Sharing Colorectal Cancer Follow-Up Using an E-Care Plan Between Cancer Services and Primary Health Care.

High quality, long term follow-up care for cancer patients needs to be coordinated, comprehensive and tailored to the diverse needs of patients. This study implemented shared follow-up care using an interactive e-care plan that provided a collaborative space to schedule and share goals, tasks and information and support the monitoring of care. Qualitative results identified good relational coordination. Increasing communication from the cancer service is important.

Access to general practice for preventive health care for people who experience severe mental illness in Sydney, Australia: a qualitative study.

BACKGROUND: People with lived experience of severe mental illness (PWLE) live around 20years less than the general population. Most deaths are due to preventable health conditions. Improved access to high-quality preventive health care could help reduce this health inequity. This study aimed to answer the question: What helps PWLE access preventive care from their GP to prevent long-term physical conditions? METHODS: Qualitative interviews (n=10) and a focus group (n=10 participants) were conducted with PWLE who accessed a community mental health service and their carers (n=5). An asset-based framework was used to explore what helps participants access and engage with a GP. A conceptual framework of access to care guided data collection and analysis. Member checking was conducted with PWLE, service providers and other stakeholders. A lived experience researcher was involved in all stages of the study. RESULTS: PWLE and their carers identified multiple challenges to accessing high-quality preventive care, including the impacts of their mental illness, cognitive capacity, experiences of discrimination and low income. Some GPs facilitated access and communication. Key facilitators to access were support people and affordable preventive care. CONCLUSION: GPs can play an important role in facilitating access and communication with PWLE but need support to do so, particularly in the context of current demands in the Australian health system. Support workers, carers and mental health services are key assets in supporting PWLE and facilitating communication between PWLE and GPs. GP capacity building and system changes are needed to strengthen primary care's responsiveness to PWLE and ability to engage in collaborative/shared care.

Challenges and solutions to sharing a cancer follow-up e-care plan between a cancer service and general practice.

OBJECTIVE: This paper describes the process of developing a shared cancer care approach in follow-up, and identifies the e-health options that support an interactive e-care plan shared between a public cancer service, general practitioners (GPs) and cancer survivors. Type of program/service: The cancer service improvement initiative for shared care in follow-up targets colorectal cancer patients who have completed active treatment and who agree to shared care between specialists, GPs and other care team members. The intiative is supported by an agreed shared care pathway and an interactive e-care plan that is dynamic, can be shared and has functionalities that support collaboration. Design and development: A consultative process with stakeholders (local and state health services, a Primary Health Network, GPs and a consumer) was undertaken. Responses from individual consultations (25 stakeholders) were collated and commonalities identified to inform a workshop with 13 stakeholders to obtain consensus on the care pathway and e-health solution. Implications for policy and practice were identified throughout the process. OUTCOMES: The stakeholders agreed to a shared care pathway, which included assessment and consent, GP engagement, tailoring the care plan and communicating results and information as tasks are completed. The nurse coordinator monitored care. No interactive e-care plans were available at national, state or local health service levels. A web-based GP interactive e-care plan was selected. The main concerns raised were uncertainty about the security of e-health systems not controlled by the local health service and sharing clinical information with external health providers, engaging GPs, and patient anxiety about the capacity of general practice to provide care. The e-care plan provided a low-risk solution to sharing patient information and supported collaborative care. Challenges to share e-care plans have implications for policy and practice. LESSONS LEARNT: Stakeholders and the project team agreed that finding an e-health system that supported shared cancer care in follow-up and addressed the security and information sharing concerns could not all be adequately addressed at the local level. A GP interactive e-care plan provides a promising solution to a number of the barriers.

Assessing suitability for long-term colorectal cancer shared care: a scenario-based qualitative study.

