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1.  Barriers and facilitators to self-care in chronic heart failure: a meta-synthesis of qualitative studies 
SpringerPlus  2013;2:320.
Chronic heart failure (CHF) is a costly condition that places large demands on self-care. Failure to adhere with self-care recommendations is common and associated with frequent hospitalization. Understanding the factors that enable or inhibit self-care is essential in developing effective health care interventions. This qualitative review was conducted to address the research question, "What are the barriers and facilitators to self-care among patients with CHF?” Electronic databases including Medline, EMBASE, CINAHL, Web of Science, Scopus and Google scholar were searched. Articles were included if they were peer reviewed (1995 to 2012), in English language and investigated at least one contextual or individual factor impacting on self-care in CHF patients > 18years. The criteria defined by Kuper et al. including clarity and appropriateness of sampling, data collection and data analysis were used to appraise the quality of articles. Twenty-three articles met the inclusion criteria. Factors impacting on self-care were included factors related to symptoms of CHF and the self-care process; factors related to personal characteristics; and factors related to environment and self-care system. Important factors such as socioeconomic situation and education level have not been explored extensively and there were minimal data on the influence of age, gender, self-confidence and duration of disease. Although there is an emerging literature, further research is required to address the barriers and facilitators to self-care in patients with CHF in order to provide an appropriate guide for intervention strategies to improve self-care in CHF.
doi:10.1186/2193-1801-2-320
PMCID: PMC3727080  PMID: 23961394
Congestive heart failure; CHF; Self-management; Treatment adherence; Compliance; Self-care determinants; Qualitative review
2.  A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness 
Background
The Wagner Model provides a framework that can help to facilitate health system transition towards a chronic care oriented model. Drawing on elements of this framework as well as health policy related to patient centred care, we describe the health needs of patients with chronic illness and compare these with services which should ideally be provided by a patient-centred health system. This paper aims to increase understanding of the challenges faced by chronically ill patients and family carers in relation to their experiences with the health care system and health service providers.
Method
We interviewed patients, carers and health care professionals (HCPs) about the challenges faced by people living with complicated diabetes, chronic heart failure or chronic obstructive pulmonary disease.
Results
Patients indicated that they had a range of concerns related to the quality of health care encounters with health care professionals (HCPs), with these concerns being expressed as needs or wants. These included: 1) the need for improved communication and information delivery on the part of HCPs; 2) well organised health services and reduced waiting times to see HCPs; 3) help with self care; 4) greater recognition among professionals of the need for holistic and continuing care; and 5) inclusion of patients and carers in the decision making processes.
Conclusions
In order to address the challenges faced by people with chronic illness, health policy must be more closely aligned with the identified needs and wants of people affected by chronic illness than is currently the case.
doi:10.1186/1472-6963-13-251
PMCID: PMC3706210  PMID: 23819721
3.  The Need for Improved Detection and Management of Adult-Onset Hearing Loss in Australia 
Adult-onset hearing loss is insidious and typically diagnosed and managed several years after onset. Often, this is after the loss having led to multiple negative consequences including effects on employment, depressive symptoms, and increased risk of mortality. In contrast, the use of hearing aids is associated with reduced depression, longer life expectancy, and retention in the workplace. Despite this, several studies indicate high levels of unmet need for hearing health services in older adults and poor use of prescribed hearing aids, often leading to their abandonment. In Australia, the largest component of financial cost of hearing loss (excluding the loss of well-being) is due to lost workplace productivity. Nonetheless, the Australian public health system does not have an effective and sustainable hearing screening strategy to tackle the problem of poor detection of adult-onset hearing loss. Given the increasing prevalence and disease burden of hearing impairment in adults, two key areas are not adequately met in the Australian healthcare system: (1) early identification of persons with chronic hearing impairment; (2) appropriate and targeted referral of these patients to hearing health service providers. This paper reviews the current literature, including population-based data from the Blue Mountains Hearing Study, and suggests different models for early detection of adult-onset hearing loss.
doi:10.1155/2013/308509
PMCID: PMC3655600  PMID: 23710184
4.  Dual Sensory Impairment in Older Adults Increases the Risk of Mortality: A Population-Based Study 
PLoS ONE  2013;8(3):e55054.
