The George Institute for Global Health

Hypertension is the most common problem managed in Australian general practice, yet most adults with hypertension do not have their blood pressure (BP) treated to target. Hypertension diagnosis and management rely upon accurate BP measurements performed using a standardised protocol. However, health system barriers prevent doctors from following measurement protocols, leading to inaccurate BP assessments. A practical BP measurement protocol that can be widely implemented is urgently warranted. Automated office BP (AOBP) is the recommended measurement standard for the diagnosis and management of hypertension. AOBP involves using a validated automated upper-arm cuff BP device programmed to record multiple BP readings at set intervals starting after a rest period. It is done by a trained operator using a standardised protocol in a quiet setting with the correct patient setup, no distractions, and in the absence of a doctor. The device automatically calculates the average of the AOBP recordings and this is comparable to the 24-h ambulatory BP daytime mean. The hypertension threshold based on AOBP is 135/85 mmHg. AOBP can also be applied in other community settings (e.g. pharmacies), provided all the above criteria are met along with communication of results to the person's usual general practitioner. In Australia, nation-wide systematic implementation of evidence based AOBP measurement is strongly recommended. This standardised approach will support healthcare professionals, especially general practitioners, in obtaining high-quality BP values with increasing confidence in clinical decision-making. Policy and practice changes, to address barriers and provide enabling mechanisms for sustained implementation of AOBP, are required.

Aims To determine the treatment effectiveness associated with mobile health‐delivered cognitive behavioural therapy for insomnia (mCBT‐I) interventions for adults with insomnia and to identify the potential characteristics associated with better treatment outcomes. Design A systematic review and meta‐analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA 2020) guidelines. Methods Seven English‐ and two Chinese‐language databases were searched, without restrictions on publication dates, up to July 2024. Reference lists of relevant reviews and grey literature were included in the search. Randomised controlled trials evaluating mCBT‐I in adults with insomnia and published in either English or Chinese were included in this meta‐analysis. A random‐effects model was used for data analysis, accompanied by additional subgroup analyses and meta‐regression. Results Sixteen studies involving 2146 participants were included in this meta‐analysis. mCBT‐I interventions were associated with significantly reduced insomnia symptoms and improved sleep quality at post intervention, at 1–3‐month follow‐up, and at 4–6‐month follow‐up. Interventions that included five components of CBT‐I, were delivered for 6 weeks or longer, and were conducted in a group format were linked to better treatment outcomes; the differences in other subgroup categories were not statistically significant. Studies involving participants with comorbid conditions showed a greater effect in reducing insomnia symptoms than those without such participants. In addition, mCBT‐I interventions delivered by healthcare professionals resulted in statistically larger effect sizes for improving sleep quality than self‐help regimens. Conclusions The systematic review and meta‐analysis identified the effectiveness of mCBT‐I in reducing insomnia symptoms and improving sleep quality and offered practical implications for the development of effective mCBT‐I interventions in clinical practice. However, future robust studies are needed to explore the long‐term effects of mCBT‐I interventions. Patient or Public Contribution No patient or public contribution. Trail Registration PROSPERO CRD: 42023454647

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the effect on blood pressure – measured as changes in systolic and diastolic blood pressure (mmHg) using standardised measurement methods – of substituting sodium salt with other edible salts (e.g. potassium chloride, magnesium chloride) in people with diabetes mellitus.

Background We developed and validated a kidney disease progression hierarchical composite end point (HCE) combining time-to-event end points with the rate of estimated glomerular filtration rate (eGFR) decline (eGFR slope) as a continuous end point. An alternative to this continuous end point is to apply various thresholds on an absolute and relative scale for the pairwise comparisons in the eGFR slope component. We assessed the impact of different thresholds on the treatment effects and statistical power on the kidney disease progression HCE analyzed using win odds. Methods We calculated the win odds in seven international phase 3 CKD trials and compared treatment effects for the original HCE versus HCEs with different eGFR thresholds (0.5, 0.75, or 1.0 mL/min/1.73m ² /year eGFR slope difference), as well as categorical thresholds and thresholds determined by percent differences in eGFR slope. In addition, we estimated the statistical power for these thresholds using a bootstrap sampling procedure to evaluate their impact on trial efficiency. Results For the seven CKD trials, the win odds estimate remained consistent, combined with a minor reduction in statistical power regardless of which eGFR thresholds were applied. For instance, for thresholds 0 (original HCE), 0.5, 0.75, and 1.0 the win odds of the DAPA-CKD trial were 1.41 (95% CI; 1.32, 1.52), 1.41 (95% CI; 1.31, 1.51), 1.40 (95% CI; 1.31, 1.51) and 1.40 (95% CI; 1.30, 1.50) with 97%, 92%, 92%, and 93% statistical power for a sample size of 500, respectively. Conclusions Our findings suggest that using eGFR thresholds in the kidney disease progression HCE did not alter treatment effect estimates and had only a minimal effect on statistical power compared to its continuous use.

