A better model of diabetes self-management? Interactions between GP communication and patient self-efficacy in self-monitoring of blood glucose.

OBJECTIVE: The aim of this exploratory study was to investigate the interaction between patient self-efficacy and GP communication in explaining diabetes self-management in a disadvantaged region of Sydney, Australia. METHODS: This study was undertaken in South West Sydney with the Fairfield Division of General Practice. We used a cross-sectional survey design to assess patients' self-reported beliefs and behaviours about diabetes self-management. We used hierarchical multiple linear regression to test for interaction effects in diabetes self-management, following tests for clustering using multilevel modeling. RESULTS: Of those eligible for survey, 105 patients completed the telephone survey (72%). There was a significant interaction between diabetes self-efficacy and GP communication in blood glucose testing; high-ratings of GP communication enhanced self-monitoring of blood glucose when patient self-efficacy was high but impeded self-monitoring of blood glucose when self-efficacy was low. There were no significant interaction effects for the general diet or exercise scales. CONCLUSION: This exploratory study suggests a complex relationship between patient self-efficacy and GP communication in self-monitoring of blood glucose. It is likely optimal diabetes self-management behaviours are produced by a fit between high patient self-efficacy and high quality GP communication. PRACTICE IMPLICATIONS: There is a risk that GPs who are sensitive to their patients' low self-efficacy in self-monitoring of blood glucose may step in and take over the monitoring role and inadvertently reduce self-management.

How to attract a nephrology trainee: quantitative questionnaire results.

AIM: Global health workforce shortages are being experienced across many specialties. Australia faces a nephrology workforce shortage coupled with increased demand for nephrology services. This study examines issues impacting on the choice of nephrology as a career and identifies factors that can be modified to improve trainee recruitment. This study provides evidence to inform those seeking to address nephrology, and by extrapolation, other specialty workforce shortages. METHODS: In Australia in 2005, a mailed self-administered questionnaire was sent to all basic physician trainees eligible for the clinical component of the Royal Australasian College of Physicians' examination. Trainees were asked about the main influences on career choice; including perceived motivators and detractors surrounding a career in nephrology. RESULTS: Of the 531 doctors surveyed, 222 (42%) responded. Younger respondents and those with previous nephrology experience were more likely to consider nephrology. Perceptions deterring respondents from considering nephrology included inflexible work hours, an absence of positive role models, the perceived restriction of the subspecialty to a hospital-based practice and poor remuneration relative to other specialties. CONCLUSION: Exposure to a nephrology term in early postgraduate years is an important factor in a decision to undertake nephrology training. During these rotations; trainees need to experience positive role modelling. Effective trainee recruitment strategies should utilize the positive influence of role models, and must consider restructuring workforce and training activities to improve work hour flexibility and remuneration. Negative perceptions, acting as barriers to the pursuit of a career in nephrology, must be addressed and any misinformation corrected.

What medical students value from their teachers.

As Australian medical educators become more accustomed to the increasing pressures imposed upon them, there is a risk that the traditional educational relationship between a student and his or her teacher is replaced by a pure transactional relationship between a customer and his or her supplier. A large sample of medical students surveyed revealed that medical students seem to value directed rather than independent learning. New approaches to teaching, such as being innovative or entertaining, as well as facilitating participation, do not appear to be very important to medical students. Medical students do not seem to have strong preferences when it comes to assessment, contradicting some of the fundamental suggestions of the recent educational literature, in which assessment is often viewed as a key element in the formation and the direction of learning. The fact that medical students seem to reject many of the paradigms of the psychology-based educational literature, at least based on the large sample surveyed at the University of New South Wales, suggests that caution should be used in the development of training programs for teachers in medical faculties, and that learning and teaching should ensure that students' expectations and teachers' training do not mismatch.

Graduate capabilities for health service managers: reconfiguring health management education @UNSW.

The Master of Health Administration program at UNSW was extensively revised in 2006 to ensure that it effectively meets the challenging and dynamic environment of health service managers in local and global health contexts. This paper describes the innovative approach to the redesign of the health management program within the Faculty of Medicine. It outlines the method and considerations undertaken, particularly in identifying and embedding new graduate capabilities within the program. The paper concludes that using an outcomes-based approach and engaging with key stakeholders provides opportunity to identify and promote critical capabilities needed by managers to support the challenges confronting health services, including workforce flexibility. Further research is required on how such curriculum initiatives might impact on the performance of health service managers, but initial indications are that the health industry recognises the need and value of this approach.

