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BACKGROUND: Despite recommendations, long-acting reversible contraceptives (LARC) are not always offered as first-line contraceptives in general practice. This study aimed to describe pathways used by women for insertion of LARC. METHODS: This is a secondary analysis of data from the Australian Contraceptives ChOice pRoject (ACCORd), a cluster randomised controlled trial set in 57 general practices in Melbourne, Australia. We investigated whether an educational intervention for general practitioners (GPs) and a rapid LARC insertion clinic increased LARC uptake. The main outcome measures were the type of health service, location/provider of intrauterine device (IUD) insertion; time to insertion; and distance travelled for IUD insertion. RESULTS: During ACCORd, 149 women had LARC insertion. IUD training was reported by 37% of GPs, but only 12% inserted them. In contrast, 70% of GPs inserted implants and 95% of women accessed implant insertion through their own general practice. LARC rapid referral clinics were used by 52% (13/25) of intervention GPs, where 71% (41/56) of IUD insertions occurred in these clinics (but no implants). There was no difference in the mean time from referral to IUD insertion between women attending intervention and control GPs (mean days 37.6vs 32.7; P =0.61). GPs (including IUD inserters) used a variety of referral pathways for IUD insertion, including public and private clinics, and other GPs. Women travelled up to 90km for IUD insertion. CONCLUSIONS: Although implant insertion has been integrated into general practice, few GPs insert IUDs. Where the option exists for GPs to refer to a LARC rapid referral clinic, the majority of IUD insertions will take place there. Establishing a network of such clinics Australia wide may both increase IUD uptake and address the extensive need for GP training in IUD insertion.

Access to postpartum contraception is critical for the health of the mother and subsequent pregnancies. However, the differential roles and responsibilities of maternity care providers in contraception discussions and provision are often unclear. Our study, part of a larger study on midwifery provision of contraceptive implants, presents the perspectives of hospital-based maternity clinicians. Participants suggested that contraception discussions and provision are a shared responsibility of maternity care providers but identified inconsistencies and issues with current approaches. Access to contraception could be improved through more routine discussions antenatally and postnatally and greater collaboration between maternity care providers in hospital, community and primary care settings.

INTRODUCTION: Although primary care practitioners are the main providers of long-acting reversible contraception (LARC) and early medical abortion (EMA) in Australia, few provide these services. A professional community of practice (CoP) has the potential to improve LARC and EMA provision through evidence-based guidance, expert support and peer-to-peer engagement.The primary objective is to establish, implement and evaluate an innovative, multidisciplinary online CoP (AusCAPPS Network) to increase LARC and EMA services in Australian primary care. Secondary objectives are to (1) increase the number of general practitioners (GPs) and pharmacists certified to provide or dispense EMA, respectively, (2) increase LARC and EMA prescription rates and, (3) improve primary care practitioners' knowledge, attitudes and provision of LARC and EMA. METHODS AND ANALYSIS: A stakeholder knowledge exchange workshop (KEW) will be conducted to inform the AusCAPPS Network design. Once live, we aim to reach 3000 GPs, practice nurses and community pharmacists members. Changes in the number of GPs and pharmacists certified to provide or dispense EMA, respectively, and changes in the number of LARCs and EMAs prescribed will be gleaned through health service data. Changes in the knowledge attitudes and practices will be gleaned through an online survey with 500 individuals from each professional group at baseline and 12 months after members have joined AusCAPPs; and experiences of the AusCAPPS Network will be evaluated using interviews with the project team plus a convenience sample of 20 intervention participants from each professional group. The project is underpinned by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, and a realist framework will inform analysis. ETHICS AND DISSEMINATION: Ethical approval was received from the Monash University Human Research Ethics Committee (No. 28002). Dissemination will occur through KEWs, presentations, publications and do