Objective To estimate the long term gains in life years and quality‐adjusted life years (QALYs) and the cost savings that could be achieved if ischaemic stroke was identified in women with the same level of accuracy received by men, versus the status quo. Design Decision tree and Markov model decision analysis. Settings, participants Two arms including 5513 women aged under 70 years: a hypothetical scenario, in which women receive the same level of accuracy of stroke identification as men (yet experienced symptoms relevant to women); and the status quo. Transitions between post‐stroke health states, recurrent stroke and death were made in 1‐year cycles over 50 years from a societal perspective. Main outcome measures Years of life lived, QALYs and costs per patient in the hypothetical scenario relative to the status quo. Results were extrapolated to the national level based on the annual number of ischaemic stroke hospitalisations among women across Australia in the financial year 2020–21. Results Compared with the status quo, the hypothetical arm gained 0.14 years of life, gained 0.08 QALYs and saved $2984 per patient. At the national level, for the financial year 2020–21, this equates to 252 life years and 144 QALYs gained, and cost savings of$5.4 million. Outcomes were most sensitive to the probability of an accurate assessment of stroke, short term treatment costs, patient age, and transition probabilities to 90‐day post‐stroke health states. Conclusions Enhancing the timely and accurate identification of ischaemic stroke among Australian women in the pre‐hospital setting would yield significant health benefits and cost savings to Australian society as a whole.

The Workload Indicators of Staffing Needs (WISN) is a tool used to estimate health workforce requirements for national or sub-national regions and health facilities. We determined the implementation of WISN for six countries in the World Health Organization South-East Asia Region (WHO-SEAR). This research ascertained whether WISN’s recommendations were adopted and operationalised after the initial assessment. This will then help policymakers identify implementation barriers and enablers for the successful implementation of WISN for the improvement of access to health workforce. We used a multi-method approach comprising qualitative, in-depth, semi-structured interviews, literature reviews and document reviews. First, we conducted a desktop review to understand the context of WISN implementation in Bangladesh, Bhutan, India, Indonesia, Nepal and Sri Lanka. Second, we interviewed a key policymaker responsible for the implementation of WISN in Sri Lanka, Bangladesh, Bhutan and India. Interviews were undertaken virtually, in English using Microsoft Teams virtual software and auto transcribed and recorded using Microsoft Teams. Literature reviews were conducted using electronic databases, documents and reports were sourced from the WHO-SEAR office and/or country of interest’s focal persons. Findings from the different methods were synthesized, triangulated and presented using four themes, namely, initial implementation, key findings, primary lessons and directions forward. This study found a high utility of WISN on informing policymakers of the health workforce needs or surplus once the service activity standards were determined. However, all the countries did not have pre-defined service standards and they did not always have the required service data or health information. For WISN to be of utility, countries need to first strengthen their health workforce information systems and digitize workload standards. Furthermore, the government treasury and the employing ministry must be involved at early stages of the planning process to ensure easy phasing in and adaptation of recommendations.

