Journal articles on the topic 'Primary care (Medicine) Australian Capital Territory'

IntroductionThere are little published data on the long-term psychological outcomes in intensive care unit (ICU) survivors and their family members in Australian ICUs. In addition, there is scant literature evaluating the effects of psychological morbidity in intensive care survivors on their family members. The aims of this study are to describe and compare the long-term psychological outcomes of intubated and non-intubated ICU survivors and their family members in an Australian ICU setting.Methods and analysisThis will be a prospective observational cohort study across four ICUs in Australia. The study aims to recruit 150 (75 intubated and 75 non-intubated) adult ICU survivors and 150 family members of the survivors from 2015 to 2018. Long-term psychological outcomes and effects on health-related quality of life (HRQoL) will be evaluated at 3 and 12 months follow-up using validated and published screening tools. The primary objective is to compare the prevalence of affective symptoms in intubated and non-intubated survivors of intensive care and their families and its effects on HRQoL. The secondary objective is to explore dyadic relations of psychological outcomes in patients and their family members.Ethics and disseminationThe study has been approved by the relevant human research ethics committees (HREC) of Australian Capital Territory (ACT) Health (ETH.11.14.315), New South Wales (HREC/16/HNE/64), South Australia (HREC/15/RAH/346). The results of this study will be published in a peer-reviewed medical journal and presented to the local intensive care community and other stakeholders.Trial registration numberACTRN12615000880549; Pre-results.

ObjectiveTo provide deeper insight into why patients are admitted to hospital with gout and discover potential targets for better disease control.DesignData from semi-structured interviews were analysed using a thematic analysis approach.Participants and settingEleven inpatients from a tertiary institution in the Australian Capital Territory of Australia and their respective general practitioners (GPs) were invited to participate in the semi-structured interviews.ResultsDespite significant pain and disability that accompanied acute flares, patients continue to experience shame in seeking treatment and regarded gout as being not particularly important. Other barriers included patients’ poor continuity of care with and lack of confidence in GPs, suboptimal management in outpatient and inpatient settings, poor understanding of disease and treatment, and misconceptions held by both patients and physicians leading to uncontrolled disease activity.ConclusionsBarriers to optimal gout management including patient and health practitioner factors have produced a complex effect which has led to a cycle of treatment avoidance behaviours and recurrent hospitalisations for severe acute gout flares. These barriers could be addressed using a multipronged approach guided by the chronic care model which has been applied in a variety of other chronic diseases with improved patient and professional-level outcomes. Managing gout according to best practice for chronic disease is more likely to prevent recurrent hospitalisations and improve health outcomes in patients with gout.

IntroductionCardiac rehabilitation (CR) is recommended for secondary prevention of cardiovascular disease and reducing the risk of repeat cardiac events. Physical activity is a core component of CR; however, studies show that participants remain largely sedentary. Sedentary behaviour is an independent risk factor for all-cause mortality. Strategies to encourage sedentary behaviour change are needed. This study will explore the effectiveness and costs of a smartphone application (Vire) and an individualised online behaviour change program (ToDo-CR) in reducing sedentary behaviour, all-cause hospital admissions and emergency department visits over 12 months after commencing CR.Methods and analysisA multicentre, assessor-blind parallel randomised controlled trial will be conducted with 144 participants (18+ years). Participants will be recruited from three phase-II CR centres. They will be assessed on admission to CR and randomly assigned (1:1) to one of two groups: CR plus the ToDo-CR 6-month programme or usual care CR. Both groups will be re-assessed at 6 months and 12 months for the primary outcome of all-cause hospital admissions and presentations to the emergency department. Accelerometer-measured changes in sedentary behaviour and physical activity will also be assessed. Logistic regression models will be used for the primary outcome of hospital admissions and emergency department visits. Methods for repeated measures analysis will be used for all other outcomes. A cost-effectiveness analysis will be conducted to evaluate the effects of the intervention on the rates of hospital admissions and emergency department visits within the 12 months post commencing CR.Ethics and disseminationThis study received ethical approval from the Australian Capital Territory Health (2019.ETH.00162), Calvary Public Hospital Bruce (20–2019) and the University of Canberra (HREC-2325) Human Research Ethics Committees (HREC). Results will be disseminated through peer-reviewed academic journals. Results will be made available to participants on request.Trial registration numberACTRN12619001223123.

ObjectivesThe aim of this study was to investigate factors associated with unplanned 30-day readmissions following a total knee arthroplasty (TKA), including association with post-hospital syndrome, patient enablement and transition from hospital to home.Design, setting and participantsA cross-sectional written survey of public and private patients attending a 6-week follow-up appointment after TKA at one of four clinical services in the Australian Capital Territory (ACT) between 1 February 2018 and 31 January 2019. Multiple logistic regression analyses were used to measure associations between patient, hospital and transitional care factors with unplanned 30-day readmissions, while controlling for known confounders.ResultsOf the 380 participants who completed the survey (n=380, 54% of TKAs undertaken over the study period), 3.4% (n=13; 95% CI: 1.8 to 5.8) were subsequently readmitted within 30 days of discharge after a primary hospitalisation. Public patients were significantly more likely to be readmitted within 30 days compared with private patients (adjusted OR=6.31, 95% CI: 1.59 to 25.14, p=0.009), and patients who attended rehabilitation were significantly less likely to be readmitted within 30 days of discharge than those who did not (adjusted OR=0.16, 95% CI: 0.04 to 0.57, p=0.005). There were no associations between post-hospital syndrome or patient enablement and 30-day readmissions in this study.ConclusionReasons underlying the difference in unplanned readmission rates for public versus private patients need to be explored, including differences in surgical waiting times and the consequences for impairment and disease complexity. Strategies to foster increased participation post-surgical rehabilitation programmes need to be developed as an avenue to mitigate the burden of unplanned 30-day readmissions on individuals and health systems.

Context.— Since 2008, the Northern Territory Point-of-Care Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services. Objective.— To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network. Design.— Four years (2016–2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility. Results.— From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result. Conclusions.— The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years.

The aim of this study is to describe average out-of-pocket costs across different regions of Australia, as defined by Primary Health Network (PHN) boundaries, and assess the association between population characteristics and out-of-pocket costs for selected primary care services. A combination of descriptive and regression analysis was undertaken using administrative data from the Australian Department of Human Services reporting on the health services used across PHNs in Australia. Those in regional areas paid significantly more for Allied Health services than those in capital cities (A$5.68, P=0.006). The proportion of an area’s population aged 65 years and over was inversely related to out-of-pocket charges for Allied Mental Health (–A$79.12, P=0.029). Some areas had both high charges and disadvantaged populations: Country South Australia, Northern Queensland, Country Western Australia, Tasmania and Northern Territory, or populations with poor health: Northern Territory and Tasmania. Although there was a large amount of variation in out-of-pocket charges for primary care services between PHNs in Australia, there was little evidence of inequality based on health, age and socioeconomic characteristics of a population or the proportion of Aboriginal and Torres Strait Islander people.

Objective: For at least two decades, concerns have been raised about inappropriate psychotropic prescribing in Australian residential aged care facilities, due to their modest therapeutic benefit and increased risk of falls and mortality. To date, the majority of prevalence data has been collected in Sydney exclusively and it is not known if recent initiatives to promote appropriate psychotropic prescribing have impacted utilisation. Thus, we aimed to comprehensively analyse psychotropic use in a large national sample of residential aged care facility residents. Method: A cross-sectional, retrospective cohort study of residents from 150 residential aged care facilities distributed nationally during April 2014–October 2015. Antipsychotic, anxiolytic/hypnotic and antidepressant utilisation was assessed, along with anticonvulsant and anti-dementia drug use. Negative binomial regression analysis was used to examine variation in psychotropic use. Results: Full psychotropic prescribing data was available from 11,368 residents. Nearly two-thirds (61%) were taking psychotropic agents regularly, with over 41% prescribed antidepressants, 22% antipsychotics and 22% of residents taking benzodiazepines. Over 30% and 11% were charted for ‘prn’ (as required) benzodiazepines and antipsychotics, respectively. More than 16% of the residents were taking sedating antidepressants, predominantly mirtazapine. South Australian residents were more likely to be taking benzodiazepines ( p < 0.05) and residents from New South Wales/Australian Capital Territory less likely to be taking them ( p < 0.01), after adjustment for rurality and size of residential aged care facility. Residents located in New South Wales/Australian Capital Territory were also significantly less likely to take antidepressants ( p < 0.01), as were residents from outer regional residential aged care facilities ( p < 0.01). Antipsychotic use was not associated with State, rurality or residential aged care facility size. Conclusion: Regular antipsychotic use appears to have decreased in residential aged care facilities but benzodiazepine prevalence is higher, particularly in South Australian residential aged care facilities. Sedating antidepressant and ‘prn’ psychotropic prescribing is widespread. Effective interventions to reduce the continued reliance on psychotropic management, in conjunction with active promotion of non-pharmacological strategies, are urgently required.

