General Practice and Primary Care - Research Publications
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ItemThis isn't what mine looked like': a qualitative study of symptom appraisal and help seeking in people recently diagnosed with melanoma(BMJ PUBLISHING GROUP, 2014)OBJECTIVE: To explore symptom appraisal and help-seeking decisions among patients recently diagnosed with melanomas, and to compare experiences of people with 'thinner' (<1 mm) and 'thicker' (>2 mm) melanomas, as thickness at diagnosis is an important prognostic feature. METHODS: In-depth interviews with patients within 10 weeks of melanoma diagnosis explored the factors impacting on their pathways to diagnosis. Framework analysis, underpinned by the Model of Pathways to Treatment, was used to explore the data with particular focus on patients' beliefs and experiences, disease factors, and healthcare professional (HCP) influences. RESULTS: 63 patients were interviewed (29-93 years, 31 women, 30 thicker melanomas). All described their skin changes using rich lay vocabulary. Many included unassuming features such as 'just a little spot' as well as common features of changes in size, colour and shape. There appeared to be subtly different patterns of symptoms: descriptions of vertical growth, bleeding, oozing and itch were features of thicker melanomas irrespective of pathological type. Appraisal was influenced by explanations such as normal life changes, prior beliefs and whether skin changes matched known melanoma descriptions. Most decisions to seek help were triggered by common factors such as advice from family and friends. 11 patients reported previous reassurance about their skin changes by a HCP, with little guidance on monitoring change or when it would be appropriate to re-consult. CONCLUSIONS: Patients diagnosed with both thinner and thicker melanomas often did not initially recognise or interpret their skin changes as warning signs or prompts to seek timely medical attention. The findings provide guidance for melanoma awareness campaigns on more appropriate images, helpful descriptive language and the need to stress the often apparently innocuous nature of potentially serious skin changes. The importance of appropriate advice, monitoring and safety-netting procedures by HCPs for people presenting with skin changes is also highlighted.
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ItemChronic disease prevention in primary care: how and when will genomics impact?(ROYAL COLL GENERAL PRACTITIONERS, 2014-07)
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ItemA qualitative exploration of the use of calendar landmarking instruments in cancer symptom research(BIOMED CENTRAL LTD, 2014-10-25)BACKGROUND: Late diagnosis is considered to be a major factor contributing to poorer cancer survival rates in the UK. Interventions have focussed on the promotion of earlier diagnosis in patients with potential cancer symptoms. However, to assess the effectiveness of these interventions, the time from symptom onset to presentation needs to be reliably and accurately measured. This qualitative study explored the use of calendar landmarking instruments in cancer symptom research. METHODS: We performed a secondary analysis of transcripts of interviews using the calendar landmarking instrument, undertaken with patients who had either been diagnosed with cancer (n = 40, IRCO study, Western Australia), or who had symptoms suggestive of cancer (n = 38, SYMPTOM study, North East and Eastern England). We used constant comparison methods to identify use of the calendar landmarking instruments and the impact of their application. RESULTS: The calendar landmarking instrument appeared to help many patients, either by acting as a prompt or helping to refine recall of events. A combination of personal (e.g. birthday) and national (e.g. Christmas) landmarks seemed to be the most effective. Calendar landmarking instruments appeared more useful where the time period between onset of symptoms and date of first consultation was less than three months. The interviewee's age, gender and cancer type did not appear to influence whether or not the instrument facilitated recall, and there were no instances where the use of the instrument resulted in the disclosure of a new first symptom. Symptoms of similar chronic conditions could create difficulties when applying the instrument; it was difficult for these participants to characterise and disentangle their symptoms which prompted their decisions to seek help. Some participants tended to prefer to use their own, already personalised, diaries to assist in their recall of events. CONCLUSIONS: This study is the first to describe the potential role of calendar landmarking instruments to support research interviews which explore symptoms and events along the cancer diagnostic pathway. The major challenge remains as to whether they actually improve accuracy of recall.
