Medical Education - Research Publications
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ItemA qualitative exploration of obtaining informed consent in medical consultations with Burma-born women(CSIRO Publishing, 2022-11-29)BACKGROUND: Conciliatory attitudes, respect for medical professionals and avoidance of being direct can make health consultations with Burma-born patients difficult to navigate. Coupled with linguistic barriers, this may make the sensitive nature of many women's health consultations challenging. Little is known about current practices for obtaining informed consent in this context. The objectives of this study were to explore current practices, barriers and strategies to obtaining informed consent in medical consultations with women born in Burma. METHODS: Purposive and snowball sampling was used to recruit health practitioners (n=15, 2 male, 13 female) of different ages, years of professional experience, and country of origin, from clinics in Victoria that see a high volume of Burma-born patients. Thirty to sixty minute semi-structured interviews were conducted with four general practitioners, eight nurses and three interpreters, and de-identified audio recordings were transcribed for inductive thematic analysis. RESULTS: Five key themes were generated: (1) cultural cognisance; (2) influence of community; (3) skilful navigation of communication; (4) favourable consultation attributes; and (5) individual tailoring of consent conversations. Differing cultural expectations, and linguistic and educational barriers, were highlighted as challenges to obtaining informed consent, whereas thoughtful utilisation of non-verbal communication, and intentional customisation of consent conversations were identified as facilitators. CONCLUSION: The findings of this study provide practical ways to optimise the informed consent process within the Australian primary healthcare context, and reinforce that accepted Western-based practices for obtaining informed consent are not a 'one-size-fits-all' process.
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ItemLongitudinal Digital Glucometric Benchmarking to Evaluate the Impact of Institutional Diabetes Care Initiatives in Adults With Diabetes Mellitus Over the 2016-2020 Period.(SAGE Publications, 2022-11-22)BACKGROUND: While glucometric benchmarking has been used to compare glucose management between institutions, the value of longitudinal intra-institution benchmarking to assess quality improvement changes is not established. METHODS: A prospective six-month observational study (October 2019-March 2020 inclusive) of inpatients with diabetes or newly detected hyperglycemia admitted to eight medical and surgical wards at the Royal Melbourne Hospital. Networked blood glucose (BG) meters were used to collect capillary BG levels. Outcomes were measures of glycemic control assessed by mean and threshold glucometric measures and comparison with published glucometric benchmarks. Intra-institution comparison was over the 2016-2020 period. RESULTS: In all, 620 admissions (588 unique individuals) met the inclusion criteria, contributing 15 164 BG results over 4023 admission-days. Compared with the 2016 cohort from the same institution, there was increased BG testing (3.8 [SD = 2.2) vs 3.3 [SD = 1.7] BG measurements per patient-day, P < .001), lower mean patient-day mean glucose (PDMG; 8.9 mmol/L [SD = 3.2] vs 9.5 mmol/L [SD = 3.3], P < .001), and reduced mean and threshold measures of hyperglycemia (P < .001 for all). Comparison with institutions across the United States revealed lower incidence of mean PDMG >13.9 or >16.7 mmol/L, and reduced hypoglycemia (<3.9, <2.8, and <2.2 mmol/L), when compared with published benchmarks from an earlier period (2009-2014). CONCLUSIONS: Comprehensive digital-based glucometric benchmarking confirmed institutional quality improvement changes were followed by reduced hyperglycemia and hypoglycemia in a five-year comparison. Longitudinal glucometric benchmarking enables evaluation and validation of changes to institutional diabetes care management practices.
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ItemAccelerated partner therapy should be part of the suite of contact tracing options.(Elsevier BV, 2022-10)
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ItemHIV prevalence ratio of international migrants compared to their native-born counterparts: A systematic review and meta-analysis(ELSEVIER, 2022-11-01)BACKGROUND: People on the move, including international migrants, may face health inequities that expose them to a higher risk for HIV than native-born populations. We conducted a systematic review to calculate the HIV prevalence ratio of international migrants compared with native-born populations. METHODS: We searched five databases between January 2010 and March 2022. Using random-effects meta-analysis, we calculated the pooled HIV prevalence ratios (PR) by comparing the HIV prevalence of migrants with native-born populations. Our research protocol is registered in the International prospective register of systematic reviews (PROSPERO, CRD42021250867). FINDINGS: In total, 5,121 studies were screened, and 38 were included in the final analysis: 7,121,699 migrants and more than 270 million natives were included in the analysis. The pooled PR for any foreign-born migrants was 1·70 (95% CI 1·11 - 2·61, I2 =99·67%, n = 33 studies), refugees was 2·37 (95% CI 0·33-16·99, I2 =99·5%, n = 5), undocumented people was 3·98 (95% CI 0·11-143·01, I2 =94·6%, n = 3), whilst asylum seekers was 54·79 (95% CI 17·23-174·23, I2 =90·2%, n = 2). Meta-regression revealed that population type (adjusted R-squared 11.5%), region of origin (11.3%) and migrant type (10.8%) accounted for heterogeneity more than country-income (2.4%) and study setting (2.3%). INTERPRETATION: Although it was not possible to assess if HIV infection occurred in the country of origin or destination, the HIV prevalence ratio was higher among migrants than in native-born populations. Inclusive health policies and strategies for delivering HIV testing, prevention and treatment services for migrant populations tailored to their needs are urgently needed. FUNDING: J.J.O. and E.P.F.C. are supported by the Australian National Health and Medical Research Council (NHMRC) Emerging Leader Fellowship (GNT1193955 and GNT1172873, respectively).