This evaluation of the Researcher Development Program (RDP) in NSW and ACT aimed to determine whether the RDP was effective in assisting novice researchers to undertake primary health care research. In mid-2008, 47 participants of the NSW and ACT RDP during 2005–07 were invited to participate in a postal survey. The survey included questions regarding previous research training and experience, outcomes during and after participation in the program, and organisational aspects of the program. Follow-up interviews were conducted with selected participants. Interview questions covered time in the program, supervision, organisational support and placement outcomes. Thirty-seven participants responded to the survey and 23 (62%) participants took part in the semi-structured interviews. Seventy-eight per cent of survey respondents felt that the RDP helped them move from novice to a more experienced researcher with effective supervision identified by participants as a key element in determining the success of the program. Many felt that time allocation was inadequate and 20% thought their capacity to maintain their workload was adversely affected by participating. Outcomes were considerable given the modest nature of the program. Notable outcomes were that most participants published their research and presented their research at a conference. Furthermore, one-fifth of survey respondents had enrolled in higher degrees. Several interviewees reported that their research led to changes in practice. Most respondents found the RDP valuable and considered that undertaking the program increased their research knowledge.

This case study examines the financial viability, benefits and challenges of employing a primary healthcare (PHC) nurse practitioner (NP) in a bulk-billing healthcare cooperative in the Australian Capital Territory. There are few empirical case reports in the Australian literature that demonstrate financial sustainability of this type of healthcare professional in primary healthcare. This case study demonstrates that the costs of employing a PHC-NP in general practice are offset by direct and indirect Medicare billings generated by the PHC-NP, resulting in a cost-neutral healthcare practitioner. The success of this model relies on bidirectional collaborative working relationships amongst general practitioners and NPs. PHC-NPs should have a generalist scope of practice and specialist expertise in order to maximise their utility within the general practice environment. What is known about the topic? NPs represent a growing workforce of highly trained and educated advanced practice nurses that aims to improve access to timely and affordable healthcare for underserviced populations. Recent legislation has allowed for greater exploration of innovative models of care using NPs in Australian primary healthcare. What does this paper add? This case study provides practical information on the financial and logistical implications of employing an NP in a bulk-billing general practice. It demonstrates the broad capability of this workforce in Australian primary healthcare, and gives an overview of the facilitators and barriers to their use in private practice. What are the implications for practitioners? Employment of a PHC NP in general practice requires careful consideration of the direct and indirect benefits associated with the complimentary care they offer. NP access to the Medicare Benefits Schedule is severely restricted, which impairs their ability to achieve a full scope of practice and may contribute to increased health system costs and inefficiencies. There are opportunities for integration and facilitation of this emerging role in general practice with existing nursing workforce. Further research into this evolving area would be of benefit.

BackgroundStudying centre-to-centre (CTC) variation in mortality rates is important because inferences about quality of care can be made permitting changes in practice to improve outcomes. However, comparisons between hospitals can be misleading unless there is adjustment for population characteristics and severity of illness.ObjectiveWe sought to report the risk-adjusted CTC variation in mortality among preterm infants born <32 weeks and admitted to all eight tertiary neonatal intensive care units (NICUs) in the New South Wales and the Australian Capital Territory Neonatal Network (NICUS), Australia.MethodsWe analysed routinely collected prospective data for births between 2007 and 2014. Adjusted mortality rates for each NICU were produced using a multiple logistic regression model. Output from this model was used to construct funnel plots.ResultsA total of 7212 live born infants <32 weeks gestation were admitted consecutively to network NICUs during the study period. NICUs differed in their patient populations and severity of illness.The overall unadjusted hospital mortality rate for the network was 7.9% (n=572 deaths). This varied from 5.3% in hospital E to 10.4% in hospital C. Adjusted mortality rates showed little CTC variation. No hospital reached the +99.8% control limit level on adjusted funnel plots.ConclusionCharacteristics of infants admitted to NICUs differ, and comparing unadjusted mortality rates should be avoided. Logistic regression-derived risk-adjusted mortality rates plotted on funnel plots provide a powerful visual graphical tool for presenting quality performance data. CTC variation is readily identified, permitting hospitals to appraise their practices and start timely intervention.

Abstract Background Patient-delivered partner therapy (PDPT) is a method for an index patient to give treatment for genital chlamydia to their sexual partner(s) directly. In Australia, PDPT is considered suitable for heterosexual partners of men and women, but is not uniformly endorsed. We explored the policy environment for PDPT in Australia and considered how PDPT might become a routine option. Methods: Structured interviews were conducted with 10 key informants (KIs) representing six of eight Australian jurisdictions and documents relevant to PDPT were appraised. Interview transcripts and documents were analysed together, drawing on KIs’ understanding of their jurisdiction to explore our research topics, namely the current context for PDPT, challenges, and actions needed for PDPT to become routine. Results: PDPT was allowable in three jurisdictions (Victoria, New South Wales, Northern Territory) where State governments have formally supported PDPT. In three jurisdictions (Western Australia, Australian Capital Territory, Tasmania), KIs viewed PDPT as potentially allowable under relevant prescribing regulations; however, no guidance was available. Concern about antimicrobial stewardship precluded PDPT inclusion in the South Australian strategy. For Queensland, KIs viewed PDPT as not allowable under current prescribing regulations and, although a Medicine and Poisons Act was passed in 2019, it is unclear if PDPT will be possible under new regulations. Clarifying the doctor–partner treating relationship and clinical guidance within a care standard were viewed as crucial for PDPT uptake, irrespective of regulatory contexts. Conclusion: Endorsement and guidance are essential so doctors can confidently and routinely offer PDPT in respect to professional standards and regulatory requirements.

This paper reports on a qualitative study exploring the capacity of the community sector to support a whole-of-system response to cardiovascular disease prevention in primary health care. As a component of the Model for Prevention (MoFoP) study, community-based lifestyle modification providers were recruited in the Australian Capital Territory to participate in focus group discussions; 34 providers participated across six focus groups: 20 Allied Health Professionals (four groups) and 14 Lifestyle Modification Program providers (two groups). Thematic analysis of focus group transcripts was undertaken using a mixed deductive and inductive approach. Participant responses highlight several barriers to their greater contribution to cardiovascular disease prevention. These included that prevention activities are not valued, limited sector linkages, inadequate funding models and the difficulty of behaviour change. Findings suggest that improvements in the value proposition of prevention for all stakeholders would be supported by improved funding mechanisms and increased opportunities to build relationships across health and community sectors.

A government-funded service to provide forensic and medical care to survivors of sexual assault was established in the Australian Capital Territory (ACT) in 2001. Doctors employed by the service lacked the specific skills required to care comprehensively for survivors. Our aim was to develop, implement and evaluate a sexual assault medical education program. It consisted of an `in-house' education program, and external university course and incorporated team-building, networking activities and protocol development. Core elements were: forensic evidence collection, assessment and management of injuries, prevention of sexually transmissible infections and pregnancy, counselling and emotional support. Participant satisfaction and knowledge acquisition were evaluated using a semi-structured interview and a questionnaire. Seven doctors participated in a 16-session program conducted by the director and nurse coordinator with help from local forensic, legal and medical experts. All doctors successfully completed the Certificate in Forensic Medicine, and reported satisfaction with the program and their increased knowledge, particularly associated with collection of forensic evidence and court procedures. A compete set of protocols was developed and cohesive networks established. We have designed an effective education program for doctors working in the field of sexual assault and offer it as a template to other health professionals working in this area.