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ItemPhysical activity and fitness in women with metastatic breast cancer(SPRINGER, 2014-12)PURPOSE: This study aimed to explore differences in physical activity and fitness between women with metastatic breast cancer compared to healthy controls and factors associated with their physical activity levels. METHODS: Seventy-one women with metastatic breast cancer, aged (mean (SD)) 57.7 (9.5) and 2.9 (3.1) years after the onset of metastatic disease, and 71 healthy controls aged 55.0 (9.4) years participated. Of those with metastatic disease, 27% had bone-only metastases, 35% visceral-only metastases and 38% bone and visceral metastases. Patient-reported outcomes and physical measures of muscle strength and aerobic fitness assessments were obtained. Participants wore a SenseWear® physical activity monitor over 7 days, and the average steps/day and the time spent in moderate-to-vigorous intensity physical activity were determined. RESULTS: Women with metastases were significantly (i) less aerobically fit than the control group (25.3 (5.4) vs. 31.9 (6.1) mL • kg(-1) • min(-1); P < 0.001); (ii) weaker (e.g. lower limb strength for the metastatic and control groups was 53.5 (23.7) vs. 76.0 (27.4) kg, respectively; P < 0.001); (iii) less active, with the metastatic group attaining only 56% of the mean daily step counts of the healthy women; and (iv) more symptomatic, reporting higher levels of fatigue and dyspnoea (P < 0.001). CONCLUSION: Women living in the community with metastatic breast cancer possessed lower aerobic fitness, reduced muscular strength and less daily physical activity compared to healthy counterparts. They also experienced poorer functioning and higher symptom burden. IMPLICATIONS FOR CANCER SURVIVORS: Women living with metastatic breast cancer may benefit from a physical activity programme to address their physical impairments.
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ItemImpact of Specific Beers Criteria Medications on Associations between Drug Exposure and Unplanned Hospitalisation in Elderly Patients Taking High-Risk Drugs: A Case-Time-Control Study in Western Australia(ADIS INT LTD, 2014-04)BACKGROUND: Certain broad medication classes have previously been associated with high rates of hospitalisation due to related adverse events in elderly Western Australians, based on clinical coding recorded on inpatient summaries. Similarly, some medications from the Beers Criteria, considered potentially inappropriate in older people, have been linked with an increased risk of unplanned hospitalisation in this population. OBJECTIVE: Our objective was to determine whether risk estimates of drug-related hospitalisations are altered in elderly patients taking 'high-risk drugs' (HRDs) when specific Beers potentially inappropriate medications (PIMS) are taken into consideration. METHODS: Using the pharmaceutical claims of 251,305 Western Australians aged ≥65 years (1993-2005) linked with other health data, we applied a case-time-control design to estimate odds ratios (ORs) for unplanned hospitalisations associated with anticoagulants, antirheumatics, opioids, corticosteroids and four major cardiovascular drug groups, from which attributable fractions (AFs), number and proportion of drug-related admissions were derived. The analysis was repeated, taking into account exposure to eight specific PIMs, and results were compared. RESULTS: A total of 1,899,699 index hospitalisations were involved. Of index subjects, 12-57 % were exposed to each HRD at the time of admission, although the proportions taking both an HRD and one of the selected PIMs were much lower (generally ≤2 %, but as high as 8 % for combinations involving temazepam and for most PIMs combined with hypertension drugs). Included PIMs (indomethacin, naproxen, temazepam, oxazepam, diazepam, digoxin, amiodarone and ferrous sulphate) all tended to increase ORs, AFs and drug-related hospitalisation estimates in HRD combinations, although this was less evident for opioids and corticosteroids. Indomethacin had the greatest overall impact on HRD ORs/AFs. Indomethacin (OR 1.40; 95 % confidence interval [CI] 1.27-1.54) and naproxen (OR 1.22; 1.14-1.31) were associated with higher risks of unplanned hospitalisation than other antirheumatics (overall OR 1.09; 1.06-1.12). Similarly, among cardiac rhythm regulators, amiodarone (OR 1.22; 1.13-1.32) was riskier than digoxin (OR 1.08; 1.04-1.13). For comparisons of drug-related hospitalisation estimates, temazepam yielded the greatest absolute increases, especially with hypertension drugs. CONCLUSIONS: Indomethacin and temazepam should be prescribed cautiously in elderly patients, especially in drug combinations. Furthermore, it appears other antirheumatics should be favoured over indomethacin/naproxen and, in situations where both drugs may be appropriate, digoxin over amiodarone. Our methodology may help assess the safety of new medications in drug combinations in preliminary pharmacovigilance investigations.