Equity in resource allocation for health: a comparative study of the Ashanti and Northern Regions of Ghana.

Debate over the equitable allocation of financial resources in the health sector has focused overwhelmingly on allocation from national to regional levels. More equitable allocation of such resources within regions has been virtually ignored, creating a vacuum in knowledge regarding how resources are allocated intra-regionally and their potential influence on promoting health equity. In this paper, we report an empirical study examining progress towards equity in intra-regional resource allocation in the Ashanti and Northern regions of Ghana. Relative deprivation across the 31 districts of the two regions was measured as a proxy of health needs. The result was used to develop an equity-adjusted share index (EAS) applied as a yardstick against which progress towards equity was assessed. The study found a significant correlation between districts' share of donor pooled funds (DPF) and the EAS in the Northern region for three of the 4 years investigated. In Ashanti region, a worsening trend in relation to equity in DPF allocation was discovered. The proportion of variance in the share of DPF that could be explained by the EAS reduced incrementally from 56% in 1999 to less than 1% in 2002. The study highlights the need for more emphasis on intra-regional equity in resource allocation in Ghana.

Keeping track to keep Australia's overseas aid on track.

In the competition for official development assistance, health is losing out to governance and security.

Costs of managing urinary and faecal incontinence in a sub-acute care facility: a "bottom-up" approach.

AIMS: To measure accurately the direct costs of managing urinary and faecal incontinence in the sub-acute care setting. MATERIALS AND METHODS: Prospective observational study was undertaken in two sub-acute care units in a metropolitan hospital. A consecutive series of 29 consecutive patients with urinary and/or faecal incontinence, who were in-patients in a geriatric rehabilitation or sub-acute neurologic unit underwent routine timed voiding protocol, as per usual care. Face-to-face bedside recordings of all incontinence care, with detailed cost analysis, were undertaken. RESULTS: A total of 3,621 occasions of continence care were costed. The median time per 24 hr spent caring for incontinence per patient was 109 min (interquartile range 88-140). Isolated urinary incontinence episodes occurred in 28 patients (96.5%), mixed urinary/faecal incontinence episodes observed in 79.3%, and episodes of pure faecal incontinence were seen in 62%. The median costs of incontinence care in the sub-acute setting was $49AU per 24 hr, the major share ($41) spent on staff wages. The incontinence tasks of toileting assistance, pad changes, bed changes and catheter care were spread evenly across the three 8 hr shifts of duty. CONCLUSIONS: As our population demographics include an increasingly greater portion of the elderly, for whom long term institutional care is becoming relatively more scarce, provision of care in the sub-acute unit that may allow rehabilitation and return to home warrants scrutiny. This is the first study that delineates the costs of managing urinary and faecal incontinence in the sub-acute care setting. Such costs are substantial and place a heavy burden upon night-time carers.

Urinary incontinence in subacute care--a retrospective analysis of clinical outcomes and costs.

OBJECTIVE: To investigate the effect of incontinence on clinical outcomes and costs for patients in subacute care. DESIGN: Retrospective analysis of data collected over a 3-month period in 1996. SETTING: 54 medical facilities in Australia and New Zealand providing subacute care in an inpatient setting. PATIENTS: 6773 episodes of care provided to 6455 rehabilitation and geriatric evaluation and management patients. MAIN OUTCOME MEASURES: Urinary continence status, treatment outcomes, length of stay, discharge destination, and nursing and allied healthcare costs. RESULTS: Discharge destination differed between incontinent and continent patients (57% compared with 82%, respectively, discharged home, and 29% compared with 12%, respectively, discharged to a nursing home or to further care). There was a difference in cost between patients who were continent and those who were incontinent throughout their episode of care (rehabilitation: $185.60 [95% CI, $181-$190] per day for incontinent and $156.82 [95% CI, $153-$160] for continent patients; and geriatric evaluation and management: $164.62 [95% CI, $157-$172] for incontinent and $121.40 [95% CI, $114-$129] for continent patients). However, multilevel analyses showed that, after allowing for age and level of functional independence, the contribution of continence status to the cost of care depended on the functional independence of the patient (cognitive function for orthopaedic patients [P < 0.01] and motor function for stroke patients [P = 0.04]). CONCLUSION: The relationship between continence status and cost of care is complex. However, the cost differences found in our study need to be considered in payment systems, allocation of staff levels on wards and in development of casemix classifications.