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ItemFrom Traditional to Programmatic Assessment in Three (Not So) Easy Steps(MDPI, 2022-07-01)Programmatic assessment (PA) has strong theoretical and pedagogical underpinnings, but its practical implementation brings a number of challenges—particularly in traditional university settings involving large cohort sizes. This paper presents a detailed case report of an in-progress programmatic assessment implementation involving a decade of assessment innovation occurring in three significant and transformative steps. The starting position and subsequent changes represented in each step are reflected against the framework of established principles and implementation themes of PA. This case report emphasises the importance of ongoing innovation and evaluative research, the advantage of a dedicated team with a cohesive plan, and the fundamental necessity of electronic data collection. It also highlights the challenge of traditional university cultures, the potential advantage of a major pandemic disruption, and the necessity for curriculum renewal to support significant assessment change. Our PA implementation began with a plan to improve the learning potential of individual assessments and over the subsequent decade expanded to encompass a cohesive and course wide assessment program involving meaningful aggregation of assessment data. In our context (large cohort sizes and university-wide assessment policy) regular progress review meetings and progress decisions based on aggregated qualitative and quantitative data (rather than assessment format) remain local challenges.
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ItemEquipping Families and Friends to Offer Spiritual Care to People Living with Dementia: Findings from a Meta-Synthesis(MDPI, 2022-05-01)Our work presents a meta-synthesis of 76 peer-reviewed, qualitative-research journal articles related to our research interest in the spiritual care training available for relatives and friends of people living with dementia. A total of 244 articles was reviewed prior to the application of selection criteria. The final sample of 2698 research participants across our selection of 76 peer-reviewed qualitative-research studies serves to demonstrate the value of spiritual care as an aspect of holistic palliative and dementia care. The development and implementation of spiritual-care standards and practices in healthcare generally is increasingly widespread. Most current training resources are designed for healthcare professionals, and our meta-synthesis identifies the need for training resources that equip and train volunteer spiritual carers, namely, the relatives and friends of people living with dementia. Our meta-synthesis suggests there is a need to develop training resources that equip relatives and friends with skills that prioritise attentive presence, spiritual intelligence, emotional intelligence, and, primarily, sensory spiritual practices. Beyond this meta-synthesis, developing and trialling suitable training materials and events will become the focus of an action research project.
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ItemHealth-related quality of life with pembrolizumab monotherapy in patients with previously treated advanced microsatellite instability high/mismatch repair deficient endometrial cancer in the KEYNOTE-158 study.(Elsevier BV, 2022-08)OBJECTIVE: Pembrolizumab demonstrated a clinically meaningful objective response rate in patients with previously treated, advanced MSI-H/dMMR endometrial cancer in the multicohort phase 2 KEYNOTE-158 study (ClinicalTrials.gov, NCT02628067). We present health-related quality of life (HRQoL) results for these patients. METHODS: This analysis included patients from cohorts D (endometrial cancer with any MSI status) and K (any MSI-H/dMMR solid tumor except colorectal) who had previously treated, advanced MSI-H/dMMR endometrial cancer. Patients received pembrolizumab 200 mg Q3W for 35 cycles. EORTC QLQ-C30 and EQ-5D-3L questionnaires were administered at baseline, at regular intervals during treatment, and 30 days after treatment discontinuation. Pre-specified exploratory analyses included changes from baseline to week 9 in QLQ-C30 global health status (GHS)/QoL and EQ-5D-3L visual analog scale (VAS) score for all patients and by best overall response. RESULTS: 84 of 90 enrolled patients completed ≥1 HRQoL questionnaire and were included in the analysis. QLQ-C30 and EQ-5D-3L compliance rates were 90% and 94%, respectively, at baseline, and 92% and 93% at week 9. Mean (95% CI) QLQ-C30 GHS/QoL scores improved from baseline to week 9 by 6.08 (0.71-11.46) points in the overall population, with greater improvement in patients who achieved complete or partial response (11.67 [5.33-18.00]-point increase). Mean (95% CI) EQ-5D-3L VAS scores improved by 6.00 (2.25-9.75) points in the overall population and 9.11 (5.24-12.98) points in patients with CR/PR. CONCLUSIONS: Pembrolizumab maintained or improved HRQoL in patients with previously treated, advanced MSI-H/dMMR endometrial cancer, further supporting efficacy and safety results from KEYNOTE-158 and pembrolizumab use in this setting.
