Cognitive impairment and service use: The relationship between research and policy

This thesis examines the association between healthcare service use and cognitive functioning in individuals aged 60 years and over. It examines the association between use of primary and secondary health care services, specifically general practitioners and hospitals, and cognitive impairment. This thesis uses secondary data from the ANU Personality and Total Health (PATH) Through life study. PATH is a longitudinal health study which examines three age-cohorts residing in the Australian Capital Territory and surrounding regions over 12 years. The PATH study also has a number of sub-studies, one of which is the Health and memory sub-study. This sub-study identifies individuals in the PATH sample who would be clinically classified as having mild cognitive disorder (MCD) or dementia. Data on health service use has been obtained by linking three administrative datasets to PATH. Data on primary health care usage was obtained from the Medicare Benefits Schedule. Data on secondary health care usage was obtained from the ACT Admitted Patient Care dataset and the ACT Emergency Department Information. From this linkage, we have information on number of general practitioner visits over a year, number of hospital admissions, length of hospital stay and number of emergency department presentations for each consenting participant. Analysis of general practitioners focused on the impact cognitive impairment had on use over the 12 years of study. Using negative binomial models this analysis found that individuals with MCD visited their general practitioner significantly more than individuals who were cognitively healthy. This use almost doubled when individuals had a comorbid condition of depression or arthritis. Analysis relating to hospitalisation also focused on the association between use and cognitive impairment longitudinally. This analysis found that individuals who were hospitalised had significant declines in particular cognitive tests compared to individuals who were not hospitalised. This thesis also examined factors which impacted on general practitioner, hospital and emergency department use. Predictors of use were examined for individuals with MCD or dementia compared with cognitively healthy individuals, based on the Andersen-Newman model of health behaviour. Analysis using logistic regression models found that individuals with MCD and dementia had higher usage of all three services compared to cognitively healthy individuals. This study also found that need variables were the strongest predictor of healthcare service use. However, the types of predisposing, enabling and need variables varied depending on the healthcare service (general practitioner, same day hospital, multiple day hospital or emergency department) and whether the individual had MCD, dementia or was cognitively healthy. The information and findings relating to cognitive impairment and health service use are important for policy and practice. Communication of research to policy makers for the development of policy, termed knowledge translation, is discussed in the thesis. Several important models of knowledge translation are outlined and there is a discussion about how to strengthen the relationship between researchers and policy makers. The thesis concludes with a discussion on future policies and practices to increase early detection and diagnosis of MCD and dementia through prevention and screening in healthcare services

The use of secondments as a tool to increase knowledge translation

This paper discusses the use of secondments as a tool to increase knowledge translation between academics and policy makers by developing individual capacity. A case study is presented of a reciprocal secondment between a government department and a university. Enablers of knowledge translation included flexibility and support, a prior relationship between the two organisations, and a government culture that values use of research in policy making. Barriers included the lack of a planned approach with agreed outcomes, and a lack of evaluation at the end of the secondment. Recommendations for future secondments include establishing ongoing secondments between organisations; trialling different types of secondments; and having a detailed plan at the beginning of a secondment, including how the success of the secondment will be measured, and a formal evaluation at the end.LOJ is supported by the Australian Research Council Centre of Excellence in Population Ageing Research (project CE110001029) and the Australian Research Council Linkage Project (project LP120200609). KA is funded by NHMRC Fellowship (#1102694)

Aboriginal and Torres Strait Islander absolute cardiovascular risk assessment and management: systematic review of evidence to inform national guidelines

Australia’s absolute cardiovascular disease (CVD) risk assessment algorithm1 first examines whether individuals meet criteria for clinically determined high CVD risk and, in those not meeting these criteria, applies the Framingham Risk Equation to estimate an individual’s risk of having a CVD event in the next 5 years. The same risk equation is used for Aboriginal and Torres Strait Islander people and non-Indigenous Australians, although there is variation in underlying risk across the two populations, with the former experiencing a greater burden of cardiovascular risk factors.This research was funded by a grant from the Australian Government Department of Health

