Development and internal validation of the Edmonton Obesity Staging System-2 Risk screening Tool (EOSS-2 Risk Tool) for weight-related health complications: a case-control study in a representative sample of Australian adults with overweight and obesity.

OBJECTIVE: Excess weight and related health complications remain under diagnosed and poorly treated in general practice. We aimed to develop and validate a brief screening tool for determining the presence of unknown clinically significant weight-related health complications for potential application in general practice. DESIGN: We considered 14 self-reported candidate predictors of clinically significant weight-related health complications according to the Edmonton Obesity Staging System (EOSS score of ≥2) and developed models using multivariate logistic regression across training and test data sets. The final model was chosen based on the area under the receiver operating characteristic curve and the Hosmer-Lemeshow statistic; and validated using sensitivity, specificity and positive predictive value. SETTING AND PARTICIPANTS: We analysed cross-sectional data from the Australian Health Survey 2011-2013 sample aged between 18 and 65 years (n=7518) with at least overweight and obesity. RESULTS: An EOSS≥2 classification was present in 78% of the sample. Of 14 candidate risk factors, 6 (family history of diabetes, hypertension, high sugar in blood/urine, high cholesterol and self-reported bodily pain and disability) were automatically included based on definitional or obvious correlational criteria. Three variables were retained in the final multivariate model (age, self-assessed health and history of depression/anxiety). The EOSS-2 Risk Tool (index test) classified 89% of those at 'extremely high risk' (≥25 points), 67% of those at 'very high risk' (7-24 points) and 42% of those at 'high risk' (<7 points) of meeting diagnostic criteria for EOSS≥2 (reference). CONCLUSION: The EOSS-2 Risk Tool is a simple, safe and accurate screening tool for diagnostic criteria for clinically significant weight-related complications for potential application in general practice. Research to determine the feasibility and applicability of the EOSS-2 Risk Tool for improving weight management approaches in general practice is warranted.

Issues for reregulation of private hospital insurance in Australia.

Objective The aim of this study is to explore policy paths towards private health insurance (PHI) reform that might reduce out-of-pocket costs, restore public confidence and allow insurers to finance value-based care. Methods This study used thematic analysis of semi-structured interviews with informed opinion holders, including a politician, three former senior public servants and an industry lobbyist. Critical analysis of peer reviewed and grey literature was also conducted. Results PHI regulation is contributing to unexpected out-of-pocket expenses and low-value care. Modification of existing tax incentives would be incapable of significantly increasing PHI coverage. Regulatory reform could restore confidence among policy holders by promoting value-based care, wherein health outcomes are measured and incentivised with remuneration. Conclusions Targeted relaxation of out-of-hospital restrictions should be explored to promote value-based competition and facilitate bundled payments for chronic disease management and community services. To address out-of-pocket diagnostic and procedural costs, insurers should have more responsibility for private specialist's fees, including by financing the entire provider's bill through insurance and redirecting the Medicare Benefits Schedule fee to the insurer. What is known about the topic? Healthcare expenditure and out-of-pocket costs have grown rapidly, while confidence and depth of coverage in private health insurance has declined, as has the fiscal appetite for expanding public financing for health care. What does this paper add? This paper outlines the regulatory and policy factors that are contributing to low-value care and unmet expectations from insurance policy holders. It also maps the strategic terrain of the non-government health sector and considers feasible policy options for reforming the PHI industry that do not increase drawings on the public purse. What are the implications for practitioners? An appreciation of the ongoing challenges to financing value-based care provision will inform key stakeholders, including policymakers and health service providers, as reforms are debated and implemented.

Comparing the predictive ability of the Edmonton Obesity Staging System with the body mass index for use of health services and pharmacotherapies in Australian adults: A nationally representative cross-sectional study.

We assessed the value of the Edmonton Obesity Staging System (EOSS) compared with the body mass index (BMI) for determining associations with use of health services and pharmacotherapies in a nationally representative sample of participants in the 2011-2013 Australian Health Survey. A subsample of participants aged 18 years or over, with at least overweight (BMI ≥ 25 kg/m2 ) or central obesity (waist measurement of ≥102 cm for men; ≥88 cm for women), and who had provided physical measurements (n = 9730) were selected for analysis. For statistical significance of each predictor, we used logistic regression for model comparisons with the BMI and EOSS separately, and adjusted for covariates. For relative explanatory ability, we used the Nagelkerke pseudo R2 , receiver operating characteristic curve, and area under curve statistic. The EOSS was significantly better than the BMI for predicting polypharmacy and most of the health service use variables. Conversely, the BMI was significantly better than the EOSS for predicting having discussed lifestyle changes relevant to weight loss with the primary care physician. Clinicians, health care professionals, consumers, and policy makers should consider the EOSS a more accurate predictor of polypharmacy and health service use than the BMI in adults with overweight or obesity.

Determining patient attendance, access to interventions and clinical outcomes in a publicly funded obesity programme: Results from the Canberra Obesity Management Service.

Multi-disciplinary specialist services have a crucial role in the management of patients with obesity. As demand for these services increases, so too does the need to monitor individual service performance and compare outcomes across multiple sites. This paper reports on results from the publicly funded Canberra Obesity Management Service. A descriptive observational study was conducted on new patients who attended an initial medical review from July 2016 to June 2017. Baseline characteristics, comorbidities, attendance, service utilization and outcomes were collated until June 2018. Of the 162 patients identified, 64% continued to attend beyond initial medical review. Dietetics was the most commonly accessed allied health service, followed by exercise physiology and psychology. Very low-energy diet was the most commonly trialled intensive intervention, followed by pharmacotherapy and bariatric surgery. Mean baseline weight for those who continued beyond initial medical review was 142.0 kg (SD 26.6 kg), with a mean weight change of -6.2 kg (SD 10.2 kg) and a mean change in percentage body weight of -5% (SD 7%). Clinically significant weight loss was achieved in 36% of these patients, with a further 47% achieving weight stabilization. Mean Depression, Anxiety and Stress Scale scores reduced from 8-6-8 to 7-5-5, and mean Epworth Sleepiness Scale scores decreased from 8/24 to 6/24. Polysomnography referrals were made for 37% of all new patients, 87% of whom were diagnosed with varying degrees of obstructive sleep apnoea. We present these findings in the hope that they may serve as an example for data collection, individual service monitoring and comparison across multiple obesity services.

Health insurance coverage among women in Indonesia's major cities: A multilevel analysis.

We examined women's access to health insurance in Indonesia. We analyzed IFLS-4 data of 1,400 adult women residing in four major cities. Among this population, the health insurance coverage was 24%. Women who were older, involved in paid work, and with higher education had greater access to health insurance (p < .05). We also found there were disparities in the probability of having health insurance across community levels (Median Odds Ratios = 3.40). Given the importance of health insurance for women's health, strategies should be developed to expand health insurance coverage among women in Indonesia, including the disparities across community levels. Such problems might also be encountered in other developing countries with low health insurance coverage.

The dynamic of non-communicable disease control policy in Indonesia.

Objective The aim of the present study was to examine non-communicable disease (NCD) policy formation and implementation in Indonesia. Methods Interviews were conducted with 13 Indonesian health policy workers. The processes and issues relating to NCD policy formation were mapped, exploring the interactions between policy makers, technical/implementation bodies, alliances across various levels and the mobilisation of non-policy actors. Results Problems in NCD policy formation include insufficient political interest in NCD control, disconnected policies and difficulty in multisectoral coordination. These problems are well illustrated in relation to tobacco control, but also apply to other control efforts. Nevertheless, participants were optimistic that there are plentiful opportunities for improving NCD control policies given growing global attention to NCD, increases in the national health budget and the growing body of Indonesia-relevant NCD-related research. Conclusion Indonesia's success in the creation and implementation of NCD policy will be dependent on high-level governmental leadership, including support from the President, the Health Minister and coordinating ministries. What is known about the topic? The burden of NCD in Indonesia has increased gradually. Nationally, NCD-related mortality accounted for 65% of deaths in 2010. Indonesia is also a country with the highest burden of tobacco smoking in the world. However, the government has not instituted sufficient policy action to tackle NCDs, including tobacco control. What does this paper add? This paper deepens our understanding of current NCD control policy formation in Indonesia, including the possible underlying reason why Indonesia has weak tobacco control policies. It describes the gaps in the current policies, the actors involved in policy formation, the challenges in policy formation and implementation and potential opportunities for improving NCD control. What are the implications for practitioners? An effective NCD control program requires strong collaboration, including between government and health professionals. Health professionals can actively engage in policy formation, for example through knowledge production.

