Evaluation of a Community-wide Diabetes Prevention Program

This thesis is an evaluation of the effectiveness of a community-wide diabetes prevention program conducted in three Divisions of General Practice in Sydney, Australia. The aims were to assess whether translation of diabetes prevention programs was feasible in real-life settings and whether results achieved were comparable with those of randomised trials on which this intervention was based. Its primary goals were to assess whether the lifestyle intervention could increase participation in moderate-to-vigorous physical activity to 210 minutes per week, reduce total fat and saturated fat consumption to 30% and 10% of total daily energy intake, increase fibre consumption to 15 g/1,000 kcal/day, and lead to 5% weight loss over one year. The background section covers the physiopathology of type 2 diabetes, its risk factors, and the available population screening tools to identify people at risk. The growing morbidity and mortality burden, the economic implications of this public health problem, and the importance and feasibility of preventing or delaying the onset by intervening in the precursor stages are then summarised. Evidence for preventability is examined through a literature review of lifestyle interventions in research settings comprising highly structured and closely monitored physical activity and dietary programs under controlled conditions. Examples of the effectiveness of translation of randomised controlled trials (RCTs) into less stringent programs in community settings such as workplaces, churches, indigenous communities and whole-of-country initiatives are presented. A systematic review and meta-analysis of effectiveness of the lifestyle approaches in routine clinical practice supplements the evidence for application of prevention principles in real-life settings. The main chapters of the thesis centre on process and impact evaluation of the semi-structured Sydney-based intervention, which recruited 1,250 participants from the mainstream Australian 29 public using general practitioner services in the study area, who were followed for 12 months. The intervention’s goals aligned with those of the Finnish Diabetes Prevention Program but with less stringent entry criteria and less intensive intervention components delivered by purpose-trained lifestyle officers. The Program included an initial individual assessment and coaching session, three subsequent group sessions in the following three months, then three follow-up coaching calls at three, six and nine months. A final assessment at one year, using the same objective and self-reported measures as in the initial assessment, captured changes in body weight, physical activity and dietary habits. The process evaluation showed that it is feasible and effective to use targeted screening to identify and recruit high-risk individuals into a free-of-charge program in the general practice setting, however a quarter of participants were lost to follow-up by one year. While minor variations in aspects of the Program were required to meet local need, Program fidelity in delivering components, and self-reported adherence to diet and physical activity was high. Using a before-after study design, the impact evaluation measured 1-year changes in key Program parameters in relation to baseline. These comprised: measured weight, waist circumference, BMI, and glycaemia measurements; and self-reported dietary intake and structured physical activity, using a 3-day food record and the Physical Activity Scale for the Elderly (PASE) questionnaire, respectively. The main findings at 12 months for the 586 completers as at December 2010 were: a mean weight loss of 2.1 kg; waist circumference reduction of 2.5 cm; no significant change in glycaemia; 3% reduction of fat and saturated fat intake; 16% increase in fibre intake; and mean increase in moderate-to-vigorous physical activity of 13.7 minutes/week. All these changes were smaller than those achieved by the RCTs in research settings, most likely due to the lower intensity and monitoring of the Sydney intervention. Weight loss and waist circumference reductions were similar for participants in 30 group session and those who received telephone-only coaching. Diabetes incidence was 1% at the end of the first year. An economic appraisal of the Program implementation completes the evaluation. A cost of A$400 per kg lost among people achieving the weight goal was estimated on Program completion, but the cost was double for the overall group that included non weight losers. The cost of achieving the physical activity goal and the dietary goals was not feasible or sustainable with resources available in routine clinical settings. The costs per outcome were similar for participants not attending group sessions, who received only telephone coaching. Hence it is worth exploring this less labour-intensive modality if a general practice based Program were to be delivered as routine preventive care. In sum, the evaluation of this community-wide diabetes prevention program showed that translation of diabetes prevention programs into routine practice, while feasible at less intensive levels than in RCTs, has a somewhat lower effect on diabetes risk reduction and it can still be a financial burden in clinical settings. However, given the potential for population-wide benefit, the effectiveness of alternative delivery modes, number and duration of program components and more targeted patient sub-groups should be investigated.The Sydney Diabetes Prevention Program was funded by New South Wales Health as part of the Australian Better Health Initiative. Financial contribution and other in-kind support were provided by the Sydney South West Area Health Service and the Australian Diabetes Council -NSW

Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis

Introduction: The decision to deprescribe medications used for both disease prevention and symptom control (dual-purpose medications or DPMs) is often challenging for clinicians. We aim to establish the impact of deprescribing DPMs on patient-related outcomes for older adults near end-of-life (EOL). Methods: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google Scholar until December 2019 for studies on deprescribing intervention with a control group (with or without randomisation); targeting ⩾65-year olds, at EOL, with at least one life-limiting illness and at least one potentially inappropriate DPM. We were interested in any patient-related outcomes. Studies with similar outcome assessment criteria were subjected to meta-analysis and narrative synthesis otherwise. The risk of bias was assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised controlled trials (RCTs) and quasi-experimental non-randomised controlled studies, respectively. Results: Five studies covering 689 participants with mean age 81.6–85.7 years, the majority (74.6–100%) with dementia were included. The risk of bias was moderate to low. The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44–0.79) and referral to acute care facilities (RR = 0.40, 95% CI = 0.22–0.73), but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits. No significant difference was observed in the quality of life, physical and cognitive functions between the intervention and control groups. Conclusion: There is some evidence that deprescribing of DPMs for older adults near the EOL can lower the risk of mortality and referral to acute care facilities, but there are insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events. Plain Language Summary What is the health impact of withdrawal or dose reduction of medication used for disease prevention and symptom control in older adults near end-of-life? Introduction: Older adults (aged ⩾ 65 years) with advanced diseases such as cancer, dementia, and organ failure tend to have a limited life expectancy. With the progression of these diseases towards the end-of-life, the intensity for day-to-day supportive care becomes increasingly necessary. The use of medications for symptom management is a critical part of such care, but the use of medications for long-term disease prevention can become irrelevant due to the already shortened life expectancy and may become harmful due to alterations in physiology and pharmacology associated with age and frailty. This necessitates the withdrawal or dose reduction of inappropriate medications, the process called deprescribing. The decision to deprescribe medications used for both disease prevention and symptom control (DPMs) in this population is often challenging for clinicians. In this context, whether deprescribing of DPMs can improve patient-related health outcomes is unknown. Methods: Evidence from the literature was reviewed and analysed, and the quality of studies was assessed. Five studies were identified, which had 689 participants with an average age above 80 years and mostly suffering from dementia. Results: The analysis of these studies showed deprescribing of DPMs lowered the risk of death and referral to acute care facilities at 12 months but had no significant impact on falls, non-vertebral fractures, emergency presentations, unplanned hospital admission, general practitioner visits, quality of life, physical and mental functions. Conclusion: In conclusion, there were insufficient numbers of high-quality studies powered to confirm whether deprescribing of DPMs reduces adverse events, health service use, or improves the quality of life or functioning in older adults near the end of life

COVID-19 impact on medical education and the future post-pandemic era for medical students

The COVID-19 global emergency has brought about unexpected changes in the format and quality of undergraduate medical education in a short period of time. The impact of remote delivery on medical students learning, satisfaction, confidence, social relationships, communications and emotional wellbeing has been significant. The lack of direct patient and teacher contact is generating anxiety about their future competence. The ambivalence about urge to help without sufficient clinical skills and the fear of being either infected or becoming an asymptomatic carrier that puts patient safety at risk is of concern to them. Suggestions for enhancing pandemic or global emergency preparedness for the future are made. Strategies to manage the way in which remote learning is delivered need to be implemented as a matter of urgency should social distancing and quarantine regulations keep medical students away from hands-on clinical practice for long periods. Actions to maintain motivation and trust in the medical schools to meet their learning needs now and in the future are warranted

End-of-life priorities of older adults with terminal illness and caregivers: A qualitative consultation

Abstract Background As older adults approach the end‐of‐life (EOL), many are faced with complex decisions including whether to use medical advances to prolong life. Limited information exists on the priorities of older adults at the EOL. Objective This study aimed to explore patient and family experiences and identify factors deemed important to quality EOL care. Method A descriptive qualitative study involving three focus group discussions (n = 18) and six in‐depth interviews with older adults suffering from either a terminal condition and/or caregivers were conducted in NSW, Australia. Data were analysed thematically. Results Seven major themes were identified as follows: quality as a priority, sense of control, life on hold, need for health system support, being at home, talking about death and competent and caring health professionals. An underpinning priority throughout the seven themes was knowing and adhering to patient's wishes. Conclusion Our study highlights that to better adhere to EOL patient's wishes a reorganization of care needs is required. The readiness of the health system to cater for this expectation is questionable as real choices may not be available in acute hospital settings. With an ageing population, a reorganization of care which influences the way we manage terminal patients is required