Although concurrent vision and hearing loss are common in older adults, population-based data on their relationship with mortality is limited. This cohort study investigated the association between objectively measured dual sensory impairment (DSI) with mortality risk over 10 years. 2812 Blue Mountains Eye Study participants aged 55 years and older at baseline were included for analyses. Visual impairment was defined as visual acuity less than 20/40 (better eye), and hearing impairment as average pure-tone air conduction threshold greater than 25 dB HL (500–4000 Hz, better ear). Ten-year all-cause mortality was confirmed using the Australian National Death Index. After ten years, 64% and 11% of participants with DSI and no sensory loss, respectively, had died. After multivariable adjustment, participants with DSI (presenting visual impairment and hearing impairment) compared to those with no sensory impairment at baseline, had 62% increased risk of all-cause mortality, hazard ratio, HR, 1.62 (95% confidence intervals, CI, 1.16–2.26). This association was more marked in those with both moderate-severe hearing loss (>40 dB HL) and presenting visual impairment, HR 1.84 (95% CI 1.19–2.86). Participants with either presenting visual impairment only or hearing impairment only, did not have an increased risk of mortality, HR 1.05 (95% CI 0.61–1.80) and HR 1.24 (95% CI 0.99–1.54), respectively. Concurrent best-corrected visual impairment and moderate-severe hearing loss was more strongly associated with mortality 10 years later, HR 2.19 (95% CI 1.20–4.03). Objectively measured DSI was an independent predictor of total mortality in older adults. DSI was associated with a risk of death greater than that of either vision loss only or hearing loss alone.
doi:10.1371/journal.pone.0055054
PMCID: PMC3587637  PMID: 23469161
5.  Initial Antihypertensive Prescription and Switching: A 5 Year Cohort Study from 250,851 Patients 
PLoS ONE  2013;8(1):e53625.
Purpose
Adverse effects of antihypertensive therapy incur substantial cost. We evaluated whether any major classes of antihypertensive drugs were significantly associated with switching as a proxy measure of medication side effects in a large Chinese population in Hong Kong.
Methods
From a clinical database, all adult patients newly prescribed an antihypertensive mono-therapy in Hong Kong between the years 2001–2003 and 2005 were included. Those who paid only one visit, died or stayed in the cohort for <180 days after the prescription, or prescribed more than one antihypertensive agent were excluded. The factors associated with switching at 180 days were evaluated by multivariate regression analyses. Age, gender, payment status, service type, district of residence, drug class, systolic and diastolic blood pressure levels were predictor variables.
Results
From 250,851 subjects, 159,813 patients were eligible. A total of 6,163 (3.9%) switched their medications within 180 days. Patients prescribed thiazide diuretics had the highest switching rate (5.6%), followed by ACEIs (4.5%), CCBs (4.4%) and beta-blockers (3.2%). When compared with ACEIs, patients on thiazide diuretics were significantly more likely to be switchers (adjusted odds ratio [AOR] 1.49, 95% C.I. 1.31–1.69, p<0.001), whilst patients prescribed CCBs and beta-blockers were similarly likely to have switching. Following these patients up for 5 years showed that thiazide had the most marked increase in switching rate.
Conclusions
The higher rates of switching among thiazide diuretics in this study might raise a probably greater incidence of their adverse effects in this Chinese population, yet other factors might also influence switching rates. Patients prescribed thiazide diuretics for longer term should be observed for their intolerability.
doi:10.1371/journal.pone.0053625
PMCID: PMC3544913  PMID: 23341959
6.  Rose Angina Questionnaire: Validation with cardiologists' diagnoses to detect coronary heart disease in Bangladesh 
Indian Heart Journal  2013;65(1):30-39.
Aim/objectives
The study aimed to validate the Rose Angina Questionnaire (RAQ) to detect coronary heart disease (CHD) by comparing with cardiologists' diagnoses in Bangladesh.
Methods
Patients aged 40–75 years attending to two cardiac hospitals were diagnosed as either CHD positive or CHD negative by cardiologists. The RAQ was used to reclassify them into CHD positive [RAQ] and CHD negative [RAQ].
Findings
There were 302 CHD positive [cardiologists] and 302 CHD negative [cardiologists] individuals. The RAQ reclassified 194 individuals as CHD positive [RAQ] and 409 individuals as CHD negative [RAQ]. Therefore, the RAQ had 53% sensitivity and 89% specificity. There was no difference in sensitivity and specificity during subgroup analyzes by age and gender; the sensitivity was higher among people from lower socio-economic status.
