Medicine (Western Health) - Research Publications
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ItemChronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial(SAGE PUBLICATIONS LTD, 2023)BACKGROUND: Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases. METHODS: Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts. RESULTS: At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables. CONCLUSIONS: This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.
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ItemUsing electronic medical record data to assess chronic kidney disease, type 2 diabetes and cardiovascular disease testing, recognition and management as documented in Australian general practice: a cross-sectional analysis(BMJ PUBLISHING GROUP, 2022-02)OBJECTIVES: To evaluate the capacity of general practice (GP) electronic medical record (EMR) data to assess risk factor detection, disease diagnostic testing, diagnosis, monitoring and pharmacotherapy for the interrelated chronic vascular diseases-chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease. DESIGN: Cross-sectional analysis of data extracted on a single date for each practice between 12 April 2017 and 18 April 2017 incorporating data from any time on or before data extraction, using baseline data from the Chronic Disease early detection and Improved Management in PrimAry Care ProjecT. Deidentified data were extracted from GP EMRs using the Pen Computer Systems Clinical Audit Tool and descriptive statistics used to describe the study population. SETTING: Eight GPs in Victoria, Australia. PARTICIPANTS: Patients were ≥18 years and attended GP ≥3 times within 24 months. 37 946 patients were included. RESULTS: Risk factor and disease testing/monitoring/treatment were assessed as per Australian guidelines (or US guidelines if none available), with guidelines simplified due to limitations in data availability where required. Risk factor assessment in those requiring it: 30% of patients had body mass index and 46% blood pressure within guideline recommended timeframes. Diagnostic testing in at-risk population: 17% had diagnostic testing as per recommendations for CKD and 37% for T2D. Possible undiagnosed disease: Pathology tests indicating possible disease with no diagnosis already coded were present in 6.7% for CKD, 1.6% for T2D and 0.33% familial hypercholesterolaemia. Overall prevalence: Coded diagnoses were recorded in 3.8% for CKD, 6.6% for T2D, 4.2% for ischaemic heart disease, 1% for heart failure, 1.7% for ischaemic stroke, 0.46% for peripheral vascular disease, 0.06% for familial hypercholesterolaemia and 2% for atrial fibrillation. Pharmaceutical prescriptions: the proportion of patients prescribed guideline-recommended medications ranged from 44% (beta blockers for patients with ischaemic heart disease) to 78% (antiplatelets or anticoagulants for patients with ischaemic stroke). CONCLUSIONS: Using GP EMR data, this study identified recorded diagnoses of chronic vascular diseases generally similar to, or higher than, reported national prevalence. It suggested low levels of extractable documented risk factor assessments, diagnostic testing in those at risk and prescription of guideline-recommended pharmacotherapy for some conditions. These baseline data highlight the utility of GP EMR data for potential use in epidemiological studies and by individual practices to guide targeted quality improvement. It also highlighted some of the challenges of using GP EMR data.
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ItemEpidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study(WILEY, 2021-11)OBJECTIVE: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). BACKGROUND: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. METHODS: An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. RESULTS: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). CONCLUSION: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.
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ItemClinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study(WILEY, 2022-03)OBJECTIVE: To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS: Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSIONS: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.
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ItemTrial registration and abstracts from the American Society of Anesthesiologists meetings 2010-2013: a retrospective observational study of methods( 2018)Purpose: Publication bias of positive studies has been demonstrated in many areas of medicine. In order to estimate publication bias in the anaesthesia literature and the effect of mandatory trial registration, we will pose the following research questions: Part One: What amount of publication bias is present in the anaesthesia literature, as seen in the abstracts presented at the 2001-2004 American Society of Anesthesiologists (ASA) annual meetings? Part Two: Has the introduction of compulsory trial registration in 2004 resulted in a decrease in publication bias, as seen in the abstracts presented at the 2010-2013 ASA meetings? Part Three: What is the proportion of prospective trial registration in abstracts presented at the 2010-2013 ASA annual meetings? What is the proportion of major discrepancies between abstract trial registration entries and the corresponding published papers? Hypotheses: That there is significant publication bias present in the anaesthesia literature. That the introduction of mandatory trial registration has not resulted in a decrease in publication bias in the anaesthesia literature. That trials that are not prospectively registered (but have a reported outcome) are more likely to have a positive outcome. Methods: All abstracts from 2001-2004 and 2010-2013 ASA annual meetings performed as randomized-controlled trials in humans will be reviewed. Their outcome results will be scored as positive or negative and the abstract quality will be assessed using a 13-point scoring system. A systematic literature search to identify any subsequent publication of the studies will be performed and the odds ratio for journal publication calculated by comparing positive vs negative studies. The odds ratio from the 2010-2013 abstracts period will be compared to the 2001-2004 period. We define a 33% decrease in the odds ratio as clinically significant. A systematic search for trial registration of the 2010-2013 abstracts will also be conducted, and any major discrepancies between registry entries and published papers recorded. We will perform a comparison between the proportion of positive outcome trials which did not have prospective registration versus the proportion of positive outcome trials with prospective registration. We define a 20% reduction in positive outcomes as clinically significant when comparing trials without prospective registration to trials with prospective registration.
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ItemThe relationship of study findings to publication outcome in anaesthesia research post implementation of mandatory trial registration( 2018)Purpose: Publication bias of positive studies has been demonstrated in many areas of medicine. In order to estimate publication bias in the anaesthesia literature and the effect of mandatory trial registration, we will pose the following research questions: Part One: What amount of publication bias is present in the anaesthesia literature, as seen in the abstracts presented at the 2001-2004 American Society of Anesthesiologists (ASA) annual meetings? Part Two: Has the introduction of compulsory trial registration in 2004 resulted in a decrease in publication bias, as seen in the abstracts presented at the 2010-2013 ASA meetings? Part Three: What is the proportion of prospective trial registration in abstracts presented at the 2010-2013 ASA annual meetings? What is the proportion of major discrepancies between abstract trial registration entries and the corresponding published papers? Hypotheses: That there is significant publication bias present in the anaesthesia literature. That the introduction of mandatory trial registration has not resulted in a decrease in publication bias in the anaesthesia literature. That trials that are not prospectively registered (but have a reported outcome) are more likely to have a positive outcome. Methods: All abstracts from 2001-2004 and 2010-2013 ASA annual meetings performed as randomized-controlled trials in humans will be reviewed. Their outcome results will be scored as positive or negative and the abstract quality will be assessed using a 13-point scoring system. A systematic literature search to identify any subsequent publication of the studies will be performed and the odds ratio for journal publication calculated by comparing positive vs negative studies. The odds ratio from the 2010-2013 abstracts period will be compared to the 2001-2004 period. We define a 33% decrease in the odds ratio as clinically significant. A systematic search for trial registration of the 2010-2013 abstracts will also be conducted, and any major discrepancies between registry entries and published papers recorded. We will perform a comparison between the proportion of positive outcome trials which did not have prospective registration versus the proportion of positive outcome trials with prospective registration. We define a 20% reduction in positive outcomes as clinically significant when comparing trials without prospective registration to trials with prospective registration.