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Abstract: Diabetes and chronic kidney disease (CKD) are two of the most prevalent co‐morbid chronic diseases in Australia. The increasing complexity of multi‐morbidity, and current gaps in health‐care delivery for people with co‐morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co‐morbid diabetes and CKD have not been co‐designed with stake‐holders or formally evaluated. Particular components of health‐care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self‐management by the patient; and upskill primary health‐care. Here we present an integrated patient‐centred model of health‐care delivery incorporating these components and co‐designed with key stake‐holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health‐professionals; and semi‐structured interviews of care‐givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient‐support through a phone advice line; and focused primary health‐care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient‐centred health‐care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas. [ABSTRACT FROM AUTHOR]

Background: Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers.Methods: This cross-sectional study recruited patients with diabetes and CKD (eGFR < 60 mL/min/1.73 m2) across 4 large hospitals. For each patient, questionnaires were completed examining clinical data, recommended care, and patient-reported barriers limiting health-care. Descriptive statistics, subgroup analyses by CKD stage and hospital, and analyses examining the relationship between health-care gaps and barriers were performed.Results: 308 patients, of mean age 66.9 (SD 11.0) years, and mostly male (69.5%) and having type 2 diabetes (88.0%), participated. 49.1% had stage 3, 24.7% stage 4 and 26.3% stage 5 CKD. Gaps between recommended versus received care were evident: 31.9% of patients had an HbA1c ≥ 8%, and 39.3% had a measured blood pressure ≥ 140/90 mmHg. The commonest barriers were poor continuity of care (49.3%), inadequate understanding/education about CKD (43.5%), and feeling unwell (42.6%). However, barriers associated with a failure to receive items of recommended care were inadequate support from family and friends, conflicting advice from and poor communication amongst specialists, the effect of co-morbidities on self-management and feeling unmotivated (all p < 0.05).Conclusions: Barriers to health-care varied across CKD stages and hospitals. Barriers associated with a deviation from recommended care were different for different items of care, suggesting that specific interventions targeting each item of care are required. [ABSTRACT FROM AUTHOR]

Aims: To quantify the association between opioid agonist treatment (OAT) and overdose death by age group; test the hypothesis that across different age groups, opioid overdose mortality is lowest during OAT with buprenorphine compared with time out of treatment or OAT with methadone; and test associations between OAT and opioid overdose mortality in the presence of chronic circulatory, respiratory, liver and kidney diseases., Design: Retrospective observational cohort study using linked administrative data., Setting: New South Wales, Australia., Participants: A total of 37 764 people prescribed OAT, 1 August 2002 and 31 December 2017., Measurements: OAT exposure, opioid overdose mortality and key confounders were measured using linked population data sets on OAT entry and exit, hospitalization, mental health care, incarceration and mortality. ICD-10 codes were used to define opioid overdose mortality and chronic disease groups of interest., Findings: Relative to time out of treatment, time in OAT was associated with a lower risk of opioid overdose death across all age groups and chronic diseases. Among people aged 50 years and older, there was weak evidence that buprenorphine may be associated with greater protection against opioid overdose death than methadone [generalized estimating equation (GEE) adjusted incident rate ratio (aIRR) = 0.47; 95% confidence interval (CI) = 0.21, 1.02; marginal structural models (MSM) aIRR = 0.49; 95% CI = 0.17, 1.41]. Buprenorphine was associated with greater protection against overdose death than methadone for clients with circulatory (MSM aIRR = 0.27; 95% CI = 0.11, 0.67) or respiratory (MSM aIRR = 0.26; 95% CI = 0.07, 0.94) diseases, but not liver (MSM aIRR = 0.59; 95% CI = 0.14, 2.43) or kidney (MSM aIRR = 1.16; 95% CI = 0.31, 4.36) diseases., Conclusions: Opioid agonist treatment (OAT) appears to reduce mortality risk in people with opioid use disorder who are older or who have physical comorbidities. Opioid overdose mortality during OAT with buprenorphine appears to be lower and reduced in clients with circulatory and respiratory diseases compared with OAT with methadone., (© 2023 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background: Health-care for co-morbid diabetes and chronic kidney disease (CKD) is often sub-optimal. To improve health-care, we explored the perspectives of general practitioners (GPs) and tertiary health-care professionals concerning key factors influencing health-care of diabetes and CKD.Methods: A total of 65 health professionals were purposively sampled from Australia's 2 largest cities to participate in focus groups and semi-structured interviews. Four focus groups were conducted with GPs who referred to 4 tertiary health services in Australia's 2 largest cities, with 6 focus groups conducted with tertiary health-care professionals from the 4 tertiary health services. An additional 8 semi-structured interviews were performed with specialist physicians who were heads of diabetes and renal units. All discussions were facilitated by the same researcher, with discussions digitally recorded and transcribed verbatim. All qualitative data was thematically analysed independently by 2 researchers.Results: Both GPs and tertiary health-care professionals emphasised the importance of primary care and that optimal health-care was an inter-play between patient self-management and primary health-care, with specialist tertiary health-care support. Patient self-management, access to specialty care, coordination of care and a preventive approach were identified as key factors that influence healthcare and require improvement. Both groups suggested that an integrated specialist diabetes-kidney service could improve care. Unit heads emphasised the importance of quality improvement activities.Conclusions: GPs and tertiary health-care professionals emphasised the importance of patient self-management and primary care involvement in the health-care of diabetes and CKD. Supporting GPs with an accessible, multidisciplinary diabetes-renal health service underpinned by strong communication pathways, a preventive approach and quality improvement activities, may improve health-care and patient outcomes in co-morbid diabetes and CKD. [ABSTRACT FROM AUTHOR]

