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Barker A.,Northern Clinical Research Center | Barlis P.,University of Melbourne | Berlowitz D.,Northern Clinical Research Center | Berlowitz D.,University of Melbourne | And 4 more authors.
International Journal of Cardiology | Year: 2012

Background: Chronic heart failure (CHF) accounts for significant morbidity, mortality and health expenditure. Furthermore, patients with CHF are often on numerous pharmacological agents for their comorbidities. The objective of this study was to determine whether a pharmacist directed home medication review intervention had positive effects on CHF patient outcomes. Methods: A total of 120 patients hospitalised for CHF were randomised to receive a pharmacist directed post-discharge home medication review (n = 64, 53.3%) or standard care (n = 56, 46.7%). Participants were followed for 6 months. Primary outcomes were death, CHF hospitalisation and length of hospital stay. Results: There were no between group differences in mortality (hazard ratio = 1.41, 0.50 to 3.97; P = 0.514) or CHF hospitalizations (incidence rate ratio [IRR] = 1.74 95% CI: 0.85-3.60 P = 0.131) over the 6 month follow-up period. Days of hospital stay for CHF exacerbations in the 6 month follow-up were significantly greater in the intervention group (IRR = 2.34 95% CI: 1.80-3.05 P = 0.000). Conclusions: Post-discharge pharmacy directed home medication review appeared to have no effect on mortality and health care utilisation above that achieved with standard care. The post-acute management of CHF must be a collaborative multi-disciplinary effort by the health care team as it is the additive effect of interventions that are most effective. © 2011 Elsevier Ireland Ltd.


Chong A.,Western University of Health Sciences | Nazarian N.,Western University of Health Sciences | Chandrananth J.,Western University of Health Sciences | Tacey M.,Western University of Health Sciences | And 3 more authors.
Bone and Joint Journal | Year: 2015

This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of >1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years. ©2015 The British Editorial Society of Bone & Joint Surgery.


De Morton N.A.,Monash University | De Morton N.A.,Northern Clinical Research Center | Davidson M.,La Trobe University | Keating J.L.,Monash University
BMC Geriatrics | Year: 2010

Background: The de Morton Mobility Index (DEMMI) is a new mobility instrument that overcomes the limitations of existing instruments. It is the first mobility instrument that accurately measures the mobility of all older adults. The aim of this study was to provide a detailed report of investigations of the validity, responsiveness to change and minimal clinically important difference (MCID) of the DEMMI during its development in an older acute medical population. Methods: This study was conducted using a head to head comparison design in two independent samples of older acute medical patients (development sample, n = 86; validation sample, n = 106). Consecutive patients ( 65 years) were assessed using the DEMMI, Barthel Index (BI) and Hierarchical Assessment of Balance and Mobility (HABAM) within 48 hours of hospital admission and discharge. Convergent and discriminant validity were investigated using Spearman's rho and known groups validity was investigated using a independent t test to compare DEMMI scores for patients who were discharged to home compared to inpatient rehabilitation. Criterion and distribution based methods were employed for estimating instrument responsiveness to change and the MCID. Results: Significant moderate to high correlations were identified between DEMMI and BI scores (r = 0.76 and r = 0.68) and DEMMI and HABAM scores (r = 0.91 and r = 0.92) in both samples. In both samples, DEMMI scores for patients who were discharged to home were significantly higher than for patients discharged to inpatient rehabilitation and provided evidence of known groups validity. Patients who were discharged to inpatient rehabilitation (n = 8) had a mean DEMMI score of 50.75 (sd = 11.29) at acute hospital discharge compared to patients who were discharged to home (n = 70) with a mean DEMMI score of 62.14 (sd = 18.41). MCID estimates were similar across samples using distribution and criterion based methods. The MCID for the DEMMI was 10 points on the 100 point interval scale. The DEMMI was significantly more responsive to change than the BI using criterion and distribution based methods in the validation sample. Conclusion: This study has validated the DEMMI in two independent samples of older acute medical patients. Estimates of its responsiveness and MCID have also been established. This study confirms that the DEMMI overcomes the limitations of the BI and HABAM and provides an advanced method for objectively assessing mobility for older acute medical patients. © 2010 de Morton et al; licensee BioMed Central Ltd.


