Task substitution: where to from here?
Meeting future health workforce needs is a challenge for all health professionals.
Attitude of Health Personnel↗
Biomedical subjects
Peter M Brooks
Publications and source records attributed to Peter M Brooks.
The burden of musculoskeletal disease--a global perspective.
Musculoskeletal diseases are one of the major causes of disability around the world and have been a significant reason for the development of the Bone and Joint Decade. Rheumatoid arthritis, osteoarthritis and back pain are important causes of disability-adjusted-life years in both the developed and developing world. COPCORD studies in over 17 countries around the world have identified back and knee pain as common in the community and are likely to increase with the ageing population. Musculoskeletal conditions are an enormous cost to the community in economic terms, and these figures emphasise how governments need to invest in the future and look at ways of reducing the burden of musculoskeletal diseases by encouraging exercise and obesity prevention campaigns.
Cost of Illness↗
Health workforce innovation conference.
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Health Workforce↗
It's time to plan our future health system.
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Australia↗
Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: a comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis.
OBJECTIVES: To analyse the differences in patient health outcomes and out-of-pocket costs following hip and knee joint replacement for osteoarthritis between patients who went home immediately after the acute care hospital stay and those who were admitted to inpatient rehabilitation care before going home. METHODS: One hundred and eighteen patients undergoing total hip or knee replacement in Sydney, Australia completed cost diaries, SF-36 and WOMAC Index, pre-operatively and for one year post-operatively. RESULTS: The health status of all groups improved significantly from before surgery to 12 months post-surgery. No significant difference in health status at 12 months post-surgery was seen between home and rehabilitation patients for either hip or knee replacement. Both hip replacement home and rehabilitation patients and knee replacement home patients reported lower out-of-pocket expenditure from before surgery to 1 year post-surgery. DISCUSSION: The majority of total joint replacement patients can be discharged directly home and achieve excellent outcomes at 12 months post-surgery. We would recommend more focused randomized studies to explore the most suitable patient selection for rehabilitation.
Aged↗
Minimal disease activity for rheumatoid arthritis: a preliminary definition.
Agreement on response criteria in rheumatoid arthritis (RA) has allowed better standardization and interpretation of clinical trial reports. With recent advances in therapy, the proportion of patients achieving a satisfactory state of minimal disease activity (MDA) is becoming a more important measure with which to compare different treatment strategies. The threshold for MDA is between high disease activity and remission and, by definition, anyone in remission will also be in MDA. True remission is still rare in RA; in addition, the American College of Rheumatology definition is difficult to apply in the context of trials. Participants at OMERACT 6 in 2002 agreed on a conceptual definition of minimal disease activity (MDA): "that state of disease activity deemed a useful target of treatment by both the patient and the physician, given current treatment possibilities and limitations." To prepare for a preliminary operational definition of MDA for use in clinical trials, we asked rheumatologists to assess 60 patient profiles describing real RA patients seen in routine clinical practice. Based on their responses, several candidate definitions for MDA were designed and discussed at the OMERACT 7 in 2004. Feedback from participants and additional on-site analyses in a cross-sectional database allowed the formulation of 2 preliminary, equivalent definitions of MDA: one based on the Disease Activity Score 28 (DAS28) index, and one based on meeting cutpoints in 5 out the 7 WHO/ILAR core set measures. Researchers applying these definitions first need to choose whether to use the DAS28 or the core set definition, because although each selects a similar proportion in a population, these are not always the same patients. In both MDA definitions, an initial decision node places all patients in MDA who have a tender joint count of 0 and a swollen joint count of 0, and an erythrocyte sedimentation rate (ESR) no greater than 10 mm. If this condition is not met: * The DAS28 definition places patients in MDA when DAS28 < or = 2.85; * The core set definition places patients in MDA when they meet 5 of 7 criteria: (1) Pain (0-10) < or = 2; (2) Swollen joint count (0-28) < or = 1; (3) Tender joint count (0-28) < or = 1; (4) Health Assessment Questionnaire (HAQ, 0-3) < or = 0.5; (5) Physician global assessment of disease activity (0-10) < or = 1.5; (6) Patient global assessment of disease activity (0-10) < or = 2; (7) ESR < or = 20. This set of 2 definitions gained approval of 73% of the attendees. These (and other) definitions will now be subject to further validation in other databases.
Arthritis, Rheumatoid↗
Challenges and progress in adverse event ascertainment and reporting in clinical trials.
Toxicity, safety, and tolerability are integral facets of patient risk/benefit decisions, yet the capacity to define, measure, and compare these aspects is underdeveloped compared to aspects of efficacy. There are many reasons for this, scientific and administrative, but all are surmountable. Probably the greatest primary obstacle is the absence of a measurement instrument designed specifically for this purpose. There are increasing calls from various stakeholders for better evidence, and therefore better ascertainment, in this area, especially in randomized trials, and for these reasons OMERACT began deliberations about these concepts in 1994. A prototype coding instrument (the Rheumatology Common Toxicity Criteria) was developed and discussed at OMERACT 5. In the 2 years before OMERACT 7, a process of concept development and iterative design and testing were conducted to develop a patient self-report and investigator-reported adverse event instruments designed for use in trials at the time of visit. The predominant workload is performed by the patient in a self-report checklist, which is then mapped by the trialist onto a medically sophisticated version. This article presents background on the process of developing a dual adverse event instrument, which was presented and critically discussed in detail at OMERACT 7.