BACKGROUND: Shared care is the preferred model for long-term survivorship care by cancer survivors, general practitioners and specialists. However, survivorship care remains specialist-led. A risk-stratified approach has been proposed to select suitable patients for long-term shared care after survivors have completed adjuvant cancer treatment. This study aims to use patient scenarios to explore views on patient suitability for long-term colorectal cancer shared care across the risk spectrum from survivors, general practitioners and specialists. METHODS: Participants completed a brief questionnaire assessing demographics and clinical issues before a semi-structured in-depth interview. The interviews focused on the participant's view on suitability for long term cancer shared care, challenges and facilitators in delivering it and resources that would be helpful. We conducted thematic analysis using an inductive approach to discover new concepts and themes. RESULTS: Interviews were conducted with 10 cancer survivors, 6 general practitioners and 9 cancer specialists. The main themes that emerged were patient-centredness, team resilience underlined by mutual trust and stronger system supports by way of cancer-specific training, survivorship care protocols, shared information systems, care coordination and navigational supports. CONCLUSIONS: Decisions on the appropriateness of this model for patients need to be made collaboratively with cancer survivors, considering their trust and relationship with their general practitioners and the support they need. Further research on improving mutual trust and operationalising support systems would assist in the integration of shared survivorship care.

Primary health care provider-focused interventions for improving outcomes for people with type 2 diabetes: a rapid review.

Objectives and importance of the study: The bulk of care for people with type 2 diabetes occurs in primary health care. This rapid review evaluated the effectiveness of primary health care provider-focused interventions in improving biochemical, clinical, psychological and health-related quality-of-life outcomes in people with type 2 diabetes. METHODS: We searched Medline, Embase, All EBM Reviews, CINAHL, PsycINFO and grey literature focusing on the Organisation for Economic Co-operation and Development (OECD) member countries. We selected studies that targeted adults with type 2 diabetes, described a provider-focused intervention conducted in primary health care, and included an evaluation component. Four researchers extracted data and each included study was assessed for quality by two researchers. RESULTS: Of the 15 studies identified, there was one systematic review (high quality), four randomised controlled trials (RCTs) (two strong quality, one each moderate and weak) and 10 cluster RCTs (two strong quality, five moderate, three weak). The range of follow-up periods was 3-32 months. In all but one study, the intervention was compared against usual care. The applied interventions included: computerised and noncomputerised decision support; culturally tailored interventions; feedback to the healthcare provider on quality of diabetes care; practice nurse involvement; and integrated primary and specialist care. All interventions aimed to improve the biochemical outcomes of interest; 13 studies also included clinical, psychological and/or health-related quality-of-life outcomes. Outcome results were mixed. CONCLUSIONS: All interventions had mixed impacts on the outcomes of interest except the one study testing a decision aid, which did not show any improvement. A number of interventions are already available in Australia but need wider adoption. Other effective interventions are yet to be broadly adopted, and need to be evaluated for their applicability, feasibility and sustainability in the Australian context.

Linking observational data from general practice, hospital admissions and diabetes clinic databases: can it be used to predict hospital admission?

BACKGROUND: Linking process of care data from general practice (GP) and hospital data may provide more information about the risk of hospital admission and re-admission for people with type-2 diabetes mellitus (T2DM). This study aimed to extract and link data from a hospital, a diabetes clinic (DC). A second aim was to determine whether the data could be used to predict hospital admission for people with T2DM. METHODS: Data were extracted using the GRHANITE™ extraction and linkage tool. The data from nine GPs and the DC included data from the two years prior to the hospital admission. The date of the first hospital admission for patients with one or more admissions was the index admission. For those patients without an admission, the census date 31/03/2014 was used in all outputs requiring results prior to an admission. Readmission was any admission following the index admission. The data were summarised to provide a comparison between two groups of patients: 1) Patients with a diagnosis of T2DM who had been treated at a GP and had a hospital admission and 2) Patients with a diagnosis of T2DM who had been treated at a GP and did not have a hospital admission. RESULTS: Data were extracted for 161,575 patients from the three data sources, 644 patients with T2DM had data linked between the GPs and the hospital. Of these, 170 also had data linked with the DC. Combining the data from the different data sources improved the overall data quality for some attributes particularly those attributes that were recorded consistently in the hospital admission data. The results from the modelling to predict hospital admission were plausible given the issues with data completeness. CONCLUSION: This project has established the methodology (tools and processes) to extract, link, aggregate and analyse data from general practices, hospital admission data and DC data. This study methodology involved the establishment of a comparator/control group from the same sites to compare and contrast the predictors of admission, addressing a limitation of most published risk stratification and admission prediction studies. Data completeness needs to be improved for this to be useful to predict hospital admissions.

The informatics capability maturity of integrated primary care centres in Australia.

