Services doing the best they can: service experiences of young adults with type 1 diabetes mellitus in rural Australia

Aims and objectives: To describe the healthcare experiences of young adults with type 1 diabetes who access diabetes services in rural areas of New South Wales, Australia. Background: The incidence of type 1 diabetes in childhood and adolescence is increasing worldwide; internationally, difficulties are encountered in supporting young people during their transition from children to adulthood. Consumers’ experiences and views will be essential to inform service redesign. Design: This was a qualitative exploratory study. Methods: Semistructured telephone interviews were conducted with 26 people aged 18–28 years living rurally, recruited through staff in four regional healthcare centres in 2008. Results: Two key themes were evident: lack of access (comprised of transfer to adult services, access to health professionals and access to up-to-date information) and age-appropriate provision. The impact of place of residence and personal motivation crossed all themes. Participants contrasted unfavourably the seamless care and support received from paediatric outreach services with the shortages in specialist and general practice-based care and information and practical problems of service fragmentation and lack of coordination experienced as adults. They identified a range of issues including need for ongoing education, age-appropriate services and support networks related to developing their ability to self-manage. They valued personal service; online and electronic support was seldom volunteered as an alternative. Conclusion: This was a first view of rural young people’s experiences with adult diabetes services. Reported experiences were in line with previous reports from other settings in that they did not perceive services in this rural area of Australia as meeting their needs; suggestions for service redesign differed. Relevance to clinical practice: New models of age-appropriate service provision are required, to meet their needs for personal as well as other forms of support, whilst acknowledging the very real resource limitations of these locations

Lost in transition? Access to and uptake of adult health services and outcomes for young people with type 1 diabetes in regional New South Wales

Objective: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets. Design, setting and subjects: Case note audit of 239 young adults aged 18–28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74). Main outcome measures: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA1c), body mass index (BMI), and blood pressure (BP). Results: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA1c, BMI and BP across all audited years of contact (HbA1c: 73% v 94% city, 97% capital; P < 0.001). Across all years, regional area patients had the highest proportion of HbA1c values > 8.0% (79% v 62% city, 56% capital) and lowest proportion < 7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P < 0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact. Conclusion: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people’s engagement

Service usage and vascular complications in young adults with type 1 diabetes

Background: Few studies have examined young adults with type 1 diabetes use of health services and the development of vascular complications. As part of the Youth Outreach for Diabetes (YOuR-Diabetes) project, this study identified health service usage, the prevalence and factors predictive of development of vascular complications (hypertension, retinopathy and nephropathy) in a cohort of young adults (aged 16-30 years) with type 1 diabetes in Hunter New England and the Lower Mid-North Coast area of New South Wales, Australia. Methods: A cross-sectional retrospective documentation survey was undertaken of case notes of young adults with type 1 diabetes accessing Hunter New England Local Health District public health services in 2010 and 2011, identified through ambulatory care clinic records, hospital attendances and other clinical records. Details of service usage, complications screening and evidence of vascular complications were extracted. Independent predictors were modelled using linear and logistic regression analyses. Results: A cohort of 707 patients were reviewed; mean (SD) age was 23.0 (3.7) years, with mean diabetes duration of 10.2 (5.8, range 0.2 - 28.3) years; 42.4% lived/ 23.1% accessed services in non-metropolitan areas.Routine preventative service usage was low and unplanned contacts high; both deteriorated with increasing age. Low levels of complications screening were found. Where documented, hypertension, particularly, was common, affecting 48.4% across the study period. Diabetes duration was a strong predictor of vascular complications along with glycaemic control; hypertension was linked with renal dysfunction.Conclusion: Findings indicate a need to better understand young people's drivers and achievements when accessing services, and how services can be reconfigured or delivered differently to better meet their needs and achieve better outcomes. Regular screening is required using current best practice guidelines as this affords the greatest chance for early complication detection, treatment initiation and secondary prevention

An examination of the influences on New South Wales general practitioners regarding the provision of opioid substitution therapy

Introduction: Few general practitioners (GP) prescribe opioid substitution therapy. Our aim was to analyse their previously identified motivating factors by describing their frequency and demographic associations. Methods: An anonymous, cross-sectional questionnaire-based survey on opioid prescribing in pain and dependency was distributed across five New South Wales Divisions of GPs. Questions elicited opinions on 11 barriers and five facilitators previously described in qualitative literature. Data were analysed against demographic variables, including opioid substitution therapy prescriber (OSTP) status and postgraduate training status. ‘Profiles’ of non-OSTPs were then constructed using latent class analysis. Results: Of the 1735 surveys posted, there were 404 responses (23.3%), with 16% respondents being OSTPs. Frequently reported barriers included: ‘negative experiences with the opioid dependent’ (72%), ‘heavy workload’ (60%) and ‘lack of specialist support’ (58%), with most barriers less frequent among OSTPs. Facilitating factors included: ‘more accessible specialist support’ (75%), ‘more accessible training’ (67%) and ‘better evidence of safety and efficacy’ (64%), with the latter two significantly less frequently among OSTPs. Latent class analysis of the non-OSTPs revealed three distinct clusters. The smallest (‘class 3’) had the least barriers and resembled OSTPs demographically. Discussion and Conclusions: The pattern of motivating factors towards the psychological, social and behavioural challenges of the management of dependency has a predominantly negative bias. However, this lessens with postgraduate training and OSTP experience. Structural and logistical options are identified to promote OSTP recruitment and retention. GPs resembling class 3 may be more amenable to becoming OSTPs and may be worth targeting for recruitment

An evaluation of the prescription of opioids for chronic nonmalignant pain by Australian general practitioners

Objective: Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). Design: An anonymous, cross-sectional questionnaire-based survey. Setting: The setting was five Australian divisions of general practice (geographically based associations of GPs). Methods: A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. Results: We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (±8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. Conclusions: In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions