Australian and New Zealand Living Guideline cholesterol-lowering therapy for people with chronic kidney disease (CARI Guidelines): Reducing the evidence-practice gap.

AIM: People with chronic kidney disease experience high rates of cardiovascular disease. Cholesterol-lowering therapy is a mainstay in the management but there is uncertainty in the treatment effects on patient-important outcomes, such as fatigue and rhabdomyolysis. Here, we summarise the updated CARI Australian and New Zealand Living Guidelines on cholesterol-lowering therapy in chronic kidney disease. METHODS: We updated a Cochrane review and monitored newly published studies weekly to inform guideline development according to international standards. The Working Group included expertise from nephrology, cardiology, Indigenous Health, guideline development and people with lived experience of chronic kidney disease. RESULTS: The guideline recommends people with chronic kidney disease (eGFR ≥15 mL/min/1.73 m2) and an absolute cardiovascular risk of 10% or higher should receive statin therapy (with or without ezetimibe) to reduce the risk of cardiovascular events and death (strong recommendation, moderate certainty evidence). The guidelines also recommends a lower absolute cardiovascular risk threshold (≥5%) for Aboriginal and Torres Strait Islander Peoples and Maori with chronic kidney disease to receive statin therapy (with or without ezetimibe) (strong recommendation, low certainty evidence). The evidence was actively surveyed from 2020-2023 and updated as required. No changes to guideline recommendations were made, with no new data on the balance and benefits of harms. CONCLUSIONS: The development of living guidelines was feasible and provided the opportunity to update recommendations to improve clinical decision-making in real-time. Living guidelines provide the opportunity to transform chronic kidney disease guidelines.

Patient and Partner Perspectives of Pregnancy-Related Counseling and Information Needs in Women With Kidney Disease: An Australian National Survey.

Introduction: The experiences and information needs for reproductive health counseling in women with chronic kidney disease (CKD) are poorly defined, despite the known importance of pregnancy planning in this higher-risk cohort. Methods: Australian adult women with CKD and their partners or family members completed a consumer codesigned survey about experiences of and preferences for pregnancy-related counseling, support, and education. Data were analyzed descriptively and with qualitative content analysis of free-text responses. Results: Responses were received from 102 women (CKD, n = 60; dialysis, n = 11; transplant, n = 26; unsure, n = 5 ) and 17 partners/family members. Pregnancy-related discussions were initiated mostly by women themselves (60.0%) compared to nephrologists (26.7%), and only after conception in 14.7%. Women found pregnancy-related discussions satisfactory (68.0%) and useful (50.7%) but also stressful (66.7%), with only 54.7% feeling in control of decision-making. Information deficits and quality, preformed decisions, clinician-patient disconnect, and burden of decision-making contributed to usefulness and outcomes of pregnancy-related counseling. Women received insufficient information about contraception (not provided in 35.2% of cases), medication safety (40.9%), fetal complications (33.8%) and emotional and psychological impact of pregnancy (73.2%). Women preferred counseling from nephrologists (86.4%), face-to-face settings (79.6%), websites (72.7%), handouts (61.4%), and online support groups (46.6%). High-quality, multiformat information by content experts, peer support, and psychological support were also strongly desired. Conclusion: This study highlights that preconception counseling and information needs of women with CKD are currently not being met. Frameworks and tools to assist patients and clinicians, particularly nephrologists, to initiate and conduct sensitive, useful, and informed shared decision-making (SDM) about pregnancy are urgently needed.

Simulation-based training for increasing health service board members' effectiveness: a cluster randomised controlled trial.

OBJECTIVES: There is a paucity of research on how to improve the functioning of health service boards, despite their importance in influencing patient care. We examined the impact of simulation-based training on health service board members' perceptions of their skills in communicating during board meetings and of board meeting processes. DESIGN: Prospective, cluster randomised controlled trial. SETTING: Health service boards in Victoria, Australia. PARTICIPANTS: Twelve boards were randomised, and pre- and post-intervention data were collected and analysed from 57 members of these boards. INTERVENTIONS: Boards were randomly allocated to either a treatment condition in which they received a 2-hour simulation-based training session or to a wait list control condition. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome variables were board members' perceptions regarding: (1) their skill and confidence in communicating during board meetings and (2) processes at their board meetings. Measures were collected in the intervention group before and 3 months post-training and compared with a wait list control group. RESULTS: Skills and confidence in communicating during board meetings was higher after training (control marginal mean=5.11, intervention marginal mean=5.42, mean difference=0.31, 90% CI (-0.03 to 0.66), one-sided p=0.068, d=0.40). Board meeting processes were also improved after training (control marginal mean=4.97, intervention marginal mean=5.37, mean difference=0.40, 90% CI (0.14 to 0.65), one-sided p=0.005, d=0.54). CONCLUSIONS: Simulation-based training appeared to improve board members' skills and confidence, and perceptions of board meeting processes. A larger scale trial is needed to examine possible impacts on patient outcomes. TRIAL REGISTRATION: Open Science Framework: http://osf.io/jaxt6/; Pre-results.

