Public Hospital Outpatient Clinics Research Articles

Out-of-pocket fees for health care in Australia: implications for equity.

Out-of-pocket fees for health care in Australia: implications for equity.

COVID-19 vaccine hesitancy in inflammatory arthritis patients: serial surveys from a large longitudinal national Australian cohort.

ObjectivesTo determine COVID-19 vaccine hesitancy rates in inflammatory arthritis patients and identify factors associated with changing vaccine hesitancy over time.MethodsProspective cohort study of inflammatory arthritis patients from community and public hospital outpatient rheumatology clinics enrolled in the Australian Rheumatology Association Database (ARAD). Two surveys were conducted, one immediately prior to (pre-pandemic) and then approximately one year after the start of the pandemic (follow-up). COVID-19 vaccine hesitancy was measured at follow-up and general vaccine hesitancy was inferred pre-pandemic; these were used to identify factors associated with fixed and changing vaccine beliefs, including sources of information and broader beliefs about medication.ResultsOf the 594 participants who completed both surveys, 74 (12%) were COVID-19 vaccine hesitant. This was associated with pre-pandemic beliefs about medications being harmful (p< 0.001) and overused (p= 0.002), with stronger beliefs resulting in vaccine hesitancy persistent over two time points (p= 0.008, p= 0.005). For those not vaccine hesitant pre-pandemic, the development of COVID-19 vaccine hesitancy was associated with a lower likelihood of seeking out vaccine information from healthcare professionals (p< 0.001). COVID-19 vaccine hesitancy was not associated with new influenza vaccine hesitancy (p= 0.138).ConclusionIn this study of vaccine beliefs before and during the COVID-19 pandemic, factors associated with COVID-19 vaccine hesitancy in inflammatory arthritis patients varied, depending on vaccine attitudes immediately prior to the start of the pandemic. Fixed beliefs reflected broader views about medications, while fluid beliefs were highly influenced by whether they sought out information from healthcare professionals, including rheumatologists.

Yıllık 300 milyon Hasta Muayenesi; Türkiye'de 2. ve 3.Basamak Kamu Sağlık Tesisleri Acil Servis ve Poliklinik Hizmetlerinin Değerlendirilmesi

Background: There are many applications to both emergency services and polyclinics in Turkey. Emergency services are the diagnosis and treatment units that meet a significant part of the patient population in Turkey. In our study, the number of patients admitted to and examined in our country's emergency services and hospital outpatient clinics, and the number of consultations requested during the diagnosis and treatment process were examined. The aim is to identify the applications to public hospitals in our country, to examine their changes over the years, and to show the change in emergency and polyclinic services in recent years.&#x0D; Material and Methods: In this study, which is planned as a retrospective descriptive study, data on the number of patients who applied to the 2nd and 3rd level 836 public hospital outpatient clinics and emergency services in Turkey between January 1, 2016 and January 1, 2022 were discussed. The data were recorded on the spreadsheet program and their percentage changes were calculated using the tabulation program statistical formulas.&#x0D; &#x0D; Results: While the population of our country was approximately 79.8 million in 2016, it increased to 84.6 million by the end of 2021. In this process, the number of patients examined in emergency services increased from 92.6 million in 2016 to 129.5 million by the end of 2021. In the same period, the number of examinations in polyclinics decreased from 199.5 million to 136.9 million. Between these years, the number of specialist physician consultations increased from 12.1 million patients in 2016 to 14.6 million patients at the end of 2021. &#x0D; Conclusions: Along with the positive developments in health services, there has been a serious increase in the demand for health services in recent years, with the increase in accessibility to services. The number of patients examined in the emergency services, which is the area most affected by these demands, and its share in all examination rates have increased greatly over the years. In the light of these statistics, it would be appropriate to plan both emergency services and polyclinic services according to the conditions of the day.

The complexities, coordination, culture and capacities that characterise the delivery of oncology services in the common areas of ambulatory settings

BackgroundRelatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas.MethodsA purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding ‘work as done’. Data were analysed using an adapted “Qualitative Rapid Appraisal, Rigorous Analysis” approach.ResultsField observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients “falling through the cracks.” Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision.ConclusionsThe study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of ‘work-as-done’ may help OPCs to sustain high-quality care in the face of escalating service demand.

