Effect of a general practitioner management plan on health outcomes and hospitalisations in older patients with diabetes.

BACKGROUND: Little is known about the impact of a general practitioner management plan (GPMP) on health outcomes of patients with diabetes. AIM: To examine the impact of a GPMP on the risk of hospitalisation for diabetes. METHODS: A retrospective study using administrative data from the Australian Government Department of Veterans' Affairs was conducted (1 July 2006 to 30 June 2014) of diabetes patients either exposed or unexposed to a GPMP. The primary end-point was the risk of first hospitalisation for a diabetes-related complication and was assessed using Cox proportional hazard regression models with death as a competing risk. Secondary end-points included rates of receiving guideline care for diabetes, with differences assessed using Poisson regression analyses. RESULTS: A total of 16 214 patients with diabetes were included; 8091 had a GPMP, and 8123 did not. After 1 year, 545 (6.7%) patients with a GPMP and 634 (7.8%) of patients without a GPMP were hospitalised for a diabetes complication. There was a 22% reduction in the risk of being hospitalised for a diabetes complication (adjusted hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.69-0.87, P < 0.0001) for those who received a GPMP by comparison to those who did not. Increased rates of diabetes guideline care, HbA1c claims (adjusted HR 1.29, 95% CI 1.25-1.33) and microalbuminura claims (adjusted HR 1.65, 95% CI 1.58-1.72) were observed after a GPMP. CONCLUSION: Provision of a GPMP in older patients with diabetes resulted in improved health outcomes, delaying the risk of hospitalisation at 12 months for diabetes complications. GPMP should be included as part of routine primary care for older patients with diabetes.

General practitioner management plans delaying time to next potentially preventable hospitalisation for patients with heart failure.

BACKGROUND: Several studies have shown that the Australian Medicare-funded chronic disease management programme can lead to improvements in care processes. No study has examined the impact on long-term health outcomes. AIMS: This retrospective cohort study assessed the association between provision of a general practitioner management plan and time to next potentially preventable hospitalisation for older patients with heart failure. METHODS: We used the Australian Government Department of Veterans' Affairs (DVA) claims database and compared patients exposed to a general practitioner management plan with those who did not receive the service. Kaplan-Meier analysis and Cox proportional hazards models were used to compare time until next potentially preventable hospitalisation for heart failure between the exposed and unexposed groups. RESULTS: There were 1993 patients exposed to a general practitioner management plan and 3986 unexposed patients. Adjusted results showed a 23% reduction in the rate of potentially preventable hospitalisation for heart failure at any time (adjusted hazard ratio, 0.77; 95% confidence interval, 0.64 to 0.92; P = 0.0051) among those with a general practitioner management plan compared with the unexposed patients. Within one year, 8.6% of the exposed group compared with 10.7% of the unexposed group had a potentially preventable hospitalisation for heart failure. CONCLUSIONS: A general practitioner management plan is associated with delayed time to next potentially preventable hospitalisation for heart failure.

Impact of age, gender and indigenous status on access to diagnostic coronary angiography for patients presenting with non-ST segment elevation acute coronary syndromes in Australia.

Using Australian guidelines for management of acute coronary syndromes, we investigated the proportion of high-risk patients enrolled in the Acute Coronary Syndromes Prospective Audit registry who received a coronary angiogram. A prospective nationwide multicentre registry involving 39 Australian hospitals was used. The study cohort were patients with high-risk clinical features without ST segment elevation (n = 1948) admitted from emergency departments between 1 November 2005 and 31 July 2007. Eighty nine per cent of patients with ST segment elevation myocardial infarction and only 53% of eligible patients with high-risk acute coronary syndromes with no ST elevation received a diagnostic angiogram. Increasing age was associated with lower rates of angiography; a high-risk patient at the age of ≥ 70 years was 19% less likely to receive an angiogram than one at the age of <70 years (risk ratio (RR) = 0.81 95% confidence interval (CI) 0.76, 0.76). Women were 26% less likely than men to receive an angiogram (RR = 0.74; 95% CI = 0.65, 0.83). The adjusted RR from the multivariate analysis suggests that a patient at the age of ≥ 70 years was 35% less likely to receive an angiogram than one at the age of <70 years (RR = 0.65, 95% CI = 0.60, 0.73), and that women were 13% less likely than men to receive an angiogram (RR = 0.87, 95% CI = 0.80, 0.96). Indigenous patients were as likely to access angiography as eligible non-indigenous patients (RR = 1.03, 95% CI 0.85, 1.25). There is underinvestigation of high-risk patients without ST segment elevation in Australian hospitals, particularly for women and older patients. Indigenous patients are younger and have poorer risk profiles, and represent a group that would benefit from greater investment in prevention strategies.