Review of evidence for the alignment of guidelines on Aboriginal and Torres Strait Islander absolute cardiovascular disease risk: A report prepared for the Australian Government Department of Health

Policy context: Cardiovascular disease (CVD) is highly preventable. CVD continues to be the largest contributor to mortality within the Aboriginal and Torres Strait Islander population and rates of CVD are disproportionately higher within the Australian Aboriginal and Torres Strait Islander population compared to the non-Indigenous population. Improving uptake of current evidence based solutions such as the absolute risk approach to CVD within the Aboriginal and Torres Strait Islander population is important to address this disparity. Although there are several tools available supporting an absolute CVD risk approach, clinical uptake is limited due to a number of factors including an outdated continued reliance on the ‘single risk factor’ approach to prevention, diagnosis and treatment of CVD. A major barrier to uptake is inconsistent messages in the current clinical practice guidelines. Key messages: There are three main guidelines on the absolute CVD risk approach for Aboriginal and Torres Strait Islander peoples in Australia: The NVDPA Guidelines for the Management of Absolute Cardiovascular Disease Risk; The Central Australian Rural Practitioners Association Standard Treatment Manual; and the RACGP National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. There is considerable alignment between the existing guidelines, including the need for an absolute risk approach, conditions conferring automatic high risk, use of the Framingham risk equation as the basis of calculating absolute risk, and the need to treat people at a greater than 15% risk of a primary CVD event over the next five years. The guidelines diverge materially in relation to four recommendations: 1) the age at which to commence absolute CVD risk assessment; 2) whether or not calculated risk scores should be adjusted upward by 5%; 3) how often CVD risk should be assessed; and 4) treatment targets for blood pressure. Available evidence indicates that CVD events and high absolute CVD risk occurs earlier in Aboriginal and Torres Strait Islander peoples, and that prevention of CVD should also start early. The proportion of Aboriginal and Torres Strait Islander peoples at high absolute CVD risk at the ages of 18-34 years broadly corresponds to the proportion at high risk among the general population aged 45-54 years. Limited evidence suggests that the current risk scores are likely to underestimate risk in Aboriginal and Torres Strait Islander peoples. Specific data on the extent of underestimation and alternative validated risk scores in this population are lacking. There is no primary data on adjusting risk scores upwards by 5% in Aboriginal and Torres Strait Islander people. Frequency of CVD risk assessment should be based on initial level of risk but the optimal interval for risk reassessment at each level of risk is not clear. There is general agreement between the guidelines to lower blood pressure as tolerated but there are inconsistencies in the exact blood pressure target. Evidence suggests that reductions in systolic blood pressure result in proportional reductions in CVD events and all-cause mortality. CVD guidelines could be kept up to date by adopting a ‘living’ guidelines model, but consideration needs to be given to how to identify relevant updated evidence and how to integrate the updates into electronic decision support tools.This research was supported by a grant from the Australian Government Department of Health

The use of secondments as a tool to increase knowledge translation

This paper discusses the use of secondments as a tool to increase knowledge translation between academics and policy makers by developing individual capacity. A case study is presented of a reciprocal secondment between a government department and a university. Enablers of knowledge translation included flexibility and support, a prior relationship between the two organisations, and a government culture that values use of research in policy making. Barriers included the lack of a planned approach with agreed outcomes, and a lack of evaluation at the end of the secondment. Recommendations for future secondments include establishing ongoing secondments between organisations; trialling different types of secondments; and having a detailed plan at the beginning of a secondment, including how the success of the secondment will be measured, and a formal evaluation at the end

Evaluating and Using Observational Evidence: The Constrasting Views of Policy Makers and Epidemiologists

