medicine in Australia is likely to be shaped by three major factors: a reduction in cost and technical barriers which limit access to computerised databases; a trend towards shared decision-making between clinicians and patients; and increased demand for information to fill the gaps in research-based evidence on specific problems.

Objectives: To identify characteristics of women seeking termination of pregnancy, their reasons for having a termination, and whether they intended to submit a Medicare claim for the procedure., Design: Survey by self-administered questionnaire., Subjects and Setting: All women who attended 11 private clinics in New South Wales (NSW) over a six-week period in 1992., Results: 2249 completed questionnaires were received (94% response rate). Terminations were frequent at all ages, but women in their 20s accounted for more than half the terminations (54%) and teenagers accounted for only 17%. Respondents were generally well educated and from various ethnic and religious backgrounds; 56% were single and 41% had had one or more previous terminations. Fifteen per cent of respondents could not or did not intend to make a Medicare claim. The most frequently cited factors contributing to the decision to seek a termination were concerns about finances, change in lifestyle, single parenthood and being too young., Conclusions: Private clinics, where most terminations are performed, clearly meet a major demand, but it is likely that terminations in NSW as recorded by Health Insurance Commission claims are under-reported by at least 15%.

Objectives: To describe the types and circumstances of traumatic work related fatalities in Australian commercial fishermen., Methods: Work related traumatic fishing fatalities were studied as part of a larger study of all work related traumatic fatalities in Australia from 1982 to 1984. Data on 47 cases were obtained from inspection of coroners' files., Results: The incidence of fatality of 143/100,000 person-years was 18 times higher than the incidence of fatality for the entire workforce, and considerably higher than that of the mining and agricultural workforces. 68% of decedents drowned and 13% died from physical trauma. Rough weather, non-seaworthy vessels, inadequate use of personal flotation devices, and inexperience were associated with many of the fatal incidents., Discussion: Improved vessel and equipment maintenance, better training of workers, greater use of personal flotation devices, and development of improved clothing and personal flotation devices are recommended.

A study of work-related fatalities, based on coroners' records, has provided national data on work-related road fatalities. A total of 1,544 work-related fatalities were identified over 1982-1984. Of these, 600 (39%) resulted from injuries sustained in road vehicle accidents on public roads; 366 (24%) in the course of work, and 234 (15%) while commuting between home and work. These figures are likely to underestimate work-related road fatalities because the coroners' records often did not contain the required information. The incidence of road fatalities declined slightly over the three years, although the proportion amongst all work-related fatalities remained constant. The at-work victims tended to be older than victims of road death generally. Fifty-six percent of the at-work cases were in the occupational group "drivers, road transport". Articulated trucks accounted for 41% of the at-work cases. Drivers made up 79% of the at-work group. In contrast, drivers accounted for only 38% of all road deaths. Two-thirds of the at-work road fatalities occurred outside capital city districts, the proportion of nonmetropolitan cases being highest for deaths involving articulated trucks. This is striking, in view of Australia's highly urbanised population. Blood alcohol data were available for 76% of the at-work cases and 79% of the commuting fatalities. Of these, 15% and 13%, respectively, had a blood alcohol of 0.05 g/100mL or more. In contrast, 6% of other workplace fatalities for which blood alcohol data were available had such levels. This difference may reflect more assiduous blood-alcohol testing of road-accident victims.(ABSTRACT TRUNCATED AT 250 WORDS)

Work-related agricultural fatalities were examined as part of a larger population-based study of all work-related fatalities in Australia in the period 1982-1984. A total of 257 farm-related fatalities were identified, of which 223 were deaths of persons in the employed civilian labor force (19.4 deaths per 100,000 persons per year) and 34 were deaths of children less than 15 years of age. The fatality incidence was higher among men, older age groups, and nonmanagers in general and in certain occupations in particular. Mobile mechanical equipment (particularly tractors) was the main fatal agent, roll-overs accounting for many of the fatalities. Better provision of information to agricultural workers, improvements in compliance to and enforcement of legislation, and changes in farming work practices are recommended to improve the safety of farms and farm work.

Work-related electrical fatalities were studied as part of a larger investigation into all work-related fatalities in Australia in the period 1982-1984. The 95 electrical fatalities (all men) represented an incidence of 0.49 per 100,000 persons (0.79/100,000 men) in the employed civilian labor force during the study period. Electricity was the fifth highest cause of work-related fatalities in Australia and resulted in 10% of all workplace deaths. Ninety-four percent of the workers were performing their usual tasks at the time of their death, and 38% of them were doing work of an electrical nature at the time. The greatest number of deaths occurred on farms and nonconstruction industrial sites, with overhead powerlines as the main source of current. Better placement of overhead powerlines, improved worker awareness of electrical hazards, and the use of residual current devices would probably have prevented most of the deaths.