IntroductionMass casualty incidents (MCIs), requiring Trauma critical care, are increasingly likely. The ability to scale operations up i.e. ‘surge capacity’, is vital for ensuring scarce resources are used efficiently. The number of intensive care unit (ICU) beds is one of the key resources and indicators of a hospital's capacity and thus a vital area to target when assessing a systems ability to surge its Trauma ICU capabilities.ObjectiveThe study attempted to assess whether ICU facilities at major hospitals in large Australian cities would be able to respond to an event on the magnitude of the Madrid tragedy. This is the first report to measure Australia's major hospitals intensive care trauma surge capacity using Madrid as a standard.MethodsIn this prospective, cross-sectional analysis, we conducted a survey of major urban ICU trauma centres in the 8 state and Territory Capital cities of Australia. 14 Trauma Centre ICU's were targeted. The study was composed of two parts, A & B. Part A of the study consisted of an online survey, Part B, consisted of a follow-up telephone questionnaire. Full Ethics approval was sought and obtained.ResultsThere were 8 replies to the survey giving a 57% participation rate. At the time of this snap-shot survey the total number of Physically available ICU beds throughout the 8 Level I trauma centres was 52.5. All hospitals had at least 3 spare beds. This ranged from 3 to 10 beds. After accounting for the flux in beds post admissions & discharges there was a 21% increase in bed availability, which was further increased by a magnitude of 28% to an average of 10.125 beds, if all elective surgical procedures were cancelled. When using the Madrid ICU surge (29 new ICU patients) as a gold standard against which to compare, it was found the largest trauma ICU in Australia could have managed 62% of this surge. On average the 8 trauma centres would have handled only 34.75% of the Madrid ICU surge.ConclusionsIn the event of a major traumatic disaster on the scale of the Madrid atrocity, few if any of Australia's major trauma centres have the capacity to cope with the requisite surge. More research and novel ways of addressing this challenge are needed.

The inclusion of pharmacists into general practices has expanded in Australia. However, there is a paucity of research examining interprofessional collaboration and team effectiveness after including a pharmacist into the general practice team in primary or community care. This is a protocol for a cross-national comparative mixed-methods study to (i) investigate interprofessional collaboration and team effectiveness within the general practice team after employing pharmacists in general practices in the Australian Capital Territory (ACT) and (ii) to compare interprofessional collaboration and team effectiveness of pharmacists in general practice across Australia with international sites. The first objective will be addressed through a multiphase sequential explanatory mixed-method design, using surveys and semi-structured interviews. The study will recruit general practice pharmacists, general practitioners, and other health professionals from eight general practices in the ACT. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interprofessional collaboration. Secondly, a quantitative descriptive design will compare findings on interprofessional collaboration (professional interactions, relationship initiation, exchange characteristics, and commitment to collaboration) and team effectiveness of general practice pharmacists in Australia with international sites from Canada and the United Kingdom. The results of the study will be used to provide recommendations on how to best implement the role of general practice pharmacists across Australia.

IntroductionSmoking remains the leading risk factor for disease burden and mortality worldwide. Heavy Smoking is often associated with poor Nutrition, Alcohol abuse and Physical inactivity (known as ‘SNAP’). Australia’s first prison smoking ban was introduced in the Northern Territory in July 2013. However, relapse to smoking after release from prison is normative. Holistic and cost-effective interventions are needed to maintain post-release abstinence to realise the potential public health impact of smoke-free prison policies. Rigorous, large-scale trials of innovative and scalable interventions are crucial to inform tobacco control policies in correctional settings.Methods and analysisThis multicentre, investigator-blinded, randomised parallel superiority trial will evaluate the effectiveness of a brief intervention on SNAP versus usual care in preventing smoking relapse among people released from smoke-free prisons in the Northern Territory, Australia. A maximum of 824 participants will be enrolled and randomly assigned to either SNAP intervention or usual care at a 1:1 ratio at baseline. The primary endpoint is self-reported continuous smoking abstinence three months after release from prison, verified by breath carbon monoxide test. Secondary endpoints include seven-day point prevalence abstinence, time to first cigarette, number of cigarettes smoked post release, Health Eating Index for Australian Adults, Alcohol Use Disorder Identification Test-Consumption and International Physical Activity Questionnaire scores. The primary endpoint will be analysed on an intention-to-treat basis using a simple log binomial regression model with multiple imputation for missing outcome data. A cost-effectiveness analysis of the brief intervention will be conducted subsequently.Ethics and disseminationThis study was approved by the University of New South Wales Human Research Ethics Committee (HREC), Menzies HREC and Central Australia HREC. Primary results of the trial and each of the secondary endpoints will be submitted for publication in a peer-review journal.Trial registration numberACTRN12617000217303; Pre-results.

ObjectivesTo examine barriers and facilitators to sustaining a sexual health continuous quality improvement (CQI) programme in clinics serving remote Aboriginal communities in Australia.DesignQualitative study.SettingPrimary health care services serving remote Aboriginal communities in the Northern Territory, Australia.ParticipantsSeven of the 11 regional sexual health coordinators responsible for supporting the Northern Territory Government Remote Sexual Health Program.MethodsSemi-structured in-depth interviews conducted in person or by telephone; data were analysed using an inductive and deductive thematic approach.ResultsDespite uniform availability of CQI tools and activities, sexual health CQI implementation varied across the Northern Territory. Participant narratives identified five factors enhancing the uptake and sustainability of sexual health CQI. At clinic level, these included adaptation of existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI as a tool to identify and act on areas for improvement, and regional facilitation of clinic level CQI activities. Three barriers were identified, including the significant workload associated with acute and chronic care in Aboriginal primary care services, high staff turnover and lack of Aboriginal staff. Considerations affecting the future sustainability of sexual health CQI included the need to reduce the burden on clinics from multiple CQI programmes, the contribution of regional sexual health coordinators and support structures, and access to and use of high-quality information systems.ConclusionsThis study contributes to the growing evidence on how CQI approaches may improve sexual health in remote Australian Aboriginal communities. Enhancing sustainability of sexual health CQI in this context will require ongoing regional facilitation, efforts to build local ownership of CQI processes and management of competing demands on health service staff.

ObjectivesThere is mixed evidence on the relationship between physical activity and behavioural and mental health. We aimed to estimate the association between physical activity and risk of behavioural and mental health disorders in early school-aged children.DesignA series of cross-sectional complete enumeration (census) surveys.SettingsAll primary schools in the Australian Capital Territory, 2014–2016.ParticipantsAll children enrolled in their first year of full-time primary education (kindergarten) were invited to participate. Of the 16 662 eligible kindergarten children, 15 040 completed the survey for the first time.Outcome measuresAverage daily physical activity participation and prevalence of risk of behavioural and mental health disorders derived from parent-reported data and the Strengths and Difficulties Questionnaire (SDQ). Characteristics associated with SDQTotal difficultiesand subscales were estimated using logistic regression.Results8340 (61.7%) children met physical activity targets (60 min or more daily) and 709 (4.8%) were at clinically significant risk of behavioural and mental health disorders (Total difficulties).Known sociodemographic correlates were also those variables associated with high risk of behavioural and mental health disorders (Total difficulties): Aboriginal and Torres Strait Islander status (OR 2.72, 95% CI 1.78–4.16), relative socioeconomic disadvantage (most disadvantaged vs least disadvantaged, OR 1.86, 95% CI 1.38–2.50) and male sex (OR 1.80, 95% CI 1.49–2.17). Average daily physical activity was not significant, despite the highest levels of physical activity (90 min or more daily) being reported in boys, Aboriginal and Torres Strait Islander children and those from more disadvantaged areas.ConclusionsOur study provides comprehensive cross-sectional data on the relationship between physical activity participation and the risk of behavioural and mental health disorders in a large cohort of early school-aged Australian children. Aboriginal and Torres Strait Islander children, boys and those from the most disadvantaged socioeconomic group were at greatest risk of clinically significant behavioural and mental health disorders.

