Medicine (St Vincent's) - Theses
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ItemEnhancing the hepatitis B care cascade in Australia: addressing barriers in the Chinese community and general practice, and evaluating cost-effectivenessXiao, Yinzong ( 2021)Chronic hepatitis B infection is a significant global public health concern, with untreated chronic hepatitis B leading to cirrhosis, liver failure and liver cancer. In 2015, an estimated 257 million people worldwide were living with chronic hepatitis B, of whom only around 10% were diagnosed, and fewer than 1% received treatment. An estimated 870,000 deaths are attributed to hepatitis B each year. In 2016, the World Health Organization launched the global health sector strategy on eliminating viral hepatitis, which provides guidance and frameworks for country efforts to eliminate viral hepatitis as a major public health threat by 2030. In Australia, despite a high hepatitis B vaccination rate by global standards, there are significant gaps in the coverage of service delivery among people living with chronic hepatitis B. One in three people with chronic hepatitis B are not diagnosed, and 78% are not receiving ongoing clinical care. One of the priority populations of hepatitis B infection are people born in endemic countries, with China being the most common country of birth among overseas-born people living with hepatitis B in Australia. To increase hepatitis B diagnosis, care and treatment (that is, to enhance the hepatitis B care cascade) in Australia, several critical areas for improvement have been identified, including adapting services to the affected population, building health workforce capacity to meet demands, and building the investment case to support models of care that will promote hepatitis B elimination. The overarching aim of the research presented in this thesis was to generate evidence targeting each of these three aspects, with particular emphasis on: 1) engaging the Chinese community in hepatitis B testing and clinical management; 2) engaging general practitioners (GPs) in the provision of hepatitis B-related care; and 3) formulating a robust hepatitis B investment case. To accomplish these objectives, five interlocking studies were conducted. The first two studies focused on an affected community (the Australian Chinese community), the second two on health service providers, and the final study on the cost effectiveness of hepatitis B care. More specifically: Study 1 was a randomised controlled pilot and feasibility study of the impacts of an educational program designed to improve hepatitis B testing uptake in the Australian Chinese community; Study 2 was a qualitative study to explore enablers of hepatitis B clinical management among the Australian Chinese community; Study 3 was a before-and-after evaluation of a self-guided learning package among GPs practising in Victoria; Study 4 was a nationwide survey of knowledge, attitudes, barriers and enablers to the provision of hepatitis B care among GPs in Australia; and Study 5 was a cost-effectiveness study analysing the impacts of enhancing hepatitis B care cascade to reach global and national targets in Australia. The findings of this research indicated that a culturally tailored education program can contribute to improving hepatitis B-related knowledge among the Australian Chinese community. Key messages identified to resonate most strongly among people living with chronic hepatitis B included availability of effective and cheap treatment, and that long-term engagement with clinical management has substantial benefits. A holistic response from community, healthcare providers and the public health sector is required to motivate testing and clinical management among the Australian Chinese community at risk of hepatitis B infection. Additionally, this research showed that concise, clear and practical resources can support GPs to identify who to test for hepatitis B. It also showed that GPs lack of awareness, knowledge, confidence and intention to prescribe treatment for hepatitis B, highlighting the need for interventions to increase their interest and skills in the provision of hepatitis B-related care. Economic evaluation findings suggest that an improvement in the hepatitis B care cascade is required for Australia to reach the global 2030 targets, and that it is cost-effective to spend up to AUD328 million to AUD538 million per year on demand generation activities to reach the national and global targets. Overall, this research provides novel evidence about feasible and effective interventions for improving the hepatitis B care cascade in Australia. It also provides insights into ways to enhance the global hepatitis B care cascade.