Proximal correlates of metabolic phenotypes during 'at-risk' and 'case' stages of the metabolic disease continuum.

OBJECTIVE: To examine the social and behavioural correlates of metabolic phenotypes during 'at-risk' and 'case' stages of the metabolic disease continuum. DESIGN: Cross-sectional study of a random population sample. PARTICIPANTS: A total of 718 community-dwelling adults (57% female), aged 18-92 years from a regional South Australian city. MEASUREMENTS: Total body fat and lean mass and abdominal fat mass were assessed by dual energy x-ray absorptiometry. Fasting venous blood was collected in the morning for assessment of glycated haemoglobin, plasma glucose, serum triglycerides, cholesterol lipoproteins and insulin. Seated blood pressure (BP) was measured. Physical activity and smoking, alcohol and diet (96-item food frequency), sleep duration and frequency of sleep disordered breathing (SDB) symptoms, and family history of cardiometabolic disease, education, lifetime occupation and household income were assessed by questionnaire. Current medications were determined by clinical inventory. RESULTS: 36.5% were pharmacologically managed for a metabolic risk factor or had known diabetes ('cases'), otherwise were classified as the 'at-risk' population. In both 'at-risk' and 'cases', four major metabolic phenotypes were identified using principal components analysis that explained over 77% of the metabolic variance between people: fat mass/insulinemia (FMI); BP; lipidaemia/lean mass (LLM) and glycaemia (GLY). The BP phenotype was uncorrelated with other phenotypes in 'cases', whereas all phenotypes were inter-correlated in the 'at-risk'. Over and above other socioeconomic and behavioural factors, medications were the dominant correlates of all phenotypes in 'cases' and SDB symptom frequency was most strongly associated with FMI, LLM and GLY phenotypes in the 'at-risk'. CONCLUSION: Previous research has shown FMI, LLM and GLY phenotypes to be most strongly predictive of diabetes development. Reducing SDB symptom frequency and optimising the duration of sleep may be important concomitant interventions to standard diabetes risk reduction interventions. Prospective studies are required to examine this hypothesis.

Does an early childhood intervention affect cardiometabolic risk in adulthood? Evidence from a longitudinal study of preschool attendance in South Australia.

OBJECTIVES: There is an expectation that a positive social, cognitive and behavioural trajectory from early childhood developmental interventions will lead to improved population health and reduced health inequalities. However, there is limited direct evidence for this. The aim of this study was to assess the effect of participation in the South Australian Kindergarten Union preschool programme on adult cardiovascular biomedical risk factors. Kindergarten Union preschools delivered high-quality, comprehensive services to children aged 2-4 years and their families, including education, parenting and health services. STUDY DESIGN: Retrospective population-based cohort study. METHODS: The effect of attendance at a Kindergarten Union preschool on a range of cardiometabolic risk factors was assessed using data from the North West Adelaide Health Study 1999-2007. The study sample was taken from participants in the 2007 survey (n = 1064, 44.8% attended preschool) who lived in South Australia as children and were born during the years 1937-1969. RESULTS: Preschool attendance had a beneficial effect on hypertension in adulthood [prevalence ratio 0.82, 95% confidence interval (CI) 0.69-0.97] and an indication of benefit on hypercholesterolaemia (prevalence ratio 0.86, 95% CI 0.71-1.05), but had no effect on dyslipidaemia, central obesity, high fasting blood glucose or metabolic syndrome. CONCLUSIONS: This study found that preschool attendance was associated with reduced risk of hypertension in adulthood, but no effect was seen for the other cardiometabolic factors. These findings may reflect differing causal pathways and trajectories of these risk factors from childhood to adulthood, but confirmation from other studies is required.