Background: Currently, little is known about the types of evidence used by policy makers. This study aimed to investigate how policy makers in the health domain use and evaluate evidence and how this differs from academic epidemiologists. By having a better understanding of how policy makers select, evaluate, and use evidence, academics can tailor the way in which that evidence is produced, potentially leading to more effective knowledge translation. Methods: An exploratory mixed-methods study design was used. Quantitative measures were collected via an anonymous online survey (n = 28), with sampling from three health-related government and non-government organizations. Semi-structured interviews with policy makers (n = 20) and epidemiologists (n = 6) were conducted to gather qualitative data. Results: Policy makers indicated systematic reviews were the preferred research resource (19%), followed closely by qualitative research (16%). Neither policy makers nor epidemiologists used grading instruments to evaluate evidence. In the web survey, policy makers reported that consistency and strength of evidence (93%), the quality of data (93%), bias in the evidence (79%), and recency of evidence (79%) were the most important factors taken into consideration when evaluating the available evidence. The same results were found in the qualitative interviews. Epidemiologists focused on the methodology used in the study. The most cited barriers to using robust evidence, according to policy makers, were political considerations (60%), time limitations (55%), funding (50%), and research not being applicable to current policies (50%). Conclusion: The policy maker's investigation did not report a systematic approach to evaluating evidence. Although there was some overlap between what policy makers and epidemiologists identified as high-quality evidence, there was also some important differences. This suggests that the best scientific evidence may not routinely be used in the development of policy. In essence, the policy-making process relied on other jurisdictions' policies and the opinions of internal staffmembers as primary evidence sources to inform policy decisions. Findings of this study suggest that efforts should be directed toward making scientific information more systematically available to policy makers

Tools for grading evidence: strengths, weaknesses, and the impact on effective knowledge translation

Rating evidence and knowledge translation: Could grading tools be selling us short? Knowledge Translation is defined by the World Health Organization as “the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health” (WHO, 2005). This objective is compromised when a body of research is oversimplified, graded incorrectly, or not fully understood by those relying on flawed grading systems to inform their decision making

Evaluating and using observational evidence: The contrasting views of policy makers and epidemiologists

Background: Currently, little is known about the types of evidence used by policy makers. This study aimed to investigate how policy makers in the health domain use and evaluate evidence and how this differs from academic epidemiologists. By having a better understanding of how policy makers select, evaluate, and use evidence, academics can tailor the way in which that evidence is produced, potentially leading to more effective knowledge translation. Methods: An exploratory mixed-methods study design was used. Quantitative measures were collected via an anonymous online survey (n = 28), with sampling from three health-related government and non-government organizations. Semi-structured interviews with policy makers (n = 20) and epidemiologists (n = 6) were conducted to gather qualitative data. Results: Policy makers indicated systematic reviews were the preferred research resource (19%), followed closely by qualitative research (16%). Neither policy makers nor epidemiologists used grading instruments to evaluate evidence. In the web survey, policy makers reported that consistency and strength of evidence (93%), the quality of data (93%), bias in the evidence (79%), and recency of evidence (79%) were the most important factors taken into consideration when evaluating the available evidence. The same results were found in the qualitative interviews. Epidemiologists focused on the methodology used in the study. The most cited barriers to using robust evidence, according to policy makers, were political considerations (60%), time limitations (55%), funding (50%), and research not being applicable to current policies (50%). Conclusion: The policy maker's investigation did not report a systematic approach to evaluating evidence. Although there was some overlap between what policy makers and epidemiologists identified as high-quality evidence, there was also some important differences. This suggests that the best scientific evidence may not routinely be used in the development of policy. In essence, the policy-making process relied on other jurisdictions' policies and the opinions of internal staffmembers as primary evidence sources to inform policy decisions. Findings of this study suggest that efforts should be directed toward making scientific information more systematically available to policy makers

Living Guidelines for absolute cardiovascular risk: assessment and management

This project was funded by the Australian Government Department of Health. EB is supported by the National Health and Medical Research Council of Australia (Principal Research Fellowship reference number #1136128). The funding bodies had no role in the design of the study and collection, analysis or interpretation of data or in writing the manuscript