Background The high burden of infectious disease and associated antimicrobial use likely contribute to the emergence of antimicrobial resistance in remote Australian Aboriginal communities. We aimed to develop and apply context-specific tools to audit antimicrobial use in the remote primary healthcare setting. Methods We adapted the General Practice version of the National Antimicrobial Prescribing Survey (GP NAPS) tool to audit antimicrobial use over 2–3 weeks in 15 remote primary healthcare clinics across the Kimberley region of Western Australia (03/2018–06/2018), Top End of the Northern Territory (08/2017–09/2017) and far north Queensland (05/2018–06/2018). At each clinic we reviewed consecutive clinic presentations until 30 presentations where antimicrobials had been used were included in the audit. Data recorded included the antimicrobials used, indications and treating health professional. We assessed the appropriateness of antimicrobial use and functionality of the tool. Results We audited the use of 668 antimicrobials. Skin and soft tissue infections were the dominant treatment indications (WA: 35%; NT: 29%; QLD: 40%). Compared with other settings in Australia, narrow spectrum antimicrobials like benzathine benzylpenicillin were commonly given and the appropriateness of use was high (WA: 91%; NT: 82%; QLD: 65%). While the audit was informative, non-integration with practice software made the process manually intensive. Conclusions Patterns of antimicrobial use in remote primary care are different from other settings in Australia. The adapted GP NAPS tool functioned well in this pilot study and has the potential for integration into clinical care. Regular stewardship audits would be facilitated by improved data extraction systems.

In Australia, compulsory microchipping legislation requires that animals are microchipped before sale or prior to 3 months in the Australian Capital Territory, New South Wales, Queensland and Victoria, and by 6 months in Western Australia and Tasmania. Describing the implementation of microchipping in animals allows the data guardians to identify individual animals presenting to differing veterinary practices over their lifetimes, and to evaluate compliance with legislation. VetCompass Australia (VCA) collates electronic patient records from primary care veterinary practices into a database for epidemiological studies. VCA is the largest companion animal clinical data repository of its kind in Australia, and is therefore the ideal resource to analyse microchip data as a permanent unique identifier of an animal. The current study examined the free-text ‘examination record’ field in the electronic patient records of 1000 randomly selected dogs and cats in the VCA database. This field may allow identification of the date of microchip implantation, enabling comparison with other date fields in the database, such as date of birth. The study revealed that the median age at implantation for dogs presented as individual patients, rather than among litters, was 74.4 days, significantly lower than for cats (127.0 days, p = 0.003). Further exploration into reasons for later microchipping in cats may be useful in aligning common practice with legislative requirements.

In the context of global concern about children&rsquo;s weight and health, this study aims to investigate the extent to which Australian fathers are involved in family food work which includes feeding the family, and associated tasks such as shopping, food selection, planning meals, preparing, cooking, and cleaning up. It seeks to identify whether fathers consider children&rsquo;s &lsquo;healthiness&rsquo; and weight gain when performing these tasks, and what, if any, nutritional information resources they accessed. A qualitative exploratory study using semi-structured face-to-face interviews was conducted with eight fathers aged between 25 to 50 years living in the Australian Capital Territory. Participants discussed their roles in food provisioning and their perceptions of the food work process. A commitment to equally sharing domestic tasks between partners was frequently acknowledged amongst participants, despite the persistence of performative gendered norms. Male participants also discussed some of the constraining factors influencing their involvement in food provisioning. These included time scarcity, working commitments and cost. Whilst nutrition was considered when selecting and preparing food, most participants reported that they had not accessed or received nutritional and health information for their children. These findings provided insights into fathers&rsquo; perceptions of their roles and responsibilities of healthy food provisioning. Furthermore, this study suggests that public health researchers and health promoters should adapt their efforts to include fathers in education about the nutritional content of food for primary aged children, given the apparent paucity in these resources.

Introduction Early childhood experiences have a lifelong impact on a child’s future. Social and environmental experiences and interactions have a profound relational effect on children’s physical and mental health which transfers agency to parents, caregivers and duty-bearers to care for the child’s welfare. In the Australian context early child development indices have been in decline in some communities. Hence, there is a sense of urgency to reverse these trends from an integrated perspective. A multisector, multi component program of interventions named A Good Start in Life is proposed and is being tested in the Australian Capital Territory across suburbs with high levels of early childhood development disadvantage. The aim of this study is to evaluate the outcomes and processes related to targeted interventions, designed to integrate child and family services within the local district and embed allied health programs into early childhood education, care services and playgroups. Methods and analysis The Good Start in Life study will use a quasi-experimental design (with a matched control geographical area) consisting of a combination of interventions that will build multisectoral collaboration across education, health and social services that connect and support families with children from birth to 5 years. The control area will be matched on demographic characteristics and early child development outcomes and trends over the pre-intervention period. Evaluation data will be collected at baseline, and then on an annual basis for a further three years. A mixed methods approach will be used to evaluate delivery processes: quantitative (checklists, questionnaires) and qualitative methods (observations, focus groups and key stakeholder interviews). Effectiveness of the programme will be evaluated by comparing early child development outcomes between the comparator areas from the Australian Early Development Census in 2024. The primary focus will be on reducing the number of children who are developmentally vulnerable on at least one early development index (EDI). Separate tests will be conducted for significant differences in the percentage of children at risk in each of the five individual EDI domains. These domains are physical health and wellbeing, social competence, emotional maturity, language and cognitive skills, and communication and general knowledge. Trial registration ACTRN12621001140842.

IntroductionAccess to high-quality primary healthcare is limited for remote residents in Australia. Increasingly, remote health services are reliant on short-term or ‘fly-in, fly-out/drive-in, drive-out’ health workforce to deliver primary healthcare. A key strategy to achieving health service access equity, particularly evident in remote Australia, has been the development of Aboriginal Community Controlled Health Services (ACCHSs). This study aims to generate new knowledge about (1) the impact of short-term staffing in remote and rural ACCHSs on Aboriginal and Torres Strait Islander communities; (2) the potential mitigating effect of community control; and (3) effective, context-specific evidence-based retention strategies.Methods and analysisThis paper describes a 3-year, mixed methods study involving 12 ACCHSs across three states. The methods are situated within an evidence-based programme logic framework for rural and remote primary healthcare services. Quantitative data will be used to describe staffing stability and turnover, with multiple regression analyses to determine associations between independent variables (population size, geographical remoteness, resident staff turnover and socioeconomic status) and dependent variables related to patient care, service cost, quality and effectiveness. Qualitative assessment will include interviews and focus groups with clinical staff, clinic users, regionally-based retrieval staff and representatives of jurisdictional peak bodies for the ACCHS sector, to understand the impact of short-term staff on quality and continuity of patient care, as well as satisfaction and acceptability of services.Ethics and disseminationThe study has ethics approval from the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (project number DR03171), Central Australian Human Research Ethics Committee (CA-19-3493), Western Australian Aboriginal Health Ethics Committee (WAAHEC-938) and Far North Queensland Human Research Ethics Committee (HREC/2019/QCH/56393). Results will be disseminated through peer-reviewed journals, the project steering committee and community/stakeholder engagement activities to be determined by each ACCHS.