CONTEXT: Integrated primary care requires systems and service integration along with financial incentives to promote downward substitution to a single entry point to care. Integrated Primary Care Centres (IPCCs) aim to improve integration by co-location of health services. The Informatics Capability Maturity (ICM) describes how well health organisations collect, manage and share information; manage eHealth technology, implementation, change, data quality and governance; and use "intelligence" to improve care. AIM: Describe associations of ICM with systems and service integration in IPCCs. METHODS: Mixed methods evaluation of IPCCs in metropolitan and rural Australia: an enhanced general practice, four GP Super Clinics, a "HealthOne" (private-public partnership) and a Community Health Centre. Data collection methods included self-assessed ICM, document review, interviews, observations in practice and assessment of electronic health record data. Data was analysed and compared across IPCCs. FINDINGS: The IPCCs demonstrated a range of funding models, ownership, leadership, organisation and ICM. Digital tools were used with varying effectiveness to collect, use and share data. Connectivity was problematic, requiring "work-arounds" to communicate and share information. The lack of technical, data and software interoperability standards, clinical coding and secure messaging were barriers to data collection, integration and sharing. Strong leadership and governance was important for successful implementation of robust and secure eHealth systems. Patient engagement with eHealth tools was suboptimal. CONCLUSIONS: ICM is positively associated with integration of data, systems and care. Improved ICM requires a health workforce with eHealth competencies; technical, semantic and software standards; adequate privacy and security; and good governance and leadership.

Structured data quality reports to improve EHR data quality.

OBJECTIVE: To examine whether a structured data quality report (SDQR) and feedback sessions with practice principals and managers improve the quality of routinely collected data in EHRs. METHODS: The intervention was conducted in four general practices participating in the Fairfield neighborhood electronic Practice Based Research Network (ePBRN). Data were extracted from their clinical information systems and summarised as a SDQR to guide feedback to practice principals and managers at 0, 4, 8 and 12 months. Data quality (DQ) metrics included completeness, correctness, consistency and duplication of patient records. Information on data recording practices, data quality improvement, and utility of SDQRs was collected at the feedback sessions at the practices. The main outcome measure was change in the recording of clinical information and level of meeting Royal Australian College of General Practice (RACGP) targets. RESULTS: Birth date was 100% and gender 99% complete at baseline and maintained. DQ of all variables measured improved significantly (p<0.01) over 12 months, but was not sufficient to comply with RACGP standards. Improvement was greatest with allergies. There was no significant change in duplicate records. CONCLUSIONS: SDQRs and feedback sessions support general practitioners and practice managers to focus on improving the recording of patient information. However, improved practice DQ, was not sufficient to meet RACGP targets. Randomised controlled studies are required to evaluate strategies to improve data quality and any associated improved safety and quality of care.

Primary health care-level interventions targeting health literacy and their effect on weight loss: a systematic review.

BACKGROUND: Enhancing individual's health literacy for weight loss is important in addressing the increasing burden of chronic disease due to overweight and obesity. We conducted a systematic review and narrative synthesis to determine the effectiveness of lifestyle interventions aimed at improving adults' knowledge and skills for weight loss in primary health care. The literature search included English-language papers published between 1990 and 30 June 2013 reporting research conducted within Organisation for Economic Cooperation and Development member countries. Twelve electronic databases and five journals were searched and this was supplemented by hand searching. The study population included adults (≥18 years old) with a body mass index (BMI) ≥25 kg/m(2) and without chronic disease at baseline. We included intervention studies with a minimum 6 month follow-up. Three reviewers independently extracted data and two reviewers independently assessed study quality by using predefined criteria. The main outcome was a change in measured weight and/or BMI over 6 or 12 months. RESULTS: Thirteen intervention studies, all targeting diet, physical activity and behaviour change to improve individuals' knowledge and/or skills for weight loss, were included with 2,089 participants. Most (9/13) of these studies were of a 'weak' quality. Seven studies provided training to the intervention deliverers. The majority of the studies (11/13) showed significant reduction in weight and/or BMI in at least one follow-up visit. There were no consistent associations in outcomes related to the mode of intervention delivery, the number or type of providers involved or the intensity of the intervention. CONCLUSIONS: There was evidence for the effectiveness of interventions that focussed on improving knowledge and skills (health literacy) for weight loss. However, there was insufficient evidence to determine relative effectiveness of individual interventions. The lack of studies measuring socio-economic status needs to be addressed in future research as the rates of obesity are high in disadvantaged population groups.