Can attending preschool reduce the risk of tobacco smoking in adulthood? The effects of Kindergarten Union participation in South Australia.

BACKGROUND: Innovative strategies beyond the health system are required to reduce the prevalence of smoking. Early child development interventions are examples of interventions that can help set children on positive social and educational trajectories, which in turn may also reduce the prevalence of smoking. The aim of this study was to examine the effect of attendance at Kindergarten Union preschools on tobacco smoking in adulthood. METHODS: Kindergarten Union preschools delivered comprehensive services to children and their families, including education, parenting and health services, with a number of features consistent with contemporary ideas of high-quality service delivery. Using a retrospective cohort design with data from the North West Adelaide Health Study, this study examined different aspects of smoking behaviour in adults aged 34-67 years who attended a Kindergarten Union preschool at some stage between 1940 and 1972. Data were analysed using generalised linear model poisson regression with robust variance estimates, adjusting for both child and adult socio-economic factors and history of parental smoking. RESULTS: People who attended preschool had a reduced risk of ever smoking (prevalence ratio 0.87, 95% CI 0.77 to 0.98) and a reduced risk of current smoking in adulthood (prevalence ratio 0.77 (95% CI 0.59 to 1.00)), compared with those who did not attend preschool. There was no effect of preschool attendance on age at smoking uptake, age at quitting or the probability of quitting smoking. CONCLUSION: Attendance at the high-quality Kindergarten Union preschools was associated with a reduction in the initial uptake of smoking and thus the probability of being a current smoker. Among their other potential social benefits, high-quality, universal preschool programmes have the potential to help reduce smoking prevalence across the population.

Does attendance at preschool affect adult health? A systematic review.

BACKGROUND: Early child development interventions can set children on positive social and educational trajectories. The aim of this review was to examine the evidence for the adult health impacts of centre-based preschool interventions for preschoolers. METHODS: Medline, Embase, ERIC, Psych Info, Sociological Abstracts, the Cochrane Library, C2-SPECTR and the Head Start database were searched (1980-2008), and reference lists were searched for articles missed by the electronic search. RESULTS: The 12 eligible articles reviewed reported multi-faceted interventions and involved disadvantaged populations in all but one study. Limitations included a restricted range of health outcomes, reliance on self-report measures (11 studies), small sample sizes (nine studies with <100 in each arm) and a relatively young adult age at follow-up. There were positive intervention effects across the majority of behavioural outcomes, and a suggestion of a reduction in symptoms of depression. Non-communicable disease outcomes (e.g. diabetes mellitus) tended to have adverse or near-zero effect estimates. CONCLUSIONS: The reviewed articles provide some support for the role of early childhood interventions to improve health behaviours but not chronic disease outcomes. Population health researchers should become more involved in the evaluation of preschool interventions as there is great potential for broad population health benefit.

Contribution of Ara h 2 to peanut-specific, immunoglobulin E-mediated, cell activation.

BACKGROUND: Ara h 2 is a potent peanut allergen but its contribution to the ability of a crude peanut extract (CPE) to cross-link IgE and activate mast cells has not been rigorously evaluated. OBJECTIVE: To measure the contribution that Ara h 2 makes to the effector function of a CPE. METHODS: Ara h 2 was specifically removed from a CPE as demonstrated by immunoblots, 2D gels, and an inhibitory ELISA. Functional assays of sham-treated and Ara h 2-depleted CPEs were performed with RBL SX-38 cells sensitized with IgE from highly peanut-allergic subjects and with naturally sensitized basophils. RESULTS: Depletion of approximately 99% of the Ara h 2 from the CPE led to an increase in the concentration of the CPE necessary to give 50% of maximal degranulation (EC50) of the SX-38 cells following sensitization with sera that contain anti-Ara h 2 IgE. Assays with a pool of 10 sera showed a small but significant increase in the EC50 following depletion of Ara h 2 (1.65+/-0.15-fold; P<0.05) and assays of seven individual sera showed a similar increase in the average EC50 (1.7+/-0.2-fold; P<0.02). The percent of the anti-peanut IgE that binds Ara h 2 correlated with an increase in the EC50 of the CPE following depletion of Ara h 2 (r=0.83; P<0.02). On the other hand, data from three of these patients studied with a basophil histamine release assay did not show a significant effect of depletion of Ara h 2. CONCLUSION: Based on its ability to cross-link IgE effectively, Ara h 2 is clearly an important peanut allergen. Its ability to cross-link IgE effectively from a specific serum is related to the proportion of anti-Ara h 2 in that serum but Ara h 2 does not account for a majority of the effector activity of the CPE for any of the sera studied.