OBJECT Time-critical neurosurgical conditions require urgent operative treatment to prevent death or neurological deficits. In New South Wales/Australian Capital Territory patients’ distance from neurosurgical care is often great, presenting a challenge in achieving timely care for patients with acute neurosurgical conditions. METHODS A protocol was developed to facilitate consultant neurosurgery locally. Children with acute, time-critical neurosurgical emergencies underwent operations in hospitals that do not normally offer neurosurgery. The authors describe the developed protocol, the outcome of its use, and the lessons learned in the 9 initial cases where the protocol has been used. Three cases are discussed in detail. RESULTS Nine children were treated by a neurosurgeon at 5 rural hospitals, and 2 children were treated at a smaller metropolitan hospital. Road ambulance, fixed wing aircraft, and medical helicopters were used to transport the Newborn and Paediatric Emergency Transport Service (NETS) team, neurosurgeon, and patients. In each case, the time to definitive neurosurgical intervention was significantly reduced. The median interval from triage at the initial hospital to surgical start time was 3:55 hours, (interquartile range [IQR] 03:29–05:20 hours). The median distance traveled to reach a patient was 232 km (range 23–637 km). The median interval from the initial NETS call requesting patient retrieval to surgical start time was 3:15 hours (IQR 00:47–03:37 hours). The estimated median “time saved” was approximately 3:00 hours (IQR 1:44–3:15 hours) compared with the travel time to retrieve the child to the tertiary center: 8:31 hours (IQR 6:56–10:08 hours). CONCLUSIONS Remote urgent neurosurgical interventions can be performed safely and effectively. This practice is relevant to countries where distance limits urgent access for patients to tertiary pediatric care. This practice is lifesaving for some children with head injuries and other acute neurosurgical conditions.

ObjectivesThe aim of this study was to identify patient, hospital and transitional factors associated with unplanned 30-day readmissions in patients who had a total hip arthroplasty (THA).DesignA cross-sectional survey was performed. All patients attending a 6-week follow-up after a THA in the Australian Capital Territory (ACT) at four public and private clinics in the ACT from 1 February 2018 to 31 January 2019, were invited to complete an ACT Transition from Hospital to Home Orthopaedic Survey.ParticipantsWithin the ACT, 431 patients over the age of 16 attending their 6-week post-surgery consultation following a THA entered and completed the survey (response rate 77%).Primary outcome measureThe primary outcome measure was self-reported readmissions for any reason within 30 days of discharge after a THA. Multiple logistic regression was used to estimate ORs of factors associated with unplanned 30-day readmissions.ResultsOf the 431 participants (representing 40% of all THAs conducted in the ACT during the study period), 27 (6%) were readmitted within 30 days of discharge. After controlling for age and sex, patients who did not feel rested on discharge were more likely to be readmitted within 30 days than those who felt rested on discharge (OR=5.75, 95% CI: (2.13 to 15.55), p=0.001). There was no association between post-hospital syndrome (ie, in-hospital experiences of pain, sleep and diet) overall and readmission. Patients who suffered peripheral vascular disease (PVD) were significantly more likely to have an unplanned 30-day readmission (OR=16.9, 95% CI: (3.06 to 93.53), p=0.001). There was no significant difference between private and public patient readmissionsConclusionsHospitals should develop strategies that maximise rest and sleep during patients’ hospital stay. Diagnosis and optimum treatment of pre-existing PVD prior to THA should also be a priority to minimise the odds of subsequent unplanned readmissions.

ObjectivesTo compare the costs and effects of higher turnover of resident nurses and Aboriginal health practitioners and higher use of agency-employed nurses in remote primary care (PC) services and quantify associations between staffing patterns and health outcomes in remote PC clinics in the Northern Territory (NT) of Australia.DesignObservational cohort study, using hospital admission, financial and payroll data for the period 2013–2015.Setting53 NT Government run PC clinics in remote communities.Outcome measuresIncremental cost-effectiveness ratios were calculated for higher compared with lower turnover and higher compared with lower use of agency-employed nurses. Costs comprised PC, travel and hospitalisation costs. Effect measures were total hospitalisations and years of life lost per 1000 person-months. Multiple regression was performed to investigate associations between overall health costs and turnover rates and use of agency-employed nurses, after adjusting for key confounders.ResultsHigher turnover was associated with significantly higher hospitalisation rates (p<0.001) and higher average health costs (p=0.002) than lower turnover. Lower turnover was always more cost-effective. Average costs were significantly (p<0.001) higher when higher proportions of agency-employed nurses were employed. The probability that lower use of agency-employed nurses was more cost-effective was 0.84. Halving turnover and reducing use of a short-term workforce have the potential to save $32 million annually in the NT.ConclusionHigh turnover of health staff is costly and associated with poorer health outcomes for Aboriginal peoples living in remote communities. High reliance on agency nurses is also very likely to be cost-ineffective. Investment in a coordinated range of workforce strategies that support recruitment and retention of resident nurses and Aboriginal health practitioners in remote clinics is needed to stabilise the workforce, minimise the risks of high staff turnover and over-reliance on agency nurses and thereby significantly reduce expenditure and improve health outcomes.

ObjectivesTo: (1) establish the prevalence of urban, regional, rural and remote practice location of early-career general practitioners (GPs); and (2) examine demographic and training-related characteristics associated with working in regional, rural or remote areas post attainment of vocational general practice qualifications.DesignCross-sectional, questionnaire-based study, combined with contemporaneously collected data from participants’ prior vocational training.SettingAustralian general practice.ParticipantsNewly vocationally qualified GPs (ie, within 6 months–2 years post fellowship) who had completed vocational training with regional training organisations in New South Wales, Australian Capital Territory, eastern Victoria, and Tasmania between January 2016 and July 2018.Primary outcome measureRurality of post-fellowship practice location, as defined by Modified Monash Model (MMM) geographical classifications, based on current practice postcode. Prevalence of regional/rural/remote (‘rural’) practice was described using frequencies, and associations of rural practice were established using multivariable logistic regression, considering a range of demographic factors and training characteristics as independent variables.ResultsA total of 354 participants completed the questionnaire (response rate 28%) with 319 providing information for their current practice location. Of these, 100 (31.4%) reported currently practising in a rural area (MMM2-7). Factors most strongly associated with practising in a rural area included having undertaken vocational GP training in a rural location OR 16.0 (95% CI 6.79 to 37.9); p<0.001; and undertaking schooling in rural area prior to university OR 4.21 (1.98, 8.94); p<0.001.ConclusionsThe findings suggest that vocational training experience may have a role in rural general practice location post fellowship, attenuating the previously demonstrated ‘leakage’ from the rural practice pipeline.

Objectives: The aim of the present study was to determine the characteristics and short-term outcomes of mother–infant pairs with comorbid drug dependency and psychiatric disorders. Methods: A population-based retrospective chart review was carried out of 879 drug-dependent mother and infant pairs in New South Wales (NSW) and the Australian Capital Territory (ACT) who delivered between 1 January and 31 December 2004. Results: Psychiatric comorbidity (dual diagnosis, DD) was identified in 396 (45%) of the 879 drug-dependent women. DSM-IV depression (79%), followed by anxiety (20%), was most prevalent. DD women were more likely to use amphetamines (29% vs 18%, p < 0.05), less likely to use opiates (42% vs 51%, p < 0.05) and to have had no antenatal care (24% vs 8%, p < 0.05). They also had more previous pregnancies (4, range = 2–5 vs 3, range = 2–5, p < 0.05) and domestic violence (29% vs 14%, p < 0.05) was more common. DD infants were less likely to be admitted to a nursery (47% vs 55%, p < 0.05). Withdrawal scores were similar (maximum median Finnegan scores = 4 (interquartile range = 3–8) vs 10 (interquartile range = 7–12, p = 0.30) but fewer needed withdrawal medication (19% vs 27%, p < 0.05). Maternal psychotropic agents did not worsen the severity of neonatal withdrawal. Conclusions: Psychiatric comorbidity, especially depression, is common and affects almost half of drug-using mothers. Antenatal care, drug use and social outcomes are worse for DD mothers and their infants. It is recommended that all drug-using women be assessed antenatally for psychosocial disorders so that timely mental health intervention can be offered, if required.