Evaluation of a Regional Australian Nurse-Led Parkinson's Service Using the Context, Input, Process, and Product Evaluation Model.

OBJECTIVE: A nurse-led Parkinson's service was introduced at Canberra Hospital and Health Services in 2012 with the primary objective of improving the care and self-management of people with a diagnosis of Parkinson's disease (PD) and related movement disorders. Other objectives of the Service included improving the quality of life of patients with PD and reducing their caregiver burden, improving the knowledge and understanding of PD among healthcare professionals, and reducing unnecessary hospital admissions. This article evaluates the first 2 years of this Service. METHODS: The Context, Input, Process, and Product Evaluation Model was used to evaluate the Parkinson's and Movement Disorder Service. CONTEXT: The context evaluation was conducted through discussions with stakeholders, review of PD guidelines and care pathways, and assessment of service gaps. Input: The input evaluation was carried out by reviewing the resources and strategies used in the development of the Service. PROCESS: The process evaluation was undertaken by reviewing the areas of the implementation that went well and identifying issues and ongoing gaps in service provision. Product: Finally, product evaluation was undertaken by conducting stakeholder interviews and surveying patients in order to assess their knowledge and perception of value, and the patient experience of the Service. Admission data before and after implementation of the Parkinson's and Movement Disorder Service were also compared for any notable trends. CONTEXT: Several gaps in service provision for patients with PD in the Australian Capital Territory were identified, prompting the development of a PD Service to address some of them. Input: Funding for a Parkinson's disease nurse specialist was made available, and existing resources were used to develop clinics, education sessions, and outreach services. PROCESS: Clinics and education sessions were implemented successfully, with positive feedback from patients and healthcare professionals. However, outreach services were limited because of capacity constraints on the Parkinson's disease nurse specialist. Product: The Service has filled an important health need in the local context; 98.3% of patients surveyed reported that the Service met their needs and helped them understand their care plan, achieving the primary objective of improving patient self-management. Interviews with stakeholders provided positive feedback about the value and usefulness of the Service, and healthcare professionals reported improvement in their knowledge about PD management. The evaluation also identified ongoing gaps in service provision and highlighted areas for potential improvement. No discernible trends in admission rates before and after the implementation of the Service were identified. CONCLUSION: The introduction of a nurse-led PD service has had a positive impact on the provision of care for patients with PD and is a valued service. The evaluation highlighted some ongoing gaps in service provision and has generated some recommendations to address these.

Exploring the implementation of poslansia,†Indonesia's community-based health programme for older people.

AIM: To explore the implementation of poslansia, a community-based integrated health service implemented across Indonesia to improve the health status of older people through health promotion and disease prevention. METHODS: Data analysis of 307 poslansia surveyed in the 4th wave of Indonesia Family Life Survey (IFLS-4). We examined the services provided in the programme, resources and perceived problems. RESULTS: The services provided by poslansia focused mostly on risk factor screening and treatment for minor illness, and less on health promotion activities. Lack of support from community health centres, no permanent place for holding poslansia and lack of participant interest in joining the programme were associated with fewer services provided in the programme (P < 0.05). CONCLUSION: The findings indicate existing support from the community, community health centres and related institutions for poslansia is not adequate for optimal service function. Health awareness among the older population should also be increased for programme sustainability.

Gender Inequalities in Noncommunicable Disease Risk Factors Among Indonesian Urban Population.

Gender is an important determinant of health. We conducted a study to examine hypertension, obesity, hypercholesterolemia, and smoking behavior among adults aged >15 years in urban Indonesia. We compared the prevalence, predicted socioeconomic factors, the gender inequalities, and the contributing factors to the inequalities. Women had a higher risk of obesity and hypercholesterolemia and raised blood pressure in later life (P< .001). In contrast, men had a higher risk of being a current smoker and raised blood pressure at younger age (P< .001). The gender inequalities in hypertension, obesity, and hypercholesterolemia can be accounted for by disparities in socioeconomic factors between men and women, particularly involvement in paid work. However, the inequalities were also accounted for by different effects of the socioeconomic factors in men and women. Gender is interlinked with socioeconomic and biological factors in determining health. This emphasizes the need of gender responsive policies to control and prevent chronic disease.

Do women in major cities experience better health? A comparison of chronic conditions and their risk factors between women living in major cities and other cities in Indonesia.

BACKGROUND: Inhabitants of rural areas can be tempted to migrate to urban areas for the type and range of facilities available. Although urban inhabitants may benefit from greater access to human and social services, living in a big city can also bring disadvantages to some residents due to changes in social and physical environments. DESIGN: We analysed data from 4,208 women aged >15 years old participating in the fourth wave of the Indonesia Family Life Survey. Chronic condition risk factors - systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI), and tobacco use - among women in four major cities in Indonesia (Jakarta, Surabaya, Medan, and Bandung) were compared against other cities. Fractional polynomial regression models were applied to examine the association between living in the major cities and SBP, DBP, BMI, and tobacco use. The models were also adjusted for age, education, employment status, migration status, ethnic groups, and religion. The patterns of SBP, DBP, and BMI were plotted and contrasted between groups of cities. RESULTS: Chronic condition prevalence was higher for women in major cities than in contrasting cities (p<0.005). Living in major cities increased the risk of having higher SBP, DBP, BMI and being a current smoker. Chronic disease risk factors in major cities were evident from younger ages. CONCLUSIONS: Women residing in Indonesia's major cities have a higher risk of developing chronic conditions, starting at younger ages. The findings highlight the challenges inherent in providing long-term healthcare with its associated cost within major Indonesian cities and the importance of chronic disease prevention programmes targeting women at an early age.

Grasping the health horizon: toward a virtual, interoperable platform of health innovations.

The emergence of digital health, wearables, apps, telehealth and the proliferation of health services online are all indications that health is undergoing rapid innovation. Health innovation however has been traditionally slow, high cost and the commercialisation journey was not a guaranteed path to adoption outside the setting where it was developed whether in a hospital, university, clinic or lab. Most significant with this new explosion of health innovations is the sheer volume. The startup revolution, mobile health, personalised heath and globalisation of knowledge means that consumers are demanding innovations and are pulling health innovations through commercialisation with new modes of funding such as crowdsourcing and direct vendor purchases. Our Australian team initiated a project to use machine learning, data mining and classification techniques to bring together and analyse this expansion of heath innovations from all over the world. Following two years of data aggregation and quality analysis we present our findings which are applied to over 200,000 innovations from more than 25,000 organisations. Our findings have identified the dynamics and basis for a marketplace for health innovations that could assist innovators, health practitioners, consumers, investors and other health participants to research, evaluate and promote these innovations.

Socioeconomic related inequality in depression among young and middle-adult women in Indonesia׳s major cities.

PURPOSE: Difficult living conditions in urban areas could result in an increased risk of developing depression, particularly among women. One of the strong predictors of depression is poverty, which could lead to inequality in risk of depression. However, previous studies found conflicting results between poverty and depression. This study examines whether depression was unequally distributed among young and middle-adult women in Indonesia׳s major cities and investigate the factors contributed to the inequality. METHODS: Data from 1117 young and middle-adult women in Indonesia׳s major cities (Jakarta, Surabaya, Medan, and Bandung) were analysed. Concentration Index (CI) was calculated to measure the degree of the inequality. The CI was decomposed to investigate the factor contributing most to the inequality. RESULTS: The prevalence of depression was 15% and more concentrated among lower economic group (CI=-0.0545). Compared to the middle-adult group, the prevalence of depression among women in the young-adult group was significantly higher (18% vs 11%, p<0.05) and more equally distributed (CI=-0.0343 vs CI=-0.1001). Household consumption expenditure was the factor that contributed most to inequality in both group. Other factors contributing to inequality were smoking in young-adult group and marital status in middle-adult group. Contribution of education to inequality varied for different age groups. CONCLUSION: Depression is more concentrated among the lower economic groups, with household expenditure being the major factor contributing to the inequality. This finding emphasises the importance of primary care level mental health services, particularly in poorer urban communities. LIMITATION: This study is based on a cross-sectional data, and only assesses social determinants of depression. These determinants are important to address in addition to biological determinants and other factors.

