Beyond the pipeline: a critique of the discourse surrounding the development of an Indigenous primary healthcare workforce in Australia.

A central strategy in addressing health disparities experienced by Indigenous people has been based on a concern with workforce improvement. In this paper, the Indigenous Australian healthcare workforce literature since 1977 is reviewed and its scope of concern, as being often limited to questions of 'supply', is critiqued. The pipeline metaphor, whether used explicitly or implied, regularly focuses attention on closing the gap on Indigenous representation within the health workforce. The exception though is the discourse concerning Indigenous Health Workers (IHWs), where questions concerning the legitimacy of the role continue to abound within a workforce hierarchy where community knowledge, though shown to be crucial to culturally safe health service provision, is trumped by the other health professions whose knowledges and legitimacy are not in question. This contrast exemplifies the need to examine the working of power not just 'supply'. The pipeline metaphor is disrupted with concerns about a range of other 'gaps' - gaps in the recognition of Indigenous knowledges, in organisational structures, in governance and in self-awareness by the health professions of their whiteness. As the health system continues to measure workforce development in terms of pipeline capacity, our study questions what happens beyond the pipeline.

So far, so good: Maintenance of prevention is required to stem HIV incidence in Aboriginal and Torres Strait Islander communities in Australia.

Indigenous people globally remain resilient yet vulnerable to the threats of HIV. Although Australian Aboriginal and Torres Strait Islander peoples experience the worst health status of any identifiable group in Australia, with a standardized morbidity rate three times that of non-Indigenous Australians, the Australian response to HIV has resulted in relatively low and stable rates of HIV infection among Australia's Indigenous peoples. This paper examines the reasons for the success of HIV prevention efforts. These include early recognition by Indigenous peoples of the potential effect that HIV could have on their communities; the supply of health hardware (needle and syringe programs and condoms); the development and implementation of culturally-appropriate health promotion messages such as the internationally-recognized Condoman campaign; the inclusion of dedicated Aboriginal and Torres Strait Islander Sexual Health Workers in communities; and an inclusive policy and partnership approach. Furthermore, the efforts of peak Aboriginal health organizations including NACCHO and its member services and Indigenous programs in peak mainstream organizations like AFAO and its member organizations, have all contributed to prevention success. Efforts need to be maintained however to ensure an escalated epidemic does not occur, particularly among heterosexual people, especially women, and people who inject drugs. New ideas are required as we enter a new era of HIV prevention within the context of the new paradigm of treatment as prevention, and getting to zero new infections.

The multifaceted nature of access to compounded progesterone: a cross-sectional study from Australia.

OBJECTIVE: To explore the influences on accessibility of compounded progesterone therapy for Australian women. STUDY DESIGN: A cross-sectional survey of a stratified sample of Australian women who use progesterone only products using the 'Perspectives on Progesterone' questionnaire. MAIN OUTCOME MEASURES: Principle components analysis (PCA) to determine components of access to progesterone treatment and multi-way analysis of variance to compare groups. RESULTS: Women using compounded progesterone were likely to have made at least one lifestyle adaptation (73%), and to have tried and stopped using at least one complementary and alternative medicine therapy (63%) or conventional hormone therapy (41%). PCA revealed six components of access to progesterone treatment: affordable, values natural treatments and is concerned about other treatments, conventionally available, perceived knowledge, values information gathered from a variety of sources, and rural & disadvantaged. The multifaceted nature of progesterone use illustrates that there are multiple aspects to use of non-conventional medicines. Women looking for non-conventional treatment are neither stupid nor uninformed, their understandings, based on experience and research, need to be addressed by health professionals while assessing their condition prior to discussing the risks and benefits of non-conventional medicines. CONCLUSION: Access to compounded progesterone is multifaceted, and many of the women who use it have tried other treatments first. Despite the clinical ambivalence towards progesterone as an alternative for women who may have tried and rejected other treatments, including conventional hormone therapy, the women described in this paper are using it.

Compounded progesterone and the Behavioral Model of Health Services Use.

Compounded progesterone (P4) is a product that, from a clinical experience-based perspective, effectively relieves a range of symptoms. In contrast, from a conventional evidence-based medicine perspective, P4 is ineffective. As P4 is not a product prescribed by conventional medicine, it is unlikely to be prescribed by family doctors, which increases the barriers to utilization. Utilization of medicines is influenced by many contextual and individual characteristics. The Behavioral Model of Health Services Use provides a multidimensional framework to conceptualize utilization of health services including medicine use. The 4 main components of this model are: contextual characteristics, individual characteristics, health behaviors and outcomes. This paper reports on the application of The Behavioral Model of Health Services Use to medicines and shows how it can be applied to the use of P4. The model enables some of the positive reinforcement that contributes to women continuing to use P4 to be explained. The Behavioral Model of Health Services Use was found to offer the potential to identify and then address issues with access to prescription medicines.