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ItemThe feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial(FRONTIERS MEDIA SA, 2022-09-15)BACKGROUND: While multiple clinical trials have demonstrated benefits of early palliative care for people with cancer, access to these services is frequently very late if at all. Establishing evidence-based, disease-specific 'triggers' or times for the routine integration of early palliative care may address this evidence-practice gap. AIM: To test the feasibility of using defined triggers for the integration of standardised, early palliative (STEP) care across three advanced cancers. METHOD: Phase II, multi-site, open-label, parallel-arm, randomised trial of usual best practice cancer care +/- STEP Care conducted in four metropolitan tertiary cancer services in Melbourne, Australia in patients with advanced breast, prostate and brain cancer. The primary outcome was the feasibility of using triggers for times of integration of STEP Care, defined as enrolment of at least 30 patients per cancer in 24 months. Triggers were based on hospital admission with metastatic disease (for breast and prostate cancer), or development of disease recurrence (for brain tumour cohort). A mixed method study design was employed to understand issues of feasibility and acceptability underpinning trigger points. RESULTS: The triggers underpinning times for the integration of STEP care were shown to be feasible for brain but not breast or prostate cancers, with enrolment of 49, 6 and 10 patients across the three disease groups respectively. The varied feasibility across these cancer groups suggested some important characteristics of triggers which may aid their utility in future work. CONCLUSIONS: Achieving the implementation of early palliative care as a standardized component of quality care for all oncology patients will require further attention to defining triggers. Triggers which are 1) linked to objective points within the illness course (not dependent on recognition by individual clinicians), 2) Identifiable and visible (heralded through established service-level activities) and 3) Not reliant upon additional screening measures may enhance their feasibility.
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ItemNon-conventional interventions to prevent gonorrhea or syphilis among men who have sex with men: A scoping review.(Frontiers Media SA, 2022)OBJECTIVES: We assessed nonconventional interventions that did not traditionally focus on increasing condom use and/or testing among men who have sex with men (MSM) and the evidence for these interventions. METHODS: Guided by the Participants, Concept and Context (PCC) framework, we searched five online databases from inception to 9 August 2021 for original research on interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis in MSM. Two researchers screened titles and abstracts to assess eligibility, reviewed articles' full text and resolved discrepancies through discussion. We charted relevant study information, and the included studies were critically appraised. RESULTS: Of 373 articles retrieved, 13 studies were included. These studies were conducted in Australia (n = 3), Belgium (n = 2), China (n = 3), the Netherlands (n = 1) and the US (n = 4). Two randomized controlled trials (RCTs) of doxycycline as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) reduced any STI incidence (gonorrhea, syphilis, or chlamydia), but only doxycycline PEP significantly reduced syphilis incidence. Six studies of interventions that facilitated self-collection, self-examination, and self-testing, found varied evidence for gonorrhea and/or syphilis prevention. Four RCTs and one single-arm trial examined the efficacy of mouthwash, but the evidence remains inconclusive on whether mouthwash use can prevent transmission between men. CONCLUSION: We found evidence for doxycycline PEP in reducing syphilis incidence, evidence on the use of mouthwash to prevent gonorrhea transmission between men remains inconclusive. More evidence is needed for interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis.
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ItemEpidemiology and outcomes of primary sclerosing cholangitis: an Australian multicentre retrospective cohort study(SPRINGER, 2022-06-03)BACKGROUND AND AIMS: Little is known regarding the epidemiology and outcomes of patients with primary sclerosing cholangitis (PSC) in Australia. We, therefore, evaluated the epidemiology and clinical outcomes of PSC in a large cohort of Australian patients and compared these to the general population. METHODS: We conducted a multicentre, retrospective cohort study of PSC patients at nine tertiary liver centers across three Australian states, including two liver transplant centers. RESULTS: A total of 413 PSC patients with 3,285 person-years of follow-up were included. Three hundred and seventy-one (90%) patients had large duct PSC and 294 (71%) had associated inflammatory bowel disease. A total of 168 (41%) patients developed cirrhosis (including 34 at the time of PSC diagnosis) after a median of 15.8 (95% CI 12.4, NA) years. The composite endpoint of death or liver transplantation occurred in 49 (12%) and 78 (19%) patients, respectively, with a median transplant-free survival of 13.4 (95% CI 12.2-15) years. Compared to the general population, PSC accounted for a 240-fold increased risk of development of cholangiocarcinoma (CCA) and CCA-related death. CCA risk was increased with older age of PSC diagnosis, presence of dominant stricture and colectomy. Compared to same-aged counterparts in the general population, PSC patients who were diagnosed at an older age or with longer disease duration had reduced relative survival. CONCLUSION: In this large retrospective cohort study of PSC patients in Australia, increased age and time from diagnosis was associated with increased mortality and morbidity particularly from CCA and development of cirrhosis, necessitating need for liver transplant.