Australian primary health care nurses’ knowledge, practice and attitudes relating to preconception care: learnings for service implementation.

Preconception care (PCC) entails counselling and interventions to optimise health before pregnancy. Barriers to this service delivery include access and time. Primary healthcare nurses (PHCNs) are uniquely placed to deliver PCC. The aim of this study was to understand PHCNs' knowledge, practice and attitudes to PCC. A cross-sectional study was performed of a convenience sample of PHCNs in Australia who were seeing people of reproductive age. Recruitment was via the Australian Primary Health Care Nurses Association (APNA) electronic communication platforms. The 18-item, online, anonymous survey captured demographics, as well as PCC knowledge, practices and attitudes. Descriptive statistics were used to describe our findings. In all, 152 completed surveys were received. Of all respondents, 74% stated they discuss PCC in their practice, although only 13% do so routinely. Of these, more preconception discussions are held with women than with men. In total, 95% of respondents identified at least one barrier to delivery of PCC, with lack of time and knowledge being the most common. The findings of this study can inform targeted strategies, including education programs and resources, and consideration of incentives to support PHCNs deliver PCC. This study identifies areas for improvement at the individual, organisational and health system levels to enhance the role of PHCNs in PCC.

Impact of analysis technique on our understanding of the natural history of labour: a simulation study.

OBJECTIVE: To evaluate the discrepancy between historical and more recent descriptions of the first stage of labour by testing whether the statistical techniques used recently (repeated-measures polynomial and interval-censored regression) were appropriate for detection of periods of rapid acceleration of cervical dilatation as might occur at the time of transition from a latent to an active phase of labour. DESIGN AND SETTING: A simulation study using regression techniques. SAMPLE: We created a simulated data set for 500 000 labours with clearly defined latent and active phases using the parameters described by Friedman. Additionally, we created a data set comprising 500 000 labours with a progressively increasing rate of cervical dilatation. METHODS: Repeated-measures polynomial regression was used to create summary labour curves based on simulated cervical examinations. Interval-censored regression was used to create centimetre-by-centimetre estimates of rates of cervical dilatation and their 95th centiles. MAIN OUTCOME MEASURES: Labour summary curves and rates of cervical dilatation. RESULTS: Repeated-measures polynomial regression did not detect the rapid acceleration in cervical dilatation (i.e. acceleration phase) and overestimated lengths of labour, especially at smaller cervical dilatations. There was a two-fold overestimation in the mean rate of cervical dilatation from 4 to 6 cm. Interval-censored regression overestimated median transit times, at 4- to 5-cm cervical dilatation or when cervical examinations occurred less frequently than 0.5- to 1.5-hourly. CONCLUSION: Repeated-measures polynomial regression and interval-censored regression should not be routinely used to define labour progress because they do not accurately reflect the underlying data. TWEETABLE ABSTRACT: Repeated-measures polynomial and interval-censored regression techniques are not appropriate to model first stage of labour.

Estimating the potential impact of interventions to reduce over-calling and under-calling of melanoma.

BACKGROUND: Pathologists sometimes disagree over the histopathologic diagnosis of melanoma. 'Over-calling' and 'under-calling' of melanoma may harm individuals and healthcare systems. OBJECTIVES: To estimate the extent of 'over-calling' and 'under-calling' of melanoma for a population undergoing one excision per person and to model the impact of potential solutions. METHODS: In this epidemiological modelling study, we undertook simulations using published data on the prevalence and diagnostic accuracy of melanocytic histopathology in the U.S. POPULATION: We simulated results for 10 000 patients each undergoing excision of one melanocytic lesion, interpreted by one community pathologist. We repeated the simulation using a hypothetical intervention that improves diagnostic agreement between community pathologist and a specialist dermatopathologist. We then evaluated four scenarios for how melanocytic lesions judged to be neither clearly benign (post-test probability of melanoma < 5%), nor clearly malignant (post-test probability of melanoma > 90%) might be handled, before sending for expert dermatopathologist review to decide the final diagnosis. These were (1) no intervention before expert review, (2) formal second community pathologist review, (3) intervention to increase diagnostic agreement and (4) both the intervention and formal second community pathologist review. The main outcomes were the probability of 'over-calling' and 'under-calling' melanoma, and number of lesions requiring expert referral for each scenario. RESULTS: For 10 000 individuals undergoing excision of one melanocytic lesion, interpreted by a community pathologist, a hypothetical intervention to improve histopathology agreement reduced the number of benign lesions 'over-called' as melanoma from 308 to 164 and the number of melanomas 'under-called' from 289 to 240. If all uncertain diagnoses were sent for expert review, the number of referrals would decrease from 1500 to 737 cases if formal second community pathologist review was used, and to 701 cases if the hypothetical intervention was additionally used. CONCLUSIONS: Interventions to improve histopathology agreement may reduce melanoma 'over-calling' and 'under-calling'.