Application of cognitive interviewing to improve self-administered questionnaires used in small scale social pharmacy research.

Validating questionnaires for social pharmacy research with smaller sample sizes can be unnecessarily time-consuming and costly, a solution to this is cognitive interviewing with 2 interviews per iteration. This paper shows how cognitive interviewing with pairs of interviews per iteration of the questionnaire can be used to identify overt and covert issues with comprehension, retrieval, judgment and response experienced by respondents when attempting to answer a question or navigate around the questionnaire. When used during questionnaire development in small scale social pharmacy research studies cognitive interviewing can reduce both respondent burden and response error and should result in more reliable survey results. The process of cognitive interviewing is illustrated by a case study from the development of the Perspectives on Progesterone questionnaire.

Compounded progesterone: why is it acceptable to Australian women?

OBJECTIVES: To determine factors influencing compounded progesterone products' acceptability amongst Australian women who use them. STUDY DESIGN: A cross-sectional survey of 366 women from all states of Australia who had been dispensed a compounded progesterone product, using the 'Perspectives on Progesterone' questionnaire. MAIN OUTCOME MEASURES: Descriptive statistics and a logistic regression model of acceptability. Acceptability was measured by respondents' willingness to recommend progesterone therapy to other women with a similar condition to their own and whether they had talked about their experience to other women. RESULTS: Australian women who use compounded progesterone tend to be highly educated. They were treating symptoms associated with menopause transition or hormone deficiency. The most common dosage form being used was transdermal cream. More than half the respondents reported improvement for mood swings or irritability (73%), foggy thinking (58%), hot flushes (56%), sleeping problems (55%), and anxiety (54%). Side effects were minimal with the weight gain being the most frequently reported (10%). There was no difference in symptom improvement between those who use progesterone alone or in combination with other hormones. The compounded progesterone acceptability model contains symptom improvement (very large effect size) perception that progesterone is natural and safe (large effect size), number of unexpected benefits (medium effect size) and treatment tailored to suit them (medium effect size). Concerns about other treatments or other treatments being ineffective did not contribute to acceptability. CONCLUSIONS: Acceptance of compounded progesterone therapy depends on symptom improvement, perception of safety and naturalness and tailored therapy.

Systematic review of progesterone use by midlife and menopausal women.

Progesterone treatment for menopausal symptoms is still controversial. Progesterone levels fall during menopause transition, therefore some menopausal women may benefit from progesterone therapy. A systematic review was conducted of studies published from 2001 reporting on progesterone use to treat symptoms associated with menopause or postmenopausal women. Fourteen data bases were searched using the search terms progesterone, menopause, aged, female and human; exclusions were breast cancer, animal and contraception. Thirteen studies were selected for inclusion (11 clinical trials, 1 cohort study and 1 qualitative study), evaluating progesterone effects on menopausal symptoms, bone, sleep, skin, cognition, plasma lipids and plaque progression. Most studies were of low methodological quality (GRADE low or very low). Progesterone improved vasomotor symptoms and sleep quality, with minimal risk. Large studies designed to identify confounders, such as hormone levels, menopausal status and metabolism are required to understand the place of progesterone in clinical practice.

A systematic review of psychotropic drug prescribing for prisoners.

OBJECTIVE: To conduct a review of the literature on prescribing psychotropic drugs for prisoners. METHODS: Articles were retrieved from nine databases, reference lists, citations, governmental prison websites, and contact with authors. The articles included were written in English, focused on adults' time as prisoners, included at least one drug of interest, and discussed prescribing. Thirty-two articles met these inclusion criteria. RESULTS: Five main themes were identified from the reviewed studies: polypharmacy, high-dose therapy, duration of treatment, documentation and monitoring, and issues associated with the prisoners' environment. CONCLUSIONS: Consideration of these themes within the included studies identified areas for future research, particularly models of good practice, as numerous descriptions of poor practice exist. Policy-makers and prescribers should review current systems and practices, to ensure the care being offered to prisoners is optimal.

Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?

