Biomedical subjects
Publications and source records attributed to J McCallum.
Health care professionals have been asked to do more with less and examine every possible option to cut costs but not service. To meet this challenge, a pediatric urology same-day admit/day care unit provides patients and their families with surgical and diagnostic care that has been well received by patients, families, and staff.
OBJECTIVE: To assess the association between general practitioner (GP) billing for "longer" consultations, patient factors linked with health care need, and other consultation characteristics. DESIGN: Retrospective analysis of data from Medicare (1984-1992), Australian Morbidity and Treatment Survey (1990-1991) and Australian Capital Territory Record Linkage Study (1988-1992). SETTING: Australian general practice, 1984 (introduction of Medicare) to 1992. MAIN OUTCOME MEASURES: Consultations billed as longer (> or = 20 or > 25 minutes) compared with standard; type of billing (bulk or private); patient health care need (defined as health and sociodemographic factors linked to worse health outcomes); consultation continuity, type of care given and number of problems managed. RESULTS: Longer billed consultations increased between 1984 and 1992, from 2.8% to 6.7% of all standard and longer consultations. Longer consultations were more likely to be bulk-billed than privately billed (odds ratio [OR], 1.74). They were more likely than standard consultations to deal with psychological diagnoses (OR, 2.06; 95% confidence interval [95% Cl], 1.83-2.32) or multiple problems (OR for four versus one diagnosis, 5.18; 95% Cl, 4.31-6.22) and to involve patients aged under 50 years, new to the practice or with new problems, but not chronic disease. In the ACT, those billed for longer consultations were more commonly tertiary educated (OR, 1.99; 95% Cl, 1.35-2.94), bulk-billed (OR, 2.75; 95% Cl, 2.51-3.10), aged 40-49 years and non-obese. CONCLUSION: Longer billed consultations were not associated with greater patient need, other than psychosocial need, but with bulk billing and patient socioeconomic advantage. However, evaluation was complicated by the effects of continuity of care and number of problems managed in the consultation.
OBJECTIVE: To evaluate the relationships of mortality and ischaemic heart disease (IHD) with peak expiratory flow rate (PEF) in the elderly. DESIGN: Prospective study with median follow-up of 83 months. SETTING: Dubbo, a New South Wales country town (population, 30500). SUBJECTS: Non-institutionalised residents born before 1930 (i.e., aged 60 years and over at study entry). Participation rate was 73% (1235 men and 1570 women). MAIN OUTCOME MEASURES: Baseline demographic, psychosocial and standard cardiovascular risk factors, including PEF; all-causes mortality, IHD mortality and IHD events (hospitalisations with any manifestation of IHD) by tertile of PEF. RESULTS: More subjects with PEF in the lowest tertile (I) had a past history of respiratory disease, were current cigarette smokers and were taking antihypertensive drugs. During follow-up, 321 men (26%) and 252 women (16%) died. All-causes mortality was three (men) to four (women) times higher for those in PEF tertile I than for those in tertile III. IHD mortality and IHD events showed similar trends. In a proportional hazards model adjusted for age, height, smoking status and other risk factors or confounders, the hazard ratios (95% confidence interval) for men in PEF tertile I versus tertile III were: all-causes mortality, 1.62 (1.14-2.30); IHD mortality, 1.75 (0.96-3.20); and IHD events, 1.12 (0.82-1.53). For women, respective hazard ratios were 1.92 (1.23-3.00), 2.58 (1.24-5.39), and 1.16 (0.83-1.63). CONCLUSIONS: We confirm an independent, inverse relationship between PEF and all-causes and IHD mortality. The data suggest a potential benefit for coronary risk factor management in subjects with existing airways disease and further support the case for antismoking programs.
