Finding and addressing weaknesses in GP supervisor professional development.

BACKGROUND: The Royal Australian College of General Practitioners' Standards for general practice training require supervisor continuing professional development (PD) to meet the needs of the individual supervisors and develop the supervisory team. OBJECTIVE: The aim of this article is to explore current supervisor PD and consider how it might better meet the outcomes described in the standards. DISCUSSION: General practitioner supervisor PD delivered by regional training organisations (RTOs) continues to operate without a national curriculum. It is predominantly workshop based and is complemented in some RTOs by online modules. Workshop learning is important for supervisor identity formation and establishing and maintaining communities of practice. Current programs are not structured to deliver individualised supervisor PD or develop the in-practice supervision team. Supervisors may struggle to translate workshop learning into changes in their practice. An in-practice quality improvement intervention facilitated by a visiting medical educator has been developed to address weaknesses in current supervisor PD. This intervention is ready to be trialled and further evaluated.

Lochial and endometrial cytological changes during the first 10 days post-partum with special reference to the nature of foaling and puerperium in equine.

During the puerperium, pregnancy-associated changes of the uterus need to be reversed. The duration of this process is of importance in terms of breeding efficiency and thus monitoring and treatment of the disturbed puerperium are essential. Aim of this investigation was to identify changes over time in the cellular composition of samples from endometrium and lochia in 120 mares with different obstetrical and puerperal history. In regular examinations up to 10 days post-partum the uterine involution was assessed by transrectal palpation and ultrasound. The vagina and cervix were examined using a speculum. Mares were classified as having an undisturbed or disturbed puerperium based on history and clinical findings. Uterine cytology samples were obtained with a cytology brush and lochia were obtained by manual withdrawal. Smears were done by rolling the brush or the swab on slides. They were stained using Hemacolor®-staining. In total, 238 cytology and 150 lochia smears were examined. Endometrial cells, neutrophils, and erythrocytes were distinguished by light-microscopy. Changes in the neutrophil granulocyte count in cytology and lochia smears were determined. The correlation between the number of neutrophils in cytology and lochia smears was not significant (p = 0.22). There was a significant influence of the puerperium on the percentage of neutrophils in the cytology samples (p = 0.001) but not in the lochia smears (p = 0.83). A significant decline of erythrocytes was detected in cytologies (p < 0.0001) and lochia smears (p = 0.12) of mares after eutocia but not after dystocia. Retention of fetal membranes (p = 0.0004) and time (p = 0.0034) had a significant influence on the percentage of neutrophils in the endometrial cytology. The type of birth (p = 0.0018) and the time (p = 0.0011) significantly affected the decrease in neutrophils in the cytology samples but not in the lochia smears. The influence of time was also found for the decrease of erythrocytes in cytology (p < 0.0001) and lochia (p = 0.0082) samples. A constant decline in neutrophils (p < 0.001) was found in the cytologies of mares with an undisturbed puerperium. Therefore, endometrial cytology seems to be more appropriate than lochia assessment for the evaluation of puerperal development in mares.

Risk factor management and depression post-stroke: the value of an integrated model of care.