OBJECTIVE: The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infarction (AMI) clinical pathway (CPW) on thrombolytic administration in rural emergency departments. DESIGN: Cluster randomised controlled trial. SETTING: Six rural Victorian emergency departments participated. INTERVENTION: The five-step CPW implementation process comprised (i) engaging clinicians; (ii) CPW development; (iii) reminders; (iv) education; and (v) audit and feedback. MAIN OUTCOME MEASURES: The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic and time to thrombolysis and electrocardiogram. RESULTS: Nine hundred and fifteen medical records were audited, producing a final sample of 108 patients eligible for thrombolysis. There was no significant difference between intervention and control groups for median door-to-needle time (29 mins versus 29 mins; P = 0.632), proportion of those eligible receiving a thrombolytic (78% versus 84%; P = 0.739), median time to electrocardiogram (7 mins versus 6 mins; P = 0.669) and other outcome measures. Results showed superior outcome measures than other published studies. CONCLUSIONS: The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample. Results suggest that quality of AMI treatment in rural emergency departments (EDs) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas.

The effects of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review and meta-analysis.

This paper is a summary version of the previously published Cochrane review. It may increase the reach of the topic to health researchers and practitioners and encourage further discussion. The systematic review aims to summarize the evidence and assess the effect of clinical pathways on professional practice, patient outcomes, length of hospital stay, and hospital costs. The authors searched the Database of Abstracts of Reviews of Effectiveness, the Effective Practice and Organisation of Care Register, the Cochrane Central Register of Controlled Trials and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED, and Global Health. Twenty-seven studies considering a total of 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications (odds ratio 0.58: 95% CI [0.36, 0.94] and improved documentation (odds ratio 11.95: 95% CI [4.72, 30.30]) associated with clinical pathways. Considerable variation in study design and settings prevented statistical pooling of results for length of stay (LOS) and hospital costs. The authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation.

Have we drawn the wrong conclusions about the value of care pathways? Is a Cochrane review appropriate? Response to the commentary article published by Kris Vanhaecht et al.

The commentary provided by Vanhaecht et al. from the European Pathways Association (EPA) questions whether conclusions derived from the review of effects of clinical pathways in hospitals are appropriate. They provide some methodological discussion that indicates a poor appreciation of the detailed content of the review as published in the Cochrane Library and a lack of understanding of the methodological requirements for complex interventions of the Cochrane Effective Practice and Organisation of Care (EPOC) group. In addition, Vanhaecht et al. misrepresent some important points from the review relating to the intervention reviewed. The critical commentary offered by Vanhaecht et al. is a misrepresentation of the process and content of the review and suggests they have not taken the time and effort to thoroughly read and understand this comprehensive review.

Rural Australian community pharmacists' views on complementary and alternative medicine: a pilot study.

BACKGROUND: Complementary and alternative medicines (CAMs) are being used increasingly across the world. In Australia, community pharmacists are a major supplier of these products but knowledge of the products and interactions with other medicines is poor. Information regarding the use of CAMs by metropolitan pharmacists has been documented by the National Prescribing Service (NPS) in Australia but the views of rural/regional community pharmacists have not been explored. The aim of this pilot study was to explore the knowledge, attitudes and information seeking of a cohort of rural community pharmacists towards CAMs and to compare the findings to the larger NPS study. METHODS: A cross sectional self-administered postal questionnaire was mailed to all community pharmacists in one rural/regional area of Australia. Using a range of scales, data was collected regarding attitudes, knowledge, information seeking behaviour and demographics. RESULTS: Eighty eligible questionnaires were returned. Most pharmacists reported knowing that they should regularly ask consumers if they are using CAMs but many lacked the confidence to do so. Pharmacists surveyed for this study were more knowledgeable in regards to side effects and interactions of CAMs than those in the NPS survey. Over three quarters of pharmacists surveyed reported sourcing CAM information at least several times a month. The most frequently sought information was drug interactions, dose, contraindications and adverse effects. A variety of resources were used to source information, the most popular source was the internet but the most useful resource was CAM text books. CONCLUSIONS: Pharmacists have varied opinions on the use of CAMs and many lack awareness of or access to good quality CAMs information. Therefore, there is a need to provide pharmacists with opportunities for further education. The data is valuable in assisting interested stakeholders with the development of initiatives to address the gaps in attitudes, knowledge and to improve effectiveness of information seeking behaviour.

What is a clinical pathway? Development of a definition to inform the debate.