This paper examines the performance of the SF-36 as a self-reported outcome measure in a diverse sample of Australian hospital in-patients. The data derive from the Care Continuum and Health Outcomes Project with a total of 2088 randomly selected patients, yielding a response rate of 80%. Distributions, completion rates and, in particular, correlates of measures were used to investigate the validity of the SF-36 according to clinical and psychometric criteria. Physical functioning, bodily pain, role limitations-physical, general health and vitality scales better represented physical than mental health, with the relative strength decreasing in that order; while mental health, role limitations-emotional and social functioning scales better represented mental health, with the relative strength decreasing in order. A cultural dimension was a strong independent correlate of all scales. While the SF-36 performed satisfactorily, there were weaknesses: the social functioning scale was too narrow to cover social health, both role limitations scales had crude response categories and particular subgroups, the frail elderly and those with complex health conditions, required measures with finer gradings for scales such as physical functioning and bodily pain. Further testing is needed to develop self-reports for use in hospital outcomes measurement which is already proposed in Australia.
Twenty-six patients have had cranio-peritoneal shunts placed using a new introducer allowing the combination of frameless stereotaxy and neuroendoscopy and placement of a one-piece shunt. Operating times have been acceptable, complication rates have been low, and shunt placement has been accurate in this series.
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OBJECTIVE: To identify individual and social characteristics of patients making sequential visits to a different rather than the same general practitioner (GP). METHOD: Data for this study were extracted from the "Record Linkage Pilot Study" of the National Centre for Epidemiology and Population Health, which linked information from personal interviews with Health Insurance Commission and National Heart Foundation Risk Factor Survey data. Each sequence of visits (any two consecutive visits) made by each participant to the same or a different GP from January 1991 to December 1992 was treated as an event. PARTICIPANTS: 521 subjects aged between 23 and 72 years who gave consent to release of Health Insurance Commission data. MAIN OUTCOME MEASURE: A visit to the same GP or a different GP from the one seen at the last visit. RESULTS: Logistic regression analysis showed that younger age, good physical functioning, good self-rated health, normal body mass index, shiftwork and a longer time interval between visits were significantly associated with less continuity of care. CONCLUSIONS: Our study raises questions about the relationship between chronological continuity and quality of care. For example, if infrequent visits (associated with less continuity) are for distinct illnesses, is quality of care affected by information or treatment from a previous visit? Our results also suggest that some GPs, because of the demography of their practices (more young people, a higher proportion of shift workers), may be disadvantaged by continuity-based reward systems. Moreover, because of lack of continuity young people may miss out on GPs' health promotional activities.
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BACKGROUND: A prospective study in non-institutionalised Australian elderly 60 years and over commenced in Dubbo, NSW in 1988. AIM: To examine clinical and socio-demographic predictors of all-causes mortality. METHODS: The data were derived from a community-based sample comprising 1236 men and 1569 women followed for a median period of 62 months. RESULTS: Two hundred and thirty five men (19%) and 184 women (12%) died, 46% of male and 53% of female deaths respectively related to cardiovascular disease. In a proportional hazards model, the significant predictors of mortality were: older age, being married (relative risk [RR] = 0.71 for men, 0.74 for women), current smoking for men (RR = 3.11), taking more than three alcoholic drinks per day for men (RR = 0.37), prior coronary heart disease for men (RR = 1.36), severe hypertension for women (RR = 1.99), use of anti-hypertensive medication for men (RR = 1.74), diabetes for men (RR = 1.62), poor-fair self-rated health for women (RR = 1.74) and physical disability for men (RR = 1.72). Serum cholesterol was associated with mortality in a 'J-shaped' relationship in men and in a reciprocal relationship in women. Blood pressure predicted mortality in an incremental fashion below 75 years, but in older subjects lower pressure was associated with excess mortality. CONCLUSION: Some predictors of mortality in the well elderly have been identified and a more extended period of follow-up will possibly resolve contradictory findings in some areas.
