http://nova.newcastle.edu.au/vital/access/services/Feed ${session.getAttribute("locale")} 5 http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:12306 Background: Concerns regarding the safety of transfused blood have generated considerable enthusiasm for the use of technologies intended to reduce the use of allogeneic blood (blood from an unrelated donor). Platelet-rich plasmapheresis (PRP) offers an alternative approach to blood conservation. Objectives: To examine the evidence for the efficacy of PRP in reducing peri-operative allogeneic red blood cell (RBC) transfusion, and the evidence for any effect on clinical outcomes such as mortality and re-operation rates. Search strategy: We identified studies by searching MEDLINE (1950 to 2009), EMBASE (1980 to 2009), The Cochrane Library (Issue 1, 2009), the Internet (to March 2009) and the reference lists of published articles, reports, and reviews. Selection criteria: Controlled parallel group trials in which adult patients, scheduled for non-urgent surgery, were randomised to PRP, or to a control group which did not receive the intervention. Data collection and analysis: Primary outcomes measured were: the number of patients exposed to allogeneic RBC transfusion, and the amount of RBC transfused. Other outcomes measured were: the number of patients exposed to allogeneic platelet transfusions, fresh frozen plasma, and cryoprecipitate, blood loss, re-operation for bleeding, post-operative complications (thrombosis), mortality, and length of hospital stay. Treatment effects were pooled using a random-effects model. Trial quality was assessed using criteria proposed by Schulz et al (Schulz 1995). Main results: Twenty-two trials of PRP were identified that reported data for the number of patients exposed to allogeneic RBC transfusion. These trials evaluated a total of 1589 patients. The relative risk (RR) of exposure to allogeneic blood transfusion in those patients randomised to PRP was 0.73 (95%CI 0.59 to 0.90), equating to a relative risk reduction (RRR) of 27% and a risk difference (RD) of 19% (95%CI 10% to 29%). However, significant heterogeneity of treatment effect was observed (p < 0.00001; I² = 79%). When the four trials by Boldt are excluded, the RR is 0.76 (95% CI 0.62 to 0.93). On average, PRP did not significantly reduce the total volume of RBC transfused (weighted mean difference [WMD] -0.69, 95%CI -1.93 to 0.56 units). Trials provided inadequate data regarding the impact of PRP on morbidity, mortality, and hospital length of stay. Trials were generally small and of poor methodological quality. Authors' conclusions: Although the results suggest that PRP is effective in reducing allogeneic RBC transfusion in adult patients undergoing elective surgery, there was considerable heterogeneity of treatment effects and the trials were of poor methodological quality. The available studies provided inadequate data for firm conclusions to be drawn regarding the impact of PRP on clinically important endpoints. 2013-01-30T02:03:06.085Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:12268 Objective: To systematically review interventions aiming to improve adjustment in men with prostate cancer and their partners. Methods: Medline, EMBASE, CINAHL and PsycINFO databases were searched. Inclusion criteria were: randomized controlled trials; relevant to specified clinical questions; included men who had prostate cancer (at least 80% prostate cancer patients or prostate cancer sub-group analysis); published in English between December 1999 and December 2009. Trial quality was assessed. Results: 21 studies met inclusion criteria. Trial quality was low; had not improved over the study timeframe; men with advanced disease were not targeted; minority groups were seldom included. Group cognitive-behavioral and psycho-education interventions appear helpful in promoting better psychological adjustment and QOL for men with prostate cancer; coping skills training for patient-spouse dyads improved QOL for partners. Conclusion: There are limitations in the research on effective ways to improve adjustment for men with prostate cancer of any stage and their partners; and scant research targeting minority groups and the concerns of men with advanced disease. Practice implications: Interventions for men with advanced prostate cancer could usefully target the implications of advancing disease and caregiver burden. There is an urgent need for researchers to focus efforts specifically on such men and their families 2012-12-17T23:08:10.229Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:10904 Background: Concerns regarding the safety of transfused blood, have prompted reconsideration of the use of allogeneic (blood from an unrelated donor) red blood cell (RBC) transfusion, and a range of techniques to minimise transfusion requirements. Objectives: To examine the evidence for the efficacy of cell salvage in reducing allogeneic blood transfusion and the evidence for any effect on clinical outcomes. Search strategy: We identified studies by searching CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1950 to June 2009), EMBASE (1980 to June 2009), the Internet (to August 2009) and bibliographies of published articles. Selection criteria: Randomised controlled trials with a concurrent control group in which adult patients, scheduled for non-urgent surgery, were randomised to cell salvage (autotransfusion), or to a control group, who did not receive the intervention. Data collection and analysis: Data were independently extracted and the risk of bias assessed. Relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary outcomes were the number of patients exposed to allogeneic red cell transfusion, and the amount of blood transfused. Other clinical outcomes are detailed in the review. Main results: A total of 75 trials were included. Overall, the use of cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 38% (RR=0.62: 95% CI 0.55 to 0.70). The absolute reduction in risk (ARR) of receiving an allogeneic RBC transfusion was 21% (95% CI 15% to 26%). In orthopaedic procedures the RR of exposure to RBC transfusion was 0.46 (95% CI 0.37 to 0.57) compared to 0.77 (95% CI 0.69 to 0.86) for cardiac procedures. The use of cell salvage resulted in an average saving of 0.68 units of allogeneic RBC per patient (WMD=-0.68; 95% CI -0.88 to -0.49). Cell salvage did not appear to impact adversely on clinical outcomes. Authors' conclusions: The results suggest cell salvage is efficacious in reducing the need for allogeneic red cell transfusion in adult elective cardiac and orthopaedic surgery. The use of cell salvage did not appear to impact adversely on clinical outcomes. However, the methodological quality of trials was poor. As the trials were unblinded and lacked adequate concealment of treatment allocation, transfusion practices may have been influenced by knowledge of the patients' treatment status potentially biasing the results in favour of cell salvage. 2012-06-20T23:08:58.415Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:9927 Survival from almost all cancers has improved during the last 30 years. There is debate over the reasons for the improvement. We examined trends in survival for 28 cancers from 1980 to 1996 in New South Wales (NSW), Australia, with adjustment for disease spread at diagnosis. NSW Central Cancer Registry data were used to estimate 5-year relative survival and relative excess risk of death for patients diagnosed in 1980–84, 1985–88, 1989–92 and 1993–96. Statistical significance of variation in excess deaths between periods of diagnosis was assessed using Poisson regression, with adjustment for age, sex, duration of follow-up, histology and spread of disease at diagnosis. There were statistically significant falls in excess deaths for 20 of the cancers with a 25% fall for all cancers combined. Cancers of the prostate, liver, thyroid, breast, gallbladder, body of uterus, rectum, cervix and ovary had falls of >30%. The falls varied by spread of disease; the largest being in localised and regionally spread tumours. Overall survival, when unadjusted for spread of cancer, generally fell in parallel with that in the specific categories of spread, which implies that stage migration did not contribute importantly to survival trends. While acknowledging the limitations of incomplete data on stage of cancer at diagnosis, we conclude that falls in excess deaths in NSW from 1980 to 1996 are unlikely, for many cancers, to be attributed to earlier diagnosis or stage migration; thus advances in cancer treatment have almost certainly contributed to them. 2012-02-08T22:10:17.212Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:609 In this study, we have investigated the impact of area of residence on survival from colon and rectal cancer. Relative survival and relative excess risk of death from cancer were calculated for each of 17 health areas in New South Wales, Australia. There were statistically significant differences in survival across areas for both cancers after adjusting for demographic factors. The variation remained for colon cancer but was reduced for rectal cancer after adjustment for spread of disease at diagnosis. This persistent variation in colon cancer survival suggests that variation in treatment contributes to it, and there is separate evidence for such variation. Of the 7186 patients whose deaths within five years were attributable to colorectal cancer, 784 could have had their survival increased to more than five years if the excess risk of death in all areas was reduced to the 20th centile of its distribution. Estimates such as this can assist in prioritising improvements in cancer services. 