Socioeconomic impacts on medication adherence among patients with hypertension: A multicentre cross-sectional study in Lombok, Indonesia

Socioeconomic impacts on adherence are understudied, particularly in disadvantaged areas. This study aimed to evaluate socioeconomic factors on medication adherence among patients with hypertension in Lombok, Indonesia. A cross-sectional survey was conducted in all six public hospital outpatient clinics in Lombok in 2017. Data was obtained using a validated questionnaire to which the Morisky Green Levine Adherence Scale (MGLS) questionnaire was used to assess medication adherence. Binary logistic regression was performed to determine independent socioeconomic associations. A total of 693 patients with hypertension were included (response rate 84%). The majority had low adherence (76.2%). Significant independent associations were reported between setting and education with adherence (rural versus urban setting: odds ratio 3.54, p&amp;lt;0.001; primary versus university level education: odds ratio 5.39, p&amp;lt;0.001). Socioeconomic associations provide some basis for the development of patient and population-based interventions to improve adherence among patients with hypertension in Indonesia, particularly in disadvantaged areas.

Epidemiology of haemorrhoids and publicly funded excisional haemorrhoidectomies in New Zealand (2007-2016): a population-based cross-sectional study.

Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. A total of 46095 recorded diagnoses of haemorrhoids were made, with a total of 18739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

Cohort profile: the Singapore diabetic cohort study.

PurposeThe diabetic cohort (DC) was set up to study the determinants of complications in individuals with type 2 diabetes and examine the role of genetic, physiological and lifestyle factors in the development of complications in these individuals.ParticipantsA total of 14 033 adult participants with type 2 diabetes were recruited from multiple public sector polyclinics and hospital outpatient clinics in Singapore between November 2004 and November 2010. The first round of follow-up was conducted for 4131 participants between 2012 and 2016; the second round of follow-up started in 2016 and is expected to end in 2021. A questionnaire survey, physical assessments, blood and urine sample collection were conducted at recruitment and each follow-up visit. The data set also includes genetic data and linkage to medical and administrative records for recruited participants.Findings to dateData from the cohort have been used to identify determinants of diabetes and related complications. The longitudinal data of medical records have been used to analyse diabetes control over time and its related outcomes. The cohort has also contributed to the identification of genetic loci associated with type 2 diabetes and diabetic kidney disease in collaboration with other large cohort studies. About 25 scientific papers based on the DC data have been published up to May 2019.Future plansThe rich data in DC can be used for various types of research to study disease-related complications in patients with type 2 diabetes. We plan to further investigate disease progression and new biomarkers for common diabetic complications, including diabetic kidney disease and diabetic neuropathy.

Ovulation Rate after Metformin and Clomiphene vs Clomiphene Alone in Polycystic Ovary Syndrome (PCOS): A Randomized, Double-Blind, Placebo-Controlled Trial

Background: Polycystic ovary syndrome (PCOS) affects 5%-15% of women of reproductive age and has a negative impact on their fertility. The primary outcome of this study is ovulation rate when standard (immediate release) metformin (MF) is added to clomiphene citrate (CC) in oligoovulatory and anovulatory women with PCOS. Methods: This is a randomized, double-blind, placebo-controlled trial. Twenty-seven women with PCOS (according to the Rotterdam consensus), desiring pregnancy and without another cause of subfertility were recruited from a public hospital outpatient gynecology clinic. Up to six cycles of CC (25-150 mg) plus either MF 500 mg tds (CC+MF) or placebo (CC+Pl) were offered. Student’s t-test, Chi-squared test, and Fisher’s exact test were used for analysis. Results: Thirteen women with up to six cycles each were included in the final analysis. The rate of ovulation and ovulation rate per cycle was similar between women in the CC+MF and CC+Pl groups RR 1.09 (95% CI 0.80-1.49) and RR 0.88 (95% CI 0.63-1.22), respectively as was chemical pregnancy rate RR 1.77 (95% CI 0.58-5.38). The live birth rate was higher in CC+MF RR 6.83 (95% CI 0.83-56.27) and miscarriage rate was lower RR 0.21 (95% CI 0.002-1.07). The number needed to treat for live birth was 10. Conclusion: Use of standard MF, 500 mg tds, when given with CC results in an increase in live birth rate, and a decrease in miscarriage rate.

