Medical Education - Research Publications

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    Automated Best Practice Alerts Improved Treatment Initiation Post Hip Fracture
    Chiang, C ; Barmanray, R ; Fazio, T ; Reijnierse, E ; Maier, A ; Sim, I-W ; EBELING, P ; Yates, C (Australian and New Zealand Bone and Mineral Society, 2021)
    Background: An initial fragility fracture increases risk of subsequent fracture two- to three-fold; the highest risk is evident within the first two years (1). Despite the known benefit in prompt treatment post-fracture, underutilisation of anti-resorptive medications is widespread (2). The Australian & New Zealand Hip Fracture Registry shows hip fractures, the fracture with the highest morbidity and mortality, remain sub optimally managed (3, 4). After consultation with stakeholders, Best Practice Alerts (BPA) were implemented with a built-in treatment pathway to improve Vitamin D testing, inpatient Vitamin D treatment, and pre-discharge anti-resorptive treatment initiation in patients with hip fracture. Methods: Hip fracture admission pre-BPA implementation was captured via the REStORing health of acutely unwell adulTs cohort (May 2019 – March 2020), and via electronic medical record post-BPA implementation (March - July 2021). Three BPAs were implemented: 1) order for Vitamin D testing triggered by inpatient hip fracture diagnosis, 2) order for colecalciferol triggered by vitamin D result ≤50 nmol/L AND vitamin D not already charted, 3) order for anti-resorptive treatment triggered by the discharge summary. The introduction of BPAs was supported by targeted education of stakeholders. Patient discharge medications were compared pre- and post-BPA implementation. Results: BPA fired 572 times in 75 hip fracture patients [age (mean ± SD) 79.5±8.9yrs, 61.3% female]. Parameters which did not differ pre- (n=58) and post-implementation were vitamin D testing (96.6% vs 97.3%), vitamin D level (62.5 vs 68.3 nmol/L), vitamin D treatment at discharge (75.9% vs 88%) and anti-resorptive treatment on admission (15.5% vs 20%). Anti-resorptive treatment rate on discharge increased 3-fold post-BPA implementation (21% vs 68%, p=<0.001). Conclusion: Automated BPA with an incorporated evidence-based treatment pathway provides a powerful tool to assist medical staff in overcoming the secondary fracture prevention care gap. Further fine-tuning will reduce redundant firing of BPA and avoid “alert fatigue”.
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    Changing anti-resorptive prescription rates in the last five years
    Collins, L ; Barmanray, R ; Chiang, C ; Yates, C ; Fourlanos, S (Australian and New Zealand Bone and Mineral Society, 2021)
    Background: Osteoporosis or osteopaenia affect approximately six million Australians aged > 50 years, resulting in fracture-related morbidity and mortality. The treatment dosing schedule, duration and effects after treatment cessation vary due to the different actions of the anti-resorptive medications. Importantly, a rapid increase in bone turnover markers and reduction in bone mineral density can be seen following denosumab cessation (1). Vertebral fractures have been observed eight months following the last denosumab dose due to the rebound increase of bone resorption, in contrast to bisphosphonates’ persistent skeletal action despite cessation (2). Lockdown of citizen movement in Australia occurred during the COVID-19 pandemic in 2020 causing disruption to healthcare and in-person reviews. Aim: To examine national prescribing rates from 2016 to 2021 of denosumab, alendronate and risedronate. Method: This retrospective audit analysed prescribing rates of anti-resorptive medications. Data was sourced from The Pharmaceutical Benefits Scheme ‘Date of Supply’. Time-based trends were analysed by two methods: a polynomial (quadratic) line of best fit (R2 = 0.8639) and an interrupted time series using a quasipoisson distribution, with comparison made between pre- and post-COVID-19 onset (March 2020) periods. Results: Prescription rate of denosumab increased from 2016 to 2021. The rate has been steadily slowing with intensification of this trend noted post the onset of the COVID-19 pandemic (Figure 1). The long-term rates of prescription of alendronate and risedronate have decreased, with a notable inversion in this trend following March 2020 (Figure 2). Conclusion: The rate of denosumab prescriptions has slowed, more so following March 2020. This could be related to decreased new starts and/or decreased treatment continuation. Future research is required to determine if higher rates of rebound-associated fractures are occurring. Clinicians are urged to ensure that a strict 6 monthly dosing interval for denosumab is employed to mitigate the risk of rebound fractures.