ItemAn Australian population-based study of the incidence and outcomes of hepatocellular carcinoma: the Hepatomas of Melbourne Epidemiological Research (HoMER) studyHong, Thai Phuoc ( 2019)Liver cancer, the world’s second highest cause of cancer death, is reportedly increasing in incidence in developed countries including Australia. Hepatocellular carcinoma (HCC), the predominant type of liver cancer, has a complex epidemiology involving the interplay of many dynamic risk factors including chronic viral hepatitis B and C, alcohol-related liver disease and non-alcoholic fatty liver disease. Recent trends in these risk factors, changes in Melbourne’s population demographics, together with advances in HCC diagnostics are thought to be increasing HCC incidence, although this may be currently underreported by the cancer registry. Accurate local epidemiology is required to inform healthcare policy for the appropriate allocation of resources for treatment, prevention and research that will improve clinical and economic outcomes. The major study of this thesis, to my knowledge, is the first in the world to determine the population incidence of HCC using clinical case capture independent of the cancer registry. In doing so, it is also the first study to validate the completeness and accuracy of a cancer registry in reporting HCC, which is critical given that the HCC epidemiology literature has been mostly dependent on local registry data. Over 12 months (July 2012 to June 2013), there were 272 new cases of HCC identified from multiple primary sources including multidisciplinary meeting reviews, hospital inpatient, outpatient and emergency attendance at any of Melbourne’s seven tertiary hospital networks, pathology, radiology and pharmacy databases. After cross- referencing with the Victorian Cancer Registry cases for the same period, the HCC incidence determined by this study was found to be twice as high as that reported by the registry. The recruited population-based prospective cohort of HCC patients then provided the opportunity to examine clinical outcomes across the breadth of presentation, demographics and institutional expertise. This allowed for the determination of factors associated with improved survival, in particular, the influence of HCC surveillance participation. The commonest risk factors for HCC were chronic hepatitis C (41%) and alcohol-related liver disease (39%) followed by chronic hepatitis B (22%). While participation rates were low (40%), surveillance was associated with earlier tumour stage at diagnosis, being offered curative therapies, and improved survival probability. In the era of advanced diagnostic imaging and therapeutics for HCC, only some of which is publicly funded, the economic cost of the HCC disease burden is an important consideration in cost-effectiveness analyses. This HCC incidence cohort provides the basis for the first direct costings study of HCC management in Australia, with associated clinical factors that determine high cost. The highest costs occurred at both of ends of the disease spectrum, with early stage disease curable by liver transplantation or surgical resection, as well as in the sickest patients with advanced disease and only palliative options available. Thus, investment of healthcare expenditure towards disease prevention and early detection would likely be most cost-effective with improved survival and reduced morbidity achieved. This world-first research, using a novel methodology for clinical case capture, determined the population-based incidence of HCC in Melbourne, confirmed the underreporting of incidence by the cancer registry and contributed to the correction of registry classification practices. For cancers with rapidly changing epidemiology such as HCC, accurate and contemporary local data is important in disease prevention and management and in guiding healthcare policy and research.
ItemCoaching patients on achieving cardiovascular health: the COACH program a patient targeted strategy for the secondary prevention of coronary heart diseaseVale, Margarite Julia ( 2002)It is well recognised that there is a treatment gap in the management of risk factors in coronary heart disease (CHD) - a gap between what is known from published evidence and what is actually practised. Despite major advances in scientific evidence for aggressive risk factor management, only a minority of patients with CHD are achieving the target levels for their modifiable coronary risk factors. Strategies to address the treatment gap have been usually aimed at the physician and these have often been ineffective. Few strategies have been directed at the patient. Patient targeted strategies can be subdivided into those that permit the prescribing of medication ('competitive' with usual care) such as secondary prevention clinics or disease management programs, and those where support staff do not have prescribing rights ('cooperative' with usual care). Although intuitively it may appear that any program providing attention to patients would result in improvements in risk factor levels, published work shows that only the competitive programs resulted in significant improvement in coronary risk factor status. All of the cooperative programs failed to effect an improvement in risk factor status. While competitive programs are clearly effective, they risk alienating usual medical care and in a competitive environment may be counterproductive. There is a role for a cooperative program in an environment where primary care is competitive. This has been the rationale for the development of The Coach Program to bridge the treatment gap in CI-ID. The Coach Program was not founded on sociological or psychological theory. It is an empirical technique developed