Acceptability of the copper intrauterine device as a form of emergency contraception in New South Wales, Australia.

Background: The copper-intrauterine device (Cu-IUD) is the most effective emergency contraception (EC), and the only method providing ongoing contraception; however, it is underutilised in Australia.Methods: An online cross-sectional survey of clients and clinicians at a family planning service was undertaken. Clients aged 16-55 and identifying as female or transgender male were eligible. The survey explored previous experience with and knowledge of the Cu-IUD as EC among clients, current EC practices among clinicians, and barriers and enablers among clients and clinicians.Results: Of 470 clients, 64.5% had previously used EC. Only 12.7% knew the Cu-IUD was a form of EC and 2% had used it. When given information on effectiveness, side-effects and costs, 46.8% reported they would consider the Cu-IUD for EC. However, 40% viewed cost and possible side-effects as barriers. Of the 58 clinicians surveyed, 55% reported discussing Cu-IUD as EC with clients versus 94% discussing oral EC, with time pressures reported as the main barrier.Conclusion: Low awareness among clients, and limited discussion by clinicians, highlights a need for increased education and promotion strategies for the Cu-IUD as EC. With greater knowledge, demand for this option may increase. This will require processes to ensure timely access to insertions.

Development and external validation study of a melanoma risk prediction model incorporating clinically assessed naevi and solar lentigines.

BACKGROUND: Melanoma risk prediction models could be useful for matching preventive interventions to patients' risk. OBJECTIVES: To develop and validate a model for incident first-primary cutaneous melanoma using clinically assessed risk factors. METHODS: We used unconditional logistic regression with backward selection from the Australian Melanoma Family Study (461 cases and 329 controls) in which age, sex and city of recruitment were kept in each step, and we externally validated it using the Leeds Melanoma Case-Control Study (960 cases and 513 controls). Candidate predictors included clinically assessed whole-body naevi and solar lentigines, and self-assessed pigmentation phenotype, sun exposure, family history and history of keratinocyte cancer. We evaluated the predictive strength and discrimination of the model risk factors using odds per age- and sex-adjusted SD (OPERA) and the area under curve (AUC), and calibration using the Hosmer-Lemeshow test. RESULTS: The final model included the number of naevi ≥ 2 mm in diameter on the whole body, solar lentigines on the upper back (a six-level scale), hair colour at age 18 years and personal history of keratinocyte cancer. Naevi was the strongest risk factor; the OPERA was 3·51 [95% confidence interval (CI) 2·71-4·54] in the Australian study and 2·56 (95% CI 2·23-2·95) in the Leeds study. The AUC was 0·79 (95% CI 0·76-0·83) in the Australian study and 0·73 (95% CI 0·70-0·75) in the Leeds study. The Hosmer-Lemeshow test P-value was 0·30 in the Australian study and < 0·001 in the Leeds study. CONCLUSIONS: This model had good discrimination and could be used by clinicians to stratify patients by melanoma risk for the targeting of preventive interventions. What's already known about this topic? Melanoma risk prediction models may be useful in prevention by tailoring interventions to personalized risk levels. For reasons of feasibility, time and cost many melanoma prediction models use self-assessed risk factors. However, individuals tend to underestimate their naevus numbers. What does this study add? We present a melanoma risk prediction model, which includes clinically-assessed whole-body naevi and solar lentigines, and self-assessed risk factors including pigmentation phenotype and history of keratinocyte cancer. This model performs well on discrimination, the model's ability to distinguish between individuals with and without melanoma, and may assist clinicians to stratify patients by melanoma risk for targeted preventive interventions.

Development and validation of measures to evaluate adolescents' knowledge about human papillomavirus (HPV), involvement in HPV vaccine decision-making, self-efficacy to receive the vaccine and fear and anxiety.

OBJECTIVES: We describe the development and validation of measures of human papillomavirus (HPV)/HPV vaccination knowledge, fear/anxiety about vaccination, involvement in HPV vaccine decision-making, and self-efficacy with regard to getting the vaccine, designed to evaluate the efficacy of an intervention to affect these domains (collectively termed the HAVIQ: HPV Adolescent Vaccine Intervention Questionnaire). STUDY DESIGN: Literature search, cognitive interviews and cross-sectional survey. METHODS: A literature search identified existing items that were modified for the present measures. Experts reviewed draft measures for face and content validity. Cognitive interviews with adolescents were also used to assess content validity. Adolescents completed the measures and an internal reliability analysis of each measure was performed. RESULTS: The four experts concurred that the measures had face validity. Cognitive interviews identified items requiring refinement. Content validity was examined with ten experts and was deemed acceptable. There were 1800 adolescents who completed the measures; Cronbach's alpha was >0.6 for three of the four measures. The four final measures are brief, comprising 25 items in total. CONCLUSIONS: The measures are robustly developed and validity-tested. The HAVIQ may be used in research settings to evaluate adolescents' knowledge and experiences of the process of HPV vaccination in a school-based vaccination programme.

Poor quality of external validity reporting limits generalizability of overweight and/or obesity lifestyle prevention interventions in young adults: a systematic review.

Young adulthood is a high-risk life stage for weight gain. Evidence is needed to translate behavioural approaches into community practice to prevent weight gain in young adults. This systematic review assessed the effectiveness and reporting of external validity components in prevention interventions. The search was limited to randomized controlled trial (RCT) lifestyle interventions for the prevention of weight gain in young adults (18-35 years). Mean body weight and/or body mass index (BMI) change were the primary outcomes. External validity, quality assessment and risk of bias tools were applied to all studies. Twenty-one RCTs were identified through 14 major electronic databases. Over half of the studies were effective in the short term for significantly reducing body weight and/or BMI; however, few showed long-term maintenance. All studies lacked full reporting on external validity components. Description of the intervention components and participant attrition rates were reported by most studies. However, few studies reported the representativeness of participants, effectiveness of recruitment methods, process evaluation detail or costs. It is unclear from the information reported how to implement the interventions into community practice. Integrated reporting of intervention effectiveness and enhanced reporting of external validity components are needed for the translation and potential upscale of prevention strategies.

Impact of a cancer clinical trials web site on discussions about trial participation: a cluster randomized trial.

BACKGROUND: Cancer patients want access to reliable information about currently recruiting clinical trials. PATIENTS AND METHODS: Oncologists and their patients were randomly assigned to access a consumer-friendly cancer clinical trials web site [Australian Cancer Trials (ACT), www.australiancancertrials.gov.au] or to usual care in a cluster randomized controlled trial. The primary outcome, measured from audio recordings of oncologist-patient consultations, was the proportion of patients with whom participation in any clinical trial was discussed. Analysis was by intention-to-treat accounting for clustering and stratification. RESULTS: Thirty medical oncologists and 493 patients were recruited. Overall, 46% of consultations in the intervention group compared with 34% in the control group contained a discussion about clinical trials (P=0.08). The mean consultation length in both groups was 29 min (P=0.69). The proportion consenting to a trial was 10% in both groups (P=0.65). Patients' knowledge about randomized trials was lower in the intervention than the control group (mean score 3.0 versus 3.3, P=0.03) but decisional conflict scores were similar (mean score 42 versus 43, P=0.83). CONCLUSIONS: Good communication between patients and physicians is essential. Within this context, a web site such as Australian Cancer Trials may be an important tool to encourage discussion about clinical trial participation.