Background The smallest worthwhile effect (SWE) is the minimum benefit required in addition to that from a comparator for an intervention to be considered worthwhile by patients. We aimed to estimate the SWE for rotator cuff repair (with decompression and debridement) compared to either decompression and debridement alone or to non-surgical treatment for people with atraumatic shoulder pain. Methods Benefit-harm trade-off study. We recruited English-speaking adults aged 45–75 years with shoulder pain of intensity ≥ 4 (on a 0–10 scale) for ≥ 6 months to our online survey through paid advertising on Facebook. Participants must have sought care in the past 6 months and could not have had recent shoulder surgery or significant recent shoulder trauma. Participants were explained three treatments: rotator cuff repair (with subacromial decompression and debridement), subacromial decompression and debridement alone, and non-surgical treatment. Participants completed the benefit-harm trade-off survey to determine the SWE of improvements in pain and function for rotator cuff repair compared to the other treatments and again after one week to assess reliability. We used univariable linear regression to estimate associations between baseline characteristics and SWE. Results We recruited 56 participants. The mean ± standard deviation age was 58.4 ± 6.7 years, and 39 (70%) were female. For rotator cuff repair to be worthwhile compared to decompression and debridement alone, participants needed to see at least a median 40% (interquartile range (IQR) 20–62.5) between-group improvement in pain and function. Compared to non-surgical treatment, the SWE was a median 40% (IQR 30–60). On the Western Ontario Rotator Cuff (WORC) Index, the SWE values equate to a between-group improvement of 28/100 points (533/2100 on the raw WORC score). Female sex was associated with larger SWEs for both comparisons. Reliability analyses were underpowered, 25/56 (45%) provided follow-up data. The intraclass correlation coefficient estimates ranged from 0.60 to 0.77. Conclusions This SWE indicates the benefit required by people with shoulder pain to consider the costs and risks of surgical rotator cuff repair worthwhile is larger than previously estimated minimum clinically important differences (13.5–28/100 on the WORC Index). This SWE may be used to inform the design or interpret the findings of trials of these comparisons. Trial registration Open Science Framework (osf.io/crj9p). Registered retrospectively on 11/06/2024.

Aim Habitual physical activity (PA) affects metabolism and homeostasis in various tissues and organs. However, detailed knowledge of associations between PA and cardiovascular disease (CVD) risk markers is limited. We sought to identify associations between accelerometer-assessed PA classes and 183 proteomic and 154 metabolomic CVD-related biomarkers. Method We utilized cross-sectional data from the main SCAPIS cohort (n = 4647, median age: 57.5 yrs, 50.5% female) as a discovery sample and the SCAPIS pilot cohort (n = 910, median age: 57.5 yrs, 50.3% female) as a validation sample. PA was assessed via hip-worn accelerometers, while plasma concentrations of proteomic biomarkers were measured using Olink CVD II and III panels. Metabolomic markers were assessed using the Nightingale NMR platform. We evaluated associations between four PA classes (moderate-to-vigorous PA [MVPA], low-intensity PA [LIPA], sedentary [SED], and prolonged SED [prolSED]) and biomarkers, controlling for potential confounders and applying a false discovery rate of 5% using multiple linear regressions. Results A total of eighty-five metabolomic markers and forty-three proteomic markers were validated and found to be significantly associated with one or more PA classes. LIPA and SED markers demonstrated significant mirroring or opposing relations to biomarkers, while prolSED mainly shared relations with SED. Notably, HDL species were predominantly negatively associated with SED, whereas LDL species were positively associated with SED and negatively associated with MVPA. Among the proteomic markers, eighteen were uniquely associated with MVPA (among those Interleukin – 6 [IL6] and Growth/differentiation factor 15 [GDF15] both negatively related), seven with SED (among those Metalloproteinase inhibitor 4 [TIMP4] and Tumor necrosis factor receptor 2 [TNFR2], both positively related), and eight were related to both SED/prolSED (among those Lipoprotein lipase [LPL] negatively related to SED and leptin [LEP] positively related to SED) and MVPA (with LPL positively related to MVPA and LEP negatively related to MVPA). Conclusion Our findings suggest the existence of specific associations between PA classes and metabolomic and cardiovascular protein biomarkers in a middle-aged population. Beyond validation of previous results, we identified new associations. This multitude of connections between PA and CVD-related markers may help elucidate the previously observed relationship between PA and CVD. The identified cross-sectional associations could inform the design of future experimental studies, serving as important outcome measures.