Adverse Drug Reaction Reporting Systems↗
Standardized assessment of adverse events in rheumatology clinical trials: summary of the OMERACT 7 drug safety module update.
A presentation, demonstration, and discussion of recently developed adverse event instruments were the topics for the OMERACT 7 Drug Safety Module. The module began with a plenary introducing the needs and challenges of adverse event ascertainment. It was followed by a review of module work from previous OMERACT meetings on a prototype coding instrument (Rheumatology Common Toxicity Criteria), then a brief description of the process behind the recently developed patient self-report and investigator report adverse event instruments. These current instruments are designed for use in controlled trials although they could be used in other settings. The instruments rely primarily on patient self-reporting using a checklist, which the investigator then folds into a parallel structured but more medically sophisticated instrument. In pilot testing, this innovative dual-use system has shown reliability and acceptability, while preserving validity. A "stakeholder panel" of representatives from 8 sectors followed--patient, nurse investigator, regulator, clinician scientist, industry, OMERACT, global public health/WHO, and Cochrane Collaboration--for their perspectives on the needs, challenges, and potential ways forward for adverse event ascertainment and reporting in clinical trials. At the breakout session small focus groups participated in hands-on interactive testing of one of 3 versions of the instruments, which differ in degree of comprehensiveness. Each focus group had a participatory patient with rheumatoid arthritis. At a second plenary there was group feedback by rapporteurs and presentation of results from pilot studies of iterative testing of validity, reliability, and feasibility of the instruments. During plenary discussion a frequent suggestion for improvement was to refine the process so that event ascertainment could be done entirely using the patient instrument with minimal input from the investigator at the visit, if patient-investigator agreement was high. Most found the patient checklist attractive, particularly if the patient instrument was shown to be reliable and valid. Finally, a future research agenda was discussed.
Adverse Drug Reaction Reporting Systems↗
Attributes and skills of an effective musculoskeletal consumer.
The OMERACT 7 Effective Musculoskeletal Consumer Workshop brought together people with rheumatoid arthritis, healthcare professionals, and researchers to discuss what they thought made a musculoskeletal consumer effective at managing their disease. Preliminary work before OMERACT provided a draft list of potential characteristics of an effective consumer. Participants at the workshop provided feedback about the list including relevance, missing items, format, and language. The feedback provided was useful and will be incorporated into a revised list to aid in the development of an instrument to measure health consumer effectiveness.
Arthritis, Rheumatoid↗
Undergraduate teaching of complementary medicine.
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Australia↗
Bone and joint diseases: prevention and control.
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Australia↗
The impact of chronic illness: partnerships with other healthcare professionals.
Healthcare workforce shortfalls require a rethinking of models for delivering care to people with chronic disease. Chronic disease needs to be managed by a multiskilled team of healthcare professionals with specialist input. Education at undergraduate, graduate and postgraduate levels needs to prepare healthcare professionals for this new paradigm. Some tasks currently seen only as part of a doctor's purview could be performed by other trained professionals to allow doctors to concentrate on more appropriate activities. We need to explore new collaborations to deliver multidisciplinary healthcare for chronic disease and evaluate these for patient outcomes and cost effectiveness.
Aged↗
Medical workforce issues in Australia: "tomorrow's doctors--too few, too far".
The Australian medical workforce, like those of most developed countries, is increasingly "feminised" and exposed to the global market for doctors. Demand for healthcare services is increasing in the Australian community. Concern in relation to doctor shortages is increasing, particularly in rural areas. There should be greater flexibility for entry of highly-trained overseas doctors. There is an urgent need to increase medical school student intake. Issues of workforce practice, including "task" substitution, should be explored.
Australia↗
Impact of osteoarthritis on individuals and society: how much disability? Social consequences and health economic implications.
Osteoarthritis is a major cause of disability in both the developed and developing world. With the population aging, the prevalence of osteoarthritis is increasing and its consequences are impacting significantly on society. This is one of the reasons why osteoarthritis has been adopted as a major focus (along with osteoporosis, rheumatoid arthritis, back pain, and musculoskeletal trauma) by the global initiative--the Decade of Bone and Joint Disease. Adequate studies on the costs of osteoarthritis are urgently required so that cogent arguments can be made to governments to appropriately fund prevention and treatment programs for this condition. Its recognition as a major cause of disability, particularly in the aging population, should increase community focus on this important condition.
Aged↗
Academic absenteeism.
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Academic Medical Centers↗