Background: Allogenic blood and marrow transplant (allo-BMT) is an arduous treatment used increasingly for many life-threatening conditions. Recognition of the profound impacts of the long term and late effects is ever-growing, as is the healthcare workload (treatment burden) of survivorship., Purpose: To quantify the treatment burden of long-term survival following allo-BMT, regarding the range of health services, therapies and investigations accessed by survivors., Methods: A large, multi-centre cross-sectional survey of adult allo-BMT survivors transplanted between 2000 and 2012 in Sydney, Australia. Participants completed six validated instruments and one purposed designed for the study, the Sydney Post BMT Study (SPBS), answering questions relating to medication use, medical treatments, referrals, assessments and frequency of hospital/clinic attendance., Results: Of the 441 allo-BMT survivors, over a quarter who were more than 2 years post BMT attended the hospital clinic at least monthly, and 26.7% required a number of regular medical procedures (e.g. venesection, extracorpororeal photopheresis). Specialist medical and allied health referral was very common, and compliance with internationally recommended long-term follow-up (LTFU) care was suboptimal and decreased as time from BMT increased., Conclusion: Respondents reported a large medication (conventional and complementary), screening, assessment and health care burden., Implications for Cancer Survivors: Treatment burden contributes significantly to the 'workload' of survivorship and can have a severe and negative impact on BMT survivors, carers and the healthcare system-making it difficult to comply with optimal care. Clinicians must be primed with skills to identify survivors who are overburdened by the health care required for survival and develop strategies to help ease the burden., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Estimating the mortality risk of persons with diabetes can be challenging. Associated conditions such as cardiovascular disease can become the primary cause of mortality and the underlying contribution of diabetes not recorded. Alternative methods to assess mortality risk in people with diabetes would be useful., Objective: To evaluate an Australian pharmaceutical database to identify multi-morbidity cohorts associated with diabetes and determine mortality rates in these groups using prescription exchange cessation as a proxy event for death., Methods: Australian Pharmaceutical Benefits Scheme data covering the period 2003-14 were used. Persons with diabetes, cardiovascular diseases and dyslipidemia were identified using Anatomic Therapeutic Chemical codes allocated to their recorded dispensed treatments. People with combinations of these conditions were followed and the last recorded prescription exchange used as a proxy event for mortality. Age and gender specific mortality rates and mortality rate ratios for the multi-morbidity cohorts were then calculated from the number of deaths occurring within 10 years., Results: 346,201 individuals were identified as taking treatments for diabetes, dyslipidemia and cardiovascular conditions in 2004, 86,165 deaths occurred within 10 years of follow up. Overall crude mortality was 26.2/1,000 person years. Age specific mortality rates and rate ratios were calculated for various multi-morbidity groupings. Statin treatments improved the mortality rates associated with diabetes and cardiovascular disease in persons age >54 (Log-Rank <.001)., Conclusions: Administrative pharmaceutical data can be used to identify persons with diabetes and associated multi-morbidities. Proxy mortality events defined by the cessation of treatment can generate mortality rates, providing an alternative perspective for the assessment of mortality risk., Competing Interests: Statements of conflicts of interest: The authors have no conflicts of interest to declare.

The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty., (Copyright © 2019 Elsevier B.V. All rights reserved.)