Prostate cancer survival in South West Victoria.

OBJECTIVE: To explore reasons for survival disparities for patients with prostate cancer in the Barwon South West area of Victoria. DESIGN, SETTING AND PARTICIPANTS: We have described incidence, diagnostics, treatment pathways, and survival for four regions of the Barwon South Western Victoria. Analysis included all newly diagnosed prostate cancer patients from 2009 to 2015 in the Evaluation of Cancer Outcomes Barwon South West Registry. Regions included 1: Queenscliffe 2: Geelong, Colac Otway and Corangamite 3: Moyne, Warrnambool and Southern Grampians and 4: Glenelg. Across the four regions, variables were compared using a chi square statistic or analysis of variance and survival data was assessed with the Kaplan-Meier curves. MAIN OUTCOME MEASURES: Incidence, treatment pathways and survival for prostate cancer patients. RESULTS: A total of 1776 patients were diagnosed with prostate cancer from 2009 to 2015 in the Barwon South West area. In regions 1-4, there were 298 (1.04%), 1085 (0.92%), 273 (0.97%) and 120 (1.2%) cases, respectively. There was no significant difference in Gleason score and treatment. The 5-year survival rate was 85%, 76%, 71% and 80%, respectively, as compared with the national average of 95%. PSA scores >20 ng/ml at diagnosis, as a surrogate for high-risk disease, occurred in 23%, 29%, 22% and 21%, respectively (p < 0.01). The proportions presenting with stage IV disease were 17%, 26%, 21% and 6%, respectively (p = 0.10). CONCLUSION: Men diagnosed with prostate cancer in South West Victoria have a considerably lower 5-year survival compared with the national average with later disease at presentation in some areas.

An update on the pilot trial of consumer-directed care for older persons in Australia.

The Australian Government has commenced a two-year pilot of consumer-directed care (CDC) across 500 home and community aged care packages. This policy paper discusses the model being trialled in Australia in light of the UK's Individual Budgets' Pilot Programme and the USA's Cash and Counselling Demonstration. The results of these randomised controlled studies suggest that older people vary in their preferences for consumer direction and that many find the administrative tasks of implementing CDC programs difficult. The relatively restricted model of CDC that the Australian Government is trialling may minimise the problems encountered in the overseas programs, but does not allow consumers to hire family or friends which they preferred to do overseas.

Individualized guidelines for the management of aggression in dementia - Part 2: appraisal of current guidelines.

BACKGROUND: Individualized guidelines have the potential to offer clinicians assistance in decision-making at the point of consultation to improve health outcomes for patients. This project aims to develop individualized guidelines for the management of aggression in dementia. At an earlier stage, we developed a map of concepts to consider when managing aggression. The purpose of the current study is to appraise paper-based guidelines for their representation of these concepts. METHODS: Two reviewers used a four-point scale (absent, weak, moderate, strong) to rate the guidelines on their representation of concepts relating to the patient, the aggression and dementia disorder, the treatment, and the guidelines themselves. Consensus was reached on inconsistent scores. RESULTS: Sixteen guidelines published since 2005 were evaluated for their representation of 13 key concepts. Pharmacological and non-pharmacological interventions were strongly represented overall in the guidelines, in conjunction with a consideration of the individual characteristics of the patients and their environment. Recommendations based on the presentation of the aggressive symptoms, goals of treatment, and theory of the cause of the aggression were moderately represented in the guidelines. Recommendations for the principles of restraint use and emergency treatment, as well as a consideration of the personal history of the patient, were poorly represented. Only 6 of 16 guidelines gave details of the expected review. CONCLUSION: Concepts important to the management of aggression in dementia are missing in the majority of published guidelines on dementia. This limits the ability of these tools to guide clinical practice effectively.

Individualized guidelines for the management of aggression in dementia - Part 1: key concepts.

BACKGROUND: Clinical guidelines have the potential to assist in the management of aggression in dementia. This study aims to develop a conceptual framework for the construction of individualized guidelines for this group. METHODS: A concept map of the topic "How to manage aggression in dementia" was developed by reviewing research papers, clinical guidelines, and gray literature. Titles and abstracts of papers that met search criteria were manually scanned in an iterative process for the extraction of key ideas and terminology commonly used to describe the field. Essential ideas and concepts were recorded on a concept map and hierarchically arranged. The concept map was converted into an interactive PDF document for easy distribution and sharing. RESULTS: Ten key concepts were found to be important when managing aggression in dementia clustered along three major dimensions: Patient, Disorder and Treatment. The dimension Patient was defined by the "Patient's individual characteristics," the "Personal life story," and the "Patient's environment." Disorder was defined by the "Presentation of symptoms" and "Theory of causation." Treatment was defined by "Goals and expectations," "Non-pharmacological interventions," "Pharmacological interventions," "Ethics and Restraint Use," and "Emergency treatment." Concepts relating to clinical guidelines themselves were also included in the interactive map, including "Support from evidence-based medicine," "Regular updates," "Disclosures," and "Usability." CONCLUSION: Managing aggression in dementia requires consideration of a wide range of factors relating to the patient, the dementia and behavioral disturbance, and possible treatment options. An interactive and hierarchical concept map provides a framework to develop individualized clinical guidelines.