Background Successful prosthetic socket fitting contributes to prosthesis user satisfaction and facilitates rehabilitation, but is often challenging to achieve and maintain. There is a lack of information available that explores firsthand experiences of prosthetic users throughout socket fitting sessions and, in particular, their preferences regarding information exchange between them and their prosthetist. Objectives Assess satisfaction with prosthetic service, confidence in clinical judgement, and confidence providing feedback to prosthetists, examine experiences of prosthesis users in providing feedback to prosthetists and identify the types of information that prosthesis users want to communicate to their prosthetist, as well receive before, during, and after the socket fitting process. Study Design Mixed-method (quantitative and qualitative) survey. Methods A questionnaire was designed and administered in consultation with Amputees NSW (an amputee community support group) and distributed through their membership database. Quantitative items with discrete or scale-based responses were analyzed using descriptive, nonparametric methods and described satisfaction and confidence during prosthetic fitting. A thematic analysis was performed on qualitative responses to explore prosthesis user experiences of information exchange before, during, and after socket fitting. Results There were 24 survey responses. Ninety-six percentage of respondents were satisfied with their prosthetic service and were confident in their prosthetists' clinical judgement as well as ensuring socket comfort for their client. Most prosthesis users felt comfortable to provide feedback to their prosthetist (median =100 [interquartile range = 20], where 0 = not at all confident and 100 = completely confident). Experiences in providing input on comfort and fitting fell under 4 interrelated themes: collaboration, frustrations with process, impacts of poor fit, and prosthetic fit. Experiences with exchanging information with their prosthetist before, during, and after socket fitting fell under a further 4 themes: process-based information and provision options, taking history and treatment planning, collaboration and communication, and functional concerns. Conclusions Prosthesis users' confidence to provide feedback and satisfaction with prosthetic services could be helped by ensuring a responsive working relationship, facilitating information exchange between the prosthetist and prosthesis user, as well as improved prosthesis user education on the socket fit process.

Background: This study assessed the accuracy of three International Classification of Diseases (ICD) codes methods derived from Global Burden of Disease (GBD) sepsis study (modified GBD method) in identifying sepsis, compared to the Angus method. Sources of errors in these methods were also reported. Methods: Prospective multicentre, observational, study. Emergency Department patients aged ≥ 16 years with high sepsis risk from nine hospitals in NSW, Australia were screened for clinical sepsis using Sepsis 3 criteria and coded as having sepsis or not using the modified GBD and Angus methods. The three modified GBD methods were: Explicit-sepsis-specific ICD code recorded; Implicit-sepsis-specific code or infection as primary ICD code plus organ dysfunction code; Implicit plus-as for Implicit but infection as primary or secondary ICD code. Agreement between clinical sepsis and ICD coding methods was assessed using Cronbach alpha (α). For false positive cases (ICD-coded sepsis but not clinically diagnosed), the ICD codes leading to those errors were documented. For false negatives (clinically diagnosed sepsis but ICD-coded), uncoded sources of infection and organ dysfunction were documented. Results: Of 6869 screened patients, 450 (median age 72.4 years, 48.9% females) met inclusion criteria. Clinical sepsis was diagnosed in 215/450 (47.8%). The explicit, implicit, implicit plus and Angus methods identified sepsis in 108/450 (24.0%), 175/450 (38.9%), 222/450 (49.3%) and 170/450 (37.8%), respectively. Sensitivity was 41.4%, 58.1%, 67.4% and 55.8%, and specificity 91.9%, 78.7%, 67.2% and 79.1%, respectively. Agreement between clinical sepsis and all ICD coding methods was low (α = 0.52-0.56). False positives were 19, 50, and 77, while false negatives were 126, 90, and 70 for the explicit, implicit, and implicit plus methods, respectively. For false positive cases, unspecified urinary tract infection, hypotension and acute kidney failure were commonly assigned infection and organ dysfunction codes. About half (44.3%-55.6%) of the false negative cases didn't have a pathogen documented. Conclusion: The modified GBD method demonstrated low accuracy in identifying sepsis; with the implicit plus method being the most accurate. Errors in identifying sepsis using ICD codes arise mostly from coding for unspecified urinary infections and associated organ dysfunction. Trial registration: The study was registered at the ANZCTR (ACTRN12621000333819) on 24 March 2021.