Hyperglycaemia in hospital inpatients: still a sticky situation.

BACKGROUND: Diabetes diagnosis is delayed 4-7 years and 50% are undiagnosed. Forty percent of hospitalized patients with any blood glucose level (BGL) > or = 10 mmol/L have diabetes 3 months post-discharge, yet less than 5% are detected in hospital. We review identification of, and responses to, hyperglycaemia in inpatients at a teaching hospital. METHODS: The world's largest retrospective review of medical records for inpatients with venous BGL > or = 11.1 mmol/L without known diabetes over 12 months (2005-2006). The primary outcome was recognition of hyperglycaemia; secondary outcomes were treatment and documentation of follow up. Logistic regression was performed with variables including BGL, admitting team, length of stay and endocrine team review. RESULTS: Of 10 973 people screened, 162 were eligible. The median age was 58 years and BGL 13.3 mmol/L, with increased mortality and length of stay. Hyperglycaemia was noted as definitely in 26%, maybe in 24% and definitely not in 50%. Forty percent of patients were treated in hospital and 19% on discharge. Follow up was documented for 24%. A higher BGL and review by the endocrine team were strongly associated with clinical recognition on uni- and multivariate analyses. However, where an endocrine review was sought for non-hyperglycaemia reasons, similar rates of non-recognition occurred. CONCLUSION: Despite evidence for improved inpatient outcomes when treated, and high short-term progression to frank diabetes, inpatient hyperglycaemia remains frequently missed. In-hospital recognition is cheap, and vital for the implementation of activities to improve outcomes and prevent progression and complications. Changes to systems for checking pathology results, medical officer education and inpatient screening guidelines are indicated.

Bisphosphonate use and subsequent prescription of acid suppressants.

AIM: To determine the extent of prescribing of acid suppression agents associated with initiation of bisphosphonate therapy. METHODS: This was a case control study, performed within the General Practice Network, Australia. The main outcome measure was re-attendance within six weeks from index bisphosphonate prescription for acid supression agents. RESULTS: Of the bisphosphonate cases, 2.9%[95% confidence interval (CI) 1.8, 3.9] returned within 6 weeks for a prescription for proton pump inhibitor, histamine 2 receptor antagonist or antacid, compared with 0.9% of control patients (95% CI 0.5, 1.2). However, the bisphosphonate cases had significantly higher rates of previous use of nonsteroidal anti-inflammatory agents. After controlling for previous nonsteroidal anti-inflammatory drug use, the increased use of acid suppression agents was statistically significant, the odds ratio = 3.21 (95% CI 2.02, 5.11). CONCLUSION: Bisphosphonate use appears to be associated with increased use of acid suppressant agents within 6 weeks of first supply.

Evaluation of linked cancer registry and hospital records of breast cancer.

BACKGROUND: Information on the treatment of women with breast cancer in Australia is generally available only from special surveys. Analysis of routinely collected datasets may be more timely and cost effective, if the data are sufficiently accurate and complete. OBJECTIVE: To evaluate the accuracy and completeness of data on treatment in linked records of breast cancer from two routinely collected datasets. METHODS: The NSW Department of Health linked NSW Central Cancer Registry (CCR) records for 2,636 women diagnosed with breast cancer in NSW in 1992 to all hospital admission records in the NSW In-patient Statistics Collection (ISC) from January 1991 to June 1994. We queried the original paper records of subsets of women to identify missing or miscoded information and cases not notified to the CCR. We also compared the treatment data with data collected independently from the medical records of 19% of the women. RESULTS: ISC records linked to 89% of the CCR records. The CCR had identified 94.9% of women with breast cancer treated as hospital in-patients and 83% of these women had surgical treatment recorded in the ISC. The linked dataset under-estimated the percentage of women having breast-conserving therapy (-4%) and slightly over-estimated the percentage having mastectomy (+1%). We estimated that 42% of women treated surgically for breast cancer had actually had breast-conserving surgery, compared with 39% in the original dataset. There was no evident bias by age or by urban or rural residence in the under-recording of breast conservation. There was 94% agreement on the type of surgery between the linked dataset and the independent dataset.