Conclusion
The RAQ, having moderate sensitivity but high specificity to detect CHD, can be used to screen individuals at risk of CHD in large-scale epidemiological surveys.
doi:10.1016/j.ihj.2012.09.008
PMCID: PMC3861154  PMID: 23438610
Rose Angina Questionnaire; Coronary heart disease; Bangladesh
7.  Identification of IL6R and chromosome 11q13.5 as risk loci for asthma 
Lancet  2011;378(9795):1006-1014.
Background
We aimed to identify novel genetic variants affecting asthma risk, since these might provide novel insights into molecular mechanisms underlying asthma.
Methods
We performed a genome-wide association study (GWAS) in 2,669 physician-diagnosed asthmatics and 4,528 controls from Australia. Seven loci were prioritised for replication after combining our results with those from the GABRIEL consortium (n=26,475), and these were tested in an additional 25,358 independent samples from four in-silico cohorts. Quantitative multi-SNP scores of genetic load were constructed on the basis of results from the GABRIEL study and tested for association with asthma in our Australian GWAS dataset.
Findings
Two loci were confirmed to associate with asthma risk in the replication cohorts and reached genome-wide significance in the combined analysis of all available studies (n=57,800): rs4129267 (OR=1.09, combined P=2.4×10−8) in the interleukin-6 receptor gene (IL6R) and rs7130588 (OR=1.09, P=1.8×10−8) on chromosome 11q13.5 near the leucine-rich repeat containing 32 gene (LRRC32, also known as GARP). The 11q13.5 locus was significantly associated with atopic status among asthmatics (OR = 1.33, P = 7×10−4), suggesting that it is a risk factor for allergic but not non-allergic asthma. Multi-SNP association results are consistent with a highly polygenic contribution to asthma risk, including loci with weak effects that may be shared with other immune-related diseases, such as NDFIP1, HLA-B, LPP and BACH2.
Interpretation
The IL6R association further supports the hypothesis that cytokine signalling dysregulation affects asthma risk, and raises the possibility that an IL6R antagonist (tocilizumab) may be effective to treat the disease, perhaps in a genotype-dependent manner. Results for the 11q13.5 locus suggest that it directly increases the risk of allergic sensitisation which, in turn, increases the risk of subsequent development of asthma. Larger or more functionally focused studies are needed to characterise the many loci with modest effects that remain to be identified for asthma.
Funding
A full list of funding sources appears at the end of the paper.
doi:10.1016/S0140-6736(11)60874-X
PMCID: PMC3517659  PMID: 21907864
8.  Is There Any Association between Use of Smokeless Tobacco Products and Coronary Heart Disease in Bangladesh? 
PLoS ONE  2012;7(1):e30584.
Background
Most epidemiological studies exploring the association between smokeless tobacco (SLT) use and coronary heart disease (CHD) have been in Western populations, and have focused on SLT products used in those countries. Few studies come from South Asian countries. Our objective was to determine the association between SLT use and CHD among non-smoking adults in Bangladesh.
Methods
A matched case-control study of non-smoking Bangladeshi adults aged 40–75 years was conducted in 2010. Incident cases of CHD were selected from two cardiac hospitals. Community controls, matched to CHD cases, were selected from neighbourhoods, and hospital controls were selected from outpatient departments of the same hospitals. The Rose Angina Questionnaire (RAQ) was also used to re-classify cases and controls.
Results
The study enrolled 302 cases, 1,208 community controls and 302 hospital controls. Current use was higher among community controls (38%) compared to cases (33%) and hospital controls (32%). Current use of SLT was not significantly associated with an increased risk of CHD when community controls were used (adjusted OR 0.87, 95% CI 0.63–1.19), or when hospital controls were used (adjusted OR 1.00, 95% CI 0.63–1.60), or when both control groups were combined (adjusted OR 1.00, 95% CI 0.74–1.34). Risk of CHD did not increase with use of individual types except gul, frequency, duration, past use of SLT products, or using the RAQ to re-classify cases and controls. There was a significant association between gul use and CHD when both controls were combined (adjusted OR 2.93, 95% CI 1.28–6.70).