EBM and the health of Indigenous Australians.

Implementing evidence-based medicine (EBM) in primary healthcare for Indigenous people will usually involve increasing services, particularly those for chronic conditions. As shown by the example of diabetes care, there are significant organisational, educational, economic, cultural and structural barriers to implementing EBM in many Indigenous communities. Many of these barriers could be reduced by better-organised service delivery systems at the community level, greater numbers of Indigenous health professionals and greater advocacy for healthy public policy by health services. There is evidence that delivering evidence-based primary healthcare, particularly for chronic diseases, can improve health outcomes in Indigenous communities. There is a need for more investment in strategies to implement EBM and evidence-based public health in Indigenous settings.

Improving diabetes care in the primary healthcare setting: a randomised cluster trial in remote Indigenous communities.

OBJECTIVE: To evaluate a system for improving diabetes care in remote Indigenous communities. DESIGN: Randomised, unblinded cluster trial over one year (1 March to 29 February 2000). PARTICIPANTS AND SETTING: Primary healthcare staff in 21 primary healthcare centres in the Torres Strait and Northern Peninsula Area (NPA) Health Service District, north Queensland, and 678 people with diabetes, mostly Torres Strait Islanders. INTERVENTION: Diabetes recall system established at eight of the 21 sites, as well as staff training in basic diabetes care, regular phone calls from the project officer, a two-monthly newsletter and a mid-project workshop. MAIN OUTCOME MEASURES: Regular checks of weight, blood pressure, eye and foot care, serum lipid levels and glucose monitoring and control, urinary albumin to creatinine ratio and serum creatinine levels, and administration of recommended vaccines; hospitalisation in the previous 12 months. RESULTS: There was improvement in most measures at most sites, except for blood pressure monitoring and control, and vaccination status. Intervention sites showed greater improvement in most indicators than control sites (combined relative risk [RR], 1.21; 95% CI, 1.03-1.43). The intervention group showed a 32% reduction in hospital admissions for diabetes-related conditions over the study period (P=0.012). At follow-up, patients in intervention sites were 40% less likely to be hospitalised for a diabetes-related condition than those in control sites (RR, 0.60; 95% CI, 0.41-0.86; P=0.007). CONCLUSION: A simple recall system, managed by local healthcare workers and supported by a diabetes outreach service, achieved significant improvements in diabetes care and reduced hospitalisations in a high-risk population.

Has access to hospital improved for Aborigines in the northern territory?

One of the stated aims of Australia's health care system is to achieve equity of access to health care according to need for all Australians, with the ultimate goal of moving toward statistical equality of good health for all. This paper examines how, using routinely collected population health data, we might answer the question of whether access to hospital care for Aborigines in the Northern Territory (NT) improved in relation to access for non-Aborigines during the period 1979 to 1988. Some of the advantages and shortfalls of this approach are discussed and an 'index of access' is postulated. This index is shown to be moving towards 1 during the period, suggesting that access to hospitals has improved for Aborigines compared with non-Aborigines, but that a substantial shortfall still exists. While this index can be useful for measuring progress toward achieving the horizontal equity of equal access for equal need, the more difficult task of defining and measuring progress toward vertical equity goals with respect to the persistent and gross inequalities in health status between Aboriginal and non-Aboriginal Australians deserves priority.