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    Lower limb amputations in patients with diabetes-related foot complications in the COVID-19 pandemic
    Collins, L ; Jolley, J ; Barmanray, R ; Seymour, C ; Fourlanos, S ; Wraight, P (Endocrine Society of Australia, 2021)
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    ‘Laying down tracks for point-of-care glucose monitoring in hospitals’: A journey from a manual paper-based system to an automated system of networked blood glucose meters integrated with an EMR
    Fourlanos, S ; Kyi, M ; Barmanray, R ; PLUMB, S ; Oldaker, A ; Colman, P (Australian Diabetes Society, 2021)
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    Validation of the Melbourne clinical prediction tool to identify inpatients with type 2 diabetes at risk for persistent adverse glycaemia in hospital
    Kyi, M ; Barmanray, R ; Nair, I ; Hng, T-M ; Fourlanos, S (Australian Diabetes Society, 2021)
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    The Canadian Hypoglycaemia During Hospitalization (HyDHo) Score is Externally Valid in the Australian DINGO Cohort
    Barmanray, R ; Andrews, E ; Kyi, M ; Fazio, T ; Colman, P ; Fourlanos, S (Australian Diabetes Society, 2021)
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    Hyperglycaemia in Chronic Obstructive Pulmonary Disease (COPD) is primarily associated with glucocorticoids – findings from the DINGO Cohort
    Quah, S ; Barmanray, R ; Kyi, M ; Colman, P ; Fourlanos, S (Australian Diabetes Society, 2021)
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    Teaching Problem-Based Clinical Evaluation During COVID-19: Clinician as Simulated Patient
    Barmanray, R ; Seymour, C ; Morley, P (Australian & New Zealand Association for Health Professional Educators, 2021)
    The COVID-19 pandemic forced the suspension of ward-based medical education worldwide, necessitating novel approaches to medical education. Video case-based education has been successfully trialled in specialty medicine, however, problem-specific clinical evaluation is difficult to be taught via non-interactive video cases. In March 2020 the University of Melbourne instituted a virtual problem-based patient evaluation program for second-year Doctor of Medicine students commencing clinical training. This involves students interviewing expert clinicians in a simulated clinician-patient interaction through a real-time videoconferencing platform. The clinician uses a case précis to portray a presenting complaint and patient behaviour in a realistic manner as per their experience. Differential diagnoses are then generated and consideration given to whether elements of the history make each more or less likely. Examination findings are displayed and evaluated with regard to the differential diagnoses, followed by viewing (and discussion) of an expert performing the relevant physical examination. An experienced clinician acting as the patient allows demonstration of usual patient behaviours. Unlike a student peer-portrayal of a patient, responses can be matched to the phrasing of questions and manner in which they are asked (e.g. when evaluating chest pain a student’s question “Do you have any associated features or symptoms?” might be met with simulated confusion while “Could you tell me, other than the pain were you experiencing anything else unusual, for example…” would be met with a more fruitful response from the clinician). Elements of real-world patient interactions can also be modelled (e.g. inaccurate recollection of medication names/doses, “metmorphine” for “metformin”; or frustration at having to recount their history yet again, “Don’t you have all the information in your computer?!”). Feedback and guided reflection on the simulated encounter allows students to refine their interviewing skills to manage such real-world difficulties. The program has thus far been found engaging and valuable.
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    Diabetes IN-hospital, Glucose & Outcomes - The DINGO Study
    Barmanray, R ; Kyi, M ; Worth, L ; Colman, P ; Hall, C ; Gonzalez, V ; Fourlanos, S (Australian Diabetes Society, 2020)