Embedded Motivational Interviewing combined with a smartphone app to increase physical activity in people with sub-acute low back pain: Study protocol of a cluster randomised control trial

BackgroundMotivational Interviewing is an evidence-based, client-centred counselling technique that has been used effectively to increase physical activity, including for people with low back pain. One barrier to implementing Motivational Interviewing in health care settings more broadly is the extra treatment time with therapists. The aim of this paper is to describe the design of a cluster randomised controlled trial evaluating the effect of an intervention that pairs Motivational Interviewing embedded into usual physiotherapy care with a specifically designed app to increase physical activity in people with sub-acute low back pain. MethodsThe study is a cluster randomised controlled in which patients aged over 18 years who have sub-acute low back pain (3–12 weeks duration) are recruited from four public hospital outpatient clinics. Based on the recruitment site, participants either receive usual physiotherapy care or the Motivational Interviewing intervention over 6 consecutive weekly outpatient sessions with a specifically designed app designed to facilitate participant-led physical activity behaviour change in between sessions. Outcome measures assessed at baseline and 7 weeks are: physical activity as measured by accelerometer (primary outcome), and pain-related activity restriction and pain self-efficacy (secondary outcomes). Postintervention interviews with physiotherapists and participants will be conducted as part of a process evaluation. DiscussionThis intervention, which comprises trained physiotherapists conducting conversations about increasing physical activity with their patients in a manner consistent with Motivational Interviewing as part of usual care combined with a specifically designed app, has potential to facilitate behaviour change with minimal extra therapist time.

Perspectivas de aprendizagem na consulta para clientes renais e cuidadores: estudo fenomenológico

Aim: Understanding the repercussions of the educational actions of the nursing consultation on the life of chronic kidney patients and their caregivers. Methods: Qualitative research, using the Social Phenomenology reference. Open-ended interviews with 12 patients and their 12 caregivers were conducted in a public hospital outpatient clinic in Rio de Janeiro, Brazil, in 2016. Results: The analysis of the participants' testimonies allowed the elaboration of two concrete categories of the experience lived concerning the reasons "why": Sum of learning lived by the sick and those who care also learn. Conclusion: The importance of the perspectives of chronic kidney patients and their caregivers for the design of educational actions stands out in the face-to-face interaction, in the shared approach and the approximation of the nurse

Cost of Waiting on an Orthopaedic Waiting List: a scoping review

Background: Approximately 30% Australians suffer from arthritis and other musculoskeletal disorders. From 2003-2033 there is a predicted 223% increase in expenditure on health management of musculoskeletal disorders. There is evidence of increasing prevalence of orthopaedic complaints, in longer waiting lists for specialist consultations in public hospital outpatient clinics. Little is known about the costs and ramifications of waiting for orthopaedic consultations.&#x0D; Aim: Establish what is known about the direct and indirect costs of being placed on a waiting list for an orthopaedic consultation.&#x0D; Method: Patient and Outcome search strategy of Medline, Embase, Pubmed, NHS Economic evaluation database (NHS-EED) from each database inception date. Handsearching of reference lists of included papers alsooccurred. A realist synthesis framework underpinned the review, using a ubiquitous patient journey to map available literature on the impact of waiting. Hierarchy of evidence was reported using NHMRC criteria andarticles critically appraised using either the PEDRo or CASP criteria (relevant to the design). A purpose-built data extraction instrument was developed.&#x0D; Results: We identified 786 studies, of which 139 were relevant, including a systematic review (Hoogeboom et al) with 15 included articles which were added to the list of eligible papers (and the review itself deleted), leaving 153 included articles; 17 were relevant to the review. Fourteen papers reported on quality of life and four reported on costs, two of these papers reported on both and all were of low to moderate quality. The research was not based on a comprehensive understanding of the stages of waiting, and there were inconclusive outcomes for quality of life and cost.&#x0D; Conclusion: There is scant evidence of the impact on quality of life and costs of waiting for orthopaedic outpatient appointments. Future research should aim for improved methodological quality and use patientfocused quality of life measures, and validated measures of cost.&#x0D; Abbreviations: NHMRC – National Health and Medical Research Council; PROMS – Patient Related Outcome Measures; QoL – Quality of Life; WOMAC – Western Ontario and McMaster Universities Osteoarthritis Index; YLD – Years Lived With Disability

Effect of a Community Health Worker Intervention Among Latinos With Poorly Controlled Type 2 Diabetes

