Objectives To evaluate usefulness of limited community based care for patients with chronic obstructive pulmonary disease after discharge from hospital. Design Randomised controlled trial.

BackgroundThe increased prevalence of diabetes and its significant impact on use of health care services, particularly hospitals, is a concern for health planners. This paper explores the risk factors for all-cause hospitalisation and the excess risk due to diabetes in a large sample of older Australians.MethodsThe study population was 263,482 participants in the 45 and Up Study. The data assessed were linked records of hospital admissions in the 12 months following completion of a baseline questionnaire. All cause and ambulatory care sensitive admission rates and length of stay were examined. The associations between demographic characteristics, socioeconomic status, lifestyle factors, and health and wellbeing and risk of hospitalisation were explored using zero inflated Poisson (ZIP) regression models adjusting for age and gender. The ratios of adjusted relative rates and 95% confidence intervals were calculated to determine the excess risk due to diabetes.ResultsPrevalence of diabetes was 9.0% (n = 23,779). Age adjusted admission rates for all-cause hospitalisation were 631.3 and 454.8 per 1,000 participant years and the mean length of stay was 8.2 and 7.1 days respectively for participants with and without diabetes. In people with and without diabetes, the risk of hospitalisation was associated with age, gender, household income, smoking, BMI, physical activity, and health and wellbeing. However, the increased risk of hospitalisation was attenuated for participants with diabetes who were older, obese, or had hypertension or hyperlipidaemia and enhanced for those participants with diabetes who were male, on low income, current smokers or who had anxiety or depression.ConclusionsThis study is one of the few studies published to explore the impact of diabetes on hospitalisation in a large non-clinical population, the 45 and Up Study. The attenuation of risk associated with some factors is likely to be due to correlation between diabetes and factors such as age and obesity. The increased risk in association with other factors such as gender and low income in participants with diabetes is likely to be due to their synergistic influence on health status and the way services are accessed.

Objective: To evaluate a partnership model of care for patients with a diagnosis of chronic obstructive pulmonary disease (COPD). Design, setting and participants: Cluster randomised controlled trial with blinded outcome assessment of 44 general practices in south-western Sydney comprising 451 people with a diagnosis of COPD, conducted between 2006 and 2009. Intervention: Participants from intervention group practices were visited at their home by a registered nurse with specific training in COPD care who worked with the general practitioner, the patient and other health professionals to develop and implement an individualised care plan based on best-practice guidelines. Participants from control group practices received usual care. Main outcome measures: The primary outcome was disease-related quality of life measured using the St George's Respiratory Questionnaire (SGRQ) at 12-month follow-up. Other outcomes were overall quality of life, lung function, smoking status, immunisation status, patient knowledge of COPD, and health service use. Results: Of the 451 participants, 257 (57.8%) were confirmed as having COPD on postbronchodilator spirometry. Follow-up was completed for 330 patients (73.2%). At 12 months, there was no statistically significant difference in the mean SGRQ scores between intervention and control groups (38.7 v 37.6; difference, 1.1; 95% CI, -1.53-3.74; P =0.41) or in measures of quality of life, lung function and smoking status. Compared with the control group, in the intervention group, attendance at pulmonary rehabilitation was more frequent (31.1% v 9.6%; OR, 5.16; 95% CI, 2.40-11.10; P =0.002) and the mean COPD knowledge score was higher (10.5 v 9.8; difference, 0.70; CI, 0.10-1.21; P=0.02). Conclusion: The nurse-GP partnership intervention did not have an impact on disease-related quality of life at 12-month follow-up. However, there was evidence of improved quality of care, in particular, in attendance at pulmonary rehabilitation and patient knowledge of COPD. 1 Guidelines for care of COPD provide recommendations for slowing disease progression and optimising function in people with COPD.2,3 The key interventions are smoking cessation, pulmonary rehabilitation, influenza vaccination, optimising medicines, patient education and effective management of exacerbations.There is a need for effective approaches to implementation of evidence-based treatment in primary care, where many patients with COPD are managed. Nurses, either within the practice or visiting to provide specialised care, could have a role in improving management of COPD, including by helping to implement planned care.A review of nine randomised trials of nurse-led chronic disease management for COPD concluded that there was no evidence of improvements in patients' healthrelated quality of life, psychological wellbeing, disability or pulmonary function.4 A more recent Cochrane review of nine trials of outreach programs involving nurse home visits to COPD patients concluded that providing support and education, monito...