Duke G.J.,Box Hill Hospital | Barker A.,Monash University | Rasekaba T.,Northern Health | Hutchinson A.,Northern Health | And 2 more authors.
Critical Care and Resuscitation | Year: 2013

Objective: To revise and validate the accuracy of the critical care outcome prediction equation (COPE) model, version 4. Design, participants and setting: Observational cohort analysis of 214 616 adult consecutive intensive care unit admissions recorded from 23 ICUs over 12 years. Data derived from the Victorian Admitted Episode Database (VAED) were used to identify treatment-independent risk factors consistently associated with hospital mortality. A revised version of the COPE-4 model using a random-intercept hierarchical logistic regression model was developed in a sample of 35 878 (16.7%) consecutive ICU separations. Main outcome measures: Accuracy was tested by comparing observed and predicted mortality in the remaining 178 741 (83.3%) records and in 23 institutional cohorts. Stability was assessed using the standardised mortality ratio, Hosmer-Lemeshow H10 statistic, calibration plot and Brier score. Results: The COPE-4 model had satisfactory overall discrimination with an area under receiver operating characteristic curve of 0.82 for both datasets. The development and validation datasets demonstrated good overall calibration with H10 statistics of 13.38 (P = 0.10) and 14.84 (P = 0.06) and calibration plot slopes of 0.99 and 1.034, respectively. Discrimination was satisfactory in all 23 hospitals and one or more calibration criteria were achieved in 19 hospitals (83%). Conclusions: COPE-4 model prediction of hospital mortality for ICU admissions has satisfactory performance for use as a risk-adjustment tool in Victoria. Model refinement may further improve its performance.


Aboltins C.A.,Northern Health | Aboltins C.A.,University of Melbourne | Hutchinson A.F.,Northern Clinical Research Center | Hutchinson A.F.,Deakin University | And 9 more authors.
Journal of Antimicrobial Chemotherapy | Year: 2015

Objectives: To determine whether outcomes for patients with cellulitis treated with oral antimicrobials are as good as for those who are treated with parenteral antimicrobials. Methods: A prospective randomized non-inferiority trial was conducted at a tertiary teaching hospital in Melbourne, Australia. Participants were patients referred by the emergency department for treatment of uncomplicated cellulitis with parenteral antimicrobials. Patients were randomized to receive either oral cefalexin or parenteral cefazolin. Parenteral antimicrobials were changed to oral after the area of cellulitis ceased progressing. The primary outcome was days until no advancement of the area of cellulitis. A non-inferiority margin of 15% was set for the oral arm compared with the parenteral arm. Secondary outcomes were failure of treatment, pain, complications and satisfaction with care. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000685910). Results: Twenty-four patients were randomized to oral antimicrobials and 23 to parenteral antimicrobials. Mean days to no advancement of cellulitis was 1.29 (SD 0.62) for the oral arm and 1.78 (SD 1.13) for the parenteral arm, with a mean difference of -0.49 (95% CI: -1.02 to +0.04). The upper limit of the 95% CI of the difference in means of +0.04 was below the 15% non-inferiority margin of +0.27 days, indicating non-inferiority. More patients failed treatment in the parenteral arm (5 of 23, 22%) compared with the oral arm (1 of 24, 4%), although this difference was not statistically significant (P=0.10). Pain, complications and satisfaction with care were similar for both groups. Conclusions: Oral antimicrobials are as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.


Barclay K.L.,Northern Health | Barclay K.L.,University of Melbourne | Zhu Y.-Y.,University of Melbourne | Tacey M.A.,Northern Clinical Research Center | Tacey M.A.,University of Melbourne
ANZ Journal of Surgery | Year: 2015

Background: Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context. Method: Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, post-operative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12. Results: A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0-32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2-7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2-1.5) were related. Conclusion: Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications. © 2015 Royal Australasian College of Surgeons.


Hutchinson A.,University of Melbourne | Hutchinson A.,Northern Clinical Research Center | Rasekaba T.M.,University of Melbourne | Graco M.,University of Melbourne | And 5 more authors.
Health and Quality of Life Outcomes | Year: 2013

