Costs and advance directives at the end of life: a case of the ‘Coaching Older Adults and Carers to have their preferences Heard (COACH)’ trial

Background Total costs associated with care for older people nearing the end of life and the cost variations related with end of life care decisions are not well documented in the literature. Healthcare utilisation and associated health care costs for a group of older Australians who entered Transition Care following an acute hospital admission were calculated. Costs were differentiated according to a number of health care decisions and outcomes including advance directives (ADs). Methods Study participants were drawn from the Coaching Older Adults and Carers to have their preferences Heard (COACH) trial funded by the Australian National Health and Medical Research Council. Data collected included total health care costs, the type of (and when) ADs were completed and the place of death. Two-step endogenous treatment-regression models were employed to test the relationship between costs and a number of variables including completion of ADs. Results The trial recruited 230 older adults with mean age 84 years. At the end of the trial, 53 had died and 80 had completed ADs. Total healthcare costs were higher for younger participants and those who had died. No statistically significant association was found between costs and completion of ADs. Conclusion For our frail study population, the completion of ADs did not have an effect on health care utilisation and costs. Further research is needed to substantiate these findings in larger and more diverse clinical cohorts of older people

National review of maternity services 2008: women influencing change

<p>Abstract</p> <p>Background</p> <p>In 2009 the Australian government announced a major program of reform with the move to primary maternity care. The reform agenda represents a dramatic change to maternity care provision in a society that has embraced technology across all aspects of life including childbirth.</p> <p>Methods</p> <p>A critical discourse analysis of selected submissions in the consultation process to the national review of maternity services 2008 was undertaken to identify the contributions of individual women, consumer groups and organisations representing the interests of women.</p> <p>Results</p> <p>Findings from this critical discourse analysis revealed extensive similarities between the discourses identified in the submissions with the direction of the 2009 proposed primary maternity care reform agenda. The rise of consumer influence in maternity care policy reflects a changing of the guard as doctors' traditional authority is questioned by strong consumer organisations and informed consumers.</p> <p>Conclusions</p> <p>Unified consumer influence advocating a move away from obstetric -led maternity care for all pregnant women appears to be synergistic with the ethos of corporate governance and a neoliberal approach to maternity service policy. The silent voice of one consumer group (women happy with their obstetric-led care) in the consultation process has inadvertently contributed to a consensus of opinion in support of the reforms in the absence of the counter viewpoint.</p

We should not be complacent about our population-based public health response to the first influenza pandemic of the 21st century

Background: More than a year after an influenza pandemic was declared in June 2009, the World Health Organization declared the pandemic to be over. Evaluations of the pandemic response are beginning to appear in the public domain. Discussion. We argue that, despite the enormous effort made to control the pandemic, it is now time to acknowledge that many of the population-based public health interventions may not have been well considered. Prior to the pandemic, there was limited scientific evidence to support border control measures. In particular no border screening measures would have detected prodromal or asymptomatic infections, and asymptomatic infections with pandemic influenza were common. School closures, when they were partial or of short duration, would not have interrupted spread of the virus in school-aged children, the group with the highest rate of infection worldwide. In most countries where they were available, neuraminidase inhibitors were not distributed quickly enough to have had an effect at the population level, although they will have benefited individuals, and prophylaxis within closed communities will have been effective. A pandemic specific vaccine will have protected the people who received it, although in most countries only a small minority was vaccinated, and often a small minority of those most at risk. The pandemic vaccine was generally not available early enough to have influenced the shape of the first pandemic wave and it is likely that any future pandemic vaccine manufactured using current technology will also be available too late, at least in one hemisphere. Summary. Border screening, school closure, widespread anti-viral prophylaxis and a pandemic-specific vaccine were unlikely to have been effective during a pandemic which was less severe than anticipated in the pandemic plans of many countries. These were cornerstones of the population-based public health response. Similar responses would be even less likely to be effective in a more severe pandemic. We agree with the recommendation from the World Health Organisation that pandemic preparedness plans need review

Depression in multicultural Australia: Policies, research and services

BACKGROUND: Depression is one of the leading causes of disability in Australia. The cultural and linguistic diversity of the Australian population poses a significant challenge to health policy development, service provision, professional education, and research. The purpose of this study is to explore the extent to which the fact of cultural and linguistic diversity has influenced the formulation of mental health policy, the conduct of mental health research and the development of mental health services for people with depression from ethnic minority communities. METHODS: The methods used for the different components of the study included surveys and document-based content and thematic analyses. RESULTS: Policy is comprehensive but its translation into programs is inadequate. Across Australia, there were few specific programs on depression in ethnic minority communities and they are confronted with a variety of implementation difficulties. The scope and scale of research on depression in Ethnic minority communities is extremely limited. CONCLUSION: A key problem is that the research that is necessary to provide evidence for policy and service delivery is lacking. If depression in Ethnic minority communities is to be addressed effectively the gaps between policy intentions and policy implementation, and between information needs for policies and practice and the actual research that is being done, have to be narrowed

Challenges to the co-management of biodiversity in a reflexive modernity

The marginalisation of people from natural areas has dominated conservation approaches in post-colonial societies such as Australia. Yet the approach is limited, in part because people are also excluded from co-managing their local environments, an effect that raises important questions about the future of conservation in a reflexive era where account must also be taken of how to manage risks such as bushfires. To address the complexity of social processes that influence conservation, new forms of co-management between governments and community stakeholders are evolving but do not always achieve their participatory aims. In this article, discrepancies between perceptions of conservation governance and the responsibilities and activities of the South Australian Government are examined by reference to original research involving a residential survey and a follow-up focus group discussion with local community and non-profit environmental organisations. Findings suggest that local environmental groups are knowledge-rich and strong relationships exist between local conservation actors and government officers, but those partnerships receive only limited support. In addition, opportunities for co-management between government and non-governmental environmental organisations are hindered by insufficient acknowledgement within government of the importance of unique, actionable local knowledge; an inability to effectively coordinate activities across and between government and non-government actors; and an unwillingness to engage with stakeholders in a manner that develops and maintains trust.Douglas K Bardsley, Annette M Bardsley, Emily Moskwa, Delene Weber, Guy M Robinso