BACKGROUND AND PURPOSE: Shared care initiatives, albeit commonly utilised in managing other chronic conditions have not been implemented in the area of stroke in Australia. The aims of this project were to adopt a shared care approach for stroke survivors comparing an experimental "shared-care" group with a "treatment-as-usual" control group in reference to the normalization or reversal of vascular risk factors and the detection and management of post-stroke depression. METHODS: A randomised controlled experimental research design was implemented with participants randomized to an intervention or control group and followed over a 12-month period. The treatment group consisted of a randomly selected group of patients, discharged from an acute stroke unit and transferred into the shared care model. Risk factors for stroke and depression were compared between the two groups. RESULTS: Of 97 patients originally included in the study, 17 dropped out. At 12 months, 80 patients remained for analysis (35 in the intervention group and 45 in the control group). The findings demonstrated positive trends for patients within the intervention group that were not found within the control group. The percentage of intervention patients reaching target systolic blood pressure (sBP) of 140 mmHg after 12 months tended to be greater than in the control group (p=0.11, NS). In the intervention group, at 12 months, the total cholesterol greater than 5.18 mmol/L was 12.5% compared to 58.8% at discharge. In contrast this trend was not so distinct in the control group (57.7% to 42.9%). The percentage of patients reaching target (recommended) total cholesterol of 5.18 mmol/L was significantly greater in the shared care patients intervention group relative to the control group (p=0.02). The average number of walks per week was also significantly greater in intervention group compared to the control group (p=0.048). Moreover, 45% of the control group screened as depressed compared with 20% of the intervention group at 12 months (p=0.06). CONCLUSIONS: This study demonstrates that major risk factors for recurrent stroke and vascular disease in general are better managed with the shared care model than with usual post-discharge care. The significantly reduced depression as found on the screening PHQ9 at 12 months indicated that the intervention was beneficial not only in the detection of depression but also treatment.

"Stress" and coronary heart disease: psychosocial risk factors.

An Expert Working Group of the National Heart Foundation of Australia undertook a review of systematic reviews of the evidence relating to major psychosocial risk factors to assess whether there are independent associations between any of the factors and the development and progression of coronary heart disease (CHD), or the occurrence of acute cardiac events. The expert group concluded that (i) there is strong and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and the causes and prognosis of CHD; and (ii) there is no strong or consistent evidence for a causal association between chronic life events, work-related stressors (job control, demands and strain), Type A behaviour patterns, hostility, anxiety disorders or panic disorders and CHD. The increased risk contributed by these psychosocial factors is of similar order to the more conventional CHD risk factors such as smoking, dyslipidaemia and hypertension. The identified psychosocial risk factors should be taken into account during individual CHD risk assessment and management, and have implications for public health policy and research.

Hospital in the home is cost saving for appropriately selected patients: a comparison with in-hospital care.

BACKGROUND: As the cost of acute care in hospitals increases, there is an increasing need to find alternative means of providing acute care. Hospital in the home (HITH) has developed in response to this challenge. Current evidence is conflicting as to whether HITH provides cost savings compared with in-hospital care (IHC). The heterogeneous nature of HITH and the clinical complexity of patients is the greatest obstacle to making valid comparisons between the two modes of care. OBJECTIVE: To compare costs and outcomes of HITH to IHC in hospitals in Victoria, Australia. DATA SOURCES/STUDY SETTING: Hospital morbidity data and medical records from Victoria, Australia. STUDY DESIGN: A costing study of 924 randomly selected episodes of HITH care, individually matched to 924 comparable IHC episodes. METHODS: Unadjusted total episode costs (TEC) and averaged daily costs for HITH and IHC were calculated. Mortality and length of stay (LOS) were compared for HITH and IHC episodes. Simple linear and multiple regression were used to analyse costing data, while logistic regression was used to compare in-hospital mortality and LOS in HITH versus IHC episodes. PRINCIPAL FINDINGS: The 1848 episodes of care in the sample represented a heterogeneous range of acute conditions in 31 Victoria hospitals. HITH consisted of two distinct subgroups: pure-HITH (total episode substitution) and mixed-HITH (partial episode substitution). The cost of episodes of acute care containing a HITH component were overall 9% less expensive than IHC (P = 0.04), while pure-HITH was 38% cheaper than matched IHC (P < 0.001). The variable HITH, along with LOS and chemotherapy, explained the 60% variation in TEC. The mean cost of pure-HITH episodes was 22% lower compared to mixed-HITH (P = 0.004). The in-hospital mortality rate in HITH (3.8%) and IHC (5.2%) was not significantly different. Pure-HITH was associated with shorter LOS, while mixed HITH was strongly associated with longer LOS. CONCLUSION: In our study the adjusted cost of HITH was significantly cheaper than IHC, particularly as total episode substitution. The cost needs to be adjusted because many factors other than HITH or IHC can influence crude costs. There may be potential for wider use of HITH for appropriately selected patients.