Background: Australia's ageing population means that there is increasing emphasis on developing innovative models of health care delivery for older adults. The assessment of the most appropriate mix of services and measurement of their impact on patient outcomes is challenging. The aim of this evaluation was to describe the health related quality of life (HRQoL) of older adults with complex needs and to explore the relationship between HRQoL, readmission to acute care and survival.Methods: The study was conducted in metropolitan Melbourne, Australia; participants were recruited from a cohort of older adults enrolled in a multidisciplinary case management service. HRQoL was measured at enrolment into the case-management service using The Assessment of Quality of Life (AQoL) instrument. In 2007-2009, participating service clinicians approached their patients and asked for consent to study participation. Administrative databases were used to obtain data on comorbidities (Charlson Comorbidity Index) at enrolment, and follow-up data on acute care readmissions over 12 months and five year mortality. HRQoL was compared to aged-matched norms using Welch's approximate t-tests. Univariate and multivariate logistic regression models were used to explore which patient factors were predictive of readmissions and mortality.Results: There were 210 study participants, mean age 78 years, 67% were female. Participants reported significantly worse HRQoL than age-matched population norms with a mean AQOL of 0.30 (SD 0.27). Seventy-eight (38%) participants were readmitted over 12-months and 5-year mortality was 65 (31%). Multivariate regression found that an AQOL utility score <0.37 (OR 1.95, 95%CI, 1.03 - 3.70), and a Charlson Comorbidity Index ≥6 (OR 4.89, 95%CI 2.37 - 10.09) were predictive of readmission. Multivariate analysis demonstrated that age ≥80 years (OR 7.15, 95%CI, 1.83 - 28.02), and Charlson Comorbidity Index ≥6 (OR 6.00, 95%CI, 2.82 - 12.79) were predictive of death.Conclusion: This study confirms that the AQoL instrument is a robust measure of HRQoL in older community-dwelling adults with chronic illness. Lower self-reported HRQoL was associated with an increased risk of readmission independently of comorbidity and kind of service provided, but was not an independent predictor of five-year mortality. © 2013 Hutchinson et al.; licensee BioMed Central Ltd.


PubMed | Northern Clinical Research Center, Northern Health and University of Melbourne
Type: Journal Article | Journal: ANZ journal of surgery | Year: 2015

Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context.Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, post-operative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12.A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0-32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2-7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2-1.5) were related.Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications.


PubMed | Institute for Breathing and Sleep and Northern Clinical Research Center
Type: | Journal: Health and quality of life outcomes | Year: 2015

There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation.A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007-2009 and follow-up data until 2012. Administrative data was used to classify patients primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm.There were 1999 participants (54 % male) with a mean age of 63 years (range 18-101), enrolled in the study. Participants primary health conditions at enrolment were: diabetes 915 (46 %), chronic respiratory disease 463 (23 %), cardiac disease 260 (13 %), peripheral vascular disease, and 181 (9 %) and aged care 180 (9 %). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95 % CI, 1.16-2.13, p=0.003) and admissions (OR 1.67, 95 % CI.1.21 to 2.30, p=0.002) after adjusting for differences in age and comorbidities.This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.


PubMed | Hospital In The Home, Northern Health, Deakin University, University of Melbourne and 2 more.
Type: Clinical Trial | Journal: The Journal of antimicrobial chemotherapy | Year: 2015

To determine whether outcomes for patients with cellulitis treated with oral antimicrobials are as good as for those who are treated with parenteral antimicrobials.A prospective randomized non-inferiority trial was conducted at a tertiary teaching hospital in Melbourne, Australia. Participants were patients referred by the emergency department for treatment of uncomplicated cellulitis with parenteral antimicrobials. Patients were randomized to receive either oral cefalexin or parenteral cefazolin. Parenteral antimicrobials were changed to oral after the area of cellulitis ceased progressing. The primary outcome was days until no advancement of the area of cellulitis. A non-inferiority margin of 15% was set for the oral arm compared with the parenteral arm. Secondary outcomes were failure of treatment, pain, complications and satisfaction with care. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000685910).Twenty-four patients were randomized to oral antimicrobials and 23 to parenteral antimicrobials. Mean days to no advancement of cellulitis was 1.29 (SD 0.62) for the oral arm and 1.78 (SD 1.13) for the parenteral arm, with a mean difference of -0.49 (95% CI: -1.02 to +0.04). The upper limit of the 95% CI of the difference in means of +0.04 was below the 15% non-inferiority margin of +0.27 days, indicating non-inferiority. More patients failed treatment in the parenteral arm (5 of 23, 22%) compared with the oral arm (1 of 24, 4%), although this difference was not statistically significant (P=0.10). Pain, complications and satisfaction with care were similar for both groups.Oral antimicrobials are as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis.

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