Achieving patient-centred care: the potential and challenge of the patient-as-professional role.

BACKGROUND: The patient-as-professional concept acknowledges the expert participation of patients in interprofessional teams, including their contributions to managing and coordinating their care. However, little is known about experiences and perspectives of these teams. OBJECTIVE: To investigate (i) patients' and carers' experiences of actively engaging in interprofessional care by enacting the patient-as-professional role and (ii) clinicians' perspectives of this involvement. DESIGN, SETTING AND PARTICIPANTS: A two-phased qualitative study. In Phase 1, people with chronic disease (n = 50) and their carers (n = 5) participated in interviews and focus groups. Phase 2 involved interviews with clinicians (n = 14). Data were analysed thematically. FINDINGS: Patients and carers described the characteristics of the role (knowing about the condition, questioning clinicians, coordinating care, using a support network, engaging an advocate and being proactive), as well as factors that influence its performance (the patient-clinician partnership, benefits, barriers and applicability). However, both patients and carers, and clinicians cautioned that not all patients might desire this level of involvement. Clinicians were also concerned that not all patients have the required knowledge for this role, and those who do are time-consuming. When describing the inclusion of the patient-as-professional, clinicians highlighted the patient and clinician's roles, the importance of the clinician-patient relationship and ramifications of the role. CONCLUSION: Support exists for the patient-as-professional role. The characteristics and influencing factors identified in this study could guide patient engagement with the interprofessional team and support clinicians to provide patient-centred care. Recognition of the role has the potential to improve health-care delivery by promoting patient-centred care.

Introduction of an Advance Care Planning Clinic in a Regional Care Coordination Service.

Advance Care Planning is an increasingly important consideration in health care service provision. Barriers to Advance Care Planning including lower prioritization than clinical care, and the complex logistics of completing the documentation have been identified in the literature and clinical practice. The Chronic Care Program within Canberra Hospital and Health Services introduced mobile and outpatient Advance Care Planning Clinics for care coordinated patients with chronic diseases, to address some of these barriers and facilitate end-of-life care discussion amongst this patient group. The implementation of the clinics was evaluated, looking at the practicality of running these clinics within existing resources and patient acceptability. The number of Statement of Choices completed was used as a marker of whether the clinics led to an increase in Advance Care Planning amongst this patient group. The introduction of the clinics received positive feedback from patients and was able to beimplemented without requiring additional external resources. Following introduction of the Advance Care Planning clinics, an increase in the proportion of patients with a completed a Statement of Choices was seen.

Developing an inter-organizational community-based health network: an Australian investigation.

Networks in health care typically involve services delivered by a defined set of organizations. However, networked associations between the healthcare system and consumers or consumer organizations tend to be open, fragmented and are fraught with difficulties. Understanding the role and activities of consumers and consumer groups in a formally initiated inter-organizational health network, and the impacts of the network, is a timely endeavour. This study addresses this aim in three ways. First, the Unbounded Network Inter-organizational Collaborative Impact Model, a purpose-designed framework developed from existing literature, is used to investigate the process and products of inter-organizational network development. Second, the impact of a network artefact is explored. Third, the lessons learned in inter-organizational network development are considered. Data collection methods were: 16 h of ethnographic observation; 10 h of document analysis; six interviews with key informants and a survey (n = 60). Findings suggested that in developing the network, members used common aims, inter-professional collaboration, the power and trust engendered by their participation, and their leadership and management structures in a positive manner. These elements and activities underpinned the inter-organizational network to collaboratively produce the Health Expo network artefact. This event brought together healthcare providers, community groups and consumers to share information. The Health Expo demonstrated and reinforced inter-organizational working and community outreach, providing consumers with community-based information and linkages. Support and resources need to be offered for developing community inter-organizational networks, thereby building consumer capacity for self-management in the community.

Governance, transparency and alignment in the Council of Australian Governments (COAG) 2011 National Health Reform Agreement.

