Undertaking general practice quality improvement to improve cancer screening - a thematic analysis of provider experiences

Background: Cancer is a major cause of illness and death, and its incidence and mortality can be reduced through effective screening. In order to improve below target screening rates in one region of Australia, the local Primary Health Network supported local general practices to implement a range of quality improvement initiatives. Methods: We used a qualitative approach and interviewed 18 general practice staff and five Primary Health Network staff and contractors to understand their experiences with these quality improvement initiatives. Results: In a thematic analysis, we identified four key themes related to program set-up and implementation; patient and community education and promotion; engaging patients and communities in screening; and general practice enhancement. Program roles were clear and understood, and the program received strong oversight and support. Practice staff felt supported and motivated. Information Technology was a challenge for many practices often requiring tailored assistance. Education provided by practices facilitated patient empowerment but practice staff noted difficulties engaging patients in screening. Practices were enhanced though strong leadership and teamwork and practice learning activities. Conclusions: The tailored evidence-based quality improvement initiatives were considered effective in supporting general practices to increase their cancer screening. Key facilitators reported by participants included use of Plan-Do-Study-Act cycles, enhanced data entry and audit capacity, effective recall and reminder systems and maintaining staff motivation

Remote measurement of high preeruptive water vapor emissions at Sabancaya volcano by passive differential optical absorption spectroscopy

Water (H2O) is by far the most abundant volcanic volatile species and plays a predominant role in driving volcanic eruptions. However, numerous difficulties associated with making accurate measurements of water vapor in volcanic plumes have limited their use as a diagnostic tool. Here we present the first detection of water vapor in a volcanic plume using passive visible-light differential optical absorption spectroscopy (DOAS). Ultraviolet and visible-light DOAS measurements were made on 21 May 2016 at Sabancaya Volcano, Peru. We find that Sabancaya's plume contained an exceptionally high relative water vapor abundance 6 months prior to its November 2016 eruption. Our measurements yielded average sulfur dioxide (SO2) emission rates of 800–900 t/d, H2O emission rates of around 250,000 t/d, and an H2O/SO2 molecular ratio of 1000 which is about an order of magnitude larger than typically found in high-temperature volcanic gases. We attribute the high water vapor emissions to a boiling-off of Sabancaya's hydrothermal system caused by intrusion of magma to shallow depths. This hypothesis is supported by a significant increase in the thermal output of the volcanic edifice detected in infrared satellite imagery leading up to and after our measurements. Though the measurement conditions encountered at Sabancaya were very favorable for our experiment, we show that visible-light DOAS systems could be used to measure water vapor emissions at numerous other high-elevation volcanoes. Such measurements would provide observatories with additional information particularly useful for forecasting eruptions at volcanoes harboring significant hydrothermal systems

Integrating health care in Australia : a qualitative evaluation

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses. We aimed to investigate the WSICP’s effectiveness through a qualitative evaluation focused on the 10 WSICP strategies. The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research

Using community based research frameworks to develop and implement a church-based program to prevent diabetes and its complications for Samoan communities in South Western Sydney

Pasifika communities bear a disproportionate burden of diabetes compared to the general Australian population. Community-based participatory research (CBPR), which involves working in partnership with researchers and communities to address local health needs, has gained prominence as a model of working with underserved communities. This paper describes how Le Taeao Afua (LTA) Samoan diabetes prevention program was underpinned by two CBPR frameworks to develop a culturally tailored church-based lifestyle intervention to prevent diabetes and its complications in the Australian Samoan community. The name LTA, which means ‘a new dawn,’ was chosen by the community to signify a new dawn without diabetes in the Australian Samoan community. Strategies for engaging with the Australian Samoan community in South Western Sydney are discussed mapped to the key principles from the CBPR frameworks. In particular, this paper highlights the steps involved in building relationships with Samoan community leaders and the vital role of community activators and peer support facilitators in the success of delivering the program. Lessons learnt, such as the importance of church and maintaining a Samoan way of life in daily activities, and processes to build effective partnerships and maintain long-term relationships with the Australian Samoan community, are also discussed. Our paper, through providing a case example of how to apply CBPR frameworks, will help guide future community-based health promotion programs for underserved communities