OBJECTIVE: Most Australian women access contraception through general practitioners (GPs) but choose oral methods rather than long-acting reversible contraceptives (LARCS). The Australian Contraceptive ChOice pRoject (ACCORd) successfully tested a complex intervention for LARC uptake. We aimed to explore the critical elements of this intervention to increase LARC uptake. DESIGN: ACCORd was a cluster randomised control trial conducted in 57 GP clinics in Melbourne, Australia. To explore intervention impact, fidelity checks (n=21 GPs) and interviews with 37 GPs and 40 patients were undertaken 12 months after initial consultations. Data were inductively coded, thematically analysed and mapped to Normalization Process Theory constructs. RESULTS: Doctors understood the importance of effectiveness-based contraceptive counselling (EBCC). GPs demonstrated cognitive engagement in the promotion of LARC and some appreciated the rapid referral pathways. GPs and women valued the effectiveness approach. GPs held varying views about having a rapid referral pathway, with many already having established pathways in place. Some GPs viewed intrauterine device insertion costs or insertion training as barriers to ongoing practice. Most GPs and women saw the ACCORD model as effective and sustainable. CONCLUSIONS: GP training in EBCC and the use of rapid referral pathways were critical features of an effective sustainable model for successful uptake of LARCs in primary care. IMPLICATIONS FOR PUBLIC HEALTH: Improving Australian women's access to and use of LARCs is sustainable with EBCC training and support for general practitioners.

PURPOSE: Long-acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and implants, are highly effective. However, the uptake of LARC in Australia has been slow and the oral contraceptive pill (OC) remains the best known and most widely used contraceptive. Our aim was to investigate women's preferences for the features of LARC. METHODS: We used a discrete choice experiment (DCE) in which each respondent completed 12 choice tasks. We recruited a general population sample of 621 women in Australia aged 18-49 using an online survey panel. A mixed logit model was used to analyse DCE responses; a latent class model explored preference heterogeneity. RESULTS: Overall, 391 (63%) of women were currently using contraception; 49.3% were using an OC. About 22% of women were using a LARC. Women prefer products that are more effective in preventing pregnancy, have low levels of adverse events (including negative effects on mood), and which their general practitioner (GP) recommends or says is suitable for them. CONCLUSIONS: Women have strong preferences for contraceptive products that are effective, safe, and recommended by their GP. The results indicate which characteristics of LARCs need to be front and centre in information material and in discussions between women and healthcare professionals.

BACKGROUND: Cesarean delivery rates continue to rise globally, the reasons for which are incompletely understood. OBJECTIVE: We aimed to characterize the attributable factors for the increasing cesarean delivery rates over a 30-year period within our health network. STUDY DESIGN: This was a planned observational cohort study across 2 hospitals (a large tertiary referral hospital and a metropolitan hospital) in Sydney, Australia using data from a previously published study. The following 2 time periods were compared: 1989-99 and 2009-16, between which the cesarean delivery rate increased from 19% to 30%. The participants were all women who had a cesarean delivery after 24 weeks' gestational age. The data were analyzed using multiple imputation and robust Poisson regression to calculate the differences in the adjusted and unadjusted relative risk of cesarean delivery and estimate the changes in the cesarean delivery rate attributable to maternal and clinical factors. The primary outcome was cesarean delivery. RESULTS: After 576 exclusions, 102,589 births were included in the analysis. Fifty-six percent of the increase in the rate of cesarean delivery was attributed to changes in the distribution of the maternal age, body mass index, and parity and to a history of previous cesarean delivery. An additional 10% of the increase was attributed to changes in the obstetrical management of the following high-risk pregnancies: multiple gestation, malpresentation (mainly breech), and preterm singleton birth. When prelabor cesarean deliveries for maternal choice, suspected fetal compromise, previous pregnancy issues, and suspected large fetus were excluded, 78% of the increase was attributed to either maternal factors or changes in the obstetrical management of these high-risk pregnancies. CONCLUSION: Most of the steep rise in the cesarean delivery rate from 19% to 30% was attributed to changes in the maternal demographic and clinical factors. This observation is relevant to dev