2012-01-24T05:10:02.554Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:1101 Objective: To investigate the direct impact of specialists on prescribing by general practitioners. Design: Cross-sectional, prescription-based study. Subjects and setting: 88 GPs in the Hunter Urban Division of General Practice, Hunter Valley, NSW. Main outcome measure: Proportions of specialist-initiated prescriptions for eight commonly prescribed drug classes. Results: The proportion of specialist-initiated prescriptions was greatest for proton pump inhibitors (85%), and lowest for diuretics (8%), newer antidepressants (10%) and H2-receptor antagonists (13%). Specialists initiated 29% of prescriptions for beta-blockers, 26% for calcium-channel blockers, 20% for statins and 19% for angiotensin-converting enzyme inhibitors or angiotensin II antagonists. Specialists were more likely to have been involved in starting therapy with metoprolol than other beta-blockers (51% v 23%) and diltiazem than other calcium-channel blockers (48% v 19%), and this was related to indication for treatment. In contrast, prescriptions for the more recently introduced drugs (angiotensin II antagonists and atorvastatin) were not more likely to have been specialist-initiated than prescriptions for established angiotensin-converting enzyme inhibitors and statins. Conclusions: The direct impact of specialists on prescribing in the Hunter Urban Division of General Practice is substantial and varies with the drug class. This highlights the need to engage both GPs and specialists in efforts to improve prescribing practices. 2011-02-08T22:40:03.877Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:1441 Objectives: To derive indicators of quality prescribing by Australian general practitioners based on Health Insurance Commission (HIC) data and assess the influence of incomplete capture of data on under-copayment drugs on the validity of these indicators. Design: Two expert groups proposed prescribing indicators that can be derived from aggregate prescribing data, and which reflect important clinical or cost-effectiveness issues. Indicators were examined using HIC data and compared with national prescribing trends over time using Australian Statistics on Medicines. The effect of incomplete data capture on indicator interpretation was examined by stratifying GPs into five strata based on the proportion of concession card holders in their practice. Participants: Approximately 14 000 Australian GPs providing ≥ 1500 Medicare services per year. Main outcome measures: Measures of prescribing for individual GPs (based on HIC data 1993–1997). Results: Forty-three potentially useful indicators were identified. These covered a fairly narrow range of prescribing activities and many required additional clinical information for interpretation. Indicators based on prescribing rates gave a misleading picture of prescribing trends where the extent of HIC data capture changed over time. Indicators expressed as ratios that reflected choice of agent within a drug class were less affected by incomplete data capture. Conclusions: Indicators of quality prescribing can be derived from HIC data. However, indicators for under-copayment drugs that represent prescribing rates may unfairly classify doctors practising in areas of socioeconomic disadvantage or high morbidity as "high prescribers". Ratio indicators are more robust, and may be more valid prescribing measures. If HIC data are to be used to monitor the quality of prescribing, data on all prescriptions dispensed will be needed. 2010-04-27T06:51:50.374Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:1206 Objectives: (1) To determine the extent to which Australian general practitioners (GPs) restrict the numbers of agents they prescribe within a drug class ('personal formularies'); (2) To assess concordance of these drug choices with standards based on established guidelines or recognised good prescribing practices; (3) To assess the potential of these measures as indicators of the quality of prescribing. Methods: Australian Health Insurance Commission (HIC) prescription data (1994-1997) for around 15,400 GPs providing 1500 or more Medicare services per year were analysed. Measures of an individual GP's use of a personal formulary (determined by number of agents) and concordance with prescribing criteria based on specified drugs for five classes of commonly prescribed drugs were derived. Results: Non-steroidal anti-inflammatory drugs (NSAIDs): GP concordance was higher with a non-specified personal formulary (any five NSAIDs) than with