Out-of-pocket expenditure by Australian seniors with chronic disease: the effect of specific diseases and morbidity clusters

This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.BACKGROUND: Out of pocket expenditure (OOPE) on healthcare is related to the burden of illness and the number of chronic conditions a patient experiences, but the relationship of these costs to particular conditions and groups of conditions is less studied. This study examines the effect on OOPE of various morbidity groupings, and explores the factors associated with a 'heavy financial burden of OOPE' defined by an expenditure of over 10% of equivalised household income on healthcare. METHODS: Data were collected from 4,574 senior Australians using a stratified sampling procedure by age, rurality and state of residence. Natural clusters of chronic conditions were identified using cluster analysis and clinically relevant clusters based on expert opinion. We undertook logistic regression to model the probability of incurring OOPE, and a heavy financial burden; linear regression to explore the significant factors of OOPE; and two-part models to estimate the marginal effect of factors on OOPE. RESULTS: The mean OOPE in the previous three months was AU$353; and 14% of respondents experienced a heavy financial burden. Medication and medical service expenses were the major costs. Those who experienced cancer, high blood pressure, diabetes or depression were likely to report higher OOPE. Patients with cancer or diabetes were more likely than others to face a heavy burden of OOPE relative to income. Total number of conditions and some specific conditions predict OOPE but neither the clusters nor pairs of conditions were good predictors of OOPE. CONCLUSIONS: Total number of conditions and some specific conditions predict both OOPE and heavy financial burden but particular comorbid groupings are not useful in predicting OOPE. Low-income patients pay a higher proportion of income than the well-off as OOPE for healthcare. Interventions targeting those who are likely to face severe financial burdens due to their health could address some of these differences.National Health and Medical Research Council, Australi

Time spent on health-related activities by senior Australians with chronic diseases: what is the role of multimorbidity and comorbidity?

This is the final version of the article. Available from the publisher via the DOI in this record.OBJECTIVE: To examine the effect of various morbidity clusters of chronic diseases on health-related time use and to explore factors associated with heavy time burden (more than 30 hours/month) of health-related activities. METHODS: Using a national survey, data were collected from 2,540 senior Australians. Natural clusters were identified using cluster analysis and clinical clusters using clinical expert opinion. We undertook a set of linear regressions to model people's time use, and logistic regressions to model heavy time burden. RESULTS: Time use increases with the number of chronic diseases. Six of the 12 diseases are significantly associated with higher time use, with the highest effect for diabetes followed by depression; 18% reported a heavy time burden, with diabetes again being the most significant disease. Clusters and dominant comorbid groupings do not contribute to predicting time use or time burden. CONCLUSIONS: Total number of diseases and specific diseases are useful determinants of time use and heavy time burden. Dominant groupings and disease clusters do not predict time use. IMPLICATIONS: In considering time demands on patients and the need for care co-ordination, care providers need to be aware of how many and what specific diseases the patient faces.The Serious and Continuing Illnesses Policy and Practice Study (SCIPPS) is an NHMRC-funded program conducted at The Australian National University and the University of Sydney and administered by the Menzies Centre for Health Policy

Time's up. descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey.

This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.Most Western health systems remain single illness orientated despite the growing prevalence of multi-morbidity. Identifying how much time people with multiple chronic conditions spend managing their health will help policy makers and health service providers make decisions about areas of patient need for support. This article presents findings from an Australian study concerning the time spent on health related activity by older adults (aged 50 years and over), most of whom had multiple chronic conditions. A recall questionnaire was developed, piloted, and adjusted. Sampling was undertaken through three bodies; the Lung Foundation Australia (COPD sub-sample), National Diabetes Services Scheme (Diabetes sub-sample) and National Seniors Australia (Seniors sub-sample). Questionnaires were mailed out during 2011 to 10,600 older adults living in Australia. 2540 survey responses were received and analysed. Descriptive analyses were completed to obtain median values for the hours spent on each activity per month. The mean number of chronic conditions was 3.7 in the COPD sub-sample, 3.4 in the Diabetes sub-sample and 2.0 in the NSA sub-sample. The study identified a clear trend of increased time use associated with increased number of chronic conditions. Median monthly time use was 5-16 hours per month overall for our three sub-samples. For respondents in the top decile with five or more chronic conditions the median time use was equivalent to two to three hours per day, and if exercise is included in the calculations, respondents spent from between five and eight hours per day: an amount similar to full-time work. Multi-morbidity imposes considerable time burdens on patients. Ageing is associated with increasing rates of multi-morbidity. Many older adults are facing high demands on their time to manage their health in the face of decreasing energy and mobility. Their time use must be considered in health service delivery and health system reform.National Health and Medical Research Counci

Electronic search strategies to identify reports of cluster randomized trials in MEDLINE: low precision will improve with adherence to reporting standards

