Search

The development of community services to replace two long-stay psychiatric hospitals in the North East Thames Health Authority region of the UK has been the subject of a research programme since 1985. The economic evaluation is conducted by the Personal Social Services Research Unit; research results relating to the first five cohorts of hospital leavers are reported in this paper. When followed up 1 year after discharge, almost half of the sample were living in highly supported residential care units, most of which were managed by district health authorities. More than 40 services provided outside the accommodation facility were used by clients and, although contact with certain professionals remained constant, some changes in service use over time were marked. The average total cost of community care for this group was £ 493 per week (1992-93 prices), accommodation facility costs comprising approximately 85% of the total. In the new service configuration, district health authorities fund half of the costs of supporting the hospital leavers, 50% less than when they funded long-stay hospital placements. The rest of the funding burden is borne by a range of agencies, resulting in pressure on budgets and staff case loads. [ABSTRACT FROM AUTHOR]

Limited attention has been paid to the long-term physical health consequences experienced by CSA survivors. Research has found that CSA is often associated with increased health burden in adulthood. However, research in this area is plagued by a range of methodological difficulties, rendering it difficult to draw conclusions regarding the health status of CSA survivors. This research sought to investigate associations between child sexual abuse (CSA) victimisation and rates of subsequent healthcare utilisation. The forensic medical records of 2759 cases of CSA between 1964 and 1995 were linked to commonwealth Australian medical data recorded between 2010 and 2015. Differences in rates of health service utilisation during this five-year period were compared between CSA victims and a age and gender matched comparison cohort without known abuse history. CSA was associated with increased levels of attendance at health professionals (OR = 1.51, p <.001) for medical care and for consultations related to dental (OR = 1.28, p <.001) and chronic disease (OR = 1.23, p <.001). CSA was associated with lower mean rates of attendance at gynaecologists. Gender and age at abuse significantly influenced the relationship between CSA and frequency of health service utilisation. Experiencing CSA was associated with increases in rates of contact with health professionals. Abused females and victims abused after 12 years of age demonstrated the greatest elevations in rates of service utilisation. These findings have significance for both researchers in this field, and medical practitioners providing primary care. [ABSTRACT FROM AUTHOR]

Background: There is global interest in the reconfiguration of community mental health services, including primary care, to improve clinical and cost effectiveness., Aims: This study seeks to describe patterns of service use, continuity of care, health risks, physical healthcare monitoring and the balance between primary and secondary mental healthcare for people with severe mental illness in receipt of secondary mental healthcare in the UK., Method: We conducted an epidemiological medical records review in three UK sites. We identified 297 cases randomly selected from the three participating mental health services. Data were manually extracted from electronic patient medical records from both secondary and primary care, for a 2-year period (2012-2014). Continuous data were summarised by mean and s.d. or median and interquartile range (IQR). Categorical data were summarised as percentages., Results: The majority of care was from secondary care practitioners: of the 18 210 direct contacts recorded, 76% were from secondary care (median, 36.5; IQR, 14-68) and 24% were from primary care (median, 10; IQR, 5-20). There was evidence of poor longitudinal continuity: in primary care, 31% of people had poor longitudinal continuity (Modified Modified Continuity Index ≤0.5), and 43% had a single named care coordinator in secondary care services over the 2 years., Conclusions: The study indicates scope for improvement in supporting mental health service delivery in primary care. Greater knowledge of how care is organised presents an opportunity to ensure some rebalancing of the care that all people with severe mental illness receive, when they need it. A future publication will examine differences between the three sites that participated in this study.

In 2002, Thailand achieved Universal Health Coverage for all citizens; however, it remains the case that undocumented migrants are not fully covered. The Health Insurance Card Scheme (HICS) of the Ministry of Public Health is the key policy aiming to cover undocumented migrants. This study examined the impact of this policy on the utilisation rate of public health facilities among HICS beneficiaries including undocumented migrants. Facility-based individual records between 2011 and 2015 were purposively retrieved from one provincial hospital, one district hospital, and two health centres in one of the most densely migrant-populated provinces in Thailand. Poisson regression was conducted on inpatient (IP) utilisation, while negative binomial regression was conducted on outpatient (OP) utilisation. Of 74,722 admissions, 19.0% were insured by HICS. About 14.0% of the outpatient records were for HICS beneficiaries. Overall, the HICS utilisation rate in migrants was lower than in Thai patients. Being insured with the HICS significantly increased OP utilisation by 1.7%, and IP utilisation by 11.1% (relative to uninsured). Disease status was the most important factor that positively influenced the utilisation rate. Further studies that explore the differences in health service utilisation among HICS beneficiaries with diverse economic backgrounds are recommended.

Background: Frailty makes older people vulnerable to poor outcomes and in need of intensive management to remain living at home. An integrated package of services is suggested and the model of care recommended includes; comprehensive geriatric assessment, a single access point, case management, multidisciplinary input and financial incentives to promote downward substitution. Developing a model of care requires evidence of baseline patterns in service-use, however a scoping review revealed these were often not provided in the literature on new models of integrated care for frail older people. This study describes the community-living frail older Irish population, examines their patterns of service-use and their experiences of seeking, securing and managing services, to better inform the design of future care. Methods: A sequential explanatory mixed methods design was operationalised. Data was obtained from wave one of the Irish Longitudinal Study on Ageing (TILDA) for those aged ≥65 years (n=3,422). Multivariate regression techniques examined the impact of frailty, measured by the Frailty Index, on utilisation of various hospital and community services adjusting for need, predisposing and enabling factors. Next, latent class analysis identified profiles of service-use among the TILDA participants classified as frail (n=745). Finally, data from semi-structured interviews with a qualitative sample of frail older people (n=12) examined why service-use profiles occur. Results: 24% (95%CI: 23-26) of the Irish older population were classified as frail. Frailty was a significant predictor of utilisation across many types of services adjusting for other factors. However, patterns of service use by frail older people differed. The majority (52% ±0.2) were Non-Users of services, 26% (±0.2) were Community-Care Users, a fifth (20%±0.1) were Hospital-Care Users, while 2% (±0.0) were both Hospital-and-Community Care Users. Factors which impeded access to services included community services which were only activated upon hospital discharge following a severe health event; long waiting times for specialist hospital services and a lack of services to address psychosocial needs in a meaningful way. Factors which facilitated access to services included the Public Health Nurse service which provided navigation and referral to wider community services. Discussion: The findings together indicate a supply-constrained, hospital-centric healthcare system which fails to proactively manage the needs of the frail older population. Receiving community services is a rarity rather than the norm, and these are utilised mainly by the very-frail (FI >0.40). Rather, the majority of frail older people rely on hospital and General Practitioner services only. Financial constraints such as poorly-resourced community services, and structural constraints such as inflexible budgets, meant that the required intervention was not available at the right time. Conclusions: Since the frail older population comprises a diverse set of service users, new models of care should be designed to reflect that diversity. An evidence-based approach to service re-design is advised since healthcare systems function differently. Limitations: The qualitative sample had in general high frailty scores, which limited the scope of this study to explain diverse service use profiles. Suggestions for future research: We recommend investigating the impact of service-use profiles by examining longitudinal health outcomes. [ABSTRACT FROM AUTHOR]

Background: Since 2009, community-based hypertension monitoring service (CBHMS) has been provided free of charge by the Chinese government as part of the national Essential Public Health Services (EPHS) policy. This study aimed to examine the disparity in the utilization of CBHMS between urban and rural community-dwelling middle-aged and older adults with hypertension., Methods: Subjects were 3,479 community-residing hypertensive patients, identified from the China Health and Retirement Longitudinal Study (CHARLS), 2015, a nationally representative survey of Chinese residents aged 45 years and older. The utilization of CBHMS was defined as having one's blood pressure (BP) examined at least once a season by community or village doctors. Rates of CBHMS use of urban and rural residents with hypertension were compared by using chi-square test. Multiple logistic regression analyses were conducted to examine factors associated with the utilization of CBHMS of hypertensive patients., Results: CBHMS was significantly more likely to be used by rural than urban middle-aged and older residents with hypertension (38.6% vs. 25.1%, P  < 0.001). Results from multiple logistic regression analyses showed that urban patients who were living in central (OR = 0.37) and western (OR = 0.48) regions (vs. eastern region), had an educational attainment of middle school (OR = 0.33) and college and above (OR = 0.48) (vs. illiterate), and were not taking antihypertensive agents (OR = 0.26) were less likely to use CBHMS, while rural patients who had no medical insurance (OR = 0.56), and were not taking antihypertensive agents (OR = 0.31) were less likely to use CBHMS., Conclusions: The national CBHMS is more likely to be used by rural middle-aged and older adults with hypertension in China. The urban-rural difference in the utilization of CBHMS may be resulted from the different demographics of urban and rural middle-aged and older residents and uneven distributions of health services resources between urban and rural areas. Urban-rural disparities in characteristics of CBHMS use should be taken into consideration when promoting the utilization of CBHMS in China., Competing Interests: The authors declare there are no competing interests., (©2019 Song et al.)

Background: Refugees and asylum seekers often have increased mental health needs, yet may face barriers in accessing mental health and psychosocial support (MHPSS) services in destination countries. The aim of this systematic review is to examine evidence on MHPSS service utilisation and access among refugees and asylum seekers in European Union Single Market countries., Methods: Four peer-reviewed and eight grey literature databases were searched for quantitative and qualitative literature from 2007 to 2017. Access was categorised according to Penchansky and Thomas' framework and descriptive analyses were conducted. Quality of studies was assessed by the Newcastle-Ottawa scale and the Critical Appraisal Skills Programme checklist., Results: Twenty-seven articles were included. The findings suggest inadequate MHPSS utilisation. Major barriers to accessing care included language, help-seeking behaviours, lack of awareness, stigma, and negative attitudes towards and by providers., Conclusions: Refugees and asylum seekers have high mental health needs but under-utilise services in European host countries. This underutilisation may be explained by cultural-specific barriers which need to be tackled to increase treatment demand. Training health providers on cultural models of mental illness may facilitate appropriate identification, referral, and care. Based on these findings, it is crucial to review policies regarding MHPSS provision across the EU., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: High-risk injection behaviors are associated with high prevalence of mental health problems among people who inject drugs (PWID). However, whether the use of mental health services is associated with lower risk of sharing injection material remains undetermined. This study aims to examine the association between mental health service utilisation and receptive sharing risk, and determine the potential modifying effect of psychological distress on this association., Methods: Participants answered an interviewer-administered questionnaire at 3-month intervals gathering information on sociodemographic characteristics, substance use and related behaviors, services utilisation and significant mental health markers. Relationship between the use of mental health services and receptive sharing was modeled using the generalized estimating equation (GEE), controlling for age at baseline, gender, and other potential confounders. Psychological distress was estimated using the Kessler Psychological Distress Scale (K10). Effect modification was investigated by adding an interaction term in the univariate GEE analysis., Results: 358 participants contributed to 2537 visits (median age 40.3, 82% male). Mental health service utilisation was reported in 631 visits (25%), receptive sharing in 321 visits (13%) and severe psychological distress in 359 visits (14%). In multivariate GEE analyses, a significant association was identified between receptive sharing and the use of mental health services (aOR = 0.69; 95% CI = 0.50-0.94). We found no evidence of effect modification by psychological distress., Conclusion: Among PWID, mental health service utilisation was associated with lower likelihood of receptive sharing, regardless of level of psychological distress. These findings should be taken into account when designing harm reduction strategies for this population., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The relationship between ethnicity, service use and perceptions of service effectiveness is inconclusive. This study examined differences in service use and perceptions of service effectiveness between Israeli Jewish (Jewish) and Israeli Arab (Arab) parental caregivers of individuals with intellectual disabilities and dual diagnosis of psychopathology., Methods: Parental caregivers (n = 186) of individuals with intellectual disabilities or dual diagnosis, aged 10 to 30 years, completed a self-report questionnaire., Results: Arab parental caregivers perceived health services to be more accessible than did Jewish caregivers, but there was no difference between the two groups in the use of the services. Overall, greater enabling factors and accessibility were associated with higher use of education and social services. No differences were found between the groups in their perceptions of service effectiveness., Conclusion: Arab family caregivers use education and social services less than do their Jewish peers, possibly because they have fewer enabling resources. The finding that both groups reported similar use of health services may be explained by a shared perception that informal help may not be suitable for dealing with situations of psychopathology. The similar perceptions of service effectiveness may be explained by extensive services available in Israel, to the satisfaction of both groups, or by the fact that participants perceived these services as their only alternative, and therefore fear losing them., (© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.)

Objective: Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic)., Methods: We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008-2010 (Mental Health Act 1986) and 2014-2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge - whether by the treating psychiatrist, external body or through expiry., Results: Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge - 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) - and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014., Conclusion: The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.

Background: Palliative care (PC) and psychosocial care (PSC) are essential services, which can positively impact on quality of life in patients with metastatic lung cancer, when advanced disease and poor prognosis preclude the use of curative therapies. The aims of this study were to describe patterns of PC and PSC and identify factors associated with service utilisation and overall patient survival., Method: A retrospective Australian cohort of South Western Sydney residents with newly diagnosed stage IV non-small cell lung cancer (NSCLC) in 2006-2012 was identified from the Local Health District Clinical Cancer Registry. Supplemental information was sourced from the area PC database and hospital medical records. Cox regression models with robust variance identified factors associated with PC and PSC and examined patient survival., Results: A total of 923 patients were identified. Eighty-three per cent of patients were seen by PC, with 67% seen within 8 weeks of diagnosis. PSC utilisation was 82%. Radiotherapy treatment and residential area were associated with both PC and PSC. Increasing age was associated with early PC referral. Median overall survival was 4 months. PC was associated with patient survival; however, the effect varied over time., Conclusion: The rate of PC and PSC in our metastatic NSCLC population was high when compared with published data. Despite this, there were gaps in PC and PSC provision in this population, notably with patients not receiving active treatment, and those receiving systemic therapy utilising these services less frequently. PSC and PC contact were not convincingly associated with improved patient survival.

Objective: This paper reports on substance use, mental health problems, and mental health service utilisation in an early adolescent school-based sample., Method: Participants were 1,360 grade 7 and 8 students from 4 regions of Ontario, Canada. Students completed an in-class survey on mental health and substance use. The sampling strategy and survey items on demographics, substance use, service utilisation, and distress were adapted from the Ontario Student Drug Use and Health Survey. Internalising and externalising mental health problems were assessed using the Global Assessment of Individual Needs - Short Screener. Distress was defined as fair or poor self-rated mental health., Results: Rates of internalising and/or externalising problems above the threshold exceeded 30%; yet, fewer than half had received mental health services in the past 12 mo. Substance use was associated with increased odds of internalising and externalising problems above the threshold and distress. Youth using cannabis had 10-times the odds of exceeding the threshold for internalising or externalising problems. The use of substances other than alcohol or cannabis was associated with increased odds of fair or poor self-rated mental health among grade 8 students. Of the youth who confirmed at least a substance use problem, most also reported mental health problems; this association was stronger among girls than boys., Conclusions: Early adolescent substance use was associated with concurrent self-reported mental health problems in a non-clinical sample. The low levels of service utilisation reported highlight the need for improved access to early identification and intervention to prevent the development of concurrent disorders.

Introduction: A common problem low-income and middle-income countries face is the scarcity of community-based rehabilitation (CBR) resources and low service utilisation among persons with severe mental illness (SMI). Despite this problem, the factors and pathways followed influencing one's decision on service utilisation in China have not been fully comprehended. This study aims to develop a theory-based model that systematically describes the integrated decision-making process of mental health CBR utilisation among persons with SMI in China., Methods/design: This cross-sectional, mixed-methods study involves three main stages and is expected to last 3 years, from January 2018 to December 2020. In stage 1, the Social Exchange Theory is deployed as an analytical framework to comprehensively capture factors associated with tendency to use CBR services in China using semistructured interview methodology involving patients with SMI, their primary caregivers and CBR service providers. In stage 2, interpretive structural modelling will be applied to analyse the relationships between factors in different dimensions, at different levels and with different levels of impact. Stage 3 involves a multiregion survey among at least 300 family decision-makers (either the patient or their caregivers) in six communities in three cities to statistically validate the initial model derived in stage 2 using a further structural equation modelling., Ethics and Dissemination: Ethical approval was granted by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (No 2017S319). All interviewees will be provided with written information about the study, and a signed consent will be retrieved prior to the interview. Rules on confidentiality and anonymity of data will be strictly followed. The findings of this study will be disseminated via international and domestic peer-reviewed journals, reports, conference presentations and symposium discussions. Reports will be submitted to the National Natural Science Foundation of China., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Little is known about outcomes of drug abuse related to attainment of stable housing. This study examined outcomes of cocaine use and service provision in an urban homeless sample., Methods: Two-year longitudinal study of systematically selected homeless individuals (N = 255) in St. Louis, Missouri from 1999 to 2001. The sample was interviewed three times annually using a structured diagnostic interview. Urine drug testing was conducted at every interview, and service utilisation data were obtained from the structured interviews and the agency-provided service use data., Results: Cocaine use disorder and cocaine use proved to be distinct concepts because they predicted different outcomes across time. Cocaine use predicted subsequent poor housing outcomes, but stable housing had no apparent effect on subsequent use of cocaine. Service use predicted neither subsequent reduced cocaine use nor attainment of stable housing. Services used were appropriate to type of mental health need, but cocaine use may have reduced successful utilisation of appropriate psychiatric services., Conclusion: These findings reinforce the concept that homelessness represents a complex phenomenon and consequently, service systems need to address multiple problems. Service approaches are needed that simultaneously address the complex needs of homeless individuals.

We explored the relationship between unmet care needs, health status, health utility and costs in people treated for melanoma via a cross-sectional follow-up survey (N = 455) 3 months to 5 years after complete resection of stage I-III cutaneous malignant melanoma. 51% (n = 232) had unmet care needs. This group had higher mean resource use, estimated conservatively (£28 vs. £10 per person) and worse overall health. Mean health-related utility index (AQoL6D) was 0.763 (95% CI 0.74; 0.79) in those with self-reported unmet need vs. 0.903 (0.89; 0.92) in those with no unmet need. Melanoma survivors with unmet need had worse outcomes in terms of anxiety (HADS 6.86 vs. 4.29), depression (HADS 4.29 vs. 2.01), overall quality of life (QoL: FACT-M 84.2 vs. 96.5). Higher resource use was associated with younger age (r s  = -.29, p < .001), older school-leaving age (r s  = .21, p < .001), reduced health utility (r s  = -.14, p = .005), higher anxiety (r s  = .22, p < .001), higher depression (r s  = .16, p = .001) and lower QoL (overall r s  = -.24, p < .001; melanoma QoL r s  = -.20, p < .001; surgery QoL r s  = -.19, p < .001). Lower health outcomes indicate increased service use, suggesting that interventions to address unmet need and improve health outcomes may reduce health costs. Integrated clinical and economic evaluations of interventions that target unmet need in melanoma survivors are required., (© 2018 John Wiley & Sons Ltd.)

Purpose: People with intellectual disability are a minority group who experience poorer physical and mental health than the general population and have difficulty accessing healthcare services. There is lack of knowledge about healthcare service needs and gaps experienced by people with intellectual disability. This study aims to interrogate a large linked administrative data set containing hospital admissions, presentations to emergency departments (ED) and mortality data to provide evidence to inform the development of improved health and mental health services for this population., Participants: A retrospective cohort of people with intellectual disability (n=51 452) from New South Wales (NSW), Australia, to explore health and mental health profiles, mortality, pattern of health service use and associated costs between 2005 and 2013. The cohort is drawn from: the Disability Services Minimum Data Set; Admitted Patients Data Collection; Emergency Department Data Collection, Australian Bureau of Statistics Death Registry and Registry of Births, Deaths and Marriages. Mental health service usage among those with intellectual disability will be compared to a cohort of people who used mental health services (n=1 073 139) and service usage other than for mental health will be compared with published data from the general population., Findings to Date: The median age of the cohort was 24 at the time of the last hospital admission and 21 at the last ED presentation. The cohort has a higher proportion of men than women and accounts for 0.6% of the NSW population in 2011. Over 70% had up to 5 ED presentations and hospitalisations between 2005 and 2012. A high proportion of people with intellectual disability live in the most disadvantaged neighbourhoods., Future Plans: Results will be used to inform the development of more responsive healthcare, including improved interactions between health, social and disability supports. More generally, the results will assist the development of more inclusive policy frameworks for people with intellectual disability., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