Intoxication can be a factor in unwanted sex, but research on the extent of the issue in both women and men is limited. We assessed the prevalence, correlates, and 10-year time-trends of unwanted sex due to intoxication among a representative sample of 4,279 women and 3,875 men aged 16–69 years in Australia and considered how these vary by gender. In 2012–13, 16% of women and 10% of men reported ever having had a sexual experience when they “did not want to because they were too drunk or high at the time.” For both women and men, this was associated with younger age, bisexual activity, and reports of lifetime injection drug use, sexually transmitted infections, and forced sex. Among women only, it was associated with drinking above guideline levels and ever having terminated a pregnancy. Among men only, it was associated with current tobacco smoking, elevated psychosocial distress, and poor general health. Compared with 2001–02 data, fewer men reported unwanted intoxicated sex, while there were no changes for women as a whole. Interpreting these findings through an intersectional assemblage framework supports stronger understanding of the multiple factors influencing sexuality and substance use with implications for promoting equity, safety, and sexual health.

Objective The aim of this study was to evaluate the cost-effectiveness of the Australian Contraceptive ChOice pRoject (ACCORd) intervention. Methods An economic evaluation compared the costs and outcomes of the ACCORd intervention with usual care (UC). Data from the ACCORd trial were used to estimate costs and efficacy in terms of contraceptive uptake and quality of life. Rates of contraceptive failure and pregnancy were sourced from the literature. Using a Markov model, within-trial results were extrapolated over 10 years and subjected to univariate sensitivity analyses. Model outputs were expressed as the cost per quality-adjusted life years (QALY) gained and cost per unintended pregnancy resulting in birth (UPB) avoided. Results Over 10 years, compared with UC, initiating contraception through the ACCORd intervention resulted in 0.02 fewer UPB and higher total costs (A$2505 vs A$1179) per woman. The incremental cost-effectiveness of the ACCORd intervention versus UC was A$1172 per QALY gained and A$7385 per UPB averted. If the start-up cost of the ACCORd intervention was removed, the incremental cost-effectiveness ratio was A$81 per QALY gained and A$511 per UPB averted. The results were most sensitive to the probability of contraceptive failure, the probability of pregnancy-related healthcare service utilisation or the inclusion of the costs of implementing the ACCORd intervention. Conclusions From a health system perspective, if implemented appropriately in terms of uptake and reach, and assuming an implicit willingness to pay threshold of A$50 000 the ACCORd intervention is cost-effective. What is known about the topic? The uptake of long-active reversible contraceptives (LARC) in Australia is low. The ACCORd trial assessed the efficacy of providing structured training to general practitioners (GPs) on LARC counselling, together with access to rapid referral to insertion clinics. What does this paper add? This study is the first to assess the cost-effectivenes

BACKGROUND AND OBJECTIVES: Women's ability to negotiate condom use helps prevent sexually transmissible infections (STIs) and unintended pregnancies. The aim of this study was to assess the relationship between substance use, risk perception and the certainty of using condoms in several hypothetical situations. METHOD: This is a secondary analysis from the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial. Descriptive statistics and logistic regression were used for the analysis. RESULTS: At baseline, contraceptive questions were answered by 698 women attending 57 general practices in Melbourne, Australia. Condom use was reported by 47%. Of those using condoms as the sole form of contraception (n = 137), 20% used them inconsistently. Dual protection was used by 58% of women (188/325). Condoms and the pill were more frequently used than condoms and longer-acting contraceptives. Women were less likely to be confident negotiating condom use when using substances. DISCUSSION: Substance use and the concurrent use of other forms of contraception impact use of condoms. Even when condoms are the sole form of contraception with willing partners, use is inconsistent, leaving women at risk of pregnancy and STI.

Background and objectives Women’s ability to negotiate condom use helps prevent sexually transmissible infections (STIs) and unintended pregnancies. The aim of this study was to assess the relationship between substance use, risk perception and the certainty of using condoms in several hypothetical situations. Methods This is a secondary analysis from the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial. Descriptive statistics and logistic regression were used for the analysis. Results At baseline, contraceptive questions were answered by 698 women attending 57 general practices in Melbourne, Australia. Condom use was reported by 47%. Of those using condoms as the sole form of contraception (n = 137), 20% used them inconsistently. Dual protection was used by 58% of women (188/325). Condoms and the pill were more frequently used than condoms and longer-acting contraceptives. Women were less likely to be confident negotiating condom use when using substances. Discussion Substance use and the concurrent use of other forms of contraception impact use of condoms. Even when condoms are the sole form of contraception with willing partners, use is inconsistent, leaving women at risk of pregnancy and STI.

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Background:Improvements in clinical information systems has seen a growing use of risk prediction models in chronic disease management. For example, cardiovascular risk prediction models have been adopted into systems to assist with the risk stratification of patients and subsequent management of hypertension. We identified 28 published melanoma risk prediction models in a systematic review however none have been integrated into clinical systems to assist clinicians in estimating melanoma risk. We aimed to assess whether unassisted clinician-generated melanoma risk predictions agree with model-generated melanoma risk predictions.Method:We used a cross-sectional design. Participants were recruited through “GPs Down Under”, a Facebook group comprising over 6000 authenticated general practitioners (GPs) from Australia and New Zealand. GP participants completed an online survey with questions on: (1) their overall melanoma risk in both absolute and relative terms, and (2) melanoma risk factors as identified in a validated melanoma risk prediction model to enable the calculation of absolute and relative risk. The relation between clinician- and model- generated melanoma risk prediction (both absolute and relative melanoma risk) was assessed using Pearson correlation coefficients and correlation plots.Results:136 of the 150 GP respondents completed the online survey between June to August 2019. The Pearson correlation coefficient for clinician- and model-generated melanoma risk prediction was 0.20 (95% CI 0.03 to 0.36) for remaining lifetime absolute melanoma risk and 0.60 (95% CI 0.48 to 0.70) for relative melanoma risk. There was a tendency for participants to overestimate risk when it is low, and underestimate risk when it is high.Discussion:This is the first study to compare clinician-generated melanoma risk assessments against a well-validated and prospectively evaluated model. It showed poor correlation between clinician-reported against model-generated melanoma ris

Background:Australian general practice prevention guidelines recommend a stratified approach to melanoma screening based on individualised risk levels. Melanoma risk prediction tools, based on multiple risk factors, may assist general practitioners (GPs) in risk estimation and targeting melanoma screening. Several melanoma risk prediction tools have been developed and validated, but none are routinely used in clinical practice. The future implementation of prediction tools could be supported by understanding GPs’ current approach to melanoma risk estimation and their perspectives on clinical implementation. Method:Participants were recruited through “GPs Down Under”, a Facebook group comprising over 6000 authenticated GPs from Australia and New Zealand. The GP participants were purposively sampled for semi-structured telephone interviews, which were audio-recorded and professionally transcribed. The transcripts were analysed using Grounded Theory method as described by Corbin and Strauss. Earlier analytic insights informed latter data collection (theoretical sampling) which continued until saturation was reached.Results:Twenty Australian GPs were interviewed. The explanatory model that emerged consisted of six major themes. These themes showed GP’s conceptualisation of melanoma risk estimation in practice could be understood as a linear clinical process that connects five of the six themes: patient selection, clinical assessment, risk estimation, management recommendation, and patient education. The GPs perceived prospective roles for melanoma risk prediction tools at each clinical process themes. Discussion:GPs’ estimation of melanoma risk may not reflect practice guidelines, in terms of the risk factors considered and the risk factor analysis. Their perceptions on the role of melanoma prediction tools were informed by existing tools and they were willing to consider using melanoma risk prediction tools in clinical practice.Implications for practice:Explicitly alig