Integrating electronic health record information to support integrated care: practical application of ontologies to improve the accuracy of diabetes disease registers.

BACKGROUND: Information in Electronic Health Records (EHRs) are being promoted for use in clinical decision support, patient registers, measurement and improvement of integration and quality of care, and translational research. To do this EHR-derived data product creators need to logically integrate patient data with information and knowledge from diverse sources and contexts. OBJECTIVE: To examine the accuracy of an ontological multi-attribute approach to create a Type 2 Diabetes Mellitus (T2DM) register to support integrated care. METHODS: Guided by Australian best practice guidelines, the T2DM diagnosis and management ontology was conceptualized, contextualized and validated by clinicians; it was then specified, formalized and implemented. The algorithm was standardized against the domain ontology in SNOMED CT-AU. Accuracy of the implementation was measured in 4 datasets of varying sizes (927-12,057 patients) and an integrated dataset (23,793 patients). Results were cross-checked with sensitivity and specificity calculated with 95% confidence intervals. RESULTS: Incrementally integrating Reason for Visit (RFV), medication (Rx), and pathology in the algorithm identified nearly100% of T2DM cases. Incrementally integrating the four datasets improved accuracy; controlling for sample size, data incompleteness and duplicates. Manual validation confirmed the accuracy of the algorithm. CONCLUSION: Integrating multiple data elements within an EHR using ontology-based case-finding algorithms can improve the accuracy of the diagnosis and compensate for suboptimal data quality, and hence creating a dataset that is more fit-for-purpose. This clinical and pragmatic application of ontologies to EHR data improves the integration of data and the potential for better use of data to improve the quality of care.

EHR-based disease registries to support integrated care in a health neighbourhood: an ontology-based methodology.

Disease registries derived from Electronic Health Records (EHRs) are widely used for chronic disease management. We approached registries from the perspective of integrated care in a health neighbourhood, considering data quality issues such as semantic interoperability (consistency), accuracy, completeness and duplication. Our proposition is that a realist ontological approach is required to accurately identify patients in an EHR or data repository, assess data quality and fitness for use by the multidisciplinary integrated care team. We report on this approach with routinely collected data in a practice based research network in Australia.

Validating an ontology-based algorithm to identify patients with type 2 diabetes mellitus in electronic health records.

BACKGROUND: Improving healthcare for people with chronic conditions requires clinical information systems that support integrated care and information exchange, emphasizing a semantic approach to support multiple and disparate Electronic Health Records (EHRs). Using a literature review, the Australian National Guidelines for Type 2 Diabetes Mellitus (T2DM), SNOMED-CT-AU and input from health professionals, we developed a Diabetes Mellitus Ontology (DMO) to diagnose and manage patients with diabetes. This paper describes the manual validation of the DMO-based approach using real world EHR data from a general practice (n=908 active patients) participating in the electronic Practice Based Research Network (ePBRN). METHOD: The DMO-based algorithm to query, using Semantic Protocol and RDF Query Language (SPARQL), the structured fields in the ePBRN data repository were iteratively tested and refined. The accuracy of the final DMO-based algorithm was validated with a manual audit of the general practice EHR. Contingency tables were prepared and Sensitivity and Specificity (accuracy) of the algorithm to diagnose T2DM measured, using the T2DM cases found by manual EHR audit as the gold standard. Accuracy was determined with three attributes - reason for visit (RFV), medication (Rx) and pathology (path) - singly and in combination. RESULTS: The Sensitivity and Specificity of the algorithm were 100% and 99.88% with RFV; 96.55% and 98.97% with Rx; and 15.6% and 98.92% with Path. This suggests that Rx and Path data were not as complete or correct as the RFV for this general practice, which kept its RFV information complete and current for diabetes. However, the completeness is good enough for this purpose as confirmed by the very small relative deterioration of the accuracy (Sensitivity and Specificity of 97.67% and 99.18%) when calculated for the combination of RFV, Rx and Path. The manual EHR audit suggested that the accuracy of the algorithm was influenced by data quality such as incorrect data due to mistaken units of measurement and unavailable data due to non-documentation or documented in the wrong place or progress notes, problems with data extraction, encryption and data management errors. CONCLUSION: This DMO-based algorithm is sufficiently accurate to support a semantic approach, using the RFV, Rx and Path to define patients with T2DM from EHR data. However, the accuracy can be compromised by incomplete or incorrect data. The extent of compromise requires further study, using ontology-based and other approaches.