The literature reports that rehabilitation for elderly patients with mild-to-moderate dementia who have a hip fracture improves functional outcomes. However, access to rehabilitation may be difficult due to misconceptions about the ability of these patients to engage in and benefit from rehabilitation. Additionally, people who are admitted from residential care may not have the same options for rehabilitation as those admitted from home. This study sought to understand from expert clinicians how and why decisions are made to accept a person with dementia post-fracture for rehabilitation. In this Australian-based qualitative study, 12 health professionals across a state and territory were interviewed. These clinicians were the primary decision makers in accepting or rejecting elderly patients with dementia post-fracture into rehabilitation. Three key themes emerged from the data: criteria for accessing rehabilitation, what works well and challenges to rehabilitation. The participants were unanimous in the view that access to rehabilitation should be based on the ability of the patient to engage in a rehabilitation programme and not assessed solely on cognition. In terms of clinical care, a coherent rehabilitation pathway with integration of geriatric and ortho-geriatric services was reported as ideal. Challenges remain, importantly, the perception of some health care staff that people with dementia have limited capability to benefit from rehabilitation. Rehabilitation for this growing group of patients requires multiple resources, including skilled practitioners, integrated clinical systems and staff education regarding the capabilities of people with dementia. Future research in this area with patients with moderate-to-severe dementia in residential care is warranted.

ObjectivesTo evaluate the benefit and risk of low-dose acetylsalicylic acid (aspirin) in patients from remote Aboriginal communities in the Northern Territory, Australia.DesignRetrospective cohort study using primary care and hospital data routinely used for healthcare. Aspirin users and non-users were compared before and after controlling confounders by matching. Marginal structural models (MSM) were applied to ascertain the benefit and risk.SettingThe benefit and harm of aspirin were investigated in patients aged ≥18 years from 54 remote Aboriginal communities.ParticipantsNone had a previous cardiovascular event or major bleeds. Patients on anticoagulants or other antiplatelets were excluded.InterventionAspirin at a dose of 75–162 mg/day.Outcome measuresEndpoints were all-cause, cardiovascular mortality and incidences of cardiovascular events and major bleeds.Results8167 predominantly Aboriginal adults were included and followed between July 2009 and June 2017 (aspirin users n=1865, non-users n=6302, mean follow-up 4 years with hospitalisations 6.4 per person). Univariate analysis found material differences in demographics, prevalence of chronic diseases and outcome measures between aspirin users and non-users before matching. After matching, aspirin was significantly associated with reduced all-cause mortality (HR=0.45: 95% CI 0.34 to 0.60; p<0.001), but not bleeding (HR=1.13: 95% CI 0.39 to 3.26; p=0.820). After using MSMs to eliminate the effects of confounders, loss of follow-up and time dependency of treatment, aspirin was associated with reduced all-cause mortality (HR=0.60: 95% CI 0.47 to 0.76; p<0.001), independent of age (HR=1.06; p<0.001), presence of diabetes (HR=1.42; p<0.001), hypertension (HR=1.61; p<0.001) and alcohol abuse (HR=1.81; p<0.001). No association between aspirin and major bleeding was found (HR=1.14: 95% CI 0.48 to 2.73; p=0.765). Sensitivity analysis suggested these findings were unlikely to have been the result of unmeasured confounding.ConclusionAspirin was associated with reduced all-cause mortality. Bleeding risk was less compared with survival benefits. Aspirin should be considered for primary prevention in Aboriginal people with high cardiovascular risk.

Background: The finding by Lawrence, Holman and Jablensky (Duty to Care) that mortality among the mentally ill in Western Australia was 2.5 times that of the general population, seemingly, has great significance for public policy concerning the mentally ill. ‘Mortality’ could be a useful outcome measure for mental health services. Objectives: To replicate that study in the Australian Capital territory (ACT), comparing mortality rates in the mentally ill with those of the total population. Method: A list of all people who contacted the ACT mental health services between 1985 and 2000 was compiled. Using the national register of deaths (Australian Institute of Health and Welfare), persons known to the mental health services who died between 1990 and 2000 were identified and sex, date of birth, date of death, cause of death and place of death were noted. Using Australian Bureau of Statistics data for all deaths in the ACT, deaths in the total population and in the mentally ill population were tabulated for the period 1996–2000. With 1996 data as the base, using total population data from the ABS and mental health population data derived by amending ‘the list’ to remove duplications, pre1996 deaths and post1996 additions, mortality rates for the period 1996–2000 were compared. Results: The gender and age distribution of the mentally ill population and the total population, and of deaths in those populations, were very different. One third of all deaths in the mentally ill occurred outside of the ACT. Compared with the general population, mortality in the mentally ill (including deaths outside of the ACT) was only slightly excessive for ‘all causes’ and ischaemic heart disease but grossly excessive for ‘suicide’. Conclusions: This study did not confirm the excessive mortality rate in the mentally ill reported by Lawrence et al. except for suicide. Many methodological issues in using population studies to attempt to measure the size of the increase were identified. Differences in method between the ACT and WA studies probably explain the differences in results. Caution is urged in using the results of mortality studies as determinants of public policy or to evaluate services.

IntroductionHealth literacy describes the cognitive and social skills that individuals use to access, understand and act on health information. Health literacy interventions typically take the ‘universal precautions approach’ where all consumers are presented with simplified materials. Although this approach can improve knowledge and comprehension, its impact on complex behaviours is less clear. Systematic reviews also suggest that health literacy interventions underuse volitional strategies (such as planning) that play an important role in behaviour change. A recent study found volitional strategies may need to be tailored to the participant’s health literacy. The current study aims to replicate these findings in a sample of people who have diabetes and/or are overweight or obese as measured by body mass index, and to investigate the most effective method of allocating an action plan to a participant to reduce unhealthy snacking.Methods and analysisWe plan to recruit approximately 2400 participants at baseline. Participants will receive one of two alternative online action plans intended to reduce unhealthy snacking (‘standard’ action plan or ‘literacy-sensitive’ action plan). Participants will be randomised to a method of allocation to an action plan: (1) random allocation; (2) allocation by health literacy screening tool or (3) allocation by participant selection. Primary outcome is self-reported serves of unhealthy snacks during the previous month. Multiple linear regression will evaluate the impact of health literacy on intervention effectiveness. The analysis will also identify independent contributions of each action plan, method of allocation, health literacy and participant selections on unhealthy snacking at 4-week follow-up.Ethics and disseminationThis study was approved by the University of Sydney Human Research Ethics Committee (2017/793). Findings will be disseminated through peer-reviewed international journals, conferences and updates with collaborating public health bodies (Diabetes New South Wales (NSW) & Australian Capital Territory (ACT), and Western Sydney Local Health District).Trial registration numberACTRN12618001409268; Pre-results.

IntroductionBronchiectasis is no longer considered rare or irreversible in children, yet it remains relatively under-researched and neglected in respiratory health globally. Bronchiectasis (including chronic suppurative lung disease) causes substantial morbidity for patients and significant impact on caregivers, especially during acute respiratory exacerbations. In other chronic respiratory diseases (eg, asthma), empowering consumers with an individualised plan for management of acute exacerbations improves clinical outcomes. However, in the absence of any such data specific to bronchiectasis, action management plans are rarely currently used in children or adults with bronchiectasis. We hypothesise that providing an individualised bronchiectasis action management plan (BAMP) to children with bronchiectasis reduces non-scheduled doctor consultations, compared with not having a BAMP.Methods and analysisThis multicentre, parallel, double-blind, randomised trial involving three urban Australian hospitals commenced in June 2018 and will include 198 children, aged <19 years with bronchiectasis who had 2 or more exacerbations in the previous 18 months. Children will be randomised to having an individualised BAMP or standard care (a decoy clinic letter). Primary caregivers will then be followed up monthly for 12 months. The primary outcome is the rate of acute non-scheduled doctor visits for respiratory exacerbations by 12 months. The main secondary outcomes are cough-specific quality of life scores at 6 and 12 months, overall exacerbation rate over 12 months, and proportion of children who received timely influenza vaccination by 30 May annually.Ethics and disseminationThe Human Research Ethics Committees of the Northern Territory Department of Health and Menzies School of Heath Research and Queensland Children’s Hospital approved the study. The results of the trial will be submitted for publication and the BAMP made available free online.Trial registration numberAustralia and New Zealand Clinical Trials Register ACTRN12618000604202.