Community health worker (CHW) intervention is a promising approach to address type 2 diabetes among Latinos. However, evidence from randomized clinical studies is limited. To compare a CHW intervention with enhanced usual care. This 52-week, single-blind, randomized clinical trial included 300 Latino adults aged 18 to 65 years who were treated in 2 public hospital outpatient clinics in Miami-Dade County, Florida, from July 1, 2010, through October 31, 2013. Eligible participants had a hemoglobin A1c (HbA1c) level of 8.0 or greater. Follow-up was completed January 31, 2015, and data were analyzed from March 10, 2015, to June 6, 2016. A 1-year CHW intervention consisted of home visits, telephone calls, and group-level activities. Primary outcomes included systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLC) levels, and HbA1c levels. Secondary outcomes included body mass index, medication regimen intensification, and self-reported measures of diet, physical activity, and medication regimen adherence. Of the 300 participants randomized (135 men [45%] and 165 women [55%]; mean [SD] age, 55.2 [7.0] years), we obtained follow-up data on 215 (71.7%). Participants in the CHW group received a median of 4 home visits and 20 telephone calls. After adjusting for baseline values and covariates, participants in the CHW group had an HbA1c level that was 0.51% lower (95% CI, -0.94% to -0.08%) than that of participants in the enhanced usual care group. The reduction in SBP of 4.62 mm Hg (95% CI, -9.01 to -0.24 mm Hg) did not meet the preplanned target of 8 mm Hg and was not statistically significant in unadjusted models. No significant differences in LDLC levels (mean difference, -8.2 mg/dL; 95% CI, -18.8 to 2.3 mg/dL) or any of the preplanned secondary outcomes were observed. Post hoc analyses suggest that the intervention may be more beneficial among those with worse control of their type 2 diabetes at baseline. Among Latinos with poorly controlled type 2 diabetes, a 12-month CHW intervention lowered HbA1c levels by 0.51%. The intervention did not lead to improvements in LDLC levels, and the findings with respect to SBP were variable and half of what was targeted. Future studies should examine whether CHW interventions affect other measures, such as access to health care or social determinants of health. clinicaltrials.gov Identifier: NCT01152957.

Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior

BackgroundIntimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators.MethodsIn a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators.ResultsTwelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95–2.77) and two or more conditions (AOR 12.77, 95% CI 7.97–20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ2 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137–8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99–17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64–2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression.ConclusionsThis study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.

Anxiety and Stress Levels on Liver Transplantation Candidates.

The objective of the present study was to determine the anxiety and stress levels of liver transplant candidates during the preoperative period. A cross-sectional, prospective study was conducted on 52 liver transplantation candidates seen at a specialized public hospital outpatient clinic in the interior of the state of São Paulo, Brazil. Data were collected from November 2014 to April 2015 using a self-applicable questionnaire for the assessment of anxiety (State-Trait Anxiety Inventory, short version) and stress (Perceived Stress Scale), in addition to sociodemographic and clinic characterization. The mean (±SD) anxiety level detected was 23.06 ± 5.51 points, with 1.92% of the subjects showing minimum levels (0 to 12 points), 59.62% a medium level (12 to 24 points), 36.54% a moderate level (24 to 36 points), and 1.92% a severe level (36 to 48 points) of anxiety. The mean level on the stress scale was 12.10 ± 5.62 points, with 7.69% of the subjects showing high stress levels. When individuals with good and poor stress levels were compared, a significant difference was observed between them (P= .0004). The Spearman correlation test showed that the higher the stress, the higher the levels of anxiety (r= 0.4258), P< .0001. The present study contributes to the analysis of the mental health of liver transplantation candidates in view of the need for interventions for the improvement of anxiety and stress levels since the waiting period for the organ generates emotional changes that can affect the quality of life of the patient and the success of this complex therapeutic modality.

The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial.

BackgroundNonattendance at scheduled appointments in public hospitals presents a challenge for efficient resource use and may ultimately affect health outcomes due to longer waiting times. Seven percent of all scheduled outpatient appointments in the United Kingdom are estimated to be nonattended. Various reminder systems have been shown to moderately reduce nonattendance, although the effect of issuing fines for nonattendance has not yet been tested in a randomized context. However, such use of financial incentives could impact access to care differently across the different socioeconomic groups. The aim of this study is to assess the effect of fines on hospital outpatient nonattendance.Methods/designA 1:1 randomized controlled trial of scheduled outpatient appointments was used, with follow-ups until the date of appointment. The setting is an orthopedic clinic at a regional hospital in Denmark. Appointments for users who are scheduled for diagnostics, treatment, surgery, or follow-ups were included from May 2015 to November 2015. Appointments assigned to the intervention arm include an attachment of the appointment letter explaining that a fine will be issued in the case of nonattendance without prior notice. Appointments assigned to the control arm follow usual practice (same system but no letter attachment). The primary outcome is the proportion of nonattendance. Secondary outcomes are proportions of cancellations, sociodemographics, and health-problem characteristics. Furthermore, the intervention costs and production value of nonattended appointments will be measured. An analysis of effect and cost-effectiveness will be conducted based on a 5 % significance level.DiscussionThe study is initiated and funded by the Danish Regions, which have the responsibility for the Danish public healthcare sector. The results are expected to inform future decisions about the introduction of fines for nonattendance at public hospitals.Trial registrationCurrent Controlled Trials, ISRCTN61925912. Registered on 6 July 2015.

Impact of New Regulations On Assessing Driving Status (INROADS): A South Australian seizure clinic cohort

The ability to drive is important to patients and driving restriction often leads to restriction of employment and social opportunities. In March 2012, Austroads released revised Assessing Fitness to Drive Guidelines (AFTDG) with significant changes for drivers with seizures and epilepsy. Our study aimed to assess the impact of the 2012 AFTDG on a Seizure Clinic cohort compared to the previous 2003 AFTDG and an individual’s current driving status. We also aimed to quantify the difference in AFTDG interpretation between expert and non-expert doctors. We performed a retrospective observational audit of case notes for all patients managed in a public hospital outpatient Seizure Clinic between 1 March 2010 and 1 March 2012. A total of 142 patients were included in the analysis. Comparison between the 2003 and 2012 AFTDG resulted in reduced eligibility to drive a private vehicle by 2.1% (52.5% versus 50.4%) and commercial vehicle by 2.2% (4.5% versus 2.3%). The proportion of those currently driving against guideline recommendations increased (private 8.8% versus 19%; commercial 50% versus 100%) and the non-expert assessor was more likely to agree with the experts with the 2012 AFTDG. In summary, the 2012 AFTDG has had a measurable impact on driving eligibility in individuals with seizure although it is easier to interpret for non-expert doctors. Greater awareness of the 2012 AFTDG is required to reduce the proportion of patients driving against current recommendations.

A randomised trial of robotic and open prostatectomy in men with localised prostate cancer.

BackgroundProstate cancer is the most common male cancer in the Western world however there is ongoing debate about the optimal treatment strategy for localised disease. While surgery remains the most commonly received treatment for localised disease in Australia more recently a robotic approach has emerged as an alternative to open and laparoscopic surgery. However, high level data is not yet available to support this as a superior approach or to guide treatment decision making between the alternatives. This paper presents the design of a randomised trial of Robotic and Open Prostatectomy for men newly diagnosed with localised prostate cancer that seeks to answer this question.Methods/design200 men per treatment arm (400 men in total) are being recruited after diagnosis and before treatment through a major public hospital outpatient clinic and randomised to 1) Robotic Prostatectomy or 2) Open Prostatectomy. All robotic prostatectomies are being performed by one surgeon and all open prostatectomies are being performed by one other surgeon. Outcomes are being measured pre-operatively and at 6 weeks and 3, 6, 12 and 24 months post-surgery. Oncological outcomes are being related to positive surgical margins, biochemical recurrence +/− the need for further treatment. Non-oncological outcome measures include: pain, physical and mental functioning, fatigue, summary (preference-based utility scores) and domain-specific QoL (urinary incontinence, bowel function and erectile function), cancer specific distress, psychological distress, decision-related distress and time to return to usual activities. Cost modelling of each approach, as well as full economic appraisal, is also being undertaken.DiscussionThe study will provide recommendations about the relative benefits of Robotic and Open Prostatectomy to support informed patient decision making about treatment for localised prostate cancer; and to assist in treatment services planning for this patient group.Trial registrationACTRN12611000661976

Impact of the inter-professional team approach in the development of person-centered health care within an orthopaedic out-patient clinic