BACKGROUND: Cluster randomized trials (CRTs) present unique methodological and ethical challenges. Researchers conducting systematic reviews of CRTs (e.g., addressing methodological or ethical issues) require efficient electronic search strategies (filters or hedges) to identify trials in electronic databases such as MEDLINE. According to the CONSORT statement extension to CRTs, the clustered design should be clearly identified in titles or abstracts; however, variability in terminology may make electronic identification challenging. Our objectives were to (a) evaluate sensitivity ( recall ) and precision of a well-known electronic search strategy ( randomized controlled trial as publication type) with respect to identifying CRTs, (b) evaluate the feasibility of new search strategies targeted specifically at CRTs, and (c) determine whether CRTs are appropriately identified in titles or abstracts of reports and whether there has been improvement over time. METHODS: We manually examined a wide range of health journals to identify a gold standard set of CRTs. Search strategies were evaluated against the gold standard set, as well as an independent set of CRTs included in previous systematic reviews. RESULTS: The existing strategy (randomized controlled trial.pt) is sensitive (93.8%) for identifying CRTs, but has relatively low precision (9%, number needed to read 11); the number needed to read can be halved to 5 (precision 18.4%) by combining with cluster design-related terms using the Boolean operator AND; combining with the Boolean operator OR maximizes sensitivity (99.4%) but would require 28.6 citations read to identify one CRT. Only about 50% of CRTs are clearly identified as cluster randomized in titles or abstracts; approximately 25% can be identified based on the reported units of randomization but are not amenable to electronic searching; the remaining 25% cannot be identified except through manual inspection of the full-text article. The proportion of trials clearly identified has increased from 28% between the years 2000-2003, to 60% between 2004-2007 (absolute increase 32%, 95% CI 17 to 47%). CONCLUSIONS: CRTs should include the phrase cluster randomized trial in titles or abstracts; this will facilitate more accurate indexing of the publication type by reviewers at the National Library of Medicine, and efficient textword retrieval of the subset employing cluster randomization

Intravascular ultrasound imaging of human coronary arteries in vivo. Analysis of tissue characterizations with comparison to in vitro histological specimens.

BackgroundIntravascular ultrasound imaging was performed in 27 patients after coronary balloon angioplasty to quantify the lumen and atheroma cross-sectional areas.Methods and resultsA 20-MHz ultrasound catheter was inserted through a 1.6-mm plastic introducer sheath across the dilated area to obtain real-time images at 30 times/sec. The ultrasound images distinguished the lumen from atheroma, calcification, and the muscular media. The presence of dissection between the media and the atheroma was well visualized. These observations of tissue characterization were compared with an in vitro study of 20 human atherosclerotic artery segments that correlated the ultrasound images to histological preparations. The results indicate that high-quality intravascular ultrasound images under controlled in vitro conditions can provide accurate microanatomic information about the histological characteristics of atherosclerotic plaques. Similar quality cross-sectional ultrasound images were also obtained in human coronary arteries in vivo. Quantitative analysis of the ultrasound images from the clinical studies revealed that the mean cross-sectional lumen area after balloon angioplasty was 5.0 +/- 2.0 mm2. The mean residual atheroma area at the level of the prior dilatation was 8.7 +/- 3.4 mm2, which corresponded to 63% of the available arterial cross-sectional area. At the segments of the coronary artery that appeared angiographically normal, the ultrasound images demonstrated the presence of atheroma involving 4.7 +/- 3.2 mm2, which was a mean of 35 +/- 23% of the available area bounded by the media.ConclusionsIntravascular ultrasound appears to be more sensitive than angiography for demonstrating the presence and extent of atherosclerosis and arterial calcification. Intracoronary imaging after balloon angioplasty reveals that a significant amount of atheroma is still present, which may partly explain why the incidence of restenosis is high after percutaneous transluminal coronary angioplasty

BLISS: an artificial language for learnability studies

To explore neurocognitive mechanisms underlying the human language faculty, cognitive scientists use artificial languages to control more precisely the language learning environment and to study selected aspects of natural languages. Artificial languages applied in cognitive studies are usually designed ad hoc, to only probe a specific hypothesis, and they include a miniature grammar and a very small vocabulary. The aim of the present study is the construction of an artificial language incorporating both syntax and semantics, BLISS. Of intermediate complexity, BLISS mimics natural languages by having a vocabulary, syntax, and some semantics, as defined by a degree of non-syntactic statistical dependence between words. We quantify, using information theoretical measures, dependencies between words in BLISS sentences as well as differences between the distinct models we introduce for semantics. While modeling English syntax in its basic version, BLISS can be easily varied in its internal parametric structure, thus allowing studies of the relative learnability of different parameter sets

von Willebrand disease: proposing definitions for future research

Thrombosis and Hemostasi

Inappropriate stereotypical inferences? An adversarial collaboration in experimental ordinary language philosophy

This paper trials new experimental methods for the analysis of natural language reasoning and the (re)development of critical ordinary language philosophy in the wake of J.L. Austin. Philosophical arguments and thought experiments are strongly shaped by default pragmatic inferences, including stereotypical inferences. Austin suggested that contextually inappropriate stereotypical inferences are at the root of some philosophical paradoxes and problems, and that these can be resolved by exposing those verbal fallacies. This paper builds on recent efforts to empirically document inappropriate stereotypical inferences that may drive philosophical arguments. We demonstrate that previously employed questionnaire-based output measures do not suffice to exclude relevant confounds. We then report an experiment that combines reading time measurements with plausibility ratings. The study seeks to provide evidence of inappropriate stereotypical inferences from appearance verbs that have been suggested to lie at the root of the influential ‘argument from illusion’. Our findings support a diagnostic reconstruction of this argument. They provide the missing component for proof of concept for an experimental implementation of critical ordinary language philosophy that is in line with the ambitions of current ‘evidential’ experimental philosophy