Impact of comorbidities on survival following major injury across different types of road users.

BACKGROUND: While comorbidities and types of road users are known to influence survival in people hospitalised with injury, few studies have examined the association between comorbidities and survival in people injured in road traffic crashes. Further, few studies have examined outcomes across different types of road users with different types of pre-existing comorbidities. This study aims to examine differences in survival within 30 days of admission among different road user types with and without different pre-existing comorbidities. METHOD: Retrospective cohort study using data for all major road trauma cases were extracted from the NSW Trauma Registry Minimum Dataset (1 January 2013 - 31 July 2019) and linked to the NSW Admitted Patient Data Collection, and the NSW Registry of Births, Deaths and Marriages - death dataset. Pre-existing comorbidities and road user types were identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and Charlson Comorbidity Index in the Trauma Registry, hospital admission, and death datasets. Logistic regression was used to assess the associations between six types of road users (pedestrian, pedal cycle, two- and three-wheel motorcycle, car and pick-up truck, heavy vehicle and bus, and other types of vehicle) and death within 30 days of hospital admission while controlling for comorbidities. All models used 'car and pick-up truck driver/passenger' as the road user reference group and adjusted for demographic variables, injury severity, and level of impaired consciousness. RESULTS: Within 6253 traffic injury person-records (all aged ≥15 years old, ISS>12), and in final models, injured road users with major trauma who had a history of cardiovascular diseases (including stroke), diabetes mellitus, and higher Charlson Comorbidity Index score, were more likely to die, than those without pre-existing comorbidities. Furthermore, in final models, pedestrians were more likely to die than car occupants (OR: 1.68 - 1.77, 95CI%: 1.26 - 2.29 depending on comorbidity type). CONCLUSIONS: This study highlights the need to prioritize enhanced management of trauma patients with comorbidities, given the increasing prevalence of chronic medical conditions globally, together with actions to prevent pedestrian crashes in strategies to reach Vision Zero.

Association between multimorbidity and undiagnosed obstructive sleep apnea severity and their impact on quality of life in men over 40 years old.

BACKGROUND: Multimorbidity is common but little is known about its relationship with obstructive sleep apnea (OSA). METHODS: Men Androgen Inflammation Lifestyle Environment and Stress Study participants underwent polysomnography. Chronic diseases (CDs) were determined by biomedical measurement (diabetes, dyslipidaemia, hypertension, obesity), or self-report (depression, asthma, cardiovascular disease, arthritis). Associations between CD count, multimorbidity, apnea-hyponea index (AHI) and OSA severity and quality-of-life (QoL; mental & physical component scores), were determined using multinomial regression analyses, after adjustment for age. RESULTS: Of the 743 men participating in the study, overall 58% had multimorbidity (2+ CDs), and 52% had OSA (11% severe). About 70% of those with multimorbidity had undiagnosed OSA. Multimorbidity was associated with AHI and undiagnosed OSA. Elevated CD count was associated with higher AHI value and increased OSA severity. CONCLUSION: We demonstrate an independent association between the presence of OSA and multimorbidity in this representative sample of community-based men. This effect was strongest in men with moderate to severe OSA and three or more CDs, and appeared to produce a greater reduction in QoL when both conditions were present together.

A controlled before-after study to evaluate the effect of a clinician led policy to reduce knee arthroscopy in NSW.

BACKGROUND: Clinical evidence shows knee arthroscopy has little benefit for degenerative conditions and considerable variation in the incidence of knee arthroscopy in Australia has been identified. This study aimed to evaluate a clinician-led evidence-based policy which was implemented in one local health district in New South Wales (NSW) in 2012 to reduce the use of knee arthroscopy for patients aged 50 years or over. METHODS: Trends in rates and volume of knee arthroscopy for patients 50 years or over in NSW between 2004 and 2015 by district were examined. Changes at four hospitals that adopted the policy were assessed by a quasi-experimental before and after study design with control groups, using the generalised estimating equations (GEE) Poisson model. Each case hospital was matched with four control hospitals in terms of the volume of knee arthroscopy surgeries performed in the five years prior to the intervention. RESULTS: Between 2004 and 2015, the number of knee arthroscopies in NSW initially increased and then decreased after 2011, with considerable variation across districts. While an overall reducing trend in NSW was observed between 2011 and 2015 (39%), a 58% reduction (95% CI: 55-62%) was found in the intervention district, including the private sector, being the greatest reduction found in all districts. The GEE Poisson results show that, compared with control hospitals, the number of knee arthroscopy was significantly reduced by 56% (95% CI: 11%-79%) at four hospitals that adopted the policy during the follow-up period (p = 0.02). CONCLUSIONS: Clinicians in one local health district initiated a policy to restrict knee arthroscopy for patients aged 50 years or over, which may explain the greater reduction seen in that district compared to all others, despite an overall decrease noted in the state. A significant reduction found at intervened hospitals proved the effect of the policy, suggesting that the implementation of a simple clinical governance process may help reduce inappropriate surgery.