BACKGROUND: Clinical pathways are tools used to guide evidence-based healthcare that have been implemented internationally since the 1980s. However, there is widespread lack of agreement on the impact of clinical pathways on hospital resources and patient outcomes. This can be partially attributed to the confusion for both researchers and healthcare workers regarding what constitutes a clinical pathway. This paper describes efforts made by a team of Cochrane Review authors to develop criteria to assist in the objective identification of clinical pathway studies from the literature. METHODS: We undertook a four-stage process aiming to develop criteria to define a clinical pathway: (1) identify publications exploring the definition of a clinical pathway; (2) derive draft criteria; (3) pilot test the criteria; and (4) modify criteria to maximise agreement between review authors. RESULTS: Previous literature and liaison with the European Pathways Association resulted in five criteria being used to define a clinical pathway: (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions'; (4) the intervention had timeframes or criteria-based progression; and (5) the intervention aimed to standardise care for a specific clinical problem, procedure or episode of healthcare in a specific population. After pilot testing it was decided that if an intervention met the first criteria (a structured multidisciplinary plan of care) plus three out of the other four criteria then it was included as a clinical pathway for the purposes of this review. In all, 27 studies were included in the final review. The authors of the included studies referred to these interventions as 'clinical pathways', 'protocols', 'care model', 'care map', 'multidisciplinary care', evidence-based care' and 'guideline'. CONCLUSIONS: The criteria used for the identification of relevant studies for this Cochrane Review can be used as a foundation for the development of a standardised, internationally accepted definition of a clinical pathway.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs.

BACKGROUND: Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. OBJECTIVES: To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. SEARCH STRATEGY: We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. MAIN RESULTS: Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. AUTHORS' CONCLUSIONS: Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

No more heroes.

WHO WOULD you rather be led by: an engaging nurse or a heroic one?

A cluster randomised trial to assess the impact of clinical pathways on AMI management in rural Australian emergency departments.

BACKGROUND: People living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities. While several factors, including time taken to access hospital care, contribute to this risk, it is also partially attributable to the lower uptake of evidence-based guidelines for the administration of thrombolytic drugs in rural emergency departments where up to one-third of eligible patients do not receive this life-saving intervention. Clinical pathways have the potential to link evidence to practice by integrating guidelines into local systems, but their impact has been hampered by variable implementation strategies and sub-optimal research designs. The purpose of this study is to determine the impact of a five-step clinical pathways implementation process on the timely and efficient administration of thrombolytic drugs for acute myocardial infarctions managed in rural Australian emergency departments. METHODS/DESIGN: The design is a two-arm, cluster-randomised trial with rural hospital emergency departments that treat and do not routinely transfer acute myocardial infarction patients. Six rural hospitals in the state of Victoria will participate, with three in the intervention group and three in the control group. Intervention hospitals will participate in a five-step clinical pathway implementation process: engagement of clinicians, pathway development according to local resources and systems, reminders, education, and audit and feedback. Hospitals in the control group will each receive a hard copy of Australian national guidelines for chest pain and acute myocardial infarction management. Each group will include 90 cases to give a power of 80% at 5% significance level for the two primary outcome measures: proportion of those eligible for thrombolysis receiving the drug and time to delivery of thrombolytic drug. DISCUSSION: Improved compliance with thrombolytic guidelines via clinical pathways will increase acute myocardial infarction survival rates in rural hospitals and thereby help to reduce rural-urban mortality inequalities. Such knowledge translation has the potential to be adapted for a range of clinical problems in a wide array of settings. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry code ACTRN12608000209392.

What do gay men know about human papillomavirus? Australian gay men's knowledge and experience of anal cancer screening and human papillomavirus.

OBJECTIVE: The objective of this study was to determine levels of experience and knowledge concerning anal dysplasia, anal Pap smear tests, and human papillomavirus (HPV) among gay and other homosexually active men. STUDY DESIGN: Three hundred eighty-four men attending a large gay community event in Melbourne completed a short survey. RESULTS: Ninety-two percent identified as gay and 4.8% as bisexual. A total of 6.4% were HIV-positive and a further 3.5% did not know their HIV status. On a range of measures, it was clear that the men knew very little about anal cancer (19% scored zero on a 12-point knowledge scale) and virtually nothing about HPV (47% scored zero on an 8-point knowledge scale). A total of 55.1% had never heard of an anal Pap smear and 44.8% had ever heard of HPV; 56.4% did not know whether it affected men and/or women. CONCLUSIONS: The test for anal dysplasia is still largely unknown among Australian gay men and they currently have poor sense of personal susceptibility to the disease. Health education strategies are suggested to improve this situation.