a list of specified drugs (five NSAIDs of 'low' or 'medium' risk of gastrointestinal toxicity), and concordance with both increased over time. In 1997, around 70% of GPs used five or fewer NSAIDs for 90% of their prescribing; 47% of GPs had 90% of prescribing from five selected agents. Angiotensin converting enzyme inhibitors/angiotensin-II receptor antagonists: The introduction of new agents appeared to increase the size of the GPs' personal formularies, and concordance with defined standards decreased over time. Antibacterial agents: Concordance with a specified drug standard (nine drugs listed in the Australian Antibiotic Guidelines) increased substantially over time but was largely due to increased prescribing of two heavily promoted drugs. Beta-blocking agents: Over time, GPs restricted most prescribing to two agents, atenolol and metoprolol. Calcium channel blockers: GPs did not appear to restrict prescribing of these drugs; most GPs prescribed all five agents available. Conclusions: Australian GPs use 'personal formularies'. Formulary size varies with the drug class, can change over time as new agents become available, and its contents can be influenced by promotional activities. Prescribing standards based on numbers of drugs used may not always reflect rational prescribing choices. Criteria based on specified drugs provide more rigorous prescribing standards, but may give a misleading picture of prescribing quality in the absence of information on patients and the indications for treatment. Personal formulary measures are potentially useful prescribing indicators but need to be carefully defined and interpreted. GPs should be encouraged to identify their personal formularies and review the drugs included in them. 2010-04-27T06:39:22.398Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:5032 We previously investigated the impact of health area of residence on colon and rectal cancer survival by estimating area-specific relative excess risk of death (RER), stratified by stage at diagnosis. The aims of this study were to quantify errors in colorectal cancer stage obtained from an Australian population-based cancer registry and assess the potential impact of errors in stage on these estimates. For a subset of cases, we compared the cancer registry stage with that from a survey of treating surgeons. We then randomly reallocated all cases to a simulated corrected stage according to the estimated misclassification probabilities and repeated the analysis of area variation stratified by simulated stage 1,000 times. We found 70% agreement between the Registry and Survey stage. This reallocation of the Registry cases by stage resulted in substantial variation in area-specific RERs across the simulated samples. Area variation in survival for localized colon and localized rectal cancer, which were previously statistically significant when classified using Registry stage, appeared no longer to be so. Misclassification of cancer registry stage can have an important impact on estimates of spatial variation in stage-specific colon and rectal cancer survival. If population-based cancer registry data are to be effectively used in evaluating and improving cancer care, the quality of the stage data may need to be improved. 2010-04-27T04:51:04.209Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:5076 Objective: To assess the impact of socio-economic status (SES) on cancer survival in the state of New South Wales (NSW), Australia. Methods: Patients diagnosed with one of 13 major cancers during 1992–2000 in NSW were followed-up to the end of 2001. The effect of SES on survival was estimated for each individual cancer and all 13 cancers combined using multivariable modeling. The numbers of lives that could be extended if all people had the same level of excess risk of death due to cancer as patients in the highest SES areas were also estimated. Results: There were highly statistically significant variations in survival across SES groups for four cancers: stomach, liver, lung, and breast and all 13 cancers combined. Variation remained highly significant after adjusting for disease stage. Patients in lower SES areas had 10–20% higher excess risk than those in the highest SES areas. In total, there were 3,346 lives potentially extendable beyond 5 years; the highest number was for lung cancer (756). Conclusion: The significantly worse survival in lower SES areas from cancers of the stomach, liver, lung, and breast may be due to poorer access to high-quality cancer care. Estimates of the number of lives potentially extendable by improving cancer survival in lower SES areas suggest that priority should be given to improving lung cancer care in lower SES areas in NSW, Australia. 2010-04-27T04:35:08.705Z ]]>