While much literature documents the mental health needs of young people from refugee backgrounds, and the barriers they face in accessing mental health services, researchers have yet to document the perspectives of service users from this population about their contacts with clinicians and services. We therefore individually interviewed 16 young people (aged 18-25 years) who were refugees about their experiences of seeing mental health professionals. Participants were born in 9 different countries and had lived in Australia for an average of 5.2 years. They placed most emphasis on in-session factors, and particularly on interpersonal considerations. Among the main themes identified via thematic analysis were the practitioner's sensitivity to the young person's cultural background and to the stressors affecting him or her, including traumatic refugee experiences, and the therapeutic relationship-especially the qualities of trust, understanding, respect, and a caring connection. The participants had diverse reactions to treatment strategies. They emphasised the role of their preconceptions around mental health services, and called for systematic mental health awareness-raising for young people from refugee backgrounds. Implications for research, policy, and practice are discussed with a focus on findings that may guide efforts to improve service acceptability, accessibility, and effectiveness. In particular, there is a need for practitioners to attend to their clients' experiences of sessions, to adopt an attuned, contextualised, systemic approach, and especially to take a nuanced approach to cultural sensitivity.

The majority of people with dementia live at home, and informal carers assume the role of key care providers, often supported by formal services. The purpose of this pilot study was to assess home-based care arrangements, to illustrate utilisation of formal services over time and to identify factors associated with perceived stability of the care situation from the informal carer's perspective. A self-administered questionnaire (D-IVA 'Instrument for Assessing Home-Based Care Arrangements for People with Dementia') was developed and distributed in a provincial-rural setting in Germany as a cross-sectional survey. Data analysis used descriptive statistics, unbiased conditional inference trees and thematic analysis for open-ended questions. In total, 84 care arrangements were assessed. The majority of participants were direct relatives of the care-dependent person [mostly adult children (48.8%) or spouses (27.4%)]. Formal services were already sought in the first year after onset of memory problems. The most frequently used formal services were home care nursing services (53.0%), day care (49.4%) and respite care (29.6%), whereas 15.5% did not use any type of formal support. Companion home visit, home care nursing service and day care were used over the longest periods of time. The recruitment strategy used in this study may have recruited persons who were relatively more dependent on their informal carers. In this small sample, carers' perceived stability of the care situation was high, and this was associated with the country of origin and sex of the person with dementia (P = 0.004 and 0.023 respectively). Most care arrangements consisted of a mix of informal and formal services. However, informal carers assumed prime responsibility. The questionnaire D-IVA proved to be suitable. It remains a challenge to further examine factors associated with perceived stability and to explain the phenomenon in its whole complexity. Further research using the D-IVA should consider applying complementing quantitative measures as well as qualitative methods., (© 2015 John Wiley & Sons Ltd.)

Objectives: To explore the interaction of computed tomography (CT) use, dose and radiation risk of Australian Medicare-funded CT scanning and the impact on cancer incidence and mortality., Methods: This retrospective cohort study used records of Medicare subsidised CT scans in Australia (2006/07 to 2011/12) and Australian CT dosimetry. The annual number, rate and adjusted likelihood of CT were determined for gender, age and examination type. Incident cancer and cancer-related mortality attributable to CT in Australia were estimated using lifetime attributable risk coefficients, dosimetry and scan numbers., Results: The number of CT scans increased by 36% from 2006/07 to 2011/12. Only patients aged 0-4 years did not present an increase in CT scanning rates. Females were 11% more likely to be scanned than males. Head, abdomen/pelvis and spine CT scans were the most likely areas scanned. Females were attributed 61% of both incident cancers and cancer-related mortality from 55% of scans performed. Patients aged 15-44 years were attributed 37% of incident cancers and 30% of cancer-related mortality from 26% of CT scans., Conclusions: CT in Australia is increasing, including in groups at higher risk from ionising radiation. This presents a complex set of risk/benefit considerations for clinicians and policy makers., (© 2014 Public Health Association of Australia.)