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ItemLow-dose laser acupuncture for non-specific chronic low back pain: a double-blind randomised controlled trial(SAGE PUBLICATIONS LTD, 2014-04)OBJECTIVE: To determine if infrared laser acupuncture (LA) may have a specific effect in reducing pain and disability in treatment of chronic low back pain (LBP). METHODS: This was a double-blind sham laser controlled trial performed in general practices in Perth, Western Australia. The participants were 144 adults with chronic non-specific LBP. They were randomised to receive eight once-weekly treatments. Laser machines (20 mW, 840 nm diode, power density 0.1 W/cm(2)) stimulated points in three treatment groups: sham (0 joules/point), low dose (0.2 J/point) and high dose (0.8 joules/point). Participants were followed-up at 1 and 6 weeks, and 6 and 12 months post treatment. Primary outcomes were pain (Numerical Pain Rating Scale (NPRS)) and disability (Oswestry Disability Inventory (ODI)) at 6 weeks post treatment. Secondary outcomes included numerical rating scale for limitation of activity, global assessment of improvement, analgesic usage and adverse effects after treatment. RESULTS: The analysis showed no difference between sham and the laser groups at 6 weeks for pain or disability. There was a significant reduction in mean pain and disability in all groups at 6 weeks (p<0.005); NPRS: sham (-1.5 (95% CI -2.1 to -0.8)), low dose (-1.3 (-2.0 to -0.8)), high dose (-1.1 (-1.7 to -0.5)). ODI: sham (-4.0 (-7.1 to -1.0)), low dose (-4.1, (-6.7 to -1.5)), high dose (-2.6 (-5.7 to 0.5)). All secondary outcomes also showed clinical improvement over time but with no differences between groups. CONCLUSIONS: LA using energy density range (0-4 J/cm(2)) for the treatment of chronic non-specific LBP resulted in clinical improvement unrelated to laser stimulation. TRIAL REGISTRATION: http://www.anzctr.org.au ACTRN12610000043033.
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ItemProtocol for the ProCare Trial: a phase II randomised controlled trial of shared care for follow-up of men with prostate cancer(BMJ PUBLISHING GROUP, 2014)INTRODUCTION: Men with prostate cancer require long-term follow-up to monitor disease progression and manage common adverse physical and psychosocial consequences of treatment. There is growing recognition of the potential role of primary care in cancer follow-up. This paper describes the protocol for a phase II multisite randomised controlled trial of a novel model of shared care for the follow-up of men after completing treatment for low-moderate risk prostate cancer. METHODS AND ANALYSIS: The intervention is a shared care model of follow-up visits in the first 12 months after completing treatment for prostate cancer with the following specific components: a survivorship care plan, general practitioner (GP) management guidelines, register and recall systems, screening for distress and unmet needs and patient information resources. Eligible men will have completed surgery and/or radiotherapy for low-moderate risk prostate cancer within the previous 8 weeks and have a GP who consents to participate. Ninety men will be randomised to the intervention or current hospital follow-up care. Study outcome measures will be collected at baseline, 3, 6 and 12 months and include anxiety, depression, unmet needs, prostate cancer-specific quality of life and satisfaction with care. Clinical processes and healthcare resource usage will also be measured. The principal emphasis of the analysis will be on obtaining estimates of the treatment effect size and assessing feasibility in order to inform the design of a subsequent phase III trial. ETHICS AND DISSEMINATION: Ethics approval has been granted by the University of Western Australia and from all hospital recruitment sites in Western Australia and Victoria. RESULTS: of this phase II trial will be reported in peer-reviewed publications and in conference presentations. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12610000938000.