This paper reviews the data available in New South Wales on teenage fertility rates and pregnancy outcomes. Teenage births comprise six per cent of all births in New South Wales, but they constitute a significant public health problem because they are associated with elevated rates of adverse pregnancy outcomes, which include low birthweight, perinatal death and pre-eclampsia. Risk is concentrated in females under 18 years of age. Pregnancy outcomes for females aged 18 to 19 years are similar to those of women aged 20 to 24 years. Teenage fertility rates have remained stable since the mid-1980s, following a decline which began in the early 1970s. There are large geographic variations in teenage fertility within the state, with the highest rates in the far west of New South Wales and in western Sydney. Teenage pregnancy in New South Wales (as distinct from fertility which reflects births) cannot be assessed accurately because of the lack of information on terminations of pregnancy. However, available data suggest that teenage pregnancy rates have not increased during the 1980s.

Prospective data on 2634 Australian government employees over five years were examined for the effects of chronic perceived work stress on blood pressure change. The study sample (2100 men and 534 women) represented 57% of the original volunteers, or 75% of those eligible after exclusion criteria were met. Data on perceived stress were obtained by questionnaire, and a principal component analysis produced six components: qualitative demands, quantitative demands, job control, future control, work support, and outside stress. Multiple linear regression, which controlled for determinants of blood pressure, tested the main effects and specific two-way interaction effects of the chronicity scores of the six components and 30 items. Many items but only some components were associated with blood pressure change. Sex and age differences were observed. The observed interactions between job demands and control provided equivocal support for the Karasek job-strain model. The women responded to work-based support, but not necessarily as predicted.

This paper reviews a prospective study of occupational factors in coronary heart disease risk incorporated in a randomised controlled trial of a worksite based occupational health nurse counseling program for reducing coronary heart disease risk factors. The aim of the trial was to evaluate the longterm effectiveness of the counseling program in persons with mildly elevated risk factor levels. Of the 2,489 Australian government employees with mildly elevated risk factor levels who entered the intervention trial, 1,937 (78%) attended a followup examination three years later. This paper reports on changes in systolic and diastolic blood pressure. Multiple linear regression models were used with three-year blood pressure reduction as the dependent variable, intervention status as the main determinant, and sex, age, initial risk level and initial blood pressure as covariates. Although systolic and diastolic blood pressure fell in both the intervention and control groups, intervention was significantly associated with systolic blood pressure change only.

This article reports on the long-term results of a randomized controlled trial of non-pharmacological intervention for mildly-elevated levels of cardiovascular risk factors. The intervention consisted of individual counselling by occupational health professionals. From a population of 4607 volunteers who were working for Australian government organizations, a sample of 2489 subjects met the eligibility criteria for the trial, and 1937 subjects were available for follow-up examination three years later. Changes in the levels of risk factors favoured the interventional group marginally and appeared to vary with the sex, age and occupation of the subjects. A significant effect of intervention was noted for systolic blood pressure levels; however, although this interventional effect was more pronounced in men of 40 years of age or over and in administrative workers, clinically it was small. The results suggest that individual counselling, as undertaken in this study, generally is not effective in the long-term modification of mildly-elevated cardiovascular risk factors.

This paper outlines the methods used in a five-year prospective study of 4,607 Australian government employees and presents initial cross-sectional results examining associations between systolic blood pressure, occupation, and subjects' perceptions of work stress as ascertained in a questionnaire survey. The questionnaire items were grouped by means of principal component analysis into six factors representing adverse job characteristics. There were appreciable occupational differences in the mean scores for all six factors and in systolic blood pressure. The differences in systolic blood pressure among men from different occupational categories could not be explained by variation in the level of occupational stress perceived and reported by the subjects. Age, occupation, body mass index, and level of perceived stress arising from financial problems were significantly associated with systolic blood pressure level. A multiple linear regression model was used to determine the relationship between systolic blood pressure, age, and occupation after adjustment for the effects of the other variables.

A comprehensive study of deaths of work-related injuries which occurred throughout Australia in the years 1982-1984 was undertaken by means of coroners' records. Of 16,246 coroner-certified deaths that were attributed to trauma or to acute poisoning (excluding deaths of suicide or medical misadventure), the coroners' files were located for 15,462 (95.2%) deaths. From the files, a total of 1738 fatalities was judged to be work-related during the three-year period; of these, 1544 fatalities occurred in persons who were employed in the civilian labour force, which gave an average annual fatality incidence of 8.06 fatalities per 100,000 persons in the labour force. The death rate was much higher in men (12.05 fatalities per 100,000 men) than it was in women (1.34 fatalities per 100,000 women), increased with age, and was highest for the traditionally-dangerous occupations (such as mining, transport and rural occupations). The distribution of work fatalities by the main cause of death, and the nature of the injury event is described.