OBJECTIVE This article provides a policy analysis of the Australian government's National Health Reform Agreement (NHRA) by bringing to the foreground the governance arrangements underpinning the two arms of the national reforms, to primary health care and hospital services. METHODS The article analyses the NHRA document and mandate, and contextualises the changes introduced vis-à-vis the complex characteristics of the Australian health care system. Specifically, it discusses the coherence of the agreement and its underlying objectives, and the consistency and logic of the governance arrangements introduced. RESULTS The policy analysis highlights the rationalisation of the responsibilities between the Commonwealth and states and territories, the commitment towards a funding arrangement based on uniform measures of performance and the troubled emergence of a more decentralised nation-wide homogenisation of governance arrangements, plus efforts to improve transparency, accountability and statutory support to increase the standards of quality of care and safety. CONCLUSIONS It is suggested that the NHRA falls short of adequately supporting integration between primary, secondary and tertiary health care provision and facilitating greater integration in chronic disease management in primary care. Successfully addressing this will unlock further value from the reforms.

Supporting patients to self-manage chronic disease: clinicians' perspectives and current practices.

This study investigated: clinicians' perspectives of the scope of self-management, which self-management support initiatives are used, and the factors clinicians consider when deciding which initiative to use with individual patients. Three phases of data collection were used. First, clinicians were interviewed about their attitudes toward self-management (n=14). Second, clinicians and managers completed a survey about the support initiatives they use (n=38). Third, in interviews clinicians described the applications of initiatives (n=6). Data were descriptively and thematically analysed. Clinicians believed that supporting self-management involved a holistic approach. However, some also thought that not all patients had the capacity to self-manage. This idea may be at odds with the underlying notion of self-management and impact on the support provided. Clinicians reported using 54 initiatives to support self-management and identified a range of situations when each initiative may or may not be suitable. This suggests that clinicians need to be familiar with a range of support initiatives as one will not suit everyone. Deciding which initiative is most appropriate may be aided by the development of guidelines.

Stewardship of National Oral Health system in Iran: its strengths and weaknesses.

AIMS: In this study, we assess the strengths, challenges and opportunities regarding the oral health system stewardship in Iran. METHODS: A mixed methodology was used, comprised of a quantitative questionnaire using the functional standards, semi structured interviews with key stakeholders and document review. The level of current attainments of each standard was determined based on a Likert-type scale. Literature review was completed to find official documents of national organizations. RESULTS: The responsibility of policy development of oral health care at the national level mostly falls on the Oral Health Bureau. This office has formulated a strategic plan for its policy-making and has considered the required capacity to implement them. However, the Bureau has some problems in enforcing its regulatory framework, especially in the private sector. There are rigorous problems in managing information and using them for evidence-based decision making. Setting and allocation of operational budgets for implementing the policies is only partially attained, as is monitoring and evaluating the performance. CONCLUSIONS: While the Ministry of Health and Medical Education has achieved some stewardship measures, it still needs further improvements in the oral health system. It needs to strengthen its information system and its executive capacity to implement the proposed regulations. The Ministry must improve accountability in the oral health system, especially the provider accountability.

A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness.

BACKGROUND: The Wagner Model provides a framework that can help to facilitate health system transition towards a chronic care oriented model. Drawing on elements of this framework as well as health policy related to patient centred care, we describe the health needs of patients with chronic illness and compare these with services which should ideally be provided by a patient-centred health system. This paper aims to increase understanding of the challenges faced by chronically ill patients and family carers in relation to their experiences with the health care system and health service providers. METHOD: We interviewed patients, carers and health care professionals (HCPs) about the challenges faced by people living with complicated diabetes, chronic heart failure or chronic obstructive pulmonary disease. RESULTS: Patients indicated that they had a range of concerns related to the quality of health care encounters with health care professionals (HCPs), with these concerns being expressed as needs or wants. These included: 1) the need for improved communication and information delivery on the part of HCPs; 2) well organised health services and reduced waiting times to see HCPs; 3) help with self care; 4) greater recognition among professionals of the need for holistic and continuing care; and 5) inclusion of patients and carers in the decision making processes. CONCLUSIONS: In order to address the challenges faced by people with chronic illness, health policy must be more closely aligned with the identified needs and wants of people affected by chronic illness than is currently the case.