Factors associated with multiple barriers to access to primary care: an international analysis.

BACKGROUND: Disparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems. METHODS: In this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions. RESULTS: Overall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care. CONCLUSION: A greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed.

Measuring the prevalence of chronic diseases using population surveys by pooling self-reported symptoms, diagnosis and treatments: results from the World Health Survey of 2003 for South Asia.

OBJECTIVES: Measuring disease prevalence poses challenges in countries where information systems are poorly developed. Population surveys soliciting information on self-reported diagnosis also have limited capacity since they are influenced by informational and recall biases. Our aim is to propose a method to assess the prevalence of chronic disease by combining information on self-reported diagnosis, self-reported treatment and highly suggestive symptoms. METHODS: An expanded measure of prevalence was developed using data from the World Health Survey for Bangladesh, India and Sri Lanka. Algorithms were constructed for six chronic diseases. RESULTS: The expanded measures of chronic disease increase the prevalence estimates. Prevalence varies across socio-demographic characteristics, such as age, education, socioeconomic status (SES), and country. Finally, the association, as also risk factor, between chronic disease status and poor self-rated health descriptions increases significantly when one takes into account highly suggestive symptoms of diseases. CONCLUSIONS: Our expanded measure of chronic disease could form a basis for surveillance of chronic diseases in countries where health information systems have been poorly developed. It represents an interesting trade-off between the bias associated with usual surveillance data and costs.

The influence of primary health care organizational models on patients' experience of care in different chronic disease situations.

OBJECTIVES: To examine the extent to which experience of care varies across chronic diseases, and to analyze the relationship of primary health care (PHC) organizational models with the experience of care reported by patients in different chronic disease situations. METHODS: We linked a population survey and a PHC organizational survey conducted in two regions of Quebec. We identified five groups of chronic diseases and contrasted these with a no-chronic-disease group. RESULTS: Accessibility of care is low for all chronic conditions and shows little variation across diseases. The contact and the coordination-integrated models are the most accessible, whereas the single-provider model is the least. Process and outcome indices of care experience are much higher than accessibility for all conditions and vary across diseases, with the highest being for cardiovascular-risk-factors and the lowest for respiratory diseases (for people aged 44 and under). However, as we move from risk factors to more severe chronic conditions, the coordination-integrated and community models are more likely to generate better process of care, highlighting the greater potential of these two models to meet the needs of more severely chronically ill individuals within the Canadian health care system.

Acceptance of screening and completion of treatment for latent tuberculosis infection among refugee claimants in Canada.

SETTING: Primary care clinic for refugee claimants, Montreal, Canada. OBJECTIVES: To identify factors linked to the acceptance of the tuberculin skin test (TST), and assess completion of treatment for latent tuberculosis infection (LTBI). DESIGN: Asylum seekers consulting for a medical complaint or medical immigration examination between February and October 1999 were assessed for eligibility. Personal and clinical information was gathered prospectively by questionnaire. Hospital files were reviewed to assess completion of LTBI treatment. RESULTS: In our study, 296 subjects (72.4% of 409 eligible) were offered TST, of whom 227 accepted (76.7%). Of these, 49 (24.9%) had a TST > or = 10 mm and 24 (49%) completed 6 months of LTBI treatment. Logistic regression models showed that patients who had never had a TST (OR 3.2, 95%CI 1.34-7.6) or had no temporary exclusion criteria (OR 4.0, 95%CI 1.6-9.9) were more likely to accept TST. Perceiving tuberculosis as a severe disease (OR 0.29, 95%CI 0.09-0.91) and consulting for an immigration examination (OR 0.42, 95%CI 0.18-0.98) was associated with refusal of TST. Increasing age was found to be independently associated with a positive TST (OR 1.06, 95%CI 1.01-1.12). Variability in the proportion of positive results was found between TST readers. CONCLUSION: This study supports the feasibility of screening refugee claimants for LTBI during medical consultation and of developing organizational links to ensure completion of LTBI treatment.

Sport nutritional supplements: quality and doping controls.

Nutritional supplements are part of the diet of many athletes. With the exception of caffeine and ephedrine alkaloids, most of these products do not contain substances that are prohibited to competing sportsmen. In recent years, androgens, pro-hormones such as DHEA, androstenedione, androstenediol and 19-norsteroids became available for oral self-administration in many countries and on the Internet. Their claimed actions, efficiency or potency, and the possible adverse effects have not been thoroughly investigated by controlled clinical studies. Some products were shown to contain prohibited substances such as ephedrine, caffeine, or steroids, that were not listed on the label. Urine samples collected after the administration of these supplements can test positive. The administration of natural steroids such as testosterone and its precursors cannot be proven by the sole identification of the substances in the urine. The approach to detection is based upon the deviation of selected parameters of the metabolic profiles from the range of values normally found in humans. The individual's norm is also studied to exclude the few cases of systematic and natural excretion of extreme values. The combination of the GC/MS and the GC/C/IRMS offers a powerful tool to discriminate between the natural and synthetic origin of the urinary steroids.