BACKGROUND: A prospective study of Australian elderly living in Dubbo has shown that diabetes is a significant predictor of all-causes mortality and coronary heart disease (CHD). AIM: To examine and contrast clinical and socio-demographic predictors of these outcomes in those with and without diabetes. METHODS: The data are derived from a community-based sample of subjects 60 years and older followed over 62 months since 1988. Of 1155 men and 1472 women, 9.2% and 6.9% respectively manifested diabetes at baseline, based on history or fasting hyperglycaemia. RESULTS: In the presence of diabetes, all-causes mortality was increased twofold in both sexes, CHD incidence was increased twofold in men and threefold in women, stroke incidence was increased twofold in women but little changed in men. Proportional hazards models were derived separately for persons with and without diabetes and risk factors differentially predictive in diabetes were sought. Significant predictors of death in diabetes were old age and current smoking. Those factors differentially predictive were 'being married' (Relative Risk [RR] 1.60 with diabetes and 0.69 without diabetes) and higher body mass index (BMI) (RR 1.03 with diabetes and 0.79 without diabetes). Significant predictors of CHD in diabetes were old age, prior CHD, severe hypertension, low HDL cholesterol and self-rated health. Those factors differentially predictive were higher body mass index (RR 1.14 vs 0.83) and physical disability (RR 0.69 vs 1.55). Differential predictions with regard to BMI may relate in part to excess CHD and mortality at low BMI in non-diabetic subjects. CONCLUSION: The vascular disease burden of diabetes in the elderly has been confirmed, especially in women. A number of conventional risk factors are contributing to this burden and may be amenable to treatment.
BACKGROUND: A prospective study in non-institutionalised Australian elderly aged 60 years and over commenced in Dubbo, NSW in 1988. AIM: To examine the relationship between all-causes mortality and alcohol intake. METHODS: The data were derived from a community-based sample comprising 1236 men and 1569 women followed for a median period of 77 months. Regular alcohol intake was reported by 78% of men and 52% of women. Eighty-seven per cent of men and 44% of women primarily drank beer. RESULTS: Death occurred in 305 men and 236 women, 34% and 39% respectively from coronary heart disease (CHD). In a proportional hazards model, the hazard ratio (HR) for all-causes mortality in male drinkers, compared with abstainers, was 0.75 at one-seven drinks/week, 0.76 at eight-14 drinks/week, 0.69 at 15-28 drinks/week and 0.49 at > 28 drinks/week (p < 0.04), an inverse relationship. In female drinkers, HR was 0.78 at one-seven drinks/week, 0.49 at eight-14 drinks/week (p < 0.04) and 0.62 at 15-28 drinks/weeks, potentially a U shaped relationship. The effect on all-causes mortality could not be attributed to a differential effect of beer versus wine/spirit intake. Although the mortality rate was lower in those taking any alcohol compared with abstainers, those taking any alcohol exhibited an increased proportion of deaths due to cancer at the expense of a reduced proportion of CHD and stroke deaths. CONCLUSIONS: Alcohol intake in the Dubbo elderly appears to be independently associated with a significant increase in life expectancy. Mechanisms underlying the effect may emerge at a longer interval of follow-up.
Declining length of stay of older people in hospital has caused concern about shifting of costs from acute to community care services. Because the two types of care are funded through different programs and from different jurisdictions, the coordination of acute and post-acute care has become the major issue. There is, however, little information available on patterns of use and costs of post-acute care either in Australia or elsewhere. In an existing longitudinal community study of older people in Dubbo, New South Wales, data on use of services by people aged 60 years and over for 12 months of hospitalisations was collected by linkage to the records of Home and Community Care providers. Only a quarter of older people received any type of Home and Community Care service in the 12 weeks after discharge and two-thirds of these received only one type of service. While less than 5 per cent received a service from an occupational therapist, physiotherapist or speech therapist, 78 per cent visited a general practitioner after discharge. The average cost of all Home and Community Care services received after hospital discharge was around $12.50 per week per person discharged. The predictors of higher costs of service use were: living alone, and the interactions of high levels of disability with owning a house. Results on service coordination, the identification of post-acute services, cost consequences of program funding, assessment and discharge planning are related to debates emerging from the Commonwealth Heads of Government.