Multidisciplinary care: experience of patients with complex needs.

The rapidly increasing prevalence of diabetes with its high morbidity and mortality raises the need for an integrated multidisciplinary service from health care providers across health sectors. The aim of this study was to explore the diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators. Thirteen patients with type-2 diabetes admitted to the emergency department of a local hospital in NSW were interviewed and completed a demographic questionnaire. Results showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers. Separate sets of instructions from different health professionals were overwhelming, confusing and conflicting. Lack of a dedicated coordinator of care, follow up and support for self-management from health professionals were factors that contributed to patients' challenges in being actively involved in their care. The presence of multiple co-morbidities made it more difficult for patients to juggle priorities and 'commitments' to many health professionals. In addition, complex socioeconomic and cultural issues, such as financial difficulties, lack of transport and language barriers, intensified the challenge for these patients to navigate the health system independently. Few patients felt that having many health professionals involved in their care improved their diabetes control. Communication among the multidisciplinary care team was fragmented and had a negative effect on the coordination of care. The patients' perspective is important to identify the problems they experience and to formulate strategies for improving multidisciplinary care for patients with diabetes.

Electronic health records and disease registries to support integrated care in a health neighbourhood: an ontology-based methodology.

Disease registries derived from Electronic Health Records (EHRs) are widely used for chronic disease management (CDM). However, unlike national registries which are specialised data collections, they are usually specific to an EHR or organization such as a medical home. We approached registries from the perspective of integrated care in a health neighbourhood, considering data quality issues such as semantic interoperability (consistency), accuracy, completeness and duplication. Our proposition is that a realist ontological approach is required to systematically and accurately identify patients in an EHR or data repository of EHRs, assess intrinsic data quality and fitness for use by members of the multidisciplinary integrated care team. We report on this approach as applied to routinely collected data in an electronic practice based research network in Australia.

Data extraction from electronic health records - existing tools may be unreliable and potentially unsafe.

BACKGROUND: The increasing use of routinely collected data in electronic health record (EHR) systems for business analytics, quality improvement and research requires an extraction process fit for purpose. Little is known about the quality of EHR data extracts. We examined the accuracy of three data extraction tools (DETs) with two EHR systems in Australia. METHODS: The hardware, software environment and extraction instructions were kept the same for the extraction of relevant demographic and clinical data for all active patients with diabetes. The counts of identified patients and their demographic and clinical information were compared by EHR and DET. RESULTS: The DETs identified different numbers of diabetics and measures of quality of care under the same conditions. DISCUSSION: Current DETs are not reliable and potentially unsafe. Proprietary EHRs and DETs must support transparency and independent testing with standardised queries. Quality control within an appropriate policy and legislative environment is essential.

Gender differences in health-related quality of life of Australian chronically-ill adults: patient and physician characteristics do matter.

BACKGROUND: The aims of this study were to explore the health-related quality of life (HRQoL) in a large sample of Australian chronically-ill patients (type 2 diabetes and/or hypertension/ischaemic heart disease), to investigate the impact of characteristics of patients and their general practitioners on their HRQoL and to examine clinically significant differences in HRQoL among males and females. METHODS: This was a cross-sectional study with 193 general practitioners and 2181 of their chronically-ill patients aged 18 years or more using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and general practitioners at level 2) was applied to relate PCS-12 and MCS-12 to patient and general practitioner (GP) characteristics. RESULTS: Employment was likely to have a clinically significant larger positive effect on HRQoL of males (regression coefficient (B) (PCS-12) = 7.29, P < 0.001, effect size = 1.23 and B (MCS-12) = 3.40, P < 0.01, effect size = 0.55) than that of females (B(PCS-12) = 4.05, P < 0.001, effect size = 0.78 and B (MCS-12) = 1.16, P > 0.05, effect size = 0.16). There was a clinically significant difference in HRQoL among age groups. Younger men (< 39 years) were likely to have better physical health than older men (> 59 years, B = -5.82, P < 0.05, effect size = 0.66); older women tended to have better mental health (B = 5.62, P < 0.001, effect size = 0.77) than younger women. Chronically-ill women smokers reported clinically significant (B = -3.99, P < 0.001, effect size = 0.66) poorer mental health than women who were non-smokers. Female GPs were more likely to examine female patients than male patients (33% vs. 15%, P < 0.001) and female patients attending female GPs reported better physical health (B = 1.59, P < 0.05, effect size = 0.30). CONCLUSIONS: Some of the associations between patient characteristics and SF-12 physical and/or mental component scores were different for men and women. This finding underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The results suggest that chronically ill women attempting to quit smoking may need more psychological support. More quantitative studies are needed to determine the association between GP gender and patient gender in relation to HRQoL.