Conclusions
There was no statistically significant association between SLT use in general and CHD among non-smoking adults in Bangladesh. Further research on the association between gul use and CHD in Bangladesh along with SLT use and CHD in other parts of the subcontinent will guide public health policy and interventions that focus on SLT-related diseases.
doi:10.1371/journal.pone.0030584
PMCID: PMC3262837  PMID: 22276217
9.  Predictors of switching from beta-blockers to other anti-hypertensive drugs: a review of records of 19,177 Chinese patients seen in public primary care clinics in the New Territory East, Hong Kong 
Background
Beta-blocker drugs are commonly used in family practice and studies showed that they were the most popularly prescribed medications among all antihypertensive agents. This study aimed to identify the factors associated with medication switching from a beta-blocker to another antihypertensive drug among Chinese patients.
Methods
We used a validated database which consisted of the demographic and clinical information of all Chinese patients prescribed a beta-blocker from any public, family practice clinics between 01 Jan 2004 to 30 June 2007 in one large Territory of Hong Kong. The proportion of patients switched from beta-blockers to another antihypertensive agent 180 days within their first prescription was studied, and the factors associated with medication switching were evaluated by using multivariate regression analyses.
Results
From 19,177 eligible subjects with a mean age of 59.1 years, 763 (4.0%) were switched from their beta-blockers within 180 days of commencing therapy. A binary logistic regression model used medication switching as the outcome variable and controlled for age, gender, socioeconomic status, clinic setting (general out-patient clinics, family medicine specialist clinic or staff clinics), district of residence, visit type (new vs. follow-up attendance), the number of concomitant co-morbidities, and the calendar year of prescription. It was found that older patients (age 50-59 years: adjusted odds ratio [AOR] 1.38, 95% C.I. 1.12-1.70; p = 0.002; age 60-69 years: AOR 1.63 95% C.I. 1.30-2.04, p < 0.001; age ≥ 70 years: AOR 1.82, 95% C.I. 1.46-2.26, p < 0.001; referent age < 50 years) and new visitors (AOR 0.57, 95% C.I. 0.48-0.68, p < 0.001) were more likely to have their medication switched.
Conclusions
Closer monitoring of the medication taking behavior among the older patients and the new clinic visitors prescribed a beta-blocker is warranted. Future studies should evaluate the reasons of drug switching.
doi:10.1186/1447-056X-10-10
PMCID: PMC3161943  PMID: 21794107
beta-blocker; switching; pharmacoepidemiology; family practice
10.  A Cross-Sectional Study of the Microeconomic Impact of Cardiovascular Disease Hospitalization in Four Low- and Middle-Income Countries 
PLoS ONE  2011;6(6):e20821.
Objective
To estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC).
Background
Empirical evidence on the microeconomic consequences of CVD in LMIC is scarce.
Methods and Findings
We surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity.
Conclusions
Individuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.
doi:10.1371/journal.pone.0020821
PMCID: PMC3114849  PMID: 21695127
11.  A Role for Wnt Signaling Genes in the Pathogenesis of Impaired Lung Function in Asthma 
Rationale: Animal models demonstrate that aberrant gene expression in utero can result in abnormal pulmonary phenotypes.
Objectives: We sought to identify genes that are differentially expressed during in utero airway development and test the hypothesis that variants in these genes influence lung function in patients with asthma.
Methods: Stage 1 (Gene Expression): Differential gene expression analysis across the pseudoglandular (n = 27) and canalicular (n = 9) stages of human lung development was performed using regularized t tests with multiple comparison adjustments. Stage 2 (Genetic Association): Genetic association analyses of lung function (FEV1, FVC, and FEV1/FVC) for variants in five differentially expressed genes were conducted in 403 parent-child trios from the Childhood Asthma Management Program (CAMP). Associations were replicated in 583 parent-child trios from the Genetics of Asthma in Costa Rica study.
Measurements and Main Results: Of the 1,776 differentially expressed genes between the pseudoglandular (gestational age: 7–16 wk) and the canalicular (gestational age: 17–26 wk) stages, we selected 5 genes in the Wnt pathway for association testing. Thirteen single nucleotide polymorphisms in three genes demonstrated association with lung function in CAMP (P < 0.05), and associations for two of these genes were replicated in the Costa Ricans: Wnt1-inducible signaling pathway protein 1 with FEV1 (combined P = 0.0005) and FVC (combined P = 0.0004), and Wnt inhibitory factor 1 with FVC (combined P = 0.003) and FEV1/FVC (combined P = 0.003).