A new prospective study of non-institutionalised Australian elderly 60 years and over commenced in Dubbo in 1988, comprising 1236 men and 1569 women. This report examines clinical and socio-demographic predictors of coronary heart disease (CHD) over a median 62 months follow-up. CHD incidence rates (ICD-9-CM codes 410-414) were higher in men than women until 79 years, thereafter, the rates for recurrent disease were higher in women. Incidence rates for recurrent disease were three-fold those for initial disease. In Cox proportional hazards analysis, the significant predictors of all CHD were: advancing age, prior CHD (relative risk (RR) = 2.50 and 2.15 in men and women, respectively), use of anti-hypertensive medication (RR = 1.92 and 1.75 in men and women, respectively). diabetes (RR = 1.67 and 1.53 in men and women, respectively), serum cholesterol, low density lipoprotein cholesterol and serum apo B in men (RR = 1.24), serum triglycerides in women (RR = 1.23), high density lipoprotein cholesterol in men (RR = 0.82), lipoprotein (a) in women (RR = 1.99), and poorer self-rating of health (RR =1.48 and 1.93 in men and women, respectively). Serum cholesterol was not predictive of CHD in men beyond 74 years. Isolated systolic hypertension predicted CHD in women (RR = 3.76), but not in men (RR = 1.20). The findings highlight key risk factors for CHD in the elderly.
The aim of this Australian study was to explore the reasons for peoples' choice of general practitioner (GP) in an environment where they have freedom of choice of doctor on every occasion of attendance. A questionnaire was administered by trained research assistants to 555 people during an hour-long interview. Utilization of more than one general practitioner was examined in terms of sociodemographic factors, health status and satisfaction with the last general practice visit. Respondents were more likely to see more than one general practitioner if they had more visits; were dissatisfied with their last consultation with a general practitioner; were younger; were female; and were highly qualified. Further, respondents who described good communication as the rationale for their satisfaction rating for their last general practitioner visit were less likely to have seen more than one general practitioner.
The measurement properties of the Center for Epidemiological Studies Depression Scale (CES-D) were examined in an Australian community study of aged persons in order to contribute to international validation of the measure. Confirmatory analysis of polychoric correlations was conducted using the generally weighted least squares method. The original four-factor solution proposed by Radloff was successfully replicated for Australians, showing similar underlying structures as for Americans, Canadians, and Japanese. Schmid-Leiman parameterization of the second order factor analysis showed that little information was lost in considering full-scale scores rather than the four subscales separately. The behavior of the CES-D in an Australian population aligns with existing North American research and thus confirms the exceptional functioning of the Well-Being scale in Japan. More work on the behavior of the CES-D in non-English speaking societies is needed to separate issues of wording and grammar from genuine cultural variations. The CES-D was confirmed as essentially unidimensional and robust to minor changes; therefore, it is recommended for use in cross-cultural studies of depression in elderly persons.
The SF-36 is a self-reported, 36-item, generic measure of health status that has been validated for adult age groups in the United States, the United Kingdom and in some non-English-speaking countries. The Australian Bureau of Statistics used it in the 1995 National Health Survey and it has been used in health status measurement, in monitoring health outcomes and in clinical trials. The validity of the SF-36 was examined in the National Centre for Epidemiology and Population Health Record Linkage Study using a sample of 555 respondents to the National Heart Foundation Risk Factor Prevalence Survey in 1989; they were followed up in 1992. Items chosen for the scale had been used in health status assessment and had stood the test of time. The health concepts measured demonstrated good internal consistency. The eight scales of the SF-36 formed factors as predicted in the general health dimensions of physical and mental health. The component scales of the SF-36 demonstrated good discrimination between people with and without health conditions, including those with medical and those with psychiatric types of conditions. Although the SF-36 was a valid measure of general health status among Australian respondents, further work is needed to establish clinical validity and to produce population norms for Australia. Use of the SF-36 will allow Australian and international comparison of health status from the point of view of the users of health services.
The introduction of casemix in hospitals has increased concerns about cost-shifting to community services. There has been little evidence with which to test claims about shifting balances in the continuum of care, in particular for major user groups like older people. These matters have come into greater prominence with the Council of Australian Governments Communique which agreed in April to radical reforms of health and community services. We used an existing longitudinal study of people aged 60 years and over in the community of Dubbo, New South Wales, to study hospital and aged care service use over 50 months. Fifty-five per cent of those studied were hospitalised but only 1.7 per cent were admitted to nursing homes over the period. In the 12 weeks after hospital discharge, 24 per cent received Home and Community Care services, while 78 per cent visited a general practitioner. All post-acute community services over 12 weeks after discharge cost an average of $150. In the light of this new evidence, current proposals for structural reform are critically discussed.