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ItemResponding to symptoms suggestive of lung cancer: a qualitative interview study.(BMJ, 2014)BACKGROUND: Late diagnosis of lung cancer can impact on survival rates. Patients delay seeking help for a number of reasons. This study explored symptom appraisal and help-seeking decisions among patients referred to specialist respiratory services with symptoms suggestive of lung cancer. METHODS: In-depth qualitative interviews with patients as soon as possible after referral, ideally before diagnosis and mainly within 10 weeks, explored factors impacting on their pathways prior to referral. Framework analysis, underpinned by the Model of Pathways to Treatment, was used to explore the data with particular focus on patients' beliefs and experiences, disease factors and healthcare professional influences. RESULTS: 35 patients were interviewed (aged 41-88 years, 15 women, 17 with lung cancer). All described similar presenting symptoms and triggers to seek help. Appraisal of symptoms was influenced by whether they had a lung comorbidity; seriousness of symptoms was interpreted within the context of previous illness experiences. Help-seeking was triggered when: symptoms failed to respond as expected; there was an increased awareness of symptoms of lung cancer; the public nature of a cough meant others were able to endorse help-seeking. Almost half visited the general practitioner (GP) two or more times before referral; during this period they reinterpreted initial symptoms and appraised new symptoms. The meaning given to symptoms changed over time and many became increasingly concerned they may have lung cancer. The GP played a role in ensuring timely further help-seeking but often there was little guidance on how to monitor symptoms or when to reconsult. CONCLUSIONS: Patients diagnosed with and without lung cancer had similar symptom pathways. Findings provide guidance for lung cancer awareness campaigns on the importance of social networks in endorsing patient help-seeking. The importance of appropriate advice, monitoring and safety-netting procedures by GPs for people presenting with symptoms suggestive of lung cancer is also highlighted.
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ItemThe Improving Rural Cancer Outcomes (IRCO) Trial: a factorial cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural patients with cancer in Western Australia: a study protocol(BMJ PUBLISHING GROUP, 2014)INTRODUCTION: While overall survival for most common cancers in Australia is improving, the rural-urban differential has been widening, with significant excess deaths due to lung, colorectal, breast and prostate cancer in regional Australia. Internationally a major focus on understanding variations in cancer outcomes has been later presentation to healthcare and later diagnosis. Approaches to reducing time to diagnosis of symptomatic cancer include public symptom awareness campaigns and interventions in primary care to improve early cancer detection. This paper reports the protocol of a factorial cluster-randomised trial of community and general practice (GP) level interventions to reduce the time to diagnosis of cancer in rural Western Australia (WA). METHODS AND ANALYSIS: The community intervention is a symptom awareness campaign tailored for rural Australians delivered through a community engagement model. The GP intervention includes a resource card with symptom risk assessment charts and local referral pathways implemented through multiple academic detailing visits and case studies. Participants are eligible if recently diagnosed with breast, colorectal, lung or prostate cancer who reside in specific regions of rural WA with a planned sample size of 1350. The primary outcome is the Total Diagnostic Interval, defined as the duration from first symptom (or date of cancer screening test) to cancer diagnosis. Secondary outcomes include cancer stage, healthcare utilisation, disease-free status, survival at 2 and 5 years and cost-effectiveness. ETHICS AND DISSEMINATION: Ethics approval has been granted by the University of Western Australia and from all relevant hospital recruitment sites in WA. RESULTS: Results of this trial will be reported in peer-reviewed publications and in conference presentations. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12610000872033.