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BACKGROUND: Depressive and anxiety disorders have shown to be associated to premature or advanced biological aging and consequently to adversely impact somatic health. Treatments with antidepressant medication or running therapy are both found to be effective for many but not all patients with mood and anxiety disorders. These interventions may, however, work through different pathophysiological mechanisms and could differ in their impact on biological aging and somatic health. This study protocol describes the design of an unique intervention study that examines whether both treatments are similarly effective in reducing or reversing biological aging (primary outcome), psychiatric status, metabolic stress and neurobiological indicators (secondary outcomes). METHODS: The MOod Treatment with Antidepressants or Running (MOTAR) study will recruit a total of 160 patients with a current major depressive and/or anxiety disorder in a mental health care setting. Patients will receive a 16-week treatment with either antidepressant medication or running therapy (3 times/week). Patients will undergo the treatment of their preference and a subsample will be randomized (1:1) to overcome preference bias. An additional no-disease-no-treatment group of 60 healthy controls without lifetime psychopathology, will be included as comparison group for primary and secondary outcomes at baseline. Assessments are done at week 0 for patients and controls, and at week 16 and week 52 for patients only, including written questionnaires, a psychiatric and medical examination, blood, urine and saliva collection and a cycle ergometer test, to gather information about biological aging (telomere length and telomerase activity), mental health (depression and anxiety disorder characteristics), general fitness, metabolic stress-related biomarkers (inflammation, metabolic syndrome, cortisol) and genetic determinants. In addition, neurobiological alterations in brain processes will be assessed using stru

Objective Unwarranted variation in clinical practice is a target for quality improvement in health care, but there is no consensus on how to identify such variation or to assess the potential value of initiatives to improve quality in these areas. This study illustrates the use of a triple test, namely the comparative analysis of processes of care, costs and outcomes, to identify and assess the burden of unwarranted variation in clinical practice. Methods Routinely collected hospital and mortality data were linked for patients presenting with symptoms suggestive of acute coronary syndromes at the emergency departments of four public hospitals in South Australia. Multiple regression models analysed variation in re-admissions and mortality at 30 days and 12 months, patient costs and multiple process indicators. Results After casemix adjustment, an outlier hospital with statistically significantly poorer outcomes and higher costs was identified. Key process indicators included admission patterns, use of invasive diagnostic procedures and length of stay. Performance varied according to patients' presenting characteristics and time of presentation. Conclusions The joint analysis of processes, outcomes and costs as alternative measures of performance inform the importance of reducing variation in clinical practice, as well as identifying specific targets for quality improvement along clinical pathways. Such analyses could be undertaken across a wide range of clinical areas to inform the potential value and prioritisation of quality improvement initiatives. What is known about the topic? Variation in clinical practice is a long-standing issue that has been analysed from many different perspectives. It is neither possible nor desirable to address all forms of variation in clinical practice: the focus should be on identifying important unwarranted variation to inform actions to reduce variation and improve quality. What does this paper add? This paper proposes the comparativ

Stent thrombosis is a rare early complication of percutaneous coronary intervention (PCI) best managed by repeat angiography. Subsequently, our department has enforced a policy of retaining patients near a major centre for 5 days post PCI, including our rural patients. The purpose of this audit was to clarify the risk for country patients returning home within 5 days. Between January 2005 and June 2015 electronic databases identified all patients residing in SA who underwent PCI at Flinders Medical Centre (FMC), and separated them into Metro and Country designations. Demographics and comorbidities were compared, and outcomes of death, major adverse cardiac events (MACE) and MACE/Revascularisation (MACE/R) were noted within five and 30 days. In total, 3,911 patients were included (mean age: 63 years, female: 25.2%). Country patients (n= 1,412, 36.10%) were significantly less likely to have previous comorbidities, including previousACS(30.7% v 23.6%, p<0.01) and were less likely to haveMACE,both within 5 (1.5% v 0.8%, p=0.045) and 30 days (3.6% v 2.0%, p=0.004), and MACE/R within 30 days (7.0% v 4.5%, p=0.001). There was no significant difference in the rates of death within 5 or 30 days, or MACE/R within five days. Mortality by five days was low for both country and metropolitan patients (0.8% and 1.3% respectively) and did not differ significantly between groups (p=0.149). Country patients can be discharged home prior to 5 days if accepting of a <1% risk of early death within this time frame.

Background:Variation in the provision of coronary angiography is associated with healthcare inefficiency and inequity. We explored geographic, socioeconomic, health service and disease indicators associated with variation in angiography across Australia. Method(s): Australian Census and National Health Survey data were used to determine socioeconomic, health workforce and service indicators. Hospital separations and coronary deaths were identified from the National Hospital Morbidity and Mortality databases 2011. Using Medicare Locals that are responsible for primary care, age-sex standardised rates of acute coronary syndrome (ACS) incidence, coronary angiography, revascularisation and mortality were tested for correlation, and adjusted using Bayesian regression. Result(s): All 61 Medicare Locals were included. The variation in ACS rates was 3.7-fold and 2.3-fold for mortality, whereas angiography rates varied 5.3-fold. ACS and death rates within Medicare Locals were correlated (partial correlation co-efficient (CC): 0.52 (p<0.0001). There was modest correlation between ACS and angiography rates (CC: 0.31, p=0.018). Revascularisation as the proportion of angiography and the total angiogram rate was inversely correlated (CC:-0.71, (p<0.0001). Social disadvantage and remoteness correlated with disease burden, ACS incidence and mortality, but not angiography. In the adjusted analysis, admissions to private hospitals demonstrated the strongest association with local angiography rates (71 angiograms (95% C.I. 47-93) per 100,000 for every 1000 admissions). Conclusion(s):Variation in coronary angiography, not related to clinical need, occurs across Australia. A greater focus on clinical care standards and better distribution of health services will be required if these variations are to be attenuated.

Introduction: GRACE score, derived from 4 cardiac and 2 non-cardiac components, is validated for objective risk prediction in Acute Coronary syndromes (ACS). While the benefit from invasive management increases with higher GRACE score, these benefits are uncertain when risk is determined largely by the non-cardiac factors of age and renal function. We explored the interaction between GRACE risk and invasive management as a function of the non-cardiac risk components. Method(s): Five Australian ACS registries (GRACE, ACACIA, CONCORDANCE, SNAPSHOT, PREDICT[1999-2015]) recorded the GRACE score and 6-month mortality. By using the GRACE score values for age and renal function, we calculated the percentage contribution of these factors to the overall score in each patient (i.e. Age <20%, 20-39%, 40-59%,> 60%; Cr <20%, 20-29%, >30%). The interactions between GRACE score, invasive management, and age or renal function contributions were explored using general estimating equations. Result(s): In total 17,140 of patients were included, of whom 30.4% were STEMI. An increasing GRACE score was associated with a greater benefit from invasive management. However, a higher contribution of age to the score was associated with a lower impact on mortality from invasive-management. (Relative risk reduction with invasive management: Age% < 20%-82%; 20-39%-66%; 40-59%-54%: 60%-15%, interaction p value <0.001). The benefit from invasive management was constant (no interaction) regardless the contribution of renal function to GRACE score. Conclusion(s): GRACE score identifies patients benefiting from invasive management. However, with increasing contribution of age to absolute risk, the benefits of invasive management are reduced.