IntroductionIt is important to ascertain the cost-effectiveness of alternative services to traditional cardiac rehabilitation while the economic credentials of the Smartphone Cardiac Rehabilitation, Assisted self-Management (SCRAM) programme among people with coronary heart disease (CHD) are unknown. This economic protocol outlines the methods for undertaking a trial-based economic evaluation of SCRAM in the real-world setting in Australia.Methods and analysisThe within-trial economic evaluation will be undertaken alongside a randomised controlled trial (RCT) designed to determine the effectiveness of SCRAM in comparison with the usual care cardiac rehabilitation (UC) alone in people with CHD. Pathway analysis will be performed to identify all the costs related to the delivery of SCRAM and UC. Both a healthcare system and a limited societal perspective will be adopted to gauge all costs associated with health resource utilisation and productivity loss. Healthcare resource use over the 6-month participation period will be extracted from administrative databases (ie, Pharmaceutical Benefits Scheme and Medical Benefits Schedule). Productivity loss will be measured by absenteeism from work (valued by human capital approach). The primary outcomes for the economic evaluation are maximal oxygen uptake (VO2max, mL/kg/min, primary RCT outcome) and quality-adjusted life years estimated from health-related quality of life as assessed by the Assessment of Quality of Life-8D instrument. The incremental cost-effectiveness ratio will be calculated using the differences in costs and benefits (ie, primary and secondary outcomes) between the two randomised groups from both perspectives with no discounting. All costs will be valued in Australian dollars for year 2020.Ethics and disseminationThe study protocol has been approved under Australia’s National Mutual Acceptance agreement by the Melbourne Health Human Research Ethics Committee (HREC/18/MH/119). It is anticipated that SCRAM is a cost-effective cardiac telerehabilitation programme for people with CHD from both a healthcare and a limited societal perspective in Australia. The evaluation will provide evidence to underpin national scale-up of the programme to a wider population. The results of the economic analysis will be submitted for publication in a peer-reviewed journal.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12618001458224).

ObjectivesAlthough substandard and falsified (SF) blood pressure (BP) lowering medications are a global problem, qualitative research exploring factors driving this in Nigeria has not been reported. This study provides information on factors driving demand for and supply of low-quality BP lowering medications in Nigeria and potential strategies to address these factors.MethodsThis was a cross-sectional qualitative study. Between August 2020 and September 2020, we conducted 11 in-depth interviews and 7 focus group discussions with administrators of health facilities, major manufacturers and distributors of BP lowering medications, pharmacists, drug regulators, patients and primary care physicians purposively sampled from the Federal Capital Territory, Nigeria. Data were analysed using directed content analysis, with the aid of Dedoose.ResultsWe found that demand for SF BP lowering medications in Nigeria was driven by high out-of-pocket expenditure and stockouts of quality-assured BP lowering medications. Supply of low-quality BP lowering medications was driven by limited in-country manufacturing capacity, non-adherence to good manufacturing and distribution practices, under-resourced drug regulatory systems, ineffective healthcare facility operations, poor distribution practices, limited number of trained pharmacists and the COVID-19 pandemic which led to stockouts. Central medicine store procurement procedures, active pharmaceutical ingredient quality check and availability of trained pharmacists were existing strategies perceived to lower the risk of supply and demand of SF BP lowering medications.ConclusionOur findings suggest that demand for and supply of SF BP lowering medications in Nigeria are driven by multi-level, interrelated factors. Multi-pronged strategies need to target stakeholders and systems involved in drug production, distribution, prescription, consumption, regulation and pricing.

IntroductionCardiovascular disease (CVD) represents a significant burden of disease for Aboriginal and Torres Strait Islander people, a population that continues to experience a lower life expectancy than other Australians. The aim of the Better Cardiac Care Data Linkage project is to describe patient care pathways and to identify disparities in care and health outcomes between Aboriginal and Torres Strait Islander people and other Queensland residents diagnosed with CVD in the state of Queensland.MethodsThis is a population-based retrospective cohort study using linked regional, state and national health and administrative data collections to describe disparities in CVD healthcare in primary and secondary prevention settings and during hospitalisation. The CVD cohort will be identified from the Queensland Hospital Admitted Patient Data Collection for admissions that occurred between 1 July 2010 and 31 June 2016 and will include relevant International Classification of Disease codes for ischaemic heart disease, congestive heart failure, stroke, acute rheumatic fever and rheumatic heart disease. Person-level data will be linked by Data Linkage Queensland and the Australian Institute of Health and Welfare (AIHW) in accordance with ethical and public health approvals to describe the patient journey prior to, during and post the hospital admission.AnalysisThis project will focus largely on descriptive epidemiological measures and multivariate analysis of clinical care standards and outcomes for Aboriginal and Torres Strait Islander people compared with other Queenslanders, including identification of risk factors for suboptimal care and change over time. Variation in care pathways and patient outcomes will be compared by Indigenous status, sex, age group, remoteness of residence, year of index hospitalisation and socioeconomic status. Cox models for time-to-event data and mixed models or generalised estimating equations for longitudinal data will be used to measure change over time where temporal effects exist.Ethics and disseminationEthical approval has been granted by Human Research Ethics Committees of the Prince Charles Hospital (HREC/15/QPCH/289) and the AIHW (EO2016-1-233). The Northern Territory Department of Health and Menzies School of Health Research have also provided reciprocal ethical approval of the project (HREC 2019–3490). The deidentified results will be summarised in a report and shared with investigators, advisory groups, Queensland Health and key stakeholders. Findings will be disseminated through workshops, conferences and will be published in peer-reviewed journals.

IntroductionIndividuals with Rett syndrome (RTT) experience impaired gross motor skills, limiting their capacity to engage in physical activities and participation in activities. There is limited evidence of the effectiveness of supported physical activity interventions. This study aims to evaluate the effects of a telehealth-delivered physical activity programme on physical activity, sedentary behaviour and quality of life in RTT.Methods and analysisThis is a multicentre study, conducted in Australia, Denmark and Israel. It is a randomised waitlist-controlled trial comparing an intervention to support physical activity with usual care. Participants are children and adults with RTT, recruited from the Australian Rett Syndrome Database, the Danish Center for Rett Syndrome and the Rett Syndrome Association of Israel. The intervention duration is 12 weeks, including fortnightly telephone contact to plan, monitor and develop individual activity programmes. Outcomes are measured at baseline, at 13 weeks and then at 25 weeks. The primary outcomes are sedentary behaviour assessed with an activPAL accelerometer and the number of daily steps measured with a StepWatch Activity Monitor. Secondary outcomes include sleep, behaviour and quality of life. Caregiver experiences will be assessed immediately after the intervention using a satisfaction questionnaire. Group differences for each outcome will be evaluated with analysis of covariance, adjusting for baseline values on an intention-to-treat basis.Ethics and disseminationEthics approval has been obtained in Western Australia from the Child and Adolescent Health Services (RGS3371), in Denmark from the Capital Region Ethics Committee (H-19040514) and in Israel from the Ariel University Institutional Review Board (AU-HEA-ML-20190331). Manuscripts on the development of the intervention from pilot work and the results of the intervention will be submitted to peer-reviewed journals. Results will be presented at conferences and consumer forums. We will develop an online resource documenting the physical activity programme and available supporting evidence.Trial registration numberNCT04167059; Pre-results.

