General Practice and Primary Care - Theses
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ItemReducing outcome disparities for rural Victorians with colorectal cancer: understanding pathways to treatment and informing policy.( 2017)In Victoria, rural patients with colorectal cancer have poorer outcomes than urban counterparts. To date, research and policy initiatives have focused on addressing potential variation in cancer treatment. However, pre-treatment delays may also be important. Policy change is required to reduce disparities for rural patients with cancer. Determining potential models of rural cancer care and understanding the policymaking process could enhance the success of future policies to address geographic cancer disparities. The overarching aim of the research program was to develop evidence to inform potential health system policies to reduce outcome disparities for colorectal cancer patients in rural Victoria. There were three research objectives: 1. Compare rural and urban patient pathways and experiences to diagnosis and treatment for those with colorectal and breast cancer in Victoria; 2. Identify potential models of rural cancer care that could inform future policies; and 3. Understand how large-scale health service policies in cancer care develop and are implemented. The research used a multi-phase, mixed methods design in five studies. The first phase examined rural and urban patient pathways to colorectal or breast cancer diagnosis and treatment in two studies. Breast cancer patients were included as a comparison group since outcomes are equivalent for women across Victoria. In the first study, interviews with 43 patients showed that rural and urban patients with either cancer experienced relatively similar pathways, though some had difficulty accessing GPs and longer time to specialist referral. Qualitative results informed hypotheses tested in a quantitative study of time intervals to treatment. Survey data from 922 patients with colorectal (n=433) and breast cancer (n=489), 621 GPs and 370 specialists were supplemented with cancer registry data. In quantile regression analyses, the time from first symptom or screening test to treatment was significantly longer for rural than urban patients with colorectal cancer, but not breast cancer. This was likely driven by longer diagnostic intervals for rural patients with colorectal cancer. In the second phase, patient interview data were re-analysed to explore experiences of choice of cancer treatment provider. Although most patients had limited involvement in choosing a provider, decision-making considerations were more complex for rural than urban patients. Studies in the final phase were a scoping review of rural cancer models of care and an interview study with 13 local and international key informants regarding the policymaking process. Across 47 reviewed articles, telehealth models were most common. Navigator and alternative provider models were identified for the pre-treatment period, but very few studies measured time to cancer care, and none assessed clinical cancer outcomes. Developing and implementing cancer policies at national or state-level was found to involve specific change mechanisms, such as stakeholder collaboration and evidence-use, influenced by the physical, political and temporal context. Based on these results, it is recommended that policies to address rural–urban inequities in colorectal cancer patient outcomes in Victoria focus on the diagnostic interval. Initiatives such as GP endoscopy, waiting time reporting or diagnostic centres should be investigated, acknowledging the potential impact of context in policy-change. The current research provides a baseline to assess the impact of future policies, and a starting-point for further research to understand policy development and implementation in cancer care.
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ItemAn investigation of the implementation of Victorian smoking cessation guidelines in public antenatal care services( 2015)Background: Modifying smoking behaviour in pregnancy can contribute to a significant improvement in infant health outcomes. Systematic review evidence supports the effectiveness of antenatal smoking cessation interventions to reduce smoking and improve infant health outcomes, such as preterm births and low birthweight. Victorian antenatal smoking cessation guidelines were developed in the early 2000s, and follow a 5As approach (five steps to ask, assess, advise, assist and ask again about smoking behaviour). The annual auditing of Victorian public maternity hospitals, available in State Government reports, indicates that not all women are being offered smoking cessation support, and that variation exists between hospitals in the proportion of women offered initial and follow-up support. At the time of designing this study, no other evidence was available documenting how antenatal smoking cessation guidelines have been implemented in Victoria, and how implementation might be improved. Aim: The overall aim of this PhD study is to examine the implementation of Victorian smoking cessation guidelines in public antenatal care services. The primary research questions are: 1. To what extent, and how, have antenatal smoking cessation guidelines been implemented in Victorian public maternity hospitals? 2. How can implementation be improved? Methods: The study uses a mixed methods approach, with a sequential explanatory research design with two phases: 1. Secondary analyses of data from a Victorian population-based survey of women who gave birth in 2007. 2. An exploratory qualitative study with healthcare providers and managers at two Victorian public maternity hospitals. Results: The survey results show that smoking cessation guidelines in Victoria are poorly implemented, with only 9.4% of women (36/381) reporting that they had received all of the 5As. Most women smoking in pregnancy reported that they had been asked about smoking (352/377, 93.4%), and told about the harmful effects of smoking (290/350, 82.9%). However, less than half of women were offered advice (169/349, 48.4%) or given written information (159/349, 45.6%). One in five women reported being told about stop smoking programs (76/349, 21.8%), and one-third said that caregivers had discussed smoking with them on more than one occasion (135/349, 38.7%). The qualitative study shows that provision of smoking cessation advice and support is inconsistent and varies according to the model of care a woman is enrolled in, her level of medical risk, the timing of the first pregnancy visit, and social circumstances. The study also identified that the provision of smoking cessation support is influenced by organisational systems that support clinicians in their clinical practice; the relationship that develops between health professionals and individual women; health professionals’ knowledge, experience, beliefs, and understanding of risk; and the level of priority that health professionals place on smoking cessation conversations. The survey results show that women experience mixed feelings about being asked by health professionals about smoking. Approximately three-quarters of women were happy to be asked about smoking; however, one-third of women felt like they were being judged. Women who smoke during pregnancy are more likely to experience multiple stressful life events and social health issues. However, tailoring of smoking cessation support to specific populations or women’s social circumstances is not routine practice. Implications for policy and practice: Organisations and health professionals are struggling to provide smoking cessation advice and support according to the guidelines. Currently, apart from the annual auditing of the maternity performance indicator for the hospital provision of smoking cessation support, there is little innovation or guidance from the Victorian Department of Health to support hospitals to implement the Victorian smoking cessation guidelines. Funding constraints have resulted in Quit Victoria having limited capacity to provide ongoing state-wide training to support maternity healthcare organisations and health professionals to implement smoking cessation guidelines. Additionally, the findings from this study show little return on the investment for previous state-wide training initiatives, suggesting that a new approach needs to be considered for future training initiatives. Conclusion: Evidence from this study illustrates major gaps in the provision of smoking cessation support, and identifies organisational, people, and systems barriers to implementation. There needs to be a ‘whole of systems’ approach to thinking about improvements, with careful consideration given to the interactions between different parts of the system and the contextual environment. Key recommendations arising from the findings address six major areas where action is needed to improve the implementation of the guidelines. This includes the development and application of a ‘whole of systems’ approach, training, smoking cessation resources, data systems, flow of communication between GPs and public maternity hospitals, and tailored approaches to specific populations.