INTRODUCTION: Through addressing main barriers to the uptake of long-acting reversible contraceptives (LARCs) among Australian women, the Australian Contraceptive ChOice pRoject (ACCORd) trialled an educational intervention targeting general practitioners (GPs) and provided those in the intervention group with a rapid referral service for quick insertion. The cluster randomised controlled trial resulted in greater uptake of LARC in the intervention group. This protocol paper describes a longitudinal follow-up to the ACCORd Study to assess the long-term efficacy and cost-effectiveness of the intervention. METHODS AND ANALYSIS: Women participants (patients of ACCORd GPs) completed a baseline, 6-month and 12-month survey. These participants will be invited to complete an additional follow-up survey 3 years post completion of their baseline interview. Based on the original ACCORd Study tools, the online survey will address long-term outcomes including contraceptive continuation rates and reproductive history, any unintended pregnancies, satisfaction and concerns with their current contraceptive method, and an assessment of quality of life. We will analyse data using binary regression models with generalised estimating equations and robust standard errors to account for clustering. DISCUSSION: Demonstration of sustained use, effectiveness at reducing unwanted pregnancies and cost-effectiveness of this strategy among this cohort of Australian primary care patients, will strengthen the policy and programme urgency of addressing wider dissemination of these strategies and replicating the study elsewhere. ETHICS AND DISSEMINATION: The ACCORd Study received approval from the Monash University Human Research Ethics Committee: CF16/188-201000080. Additionally, an amendment to conduct this 3-year longitudinal follow-up survey has been approved. The trial follow-up outcomes will be disseminated through formal academic pathways, including journal articles, national and internation

© Author(s) (or their employer(s)) 2018. Objectives To assess evidence for 'legacy' (post-trial) effects on cardiovascular disease (CVD) mortality and all-cause mortality among adult participants of placebocontrolled randomised controlled trials (RCTs) of statins. Design Meta-analysis of aggregate data. Setting/Participants Placebo-controlled statin RCTS for primary and secondary CVD prevention. Methods Data sources: PubMed, Embase from inception and forward citations of Cholesterol Treatment Trialists' Collaborators RCTs to 16 June 2016. Study selection: Two independent reviewers identified all statin RCT follow-up reports including ≥1000 participants, and cardiovascular and all-cause mortality. Data extraction and synthesis: Two independent reviewers extracted data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Main outcomes: Post-trial CVD and all-cause mortality. Results We included eight trials, with mean post-trial follow-up ranging from 1.6 to 15.1 years, and including 13 781 post-trial deaths (6685 CVD). Direct effects of statins within trials were greater than legacy effects posttrials. The pooled data from all eight studies showed no evidence overall of legacy effects on CVD mortality, but some evidence of legacy effects on all-cause mortality (p=0.01). Exploratory subgroup analysis found possible differences in legacy effect for primary prevention trials compared with secondary prevention trials for both CVD mortality (p=0.15) and all-cause mortality (p=0.02). Pooled post-trial HR for the three primary prevention studies demonstrated possible post-trial legacy effects on CVD mortality (HR=0.87; 95% CI 0.79 to 0.95) and on all-cause mortality (HR=0.90; 95% CI 0.85 to 0.96). Conclusions Possible post-trial statin legacy effects on all-cause mortality appear to be driven by the primary prevention studies. Although these relative benefits were smaller than those observed within the trial, the absolute ben

Background and objectives We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. Design, setting, participants, & measurements A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. Results In total, 102 of 721 patients planned for conservative care, andmedian age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18%were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serumalbumin <3.0 versus 3.7-5.4 g/dl (hazard ratio, 4.31; 95%confidence interval, 2.72 to 6.81), and managementwith conservative care comparedwith RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively. Conclusions Survival after 3 years of conservative management is common, with relatively few patients