Recommendations for the prevention of deaths among nursing home residents with unexplained absences.

OBJECTIVES: Unexplained absences (UAs) contribute to the mortality and morbidity rates in the nursing home (NH) population. Valuing expert professional knowledge and skills is central to the achievement of improved care in NHs. This study developed and prioritised recommendations to prevent deaths of NH residents (NHRs) with UAs. METHODS: Two expert consultation forums using the modified nominal group technique to develop recommendations were conducted, followed by an online survey to prioritise the most important recommendations for implementation. A framework applying the temporal dimension ("pre-event," "event" and "post-event") of an internationally accepted injury prevention framework, Haddon's Matrix, was applied to the recommendations. Participants were purposively sampled and identified via aged care organisations; and were selected based on their experience in aged care practice, policy, research, elder rights, seniors' law, or missing persons search and rescue (SAR). RESULTS: Forum one comprised six, and forum two comprised nine experts from mixed disciplines. Seven participants completed the online survey. Twenty recommendations to prevent future injury and death were developed, five of which were prioritised for implementation in the aged care sector. In order of priority, these include: universal UA definition; mandated SAR plan, early assessment of NHRs; unmet needs behavioural assessments; and participation in decision-making. CONCLUSIONS: The recommendations cover the broad spectrum of complex issues raised in managing unexplained absences, and are a vital first step towards informing care providers, governments and SAR teams about how to prevent injury and death of NHRs in residents with UAs. Future research should explore how to translate and evaluate the recommendations into practice.

Simulation-based training for increasing health service board members' effectiveness: protocol for a cluster-randomised controlled trial.

INTRODUCTION: Research indicates that health service boards can influence quality of care. However, government reviews have indicated that board members may not be as effective as possible in attaining this goal. Simulation-based training may help to increase board members' ability to effectively communicate and hold hospital staff to account during board meetings. METHODS AND ANALYSIS: To test effectiveness and feasibility, a prospective, cluster-randomised controlled trial will be used to compare simulation-based training with no training. Primary outcome variables will include board members' perceived skill and confidence in communicating effectively during board meetings, and board members' perceptions of board meeting processes. These measures will be collected both immediately before training, and 3 months post-training, with boards randomly assigned to intervention or control arms. Primary analyses will comprise generalised estimating equations examining training effects on each of the primary outcomes. Secondary analyses will examine participants' feedback on the training. ETHICS AND DISSEMINATION: Research ethics approval has been granted by Monash University (reference number: 2018-12076). We aim to disseminate results through peer-reviewed journal publication, conference presentation and social media. TRIAL REGISTRATION NUMBER: Open Science Framework: http://osf.io/jaxt6/; Pre-results.

'To die, to sleep' - assisted dying legislation in Victoria: A case study.

BACKGROUND: Assisted dying remains an emotive topic globally with a number of countries initiating legislation to allow individuals access to assisted dying measures. Victoria will become the first Australian state in over 13 years to pass Assisted Dying Legislation, set to come into effect in 2019. OBJECTIVES: This article sought to evaluate the impact of Victorian Assisted Dying Legislation via narrative view and case study presentation. RESEARCH DESIGN: Narrative review and case study. PARTICIPANTS AND RESEARCH CONTEXT: case study. ETHICAL CONSIDERATIONS: This legislation will provide eligible Victorian residents with the option to request access to assisted dying measures as a viable alternative to a potentially painful, protracted death. FINDINGS: This legislation, while conservative and inclusive of many safeguards at present, will form the basis for further discussion and debate on assisted dying across Australia in time to come. DISCUSSION: The passing of this legislation by the Victorian parliament was prolonged, emotive and divided not only the parliament but Australian society. CONCLUSION: Many advocates for this legislation proclaimed it was well overdue and will finally meet the needs of contemporary society. Protagonists claim that medical treatment should not provide a means of ending life, despite palliative care reportedly often failing to relieve the pain and suffering of individuals living with a terminal illness.

Nonstandard Advance Health Care Directives in Emergency Departments: Ethical and Legal Dilemma or Reality: A Narrative Review.

People have tattooed themselves for thousands of years, and it remains popular with various groups across mainstream society. Although many people choose tattoos that express their life philosophy, epic events in their life, or their personal mantra, the use of tattooing in medicine such as a "do not resuscitate" tattoo is increasingly becoming more common (; ). As these tattoos do not meet the legal requirements for an advance health directive, they are at best a guide to the person's wishes and at worst a useless, painful exercise. New technology such as "talking tattoos" or implantable microchips could conceivably be used to record either an audible advance health directive or directions for emergency responders to access an individual's advance health directive. This article discusses the ethical and legal implications of nonstandard advance health directive tattoos in emergency treatment situations.