Rationale, aims and objectives: High demand for orthopaedic specialist consultation has resulted in long waiting lists in public hospital out-patient clinics. This prospective study with a retrospective cohort analysis was conducted to evaluate the impact of a combined orthopaedic surgeon and physiotherapy triage clinic on waiting time and outcome of the initial consultation.Methods: Two hundred and thirty-nine patients were assessed in the triage clinic, while the reference group consisted of 136 patients from the same catchment who attended the same outpatient clinic in the previous year. Comparisons in waiting list time and initial clinic outcome were conducted and patient satisfaction with the triage clinic was assessed through a questionnaire.Results: Mean waiting time over the first 6 weeks of the triage clinic was 10 weeks compared to 4 weeks over the final 6 weeks (p&lt;0.05, 95%CI:1.0 to 11.0). The mean waiting time for the triage clinic patients was 8 (SD=6) weeks, compared to 12 (SD=11) weeks for the control group patients (p&lt;0.0001, 95%CI:2.5 to 6.0). Clinic outcomes were not significantly different between groups (p=0.43-0.92). About one-third of all patients seen in the triage clinic were referred for further consultation with an orthopaedic surgeon (triage 32%, control 36%). Patients reported high levels of satisfaction with the triage clinic.Conclusion: An inter-professional triage clinic model can significantly reduce orthopaedic outpatient clinic waiting times. Two-thirds of patients attending the clinic were managed without direct consultation with an orthopaedic surgeon. Patient support for the triage clinic was strong based on satisfaction survey responses.

Quality of life of patients with epilepsy living in Kingston, Jamaica

Quality of life in epilepsy has not been documented in the English-speaking Caribbean. The aim of this study was to explore the quality of life of persons with epilepsy (PWE) living in Jamaica and determine the impact of socioeconomic factors by examining two socially distinct groups in semiprivate (Epilepsy Centre of Jamaica) and public (Kingston Public Hospital) outpatient clinics. One hundred nine consecutive patients were interviewed. Quality of life was assessed using the Quality of Life in Epilepsy-31 inventory (QOLIE-31). Both groups were matched for gender, epilepsy syndrome, epilepsy duration, and number of antiepileptic drugs. Predictors of quality of life included number of antiepileptic drugs ( P = 0.039), epilepsy duration ( P < 0.05), and functional status ( P < 0.001). Neither seizure frequency nor socioeconomic status predicted QOLIE-31 scores. Mean QOLIE-31 total score (61.57 vs 49.2, P < 0.001) and QOLIE-31 subscale scores (with the exception of the Seizure Worry score [53.8 vs 48.2, P = 0.08]) were significantly higher than the corresponding t scores. The QOLIE-31 can reliably be used in Jamaica. Our findings suggest Jamaicans living with epilepsy perceive themselves as having a better than expected quality of life.

Physiologic changes in homocysteine metabolism in pregnancy: A longitudinal study in Spain

Objective The aim was to investigate whether pregnancy-induced changes in total homocysteine (tHcy) are associated with folate and vitamin B12 nutritional status, genetic C677T polymorphism in the methylenetetrahydrofolate reductase (MTHFR) enzyme, and gestation outcome at a time when folic acid supplementation started to be recommended in the Spanish health system. Methods In total 154 pregnant women were recruited from among gynecologic patients of the Alcorcón Public Hospital Outpatient Clinic (Madrid, Spain). Blood tests were performed at weeks 15, 24, and 32 of pregnancy. Total Hcy, folate, and vitamin B12 serum fasting concentrations were measured using an IMx system. Genotype analyses were done by polymerase chain reaction/restriction fragment/length polymorphism analysis. Results Folate and vitamin B12 serum concentrations decreased significantly ( P < 0.01) through pregnancy and reached the lowest values in the third trimester. Serum tHcy concentrations were significantly ( P < 0.01) lower in the second trimester but increased in the third trimester. Frequencies of MTHFR C667T genotype were CC (35.7%), CT (57.2%), and TT (7.1%). Total Hcy concentration was not statistically influenced by maternal genotype. Plasma folate was the single negative predictor of maternal tHcy in the first trimester of pregnancy; 11.1% of gestations resulted in intrauterine growth restriction, 7.9% in gestational diabetes mellitus, and 4.8% in gestational hypertension. No significant differences in serum folate, vitamin B12, or tHcy concentrations were found in complicated pregnancies and these were unrelated to MTHFR genotype. Conclusion Although tHcy seems to be physiologically low in this Spanish population and unrelated to folate and B12 nutritional status, C677T MTHFR genotype, and some pregnancy complications, we support the statement that appropriate folate concentration may be important throughout pregnancy to prevent abnormalities associated with altered status (e.g., neural tube defects). According to our study, supplementation with folic acid seems to achieve this purpose because diet alone may be insufficient. In addition, a poor vitamin B12 status, as measured by plasma levels, may indicate that supplementation of both vitamins is needed.