A preliminary study of the relationship between general practice care and hospitalisation using a diabetes register, CARDIAB.

BACKGROUND: Diabetes can be effectively managed in general practice (GP). This study used record linkage to explore associations between diabetes care in GP and hospitalisation. METHODS: Data on patients with type 2 diabetes were extracted from a Division of GP diabetes register (CARDIAB) for 2002-05 and were linked to the New South Wales Admitted Patient and Emergency Department (ED) Data Collection to create a unit record data collection containing demographic, clinical and health service records. Rates of admission and ED presentation per patient-year of follow up were calculated for the year following CARDIAB record. RESULTS: The study included 1178 diabetic patients with 2959 patient-years of follow up. Their mean age was 65.7 years and duration of diabetes was 5.9 years. All-cause admission and ED presentation rates were 0.7 and 0.2 per patient-year of follow up respectively and length of admission 3.2 days (s.d. 11.7 days). Admission was associated with age, duration of diabetes and prior admission. The number of processes of care recorded for each patient-year was associated with admission. Admission and length of stay were not associated with achievement of clinical targets. CONCLUSIONS: These data suggest that receipt of processes of care, rather than clinical targets, will prevent admission. One explanation may be that continuity of care in GP provides opportunity for early intervention and treatment. WHAT IS KNOWN ABOUT THE TOPIC? Diabetes is a serious public health problem that is largely managed in primary care. Health care planners use health service use (hospital admissions) for diabetes as an indicator of primary care. Guidelines for diabetes care are known to be effective in reducing diabetes-related complications. WHAT DOES THIS PAPER ADD? This paper created a linked data collection comprising demographic and clinical data from general practice and administrative health records of hospital admissions and emergency department presentations. The paper explores the associations between processes of primary care and control of diabetes and cardiovascular risk factors, and use of health services for a general practice population with diabetes. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? The study suggests that processes of care and not technical control of diabetes and cardiovascular risk factors are important in preventing hospital admission. Continuity of care in general practice that ensures implementation of processes of care provides opportunity for early intervention and treatment.

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors.

BACKGROUND: To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW). METHODS: A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported. RESULTS: 52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions. CONCLUSION: Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis.

BACKGROUND: People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes. METHODS: Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review. RESULTS: 52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients. CONCLUSION: Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.

Health reform: is routinely collected electronic information fit for purpose?

OBJECTIVE: Little has been reported about the completeness and accuracy of data in existing Australian clinical information systems. We examined the accuracy of the diagnoses of some chronic diseases in an ED information system (EDIS), a module of the NSW Health electronic medical record (EMR), and the consistency of the reports generated by the EMR. METHODS: A list of ED attendees and those admitted was generated from the EDIS, using specific (e.g. angina) and possible clinical terms (e.g. chest pain) for the selected chronic diseases. This EDIS list was validated with an audit of discharge summaries, and compared with a list generated, using similar specific and possible Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), from the underlying EMR database. RESULTS: Of the 33,115 ED attendees, 2559 had diabetes mellitus (DM), cardiovascular disease or asthma/chronic obstructive pulmonary disease; of these 2559, 876 were admitted. Discharge summaries were missing for 12-15% of patients. Only three-quarters or fewer of the diagnoses were confirmed by the discharge summary audit, best for DM and worst for cardiovascular disease. Proportion of agreement between the lists generated from the EDIS and EMR was best for DM and worst for asthma/chronic obstructive pulmonary disease. Possible reasons for this discrepancy are technical, such as use of different extraction terms or system inconsistency; or clinical, such as data entry, decision-making, professional behaviour and organizational performance. CONCLUSIONS: Variations in information quality and consistency of the EDIS/EMR raise concerns about the 'fitness for purpose' of the information for care and planning, information sharing, research and quality assurance.