Bullying behaviour can have a negative impact on a child's physical and psychological health. Bullying in the classroom is a challenge for early-childhood educators. Preschool is the first place outside the home where children face social challenges when interacting with their classmates. Child-Friendly Class is the first step and part of the Children Friendly School (CSF) as a UNICEF program and an important Indonesian government policy to prevent the emergence of child bullying behaviour. This study aims to identify needs in the process of developing a Child-Friendly Classroom Management model to anticipate bullying behaviour. This research and development method uses an adaptation of the Rowntree model which includes three stages of the process and data collection techniques using interviews, questionnaires, and observation. The results of this study indicate that the preparation of an effective classroom management guidebook to create child-friendly classes needs to be followed up immediately. Several findings related to teachers' perceptions of classroom management, and child-friendly classes prove that child-friendly classes have not been implemented properly in PAUD institutions, with bullying behaviour still appearing in early childhood in PAUD institutions. PAUD teachers understand that it is important to implement classroom management but so far there has been no manual on how to manage effective classrooms as well as training related to the implementation of effective classroom management. The creation of child-friendly classes is believed to be able to help teachers suppress the emergence of bullying behaviour in early childhood. Keywords: Child-Friendly Classroom Management, Bullying Prevention, Early Childhood Education References: Allday, R. A., Hinkson-Lee, K., Hudson, T. 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During physical distancing, children do not meet their peers to play or talk together. Peer relationships have a crucial influence on all child development, especially for social skills or behaviour during early childhood. This study aims to determine changes in children's social behaviour during physical distancing during the Covid-19 pandemic. This research method is a descriptive quantitative study designed with the percentage value was used as a score for measuring the results of parental observations of children concerning the child's social behaviour instrument. Quota sampling (150 parents) was used to reach participants from various cities in Indonesia to see cultural differences. Data on children's social behaviour was obtained using the Preschool and Kindergarten Behaviour Scale (PKBS) tests. The data were then analysed using descriptive statistics. The results show that there are changes in children's social behaviour during physical distancing. Children who are less independent (58.9%) are the biggest decline in social behaviour reported by parents, while the one who changes the least is cleaning up the mess that has been made (38.7%). The implication of the results of this study is that parents should continue to pay attention to their children's social behaviour by providing opportunities for children to interact with peers in the house while still paying attention to health protocols. Keywords: Early Childhood, Social Behaviour, Physical Distancing References: Aksoy, P., & Baran, G. (2010). Review of studies aimed at bringing social skills for children in preschool period. Procedia - Social and Behavioural Sciences, 9, 663–669. https://doi.org/10.1016/j.sbspro.2010.12.214 Al-Tammemi, A. B. (2020). The Battle Against COVID-19 in Jordan: An Early Overview of the Jordanian Experience. Frontiers in Public Health, 8(May), 1–6. https://doi.org/10.3389/fpubh.2020.00188 Arkorful, V., & Abaidoo, N. (2015). 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Objectives: This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme – a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users. Methods: We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions. Results: We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty. Conclusion: Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out. Implications: This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level.

Abstract Background There is evidence that blood pressure (BP) levels vary considerably from season to season, due principally to variation in ambient temperature. This gives the potential for both under- and over-treatment if BP lowering medications are not varied seasonally, but is not acknowledged in clinical guidelines. We will describe the seasonal variation in BP and assess the association between systolic blood pressure (SBP) and outdoor maximum ambient temperature in Australia. Methods The primary care data is an extract from MedicineInsight, a national general practice data program developed and managed by NPS MedicineWise, which extracts deidentified data from almost 10% of all Australian general practices. We included patients aged 30–90 years with at least one BP measure recorded from 1 Jan 2010 to 1 Aug 2017. Australian Bureau of Meteorology daily max temperature is linked by matching observation dates and location to nearest weather station. Decomposition of the mean will determine seasonal variation. Multiple linear regression was used to estimate the associations between max temperature and SBP with adjustment for age, sex, socioeconomic index, current smoking, comorbidities, BP lowering medication use, lipid lowering medication use and year of BP measurement. Results The study population includes 2.6 million people, mean age 55 years (standard deviation [SD] 16.3). Fifty-five percent are female, over a third of the cohort reside in New South Wales, and 62.4% reside in major Australian cities. The mean (SD) temperature was 23°C (6.6). There was a mean (SD) of 7 (11.4) BP measurements per person over the study period, median 3 measures (interquartile range 1–8). A quarter had a history of hypertension, 8% had a history of cardiovascular disease, and 8% had a history of diabetes. Twenty-six percent had at least one prescription for BP lowering therapy. The average monthly SBP for the cohort demonstrated strong seasonal variation with higher values in winter. The population mean varies by 3mmHg SBP between seasons across Australia, ranging from 1.7mmHg in the Northern Territory to 3.5mmHg in South Australia (range of mean maximum temperature 3°C [30–33] and 14°C [15–29] for the capital cities respectively). Each 10°C increase in max outdoor temperature was associated with a 1.8mmHg [95% CI 1.80–1.83] lower mean SBP. The proportion of people with SBP>140mmHg varied by season, irrespective of age, sex and use of BP lowering treatment. For example, among those treated control rates varied between 70 and 81%, and among those not treated between 78 and 85% (Figure). Blood pressure seasonality in Australia Conclusions BP control rates vary considerably by season. These findings have implications for the reliable diagnosis of hypertension, and suggest seasonal adjustments in treatment should be considered for some patients. The clinical and public health relevance of this phenomenon is expected to increase with increasing climate variability. Acknowledgement/Funding National Health and Medical Research Council Australia, National Heart Foundation Australia

Abstract Background Inappropriate antibiotic use is a global health concern as it increases antibiotic resistance. Antibiotics are not routinely recommended for treating acute gastroenteritis, non-typhoidal salmonella and campylobacter infections. We investigated adherence to these recommendations in primary care. Methods We used a large electronic database of primary care records to identify presentations for acute gastroenteritis, non-typhoidal salmonella and campylobacter infections and antibiotic prescribing from 1st Jan 2013 to 31 December 2018. We estimated the proportions of cases prescribed antibiotics according to various characteristics and examined the antibiotics prescribed. Results A total of 86998, 1106, and 1952 participants were identified with acute gastroenteritis, non-typhoidal salmonella, and campylobacter infections and correspondingly 10% (8720/86998), 40% (437/1106), and 57% (1118/1952) of these cases were prescribed antibiotics in the period up to 5 days post-diagnosis. Patients residing in outer regional/remote areas and those from Northern Territory and Queensland were more likely to be prescribed antibiotics than those residing in major cities and those from other states (p &lt; =0.04). No dominant antibiotic class was prescribed for acute gastroenteritis. Quinolones (28.6%) and macrolides (27.0%) were the most frequently prescribed antibiotics for non-typhoidal salmonella, and macrolides (69%) were the predominant antibiotics prescribed for campylobacter. Conclusion The high proportion of antibiotics dispensed in the general population with acute gastroenteritis, non-typhoidal salmonella and campylobacter infections suggests that antimicrobial stewardship needs to include better education and awareness around treatment guidelines for such infections. Key messages Antibiotics use was common for Australian population with acute gastroenteritis, particularly those with non-typhoidal salmonella and campylobacter infections.

Abstract Background Implementing an evidence-based hypertension program in primary healthcare centers (PHCs) in the Federal Capital Territory, Nigeria is an opportunity to improve hypertension diagnosis, treatment, and control and reduce deaths from cardiovascular diseases. This qualitative research study was conducted in Nigerian PHCs with patients, non-physician health workers, administrators and primary care physicians to inform contextual adaptations of Kaiser Permanente Northern California's hypertension model and the World Health Organization’s HEARTS technical package for the system-level, Hypertension Treatment in Nigeria (HTN) Program. Methods Purposive sampling in 8 PHCs identified patients (n = 8), non-physician health workers (n = 12), administrators (n = 3), and primary care physicians (n = 6) for focus group discussions and interviews. The Primary Health Care Performance Initiative (PHCPI) conceptual framework and Consolidated Framework for Implementation Research (CFIR) domains were used to develop semi-structured interviews (Appendix 1, Supplemental Materials) and coding guides. Content analysis identified multilevel factors that would influence program implementation. Results Participants perceived the need to strengthen four major health system inputs across CFIR domains for successful adaptation of the HTN Program components: (1) reliable drug supply and blood pressure measurement equipment, (2) enable and empower community healthcare workers to participate in team-based care through training and education, (3) information systems to track patients and medication supply chain, and (4) a primary healthcare system that could offer a broader package of health services to meet patient needs. Specific features of the PHCPI framework considered important included: accessible and person-centered care, provider availability and competence, coordination of care, and proactive community outreach. Participants also identified patient-level factors, such as knowledge and beliefs about hypertension, and financial and transportation barriers that could be addressed with better communication, home visits, and drug financing. Participants recommended using existing community structures, such as village health committees and popular opinion leaders, to improve knowledge and demand for the HTN Program. Conclusions These results provide information on specific primary care and community contextual factors that can support or hinder implementation and sustainability of an evidence-based, system-level hypertension program in the Federal Capital Territory, Nigeria, with the ultimate aim of scaling it to other parts of the country.