Ngaa-bi-nya-nhumi-nya (to test first) : piloting the feasibility of using the growth and empowerment measure with Aboriginal pregnant women who smoke

Introduction. Aboriginal pregnant women who smoke experience barriers to quitting, including challenges to social and emotional well-being, but these are infrequently quantified. Finding an appropriate measurement tool in this setting is crucial to increase knowledge for holistic smoking cessation interventions. Aims. To pilot the Growth and Empowerment Measure (GEM) with a sample of pregnant Aboriginal women who smoke. Methods. Aboriginal women participating in the step-wedge ICAN QUIT in Pregnancy pilot study completed the GEM comprised of 14-item Emotional Empowerment Scale (EES14), 12 Scenarios (12S), and K6 items at baseline, 4 weeks, and 12 weeks. Qualitative interviews with service staff were held at the end of the study to assess feasibility. Results. 15 pregnant Aboriginal women took part between November 2016 and July 2017. At 12 weeks, n=8/12 (67%) of women reported an increase in both the EES14 and 12S scores. Total 12S scores were significantly higher at 12 weeks (p=0.0186). Total K6 had a nonsignificant trend for reduction (p=0.0547). Staff reported that the length of the survey presents challenges in this setting. Conclusions. A shortened, modified GEM is recommended in this setting. We recommend the GEM to be tested in a larger study, powered to assess its associations with smoking behaviours

Developing indicators and measures of high-quality for Australian general practice

Background: Rising health costs and health inequity are major challenges in Australia, as internationally. Strong primary health care is well evidenced to address these challenges. Primary Health Networks (PHNs) work with general practices to collect data and support quality improvement; however, there is no consensus regarding what defines high quality. This paper describes the development of an evidence-based suite of indicators and measures of high-quality general practice for the Australian context. Methods: We reviewed the literature to develop a suitable framework and revise quality assurance measures currently in use, then reviewed these in three workshops with general practitioners, practice managers, nurses, consumers and PHN staff in western Sydney. We used a descriptive qualitative research approach to analyse the data. Results: A total of 125 evidence-based indicators were agreed to be relevant, and 80 were deemed both relevant and feasible. These were arranged across a framework based on the Quadruple Aim, and include structure, process and outcome measures. Conclusions: The agreed suite of indicators and measures will be further validated in collaboration with PHNs across Australia. This work has the potential to inform health systems innovation both nationally and internationally

INFLATE : a protocol for a randomised controlled trial comparing nasal balloon autoinflation to no nasal balloon autoinflation for otitis media with effusion in Aboriginal and Torres Strait Islander children

Background: Otitis media with effusion (OME) is common and occurs at disproportionately higher rates among Indigenous children. Left untreated, OME can negatively affect language, development, learning, and health and wellbeing throughout the life-course. Currently, OME care includes observation for 3 months followed by consideration of surgical ventilation tube insertion. The use of a non-invasive, low-cost nasal balloon autoinflation device has been found beneficial in other populations but has not been investigated among Aboriginal and Torres Strait Islander children. Methods/design: This multi-centre, open-label, randomised controlled trial will determine the effectiveness of nasal balloon autoinflation compared to no nasal balloon autoinflation, for the treatment of OME among Aboriginal and Torres Strait Islander children in Australia. Children aged 3–16 years with unilateral or bilateral OME are being recruited from Aboriginal Health Services and the community. The primary outcome is the proportion of children showing tympanometric improvement of OME at 1 month. Improvement is defined as a change from bilateral type B tympanograms to at least one type A or C1 tympanogram, or from unilateral type B tympanogram to type A or C1 tympanogram in the index ear, without deterioration (type A or C1 to type C2, C3, or B tympanogram) in the contralateral ear. A sample size of 340 children (170 in each group) at 1 month will detect an absolute difference of 15% between groups with 80% power at 5% significance. Anticipating a 15% loss to follow-up, 400 children will be randomised. The primary analysis will be by intention to treat. Secondary outcomes include tympanometric changes at 3 and 6 months, hearing at 3 months, ear health-related quality of life (OMQ-14), and cost-effectiveness. A process evaluation including perspectives of parents or carers, health care providers, and researchers on trial implementation will also be undertaken. Discussion: INFLATE will answer the important clinical question of whether nasal balloon autoinflation is an effective and acceptable treatment for Aboriginal and Torres Strait Islander children with OME. INFLATE will help fill the evidence gap for safe, low-cost, accessible OME therapies. Trial registration: Australia New Zealand Clinical Trials Registry ACTRN12617001652369. Registered on 22 December 2017. The Australia New Zealand Clinical Trials Registry is a primary registry of the WHO ICTRP network and includes all items from the WHO Trial Registration data set. Retrospective registration.</p

