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Refereed/Peer-reviewed Objectives: To examine the incidence and trends in primary care, allied health, geriatric, pain and palliative care service use by permanent residential aged care (PRAC) residents and the older Australian population. Methods: Repeated cross-sectional analyses on PRAC residents (N = 318,484) and the older (≥65 years) Australian population (N ~ 3.5 million). Outcomes were Medicare Benefits Schedule (MBS) subsidised primary care, allied health, geriatric, pain and palliative services between 2012–13 and 2016–17. GEE Poisson models estimated incidence rates and incidence rate ratios (IRR). Results: In 2016–17, PRAC residents had a median of 13 (interquartile range [IQR] 5–19) regular general medical practitioner (GP) attendances, 3 (IQR 1–6) after-hours attendances and 5% saw a geriatrician. Highlights of utilisation changes from 2012–13 to 2016–17 include the following: GP attendances increased by 5%/year (IRR = 1.05, 95% confidence interval [CI] 1.05–1.05) for residents compared to 1%/year (IRR = 1.01, 95%CI 1.01–1.01) for the general population. GP after-hours attendances increased by 15%/year (IRR = 1.15, 95%CI 1.14–1.15) for residents and 9%/year (IRR = 1.08, 95%CI 1.07–1.20) for the general population. GP management plans increased by 12%/year (IRR = 1.12, 95%CI 1.11–1.12) for residents and 10%/year (IRR = 1.10, 95%CI 1.09–1.11) for the general population. Geriatrician consultations increased by 28%/year (IRR = 1.28, 95%CI 1.27–1.29) for residents compared to 14%/year (IRR = 1.14, 95%CI 1.14–1.15) in the general population. Conclusions: The utilisation of most examined services increased in both cohorts over time. Preventive and management care, by primary care and allied health care providers, was low and likely influences the utilisation of other attendances. PRAC residents' access to pain, palliative and geriatric medicine services is low and may not address the residents' needs.

Background Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes. Methods Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions. Results Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335). Conclusion Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed. Review registration CRD42021215698.

Refereed/Peer-reviewed

The aims of this work were to create a robust automatic software tool for measurement of the levator hiatal area on transperineal ultrasound (TPUS) volumes and to measure the potential reduction in variability and time taken for analysis in a clinical setting. The proposed tool automatically detects the C-plane (i.e., the plane of minimal hiatal dimensions) from a 3-D TPUS volume and subsequently uses the extracted plane to automatically segment the levator hiatus, using a convolutional neural network. The automatic pipeline was tested using 73 representative TPUS volumes. Reference hiatal outlines were obtained manually by two experts and compared with the pipeline's automated outlines. The Hausdorff distance, area, a clinical quality score, C-plane angle and C-plane Euclidean distance were used to evaluate C-plane detection and quantify levator hiatus segmentation accuracy. A visual Turing test was created to compare the performance of the software with that of the expert, based on the visual assessment of C-plane and hiatal segmentation quality. The overall time taken to extract the hiatal area with both measurement methods (i.e., manual and automatic) was measured. Each metric was calculated both for computer-observer differences and for inter-and intra-observer differences. The automatic method gave results similar to those of the expert when determining the hiatal outline from a TPUS volume. Indeed, the hiatal area measured by the algorithm and by an expert were within the intra-observer variability. Similarly, the method identified the C-plane with an accuracy of 5.76 ± 5.06° and 6.46 ± 5.18 mm in comparison to the inter-observer variability of 9.39 ± 6.21° and 8.48 ± 6.62 mm. The visual Turing test suggested that the automatic method identified the C-plane position within the TPUS volume visually as well as the expert. The average time taken to identify the C-plane and segment the hiatal area manually was 2 min and 35 ± 17 s, compared with 35 ± 4 s for the automatic result. This study presents a method for automatically measuring the levator hiatal area using artificial intelligence-based methodologies whereby the C-plane within a TPUS volume is detected and subsequently traced for the levator hiatal outline. The proposed solution was determined to be accurate, relatively quick, robust and reliable and, importantly, to reduce time and expertise required for pelvic floor disorder assessment. ispartof: ULTRASOUND IN MEDICINE AND BIOLOGY vol:47 issue:12 pages:3470-3479 ispartof: location:England status: published

Transperineal volumetric ultrasound (TPUS) imaging has become routine practice for diagnosing anorectal dysfunction, a life-challenging pelvic floor dysfunction (PFD). To assess the integrity of the whole length of the anal sphincter from three-dimensional (3D) ultrasound (US) data, sonographers first extract a tomographic US imaging (TUI) sequence from the TPUS recording. TUI sequences consist of eight equally spaced and properly oriented two-dimensional (2D) coronal-view slices of the anal sphincter complex. TUI sequences are visually assessed by a sonographer to diagnose anal sphincter injury. Obtaining TUI sequences is performed manually in clinical practice, which is labour-intensive and requires expert knowledge of pelvic floor anatomy. To the best of our knowledge, this work is the first to report an automatic method to aid this medical imaging acquisition task. We propose a novel, convolutional neural network (CNN) approach for the automatic extraction of the TUI sequences from a TPUS. The method utilises a CNN to segment the external anal sphincter (EAS), and the desired TUI sequences are subsequently extracted after several automatic post-processing steps. The proposed method is evaluated on 30 TPUS recordings and compared against manually acquired gold standard TUI sequences. One expert evaluated the quality of the automatically detected TUI sequences in terms of their clinical acceptability for diagnosis. The automatic method performs with an overall clinical acceptability of \(90.00\%\). The method reduces the time required to extract the anal sphincter complex TUI sequence of a TPUS by 52.36 s and may reduce the need for high-level expertise in anorectal dysfunction analysis.

Automatic medical image segmentation via convolutional neural networks (CNNs) has shown promising results. However, they may not always be robust enough for clinical use. Sub-optimal segmentation would require clinician's to manually delineate the target object, causing frustration. To address this problem, a novel interactive CNN-based segmentation framework is proposed in this work. The aim is to represent the CNN segmentation contour as B-splines by utilising B-spline explicit active surfaces (BEAS). The interactive element of the framework allows the user to precisely edit the contour in real-time, and by utilising BEAS it ensures the final contour is smooth and anatomically plausible. This framework was applied to the task of 2D segmentation of the levator hiatus from 2D ultrasound (US) images, and compared to the current clinical tools used in pelvic floor disorder clinic (4DView, GE Healthcare; Zipf, Austria). Experimental results show that: 1) the proposed framework is more robust than current state-of-the-art CNNs; 2) the perceived workload calculated via the NASA-TLX index was reduced more than half for the proposed approach in comparison to current clinical tools; and 3) the proposed tool requires at least 13 seconds less user time than the clinical tools, which was significant (p=0.001)., Comment: 11 pages, 3 figures, 2 tables

Aim: Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children. Methods: We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children. Results: We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices. Conclusions: Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME Refereed/Peer-reviewed

Pelvic organ prolapse (POP) decreases the quality of life for many women. To assess POP, the levator hiatus is segmented in a 2D plane of minimal hiatal dimensions, known as the C-plane. In order to automate plane detection, landmark information of key structures should be given to a plane detection algorithm. In this work, we present a fully automatic method to segment the urethra from a 3D transperineal ultrasound volume using a convolutional neural network (CNN). A dataset with 35 volumes from 20 patients during the Valsalva manoeuver (i.e. Valsalva, contraction and rest) labelled by an expert, was used for training and evaluation in a 5-fold cross-validation process. The 3D CNN model yielded an average robust Hausdorff distance of 4.68mm (95 percentile) which was comparable to intra-observer results.

BackgroundIn order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities.MethodsClinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care.ResultsFrom 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit).ConclusionA set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

Objectives: To determine the proportion of care provided to children with acute gastroenteritis (AGE) in Australia consistent with clinical practice guidelines. Methods: Indicators were developed from national and international clinical practice guideline (CPG)recommendations and validated by an expert panel. Medical records from children 15years presenting with AGE in three healthcare settings-Emergency Department (ED), hospital admissions and General Practitioner (GP) consultations-from randomly selected health districts across three Australian States were reviewed. Records were audited against35 indicators by trained paediatric nurses, to determine adherence to CPGs during diagnosis,treatment, and ongoing management. Results: A total of 14,434 indicator assessments were performed from 854 healthcare visits for AGE by 669 children, across 75 GPs, 34 EDs and 26 hospital inpatient services. Documented adherence to guidelines across all healthcare settings was 45.5% for indicators relating to diagnosis (95% CI: 40.7-50.4), 96.1% for treatment (95% CI: 94.8-97.1) and 57.6% for ongoing management (95% CI: 51.3-63.7). Adherence varied by healthcare setting, with adherence in GPs (54.6%; 95% CI: 51.1-58.1) lower than for either ED settings (84.7%;95% CI: 82.4-86.9) or for inpatients (84.3%; 95% CI: 80.0-87.9); p

Objective: The aims of this study were twofold: (1) to design and validate a set of clinical indicators of appropriate care for tonsillitis and (2) to measure the level of tonsillitis care that is in line with guideline recommendations in a sample of Australian children Study design: A set of tonsillitis care indicators was developed from available national and international guidelines and validated in 4 stages. This research used the same design as the CareTrack Kids study, which was described in detail elsewhere Setting: Samples of patient records from general practices, emergency departments, and hospital admissions were assessed Subjects and methods: Patient records of children aged 0 to 15 years were assessed for the presence of, and adherence to, the indicators for care delivered in 2012 and 2013 Results: Eleven indicators were developed. The records of 821 children (mean age, 5.0 years; SD, 4.0) with tonsillitis were screened. The reviewers conducted 2354 eligible indicator assessments across 1127 visits. Adherence to 6 indicators could be assessed and ranged from 14.3% to 73.2% (interquartile range 31.5% to 72.2%). Conclusion: Our main findings are consistent with the international literature: the treatment of many children who present with confirmed or suspected tonsillitis is inconsistent with current guidelines. Future research should consider how the indicators could be applied in a structured and automated manner to increase the reliability and efficiency of record reviews and help raise clinicians' awareness of appropriate tonsillitis management. Refereed/Peer-reviewed

IMPORTANCE The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. OBJECTIVE To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. DESIGN, SETTING, AND PARTICIPANTS Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4] , acute infection [n = 7], and injury [n = 1] ), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. EXPOSURES Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. MAIN OUTCOMES AND MEASURES Quality of care for each clinical condition and overall. RESULTS Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. Adherence to quality of care indicators was estimated at 59.8% (95% CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95% CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95% CI, 36.8%-50.4%; n = 2354) for tonsillitis. The mean adherence by condition category was estimated as 60.5% (95% CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95% CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95% CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95% CI, 75.1%-81.2%; n = 10 278) for injury. CONCLUSIONS AND RELEVANCE Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate. Refereed/Peer-reviewed

ObjectiveTo assess the proportion of Australian children aged 0–15 years that received care in line with clinical practice guidelines (CPGs) for upper respiratory tract infections (URTIs).DesignRetrospective medical record review using a multistage sampling strategy.SettingGeneral practices, hospital emergency departments and hospital inpatient service providers in three Australian states.ParticipantsChildren aged up to 15 years who received care for URTI in 2012 and 2013.Primary and secondary outcome measuresThe primary assessment was estimated adherence with 14 indicators of appropriate care as documented in medical records. Indicators were extracted from national and international CPGs and ratified by experts. Secondary assessment was adherence to two bundles of indicators (diagnostic symptoms and medical history taking), where all indicators must be adherent for the bundle to be scored as adherent.ResultsThere were 1653 children with one or more assessments of URTI care to CPG adherence. Over half of the children were under 3 years of age, with roughly equal numbers of males and females. Three indicators had fewer than 25 visits so were not reported. Overall adherence ranged from 0.5% for ‘documented advice around antibiotics’ to 88.3% for ‘documentation of medical history’. Adherence with Bundle A (documentation of all three definitive symptoms) was 43.1% (95% CI 32.8% to 54.0%) and Bundle B (documentation of all four indicators of medical history) was 30.2% (95% CI 20.9% to 40.9%).ConclusionsURTIs in children are common, usually self-limiting, conditions that are allocated considerable resources. The results suggest that there may be a need for more thorough holistic assessment of the patient and improved documentation. Since inappropriate prescription of antibiotics for URTIs is still a known problem in Australia, there is a need for consistent, clear communication around antibiotics’ lack of impact on symptoms and a high association with undesirable side effects.

Background: To address the growing burden of disease and long waiting lists for sleep services, a simplified two-stage model was developed and validated for identifying obstructive sleep apnoea (OSA) in primary care using a screening questionnaire followed by home sleep monitoring. Methods: 157 patients aged 25–70 years attending their primary care physician for any reason at six primary care clinics in rural and metropolitan regions of South Australia participated. The first 79 patients formed the development group and the next 78 patients the validation group. A screening questionnaire was developed from factors identified from sleep surveys, demographic and anthropometric data to be predictive of moderate to severe OSA. Receiver operating characteristic (ROC) curve analysis was used to validate the two-channel ApneaLink device against full polysomnography. The diagnostic accuracy of the overall two-stage model was then evaluated. Results: Snoring, waist circumference, witnessed apnoeas and age were predictive of OSA and incorporated into a screening questionnaire (ROC area under curve (AUC) 0.84, 95% CI 0.75 to 0.94, p

Introduction: A high-quality health system should deliver care that is free from harm. Few large-scale studies of adverse events have been undertaken in children's healthcare internationally, and none in Australia. The aim of this study is to measure the frequency and types of adverse events encountered in Australian paediatric care in a range of healthcare settings. Methods and analysis: A form of retrospective medical record review, the Institute of Healthcare Improvement's Global Trigger Tool, will be modified to collect data. Records of children aged

Introduction: Despite the widespread availability of clinical guidelines, considerable gaps remain between the care that is recommended (appropriate care) and the care provided. This protocol describes a research methodology to develop clinical indicators for appropriate care for common paediatric conditions. Methods and analysis: We will identify conditions amenable to population-level appropriateness of care research and develop clinical indicators for each condition. Candidate conditions have been identified from published research; burden of disease, prevalence and frequency of presentation data; and quality of care priority lists. Clinical indicators will be developed through searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts will review the indicators using a wiki-based approach and modified Delphi process. A formative evaluation of the wiki process will be undertaken Ethics and dissemination: Human Research Ethics Committee approvals have been received from Sydney Children's Hospital Network, Children's Health Queensland Hospital and Health Service, and the Women's and Children's Health Network (South Australia). Applications are under review with Macquarie University and the Royal Australian College of General Practitioners. We will submit the results of the study to relevant journals and offer national and international presentations. Refereed/Peer-reviewed

Background: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. Objectives: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. Design: cluster-randomised controlled trial. Setting: ten high-level aged care facilities. Participants: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. Intervention: two multidisciplinary case conferences involving the resident’s general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. Measurements: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. Results: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1–6.1] compared with the control group (MAI mean change 0.4, 95% CI −0.4−1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control −0.38, 95% CI −1.02−0.27 versus intervention 0.73, 95% CI 0.16–1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. Conclusion: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.

Objective: To describe a joint mental health project involving the Adelaide Northern Division of General Practice (ANDGP) and the North West Adelaide Mental Health Service (NWAMHS). Conclusions: This project has been developed to explore alternative strategies to facilitate the identification and management of patients with mental illness in the primary care setting. The project has also endeavoured to explore alternative types of psychiatrist/general practitioner interactions other than the conventional ‘general practitioner referred psychiatrist consultation’. The development of adequate and clinically relevant evaluation methods, both quantitative and qualitative, has also been an explicit objective of the project. While the project provides an exciting stimulus for ongoing development of models of Primary Psychiatric Care, it is evident that such models can only evolve in the context of significant service and systemic change. It is hoped that the experiences in the northern suburbs of Adelaide can stimulate others to explore the ongoing collaborations between psychiatric services and general practitioners in ways that can produce better mental health outcomes in our patients.

Systems to identify risks and adverse events (AEs) in Australia are limited. This study aims to explore whether general practice records contain information on AEs, and to conduct a pilot study on the type and frequency of AEs in general practice in Australia, using a global trigger tool (GTT).Five practices were recruited and consented to collect data. Practice nurses were trained to collect data at their practices. Rec-ords from randomly sampled patients aged 75 years or older were reviewed.A total of 428 patient records were reviewed. A total of 44 AEs were detected in 41 records. The percentage of patients with an AE was 9.6%. Most low preventability AEs (21/29) were medication incidents.The study found that significant levels of information about AEs exist in general practice medical records and rates of harm are broadly in line with a similar study in Scotland.

Context: Evidence-based approaches are needed to improve the delivery of specialized palliative care. Conclusion: A single case conference added to current specialized community-based palliative care reduced hospitalizations and better maintained performance status. Comparatively, patient/caregiver education was less effective; GP education was not effective. Methods: This 2 × 2 × 2 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations. Objectives: The aim of this trial was to improve on current models of service provision. Results: There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori-defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 [SE 0.10] vs. control 1.70 [SE 0.13], P = 0.0069) and better maintained performance status (AKPS case conferences 57.3 [SE 1.5] vs. control 51.7 [SE 2.3], P = 0.0368). Among patients with declining function (AKPS

What are the characteristics of case conferences between general practitioners and specialised palliative care services (SPCS)?Study participants were adults (N=461) with pain in the preceding 3 months who were referred to a SPCS and their GPs (N=230). Patients were randomised to case conferences or routine care by SPCS.One hundred and sixty-seven conferences were held; 46 patients withdrew and 142 died before the conference could be conducted. Medicare payment was requested for 72 (43%) conferences. Median time from randomisation to case conference was 52 days (SD: 55), and from case conference to death/end of study was 79 days (SD: 166). Twenty-five percent of conferences had over three health professionals participant; patients and/or their caregivers participated in 91%. Average conference duration was 39 minutes (SD: 13). Mean conference length did not increase when more health professionals were present (3 vs.3, 39 [SD: 14] vs. 42 [SD 11] minutes, p=0.274), nor when patients/caregivers were present (present vs. absent, 39 [SD: 13] vs. 44 [SD: 14] minutes, p=0.159).Case conferencing involving SPCS, the GP, other health professionals and the patient can be an efficient part of routine care.

Introduction: Australian and international clinical practice guidelines are available for common paediatric conditions. Yet there is evidence that there are substantial variations between the guidelines, recommendations (appropriate care) and the care delivered. This paper describes a study protocol to determine the appropriateness of the healthcare delivered to Australian children for 16 common paediatric conditions in acute and primary healthcare settings. Methods and analysis: A random sample of 6000-8000 medical records representing a cross-section of the Australian paediatric population will be reviewed for appropriateness of care against a set of indicators within three Australian states (New South Wales, Queensland and South Australia) using multistage, stratified sampling. Medical records of children aged

The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 × 2 × 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.

Due to rising demand for sleep services, there has been growing interest in ambulatory models of care for obstructive sleep apnea (OSA). With appropriate training and simplified management tools, primary care physicians (PCPs) are ideally positioned to take on a greater role in the diagnosis and treatment of OSA. Objective: To compare the clinical efficacy and cost-effectiveness of a simplified model of diagnosis and care for OSA in primary care relative to that in specialist sleep centres. Design: A randomised, controlled, non-inferiority study. Setting: Primary care practices in metropolitan Adelaide and 3 rural regions of South Australia and a university hospital sleep medicine centre in Adelaide, Australia. Patients: A total of 155 patients with OSA (identified by screening questionnaire and home oximetry) and Epworth Sleepiness Scale (ESS) ≥8 or resistant hypertension were randomised into the study between September 2008 to June 2010. 81 patients were randomly assigned to the primary care arm and 74 patients to the specialist arm., The study was funded by the National Health and Medical Research Council of Australia (Project Grant 426744) and a small grant from the Flinders Medical Centre Foundation. Research scholarship support was provided to Dr Chai-Coetzer by the Flinders Medical Centre Clinicians Trust. Equipment donations were received from ResMed (ApneaLink oximetry monitors and CPAP machines), Philips Respironics (CPAP machines) and SomnoMed (mandibular advancement splints).

8517 Background: Evidence-based palliative care service delivery models are needed. General practitioner (GP) and patient-centered case conferences may increase multidisciplinary interaction and enhance patient care. Educational outreach visiting in pain management may empower learners and improve care. Methods: Three interventions were tested against a routine care control in a 2×2×2 cluster factorial randomized controlled trial. Interventions were case conferencing, educational visiting for GPs, and educational visiting for patients. Subjects were adult patients referred to palliative care services in southern Adelaide, Australia, with any pain in the preceding 3 months. Participants were followed longitudinally until death. Main outcomes included performance status (Australian-modified Karnofsky Performance Status (AKPS)) and hospitalization rates. Longitudinal intention-to-treat analyses using cluster-specific methods were conducted. The sample goal was 460. Results: 461 participants were enrolled from 4/02–6/04. Mean age was 71 yrs, 50% were male, 91% had cancer. Mean and median survival was 146 and 87 days; median baseline AKPS was 60%. When participants had AKPS No significant financial relationships to disclose.

Background: This paper provides an overview of the process and tools used to develop and implement a priority setting framework for the Clinical Senate of South Australia. Established as a clinical advisory group to the Minister and Department of Health, the Clinical Senate recognised the need for an open priority setting process to fairly assign planning resources to the large number of clinical issues that needed to be addressed. Discussion: Using a workbook, developed from the literature and evidence related to priority setting, agreement was reached on the use, components and structure of the priority setting process. The final products included a Gap Finder Tool and a Priority Setting Framework. Summary: This paper describes the process used to develop the priority setting tools. Decision makers in other organisations can use similar processes and tools to develop or enhance their priority Setting processes.

(1946). Play in Education. The Journal of Health and Physical Education: Vol. 17, No. 9, pp. 520-566.

Background: Osteoarthritis (OA) is a highly disabling and costly condition with an escalating prevalence in Australia due to the ageing and increasing obesity of the population. The general practitioner (GP) plays a central role in the management of this condition. The aim of this study was to examine opinions about the management of OA by Australian GPs following the release of the Royal Australian College of General Practitioners Guideline for the non-surgical management of hip and knee OA (RACGP OA CPG), and to compare the results with an earlier survey administered by the National Prescribing Service. Methods: In January 2013, a self-administered questionnaire was sent to 228 GPs to determine their treatment approaches to OA management using a clinical vignette of a patient with OA. This was compared with results from a similar survey undertaken in 2006. Results: Seventy-nine GPs returned questionnaires (response rate 35 %). GP recommendations for paracetamol, a paracetamol/codeine compound, and oral non-steroidal anti-inflammatory drugs (NSAIDs) were consistent with recommendations in the RACGP OA CPG, and varied little from the previous survey. Notably, there was a marked increase between surveys in GP recommendations for tramadol (p = 0.004) and more potent opioids (p < 0.001). Advice about the adverse effects of NSAIDs and codeine and how to manage them increased between surveys (p = 0.038 and 0.005, respectively). For all non-pharmacological treatments, there were only minor changes in the percentage of GP recommendations when compared with the previous survey, however they remain underutilised. Conclusions: GPs generally demonstrated a conservative approach to the treatment of OA, however, the increased recommendations for more potent opioids warrants further investigation. Patients should be made aware of the risks of medications through the use of decision aids, which can provide structured guidance to treatment. Non-pharmacological interventions were not given the importance that is suggested by clinical practice guidelines. Refereed/Peer-reviewed