Dementia Care Mapping and Patient-Centred Care in Australian residential homes: An economic evaluation of the CARE Study, CHERE Working Paper 2008/4

Background: As the population ages, the incidence of dementia and its burden on society will increase. The economic costs of dementia are high, particularly for persons in the mid and late stages of the disease, when formal care arrangements such as nursing home placement are required. The need for care is often precipitated by the development of behavioural and psychological symptoms of dementia (BPSD) which also severely affect the quality of life of affected persons and their carers The Caring for Aged-Care REsident Study (CARES), the first randomised controlled trial to evaluate Dementia Care Mapping (DCM) and Person Centred Care (PCC), demonstrated that either of the two interventions improved outcomes compared to Usual Care (UC) on the primary outcome measure, the Cohen-Mansfield Agitation Inventory (CMAI). This study reports the results of an economic evaluation which was undertaken in conjunction with the trial. This information will provide additional information to assist policy makers in making choices between competing options. Methods: Fifteen nursing homes were randomised to one of three conditions: DCM, PCC or Usual Care (UC). The sample consisted of 360 residents with dementia. Data were collected at baseline, three months, and eight months by assessors blind to group assignment. In addition to the CMAI, data were collected about the use and costs of health care resources and pharmacological interventions. Total costs associated with each of the interventions were estimated, which were contrasted with the outcomes using standard health economics methodology. Results: Over one year, the cost per residential setting of implementing DCM and PCC relative to UC was $10,034 and$2,250 respectively. The additional cost per resident-level unit improvement in CMAI post-intervention (at follow-up) relative to UC was $48.95 ($46.89) for DCM and $8.01 ($6.43) for PCC. Compared to DCM, PCC produced a greater reduction in anxiety and agitation at a lower cost. Therefore, DCM was dominated by PCC and removed from the economic evaluation. Sensitivity analysis suggests this result is robust to changing model parameters. Conclusions: PCC provides a greater decrease in agitation and related behavioural and psychological symptoms of dementia, compared with DCM, at a lower cost and is the preferred option for cost-effectiveness. While there is no existing standard for a reasonable cost for a point improvement in CMAI, the cost per unit under PCC seems acceptable.Dementia, patient centred care

What women want from local primary care services for unintended pregnancy in rural Australia: a qualitative study from rural New South Wales

Background: Under the generalist model of health care in rural Australia, general practitioners (GPs) are often the first point of contact for women seeking health services for unintended pregnancy, including pregnancy decision-making support and options advice, antenatal or abortion care. Rural women are more likely to experience unintended pregnancy in Australia, yet little is known about how well local rural primary healthcare services currently meet their needs. Methods: To address this gap, this qualitative study explores through in-depth semi-structured interviews, the experiences of 20 rural women managing an unintended pregnancy, and their expectations of, and satisfaction with, the quality of care they received. The Framework Method was used to organise data and conduct an inductive thematic analysis. Results: Three themes related to management of unintended pregnancy in a rural primary care setting were identified: (1) women expect informed and efficient care once services are reached; (2) women desire greater choice and aftercare; and (3) comprehensive reproductive health should be part of rural primary care. Participants indicated an awareness of the limitations of the rural health system, yet a firm expectation that despite access delays, all of their reproductive health needs would be met. Choice, time efficiency, and aftercare were identified as gaps in the current primary care service experience. A desire for greater attention to rural reproductive health, including improved contraception, was also emphasised. Conclusions: Rural women with unintended pregnancy experienced gaps in service quality and described a lack of woman-centred care in their local rural health setting. This study offers insight into how rural primary care providers can better support women to make decisions about and reach their preferred services for unintended pregnancy

Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial

Background: Evidence for improved outcomes for people with dementia through provision of person-centred care and dementia-care mapping is largely observational. We aimed to do a large, randomised comparison of person-centred care, dementia-care mapping, and usual care. Methods: In a cluster randomised controlled trial, urban residential sites were randomly assigned to person-centred care, dementia-care mapping, or usual care. Carers received training and support in either intervention or continued usual care. Treatment allocation was masked to assessors. The primary outcome was agitation measured with the Cohen-Mansfield agitation inventory (CMAI). Secondary outcomes included psychiatric symptoms including hallucinations, neuropsychological status, quality of life, falls, and cost of treatment. Outcome measures were assessed before and directly after 4 months of intervention, and at 4 months of follow-up. Hierarchical linear models were used to test treatment and time effects. Analysis was by intention to treat. This trial is registered with the Australia and New Zealand Clinical Trials Registry, number ACTRN12608000084381. Findings: 15 care sites with 289 residents were randomly assigned. Pairwise contrasts revealed that at follow-up, and relative to usual care, CMAI score was lower in sites providing mapping (mean difference 10·9, 95% CI 0·7-21·1; p=0·04) and person-centred care (13·6, 3·3-23·9; p=0·01). Compared with usual care, fewer falls were recorded in sites that used mapping (0·24, 0·08-0·40; p=0·02) but there were more falls with person-centred care (0·15, 0·02-0·28; p=0·03). There were no other significant effects. Interpretation: Person-centred care and dementia-care mapping both seem to reduce agitation in people with dementia in residential care. Funding: Australian Health Ministers' Advisory Council

Improving Knowledge and Attitudes towards Depression: a controlled trial among Chinese medical students

<p>Abstract</p> <p>Background</p> <p>Establishing an evidence-based method of improving knowledge and attitudes concerning depression has been identified as a priority in Chinese medical education. The purpose of this study was to determine whether a self-directed learning strategy as a part of student-centred education improved knowledge of and attitudes towards depression among Chinese medical students.</p> <p>Methods</p> <p>A controlled trial in which 205 medical students were allocated to one of two groups: didactic teaching (DT) group or a combined didactic teaching and self-directed learning (DT/SDL) group. The DT/SDL group continued having a series of learning activities after both groups had a lecture on depression together. Student's knowledge and attitudes were assessed immediately after the activities, one month and six months later.</p> <p>Results</p> <p>The intervention (DT/SDL) group showed substantially greater improvements in recognition of depression as a major health issue and identifying helpful treatments than the DT group. Only the DT/SDL group demonstrated any improvement in attitudes. This improvement was sustained over six months.</p> <p>Conclusions</p> <p>Self-directed learning is an effective education strategy in improving medical students' knowledge of and attitudes towards depression.</p

Australian influenza national surveillance data (2009 to 2014) : variations by sex, age group, and influenza type

Objectives: The World Health Organization evaluation on the first wave of 2009 H1N1 pandemics revealed that the outcome of infection was generally worse for females, but sex disparity in influenza infection has not been explored extensively. This study investigates sex disparity in laboratory-confirmed influenza notifications by age and influenza type. Methods: The Australian National Notifiable Diseases Surveillance System Influenza Public Dataset (http://www9.health.gov. au/cda/source/pub_influ.cfm) was accessed on 13 March 2016. The variables in the dataset included: notification date, influenza type, age, sex, and Indigenous status. The dataset was analysed using IBM SPSS v22. Results: A total of 236,241 cases of influenza were collected over six years, with Influenza A the most common sub-type. Considering all influenza types, males had a marginally higher number of notifications at ages 0 to 19 years. However, the number of female notifications overtook from ages 20 to 39 years, and the sex disparity became less pronounced from age 45 years onwards. Similar trends were observed regardless of influenza sub-type. There were 180,475 cases (76.4%) without identification of Indigeneity, which rendered the variable inappropriate for analysis. Conclusions: This study on a large dataset revealed that the number of notifications of influenza infection was associated with sex and age. Notifications are influenced by utilisation of healthcare, and healthcare use is generally higher in females. We confirmed known, age-dependent sex disparity in influenza patterns independent of influenza subtype. Females aged 20 to 39 years had higher age-adjusted notification rates per 100,000 population, which is presumably related to being of child-bearing age, i.e. pregnancy-related reduced immunity against influenza. It is recommended that the surveillance authority should request information on pregnancy status. Other variables such as Indigenous status may shed light on susceptibility to influenza infection. These data are not universally recorded across Australia but are important to inform targeted preventive strategies

Reactions to Diversity: Using Theater to Teach Medical Students about Cultural Diversity

Training medical students to understand the effects of culture and marginalization on health outcomes is important to the future health of increasingly diverse populations. We devised and evaluated a short training module on working with diversity to challenge students’ thinking about the role of both patient and practitioner culture in health outcomes. The workshop combined didactic teaching about culture as a social determinant of health using the cultural humility model, interactive exercises, and applied theater techniques. We evaluated changes in the students’ perceptions and attitudes over time using the Reaction to Diversity Inventory. There was initial significant improvement. Women and students with no past diversity training responded best. However, scores largely reverted to baseline over 12 months