by the PhD Candidate on the basis of the Candidate's experience as a secondary school teacher. Although there is no coherent theory of coaching, coaching has been used in clinical medicine to improve doctor-patient interaction in the consultation process, assist patients to cope with painful procedures, for exercise training of patients to improve medical conditions and in staff teaching. Thus far, coaching has not been applied and evaluated in chronic disease management such as for the achievement of specific secondary prevention goals. The Coach Program is a training program for patients with CHD in which a health professional coach trains patients to aggressively pursue the target levels for their particular coronary risk factors. The coach is hospital-based and uses the telephone and mailouts to provide regular coaching sessions to patients after discharge from hospital. Coaching is directed at the patient and not at the treating doctor. Patients are coached to know their risk factor levels, know the target levels for their risk factors and how to achieve the target levels for their risk factors. Patients are persuaded to go to their own doctor(s) and ask for appropriate prescription of medication(s). Coaching also trains patients to follow appropriate lifestyle measures. The Coach Program has been validated by two randomised controlled trials. Pilot project carried out at St. Vincent's Hospital only by the PhD Candidate, a qualified dietitian. This study targeted cholesterol levels only, with the aim of achieving a TC < 4.5 mmol/L. At the end of the 6 month intervention, 107 patients who were coached achieved a mean TC (95%CI) of 5.00 (4.82-5.17) mmol/L versus 5.54 (5.36-5.72) mmol/L in 112 usual care patients (P<0.0001). Multivariate analysis showed that being coached was of equal magnitude in its effect on TC as was prescription of lipid-lowering medication. The Coach Program achieved a significantly greater ΔTC than usual care alone: mean ΔTC (95%CI) 0.54 (0.42 to 0.65) mmol/L (n=398) in The Coach Program group versus 0.18 (0.07 to 0.29) mmol/L (n=394) in the usual care group (P<0.0001). Thus, the reduction in TC from baseline to 6 months post-randomisation was 0.36 (95%CI: 0.20 to 0.52) mmol/L greater in The Coach Program group than in the usual care group. Coaching produced substantial improvements in most of the other coronary risk factors and in the patient's quality of life. The results of these two randomised controlled trials prove that coaching, delivered as The Coach Program, is a highly effective strategy in reducing TC and many other coronary risk factors in patients with CHD.
ItemEpidemiology, natural history and impact of inflammatory bowel disease in AustraliaWilson, Jarrad Leigh ( 2010)The inflammatory bowel diseases (IBD), Crohn’s disease (CD) and ulcerative colitis (UC), are chronic inflammatory disorders of the gastrointestinal tract. International studies have demonstrated a dramatic rise in the incidence of these conditions over the past several decades. There are no corresponding studies from Australia to determine the local incidence. CD has been shown to have a complicated disease course, with high requirements for surgery and progression to disability. Psychological morbidity is also common, with a negative impact on health related quality of life. International studies have also demonstrated high direct and indirect health economic costs associated with CD. Australian data in each of these areas is either limited or totally absent. The aim of this work was to address the deficiencies in each of these key areas. The first Australian population-based study of IBD incidence was conducted prospectively over a one-year period in the region of Barwon. This utilised an extensive capture-recapture methodology, with near complete case identification and rigorous verification of diagnosed cases. The IBD incidence rates observed are among the highest reported in the world literature. The natural history of CD was then assessed in a retrospective, inception cohort study over a five-year period from the time of diagnosis. There was the progressive development of a more complicated disease phenotype, with high requirements for surgery. The results from surgery were not durable, with 60 percent needing escalation of therapy within 5 years. 41 percent of the cohort met the definition of disabling disease, with the presence of perianal fistulae at diagnosis highlighted as a key risk factor. This was followed by two cross-sectional, questionnaire-based, cohort studies to assess psychological health and health related quality of life (HRQoL) in CD. The first study was conducted in patients from the Inflammatory Bowel Disease Clinic at St. Vincent’s Hospital, Melbourne. The second was in a cohort of patients from the same institution who had required the formation of an ileostomy for CD. Both studies revealed high rates of depression, anxiety and poor HRQoL. These negative factors were contributed to by increased disease activity, but the strongest predictive factor was found to be the use of a negative, maladaptive coping style. Some patients with a stoma have adapted well, but others found it to be a negative experience, with ongoing concerns regarding sexuality and body image. The health economic costs of CD were then established using prospective cost diaries. Both direct and indirect costs were high, in keeping with the complicated natural history of CD. These studies highlight that IBD is common in Australia, and that CD has a complicated natural history, with negative impacts on psychological health and HRQoL, and with high economic costs. There is a need for increased public awareness as well as ongoing research and funding to improve clinical care.