Effectiveness of an electronic patient-centred self-management tool for gout sufferers: A cluster randomised controlled trail protocol

© © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted. Introduction Gout is increasing despite effective therapies to lower serum urate concentrations to 0.36 mmol/L or less, which, if sustained, significantly reduces acute attacks of gout. Adherence to urate-lowering therapy (ULT) is poor, with rates of less than 50% 1 year after initiation of ULT. Attempts to increase adherence in gout patients have been disappointing. We aim to evaluate the effectiveness of use of a personal, self-management, a'smartphone' application (app) to achieve target serum urate concentrations in people with gout. We hypothesise that personalised feedback of serum urate concentrations will improve adherence to ULT. Methods and analysisSetting and design Primary care. A prospective, cluster randomised (by general practitioner (GP) practices), controlled trial. Participants GP practices will be randomised to either intervention or control clusters with their patients allocated to the same cluster. Intervention The intervention group will have access to the Healthy.me app tailored for the self-management of gout. The control group patients will have access to the same app modified to remove all functions except the Gout Attack Diary. Primary and secondary outcomes The proportion of patients whose serum urate concentrations are less than or equal to 0.36 mmol/L after 6 months. Secondary outcomes will be proportions of patients achieving target urate concentrations at 12 months, ULT adherence rates, serum urate concentrations at 6 and 12 months, rates of attacks of gout, quality of life estimations and process and economic evaluations. The study is designed to detect a ≥30% improvement in the intervention group above the expected 50% achievement of target serum urate at 6 months in the control group: power 0.80, significance level 0.05, assumed a'dropout' rate 20%. Ethics and dissemination This study has been approved by the University of New South Wales Human Research Ethics Committee. Study findings will be disseminated in international conferences and peer-reviewed journal. Trial registration number ACTRN12616000455460

New insights into the magmatic-hydrothermal system and volatile budget of Lastarria volcano, Chile: Integrated results from the 2014 IAVCEI CCVG 12th Volcanic Gas Workshop.