Conclusions: Wnt signaling genes are associated with impaired lung function in two childhood asthma cohorts. Furthermore, gene expression profiling of human fetal lung development can be used to identify genes implicated in the pathogenesis of lung function impairment in individuals with asthma.
doi:10.1164/rccm.200907-1009OC
PMCID: PMC2822972  PMID: 19926868
asthma; lung development; lung function; genetic variation; gene expression
12.  A pathway to a stronger research culture in health policy 
Background
There are currently limited pathways into a career in health policy research in Australia, due in part to a serious absence of health policy research capability in Australian universities.
Discussion
We define what we consider health policy research and education should comprise. We then examine what is currently on offer and propose ways to strengthen health policy research in Australia.
Summary
This paper, which is part analysis and part commentary, is offered to provoke wider debate about how health policy research can be nurtured in Australia.
doi:10.1186/1743-8462-4-19
PMCID: PMC2104534  PMID: 17927814
13.  A health policy for hearing impairment in older Australians: what should it include? 
Background
As in all western countries, Australia's older population experiences high levels of hearing impairment coupled with relatively low levels of hearing device usage. Poor hearing diminishes the quality of life of affected individuals and their families. This paper discusses how to improve Australian hearing health policies in order to better combat this impairment amongst older Australians.
Method
We searched the databases Medline, Meditext and Web of Science to find articles that discussed strategies and innovations to assist the hearing health of older people, and related this material to observations made during the Blue Mountains Hearing Study in NSW between 1997 and 2003.
Results and Discussion
The literature search identified five areas for inclusion in a comprehensive hearing health policy in Australia. These are: early intervention; addressing of hearing aid expense; the use of assisted listening devices; hearing rehabilitation, and; screening and education. Further research in Australia is critical if we are to develop a strong approach to the increasing prevalence of age-related hearing loss.
Conclusion
Australia needs to act now to address hearing impairment as it is a major cause of disability in those aged 55 and over. Federal and State governments should collaborate to construct a comprehensive hearing health policy that tackles poor levels of hearing health through early intervention, addressing hearing aid expense, encouraging the use of assisted listening devices, rehabilitation, screening and education. A good start would be to declare age related hearing impairment as a National Health Priority Area.
doi:10.1186/1743-8462-2-31
PMCID: PMC1326208  PMID: 16343355
15.  Compliance With Protocols for Prevention of Neonatal Group B Streptococcal Sepsis: Practicalities and Limitations 
Objective: To compare two protocols for intrapartum antibiotic prophylaxis (IAP) against neonatal group B streptococcal (GBS) sepsis, with respect to staff compliance, in a prospective cohort study in the obstetric units of a community hospital (A) and a university teaching hospital (B).
Methods: Cohorts comprised about 500 women attending antenatal clinics at each hospital (total 1096). Women identified as GBS carriers at 26–32 weeks'gestation and those who had intrapartum clinical risk factors (CRF) were eligible for IAP. Compliance was defined as the proportion of women eligible for IAP who received it according to protocol–as determined by audit of case records–and compared between hospitals and according to indication.
Results: Overall, 39% of women were eligible for IAP. Indications were GBS carriage alone (21%), CRF alone (13% ) and both (5% ). Compliance was similar for GBS carriers at both hospitals: 78% at Hospital A and 76% at Hospital B. However, because of the poor predictive value of screening before 32 weeks, only 65%of intrapartum GBS carriers actually received IAP. For women with CRF only, compliance was significantly lower at Hospital B than Hospital A (56 vs. 75%; p= 0.03).
Conclusions: According to currently recommended protocols, about one-third of healthy women are eligible for intrapartum antibiotics to prevent neonatal GBS sepsis. In practice, antibiotics are often used inefficiently because of poor compliance with protocols and poor predictive values of selection criteria. Better implementation strategies should improve compliance, but GBS vaccines are needed to replace prophylactic antibiotic use, with its associated disadvantages.
doi:10.1155/S1064744903000012
PMCID: PMC1852267  PMID: 12839627
16.  Rationing: Talk and Action in Health Care 
BMJ : British Medical Journal  1998;316(7139):1253.
PMCID: PMC1113015  PMID: 9553030

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