Objective.Whether patients with type 2 diabetes change their lifestyle in response to their diagnosis and maintain behavior changes is unclear. This study aimed to 1) compare changes in lifestyle behaviors among participants who were newly diagnosed with type 2 diabetes and those never diagnosed with type 2 diabetes and 2) investigate changes in lifestyle behaviors in relation to the duration of newly diagnosed type 2 diabetes.Methods.We used self-reported information from the New South Wales 45 and Up Study and a follow-up study. Changes in body weight; amount of walking, moderate to vigorous physical activity (MVPA), and sitting; fruit and vegetable consumption; and smoking status and number of cigarettes smoked were used as measures of health behavior change. These variables were compared between participants in a “new type 2 diabetes” group and a “no type 2 diabetes” group.Results.The new type 2 diabetes group had a smaller decrease in vegetable consumption, lost more weight, and were more likely to quit smoking than the no type 2 diabetes group. MVPA, fruit consumption, and number of cigarettes smoked did not change significantly for either group. Although no significant changes were found in any of the health behaviors based on time since diagnosis, the magnitude of changes in weight and walking increased as duration of diagnosis increased, whereas changes in MVPA, number of cigarettes smoked, and proportion of participants who quit smoking decreased.Conclusion.In this population-based study, participants with incident type 2 diabetes reported only minimal changes in their lifestyle factors after receiving their diagnosis.

BackgroundPrevalence studies usually depend on self-report of disease status in survey data or administrative data collections and may over- or under-estimate disease prevalence. The establishment of a linked data collection provided an opportunity to explore the accuracy and completeness of capture of information about diabetes in survey and administrative data collections.MethodsBaseline questionnaire data at recruitment to the 45 and Up Study was obtained for 266,848 adults aged 45 years and over sampled from New South Wales, Australia in 2006–2009, and linked to administrative data about hospitalisation from the Admitted Patient Data Collection (APDC) for 2000–2009, claims for medical services (MBS) and pharmaceuticals (PBS) from Medicare Australia data for 2004–2009. Diabetes status was determined from response to a question ‘Has a doctor EVER told you that you have diabetes’ (n = 23,981) and augmented by examination of free text fields about diagnosis (n = 119) or use of insulin (n = 58). These data were used to identify the sub-group with type 1 diabetes. We explored the agreement between self-report of diabetes, identification of diabetes diagnostic codes in APDC data, claims for glycosylated haemoglobin (HbA1c) in MBS data, and claims for dispensed medication (oral hyperglycaemic agents and insulin) in PBS data.ResultsMost participants with diabetes were identified in APDC data if admitted to hospital (79.3%), in MBS data with at least one claim for HbA1c testing (84.7%; 73.4% if 2 tests claimed) or in PBS data through claim for diabetes medication (71.4%). Using these alternate data collections as an imperfect ‘gold standard’ we calculated sensitivities of 83.7% for APDC, 63.9% (80.5% for two tests) for MBS, and 96.6% for PBS data and specificities of 97.7%, 98.4% and 97.1% respectively. The lower sensitivity for HbA1c may reflect the use of this test to screen for diabetes suggesting that it is less useful in identifying people with diabetes without additional information. Kappa values were 0.80, 0.70 and 0.80 for APDC, MBS and PBS respectively reflecting the large population sample under consideration. Compared to APDC, there was poor agreement about identifying type 1 diabetes status.ConclusionsSelf-report of diagnosis augmented with free text data indicating diabetes as a chronic condition and/or use of insulin among medications used was able to identify participants with diabetes with high sensitivity and specificity compared to available administrative data collections.

Objectives: To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post‐bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses. Design, setting and participants: General practitioners from practices in Sydney identified eligible patients aged 40–80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients. Main outcome measures: Frequency of COPD diagnosis on spirometry; odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses. Results: 56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years; 49% male). Of these, 257 (57.8%) had post‐bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis. Conclusions: A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.

Background a large proportion of adults with type 2 diabetes remain sedentary despite evidence of benefits from exercise for type 2 diabetes. Simplified Yang Tai Chi has been shown in one study to have no effect on insulin sensitivity in older adults. However, a modified Tai Chi form, Tai Chi for Diabetes (TCD) has recently been composed, claiming to improve diabetes control. Methods subjects were randomised to Tai Chi or sham exercise, twice a week for 16 weeks. Primary outcomes were insulin resistance 72 h post-exercise (HOMA2-IR), and long-term glucose control (HbA 1c ). Results thirty-eight subjects (65 ± 7.8 years, 79% women) were enrolled. Baseline BMI was 32.2 ± 6.3 kg/m 2 , 84% had osteoarthritis, 76% hypertension, and 34% cardiac disease. There was one dropout, no adverse events, and median compliance was 100 (0 − 100)%. There were no effects of time or group assignment on insulin resistance or HbA 1c ( −0.07 ± 0.4% Tai Chi versus 0.12 ± 0.3% Sham; P = 0.13) at 16 weeks. Improvement in HbA 1c was related to decreased body fat (r = 0.484, P = 0.004) and improvement in insulin resistance was related to decreased body fat (r = 0.37, P = 0.03) and central adiposity (r = 0.38, P = 0.02), as well as increased fat-free mass (r = −0.46, P = 0.005). Conclusions TCD did not improve glucose homeostasis or insulin sensitivity measured 72 h after the last bout of exercise. More intense forms of Tai Chi may be required to produce the body composition changes associated with metabolic benefits in type 2 diabetes.

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