Recent geophysical evidence for large-scale regional crustal inflation and localized crustal magma intrusion has made Lastarria volcano (northern Chile) the target of numerous geological, geophysical, and geochemical studies. The chemical composition of volcanic gases sampled during discrete campaigns from Lastarria volcano indicated a well-developed hydrothermal system from direct fumarole samples in A.D. 2006, 2008, and 2009, and shallow magma degassing using measurements from in situ plume sampling techniques in 2012. It is unclear if the differences in measured gas compositions and resulting interpretations were due to artifacts of the different sampling methods employed, short-term excursions from baseline due to localized changes in stress, or a systematic change in Lastarria's magmatic-hydrothermal system between 2009 and 2012. Integrated results from a two-day volcanic gas sampling and measurement campaign during the 2014 International Association of Volcanology and Chemistry of the Earth's Interior (IAVCEI) Commission on the Chemistry of Volcanic Gases (CCVG) 12th Gas Workshop are used here to compare and evaluate current gas sampling and measurement techniques, refine the existing subsurface models for Lastarria volcano, and provide new constraints on its magmatic-hydrothermal system and total degassing budget. While compositional differences among sampling methods are present, distinct compositional changes are observed, which if representative of longterm trends, indicate a change in Lastarria's overall magmatic-hydrothermal system. The composition of volcanic gases measured in 2014 contained high proportions of relatively magma- and water-soluble gases consistent with degassing of shallow magma, and in agreement with the 2012 gas composition. When compared with gas compositions measured in 2006-2009, higher relative H2O/CO2 ratios combined with lower relative CO2/St and H2O/St and stable HCl/St ratios (where St is total S [SO2 + H2S]) are observed in 2012 and 2014. These compositional changes suggest variations in the magmatic-hydrothermal system between 2009 and 2012, with possible scenarios to explain these trends including: (1) decompression-induced degassing due to magma ascent within the shallow crust; (2) crystallization-induced degassing of a stalled magma body; (3) depletion of the hydrothermal system due to heating, changes in local stress, and/or minimal precipitation; and/or (4) acidification of the hydrothermal system. These scenarios are evaluated and compared against the geophysical observations of continuous shallow inflation at ~8 km depth between 1997 and 2016, and near-surface ( < 1 km) inflation between 2000 and 2008, to further refine the existing subsurface models. Higher relative H2O/CO2 observed in 2012 and 2014 is not consistent with the depletion or acidification of a hydrothermal system, while all other observations are consistent with the four proposed models. Based on these observations, we find that scenarios 1 or 2 are the most likely to explain the geochemical and geophysical observations, and propose that targeted shallow interferometric synthetic-aperture radar (InSAR) studies could help discriminate between these two scenarios. Lastly, we use an average SO2 flux of 604 \ub1 296 t/d measured on 22 November 2014, along with the average gas composition and diffuse soil CO2 flux measurements, to estimate a total volatile flux from Lastarria volcano in 2014 of ~12,400 t/d, which is similar to previous estimates from 2012

Improving smoking cessation care in pregnancy at Aboriginal Medical Services: 'ICAN QUIT in Pregnancy' step-wedge cluster randomised study

Objectives This study aimed to examine the impact of the ‘ICAN QUIT in Pregnancy’ intervention on individual health providers (HPs) smoking cessation care (SCC) knowledge, attitudes and practices in general, and specifically regarding nicotine replacement therapy (NRT) prescription. Design Step-wedge clustered randomised controlled study. HPs answered a preintervention and 1–6 months postintervention survey. Setting Six Aboriginal Medical Services (AMSs) in three states of Australia. Participants All HPs were invited to participate. Of 93 eligible, 50 consented (54%), 45 completed the presurvey (90%) and 20 the post (40%). Intervention Included three 1-hour webinar sessions, educational resource package and free oral NRT. Outcomes HPs knowledge was measured using two composite scores—one from all 24 true/false statements, and one from 12 NRT-specific statements. Self-assessment of 22 attitudes to providing SCC were measured using a five-point Likert scale (Strongly disagree to Strongly agree). Two composite mean scores were calculated—one for 15 general SCC attitudes, and one for 7 NRT-specific attitudes. Self-reported provision of SCC components was measured on a five-point Likert scale (Never to Always). Feasibility outcomes, and data collected on the service and patient level are reported elsewhere. Results Mean knowledge composite scores improved from pre to post (78% vs 84% correct, difference 5.95, 95%CI 1.57 to 10.32). Mean NRT-specific knowledge composite score also improved (68% vs 79% correct, difference 9.9, 95%CI 3.66 to 16.14). Mean attitude composite score improved (3.65 (SD 0.4) to 3.87 (SD 0.4), difference 0.23, 95%CI 0.05 to 0.41). Mean NRT-specific attitudes composite score also improved (3.37 (SD 0.6) to 3.64 (SD 0.7), difference 0.36, 95%CI 0.13 to 0.6). Selfreported practices were unchanged, including prescribing NRT. Conclusions A multicomponent culturally sensitive intervention in AMSs was feasible, and might improve HPs provision of SCC to pregnant Aboriginal women. Changes in NRT prescription rates may require additional intensive measures