Introduction Rural areas face persistent health disparities exacerbated by workforce shortages and the geographical isolation of health professionals. Innovative approaches are needed to mitigate professional isolation and enhance access to continuous professional development. This paper explores how health professionals perceive and utilise Rural Health Pro, analysing its potential to support professional needs, enhance capability, and improve workforce retention. Objective To explore rural health professionals' experiences and perceptions of the Rural Health Pro focusing on its functionality, support for professional needs, enhancement of capability, and contribution to workforce retention. Design A qualitative study utilising thematic analysis of semi‐structured interviews with 12 allied health professionals working in rural practice, examining their experiences and perceptions of the utility of the Rural Health Pro platform. They are independent of the Rural Doctors Network. Findings Participants reported that the Rural Health Pro platform supported their capability through professional development, peer connectivity, reducing feelings of professional isolation, and leadership development. Challenges included the need for more structured support in mentoring and professional development. Conclusions Rural Health Pro facilitates resource sharing, knowledge exchange, and access to professional connectivity, enabling rural health professionals to access relevant information and support. While it enhanced users' sense of capability and reduced professional isolation, further evidence is needed to evaluate its broader impact on workforce retention and quality of care in rural health.

Background Small observational studies suggest the effect of corticosteroids in patients with vasodilatory shock vary depending on endotypes determined by gene expression. We sought to replicate these findings in a larger cohort from a randomised clinical trial. Methods In a cross-sectional substudy of the Adjunctive Glucocorticoid Therapy In Septic Shock (ADRENAL) trial, patients were classified as one of two immune endotypes using predefined gene expression signatures: immune adaptive-prevalent (IA-P) or immune innate-prevalent (IN-P). We compared the outcomes of the two endotypes using a Bayesian analysis. The primary outcome was Day-28 mortality. Findings Of 540 patients, 267 (49.4%) were classified as IA-P and 273 (50.6%) as IN-P. In a Bayesian analysis using noninformative priors, there was no difference in the effect of hydrocortisone on 28-day mortality (odds ratio [OR] 1.43, 95% credible intervals [CrI] 0.72–2.87) and OR 1.39, 95% CrI 0.74–2.61, between the IA-P and IN-P groups, respectively. In the subgroup of patients with more severe shock (n = 215/540, 40%), the corresponding figures for IA-P and IN-P were 1.21, 95% CrI (0.31–4.74) and OR 0.72 (95% CrI 0.30–1.67), respectively. In the subgroup of patients with pulmonary sepsis (232/540, 43%), IA-P patients treated with hydrocortisone had increased mortality (OR 5.55, 95% CrI 1.81–21.2). Interpretation Gene expression data from patients with septic shock reveal distinct immune endotypes. There was no evidence of a heterogeneity of treatment effect of hydrocortisone on mortality in the 2 endotypes or in the subgroup with severe shock. Patients with the IA-P endotype and pulmonary sepsis appear to be harmed by corticosteroids.

Background & Objectives Research in rural health has historically been opportunistic, lacking alignment with strategic goals or community needs. The Government of India established Model Rural Health Research Units (MRHRUs) to address these disparities through targeted research. However, inconsistent outputs highlight the need for a strategic research agenda. Identifying research priorities is critical to inform policy and funding strategies of MRHRUs. Methods A nationwide Research Priority Setting (RPS) exercise was conducted, involving 120 respondents for free listing of questions, and 250 for ranking. Respondents from various stakeholder groups, including policymakers, researchers, and community representatives, participated. Research priorities were categorised into three domains – Description, Development, and Delivery. An iterative process was employed to refine and consolidate the 122 research questions into 36, which were subsequently ranked using a scoring system that assessed their importance, feasibility, and impact. The list of priorities was finalised through stakeholder deliberation. Results The top five research priorities across the three domains addressing key rural health challenges as identified in this study are presented. ‘Descriptive’ priorities included investigating social determinants of hypertension, medicine supply chain bottlenecks, and mental health in the elderly. ‘Development’ priorities focused on interventions using electronic health records in hospitals, tuberculosis control, and menstrual hygiene education. ‘Delivery’ priorities emphasised improving healthcare resilience, emergency care, and technology-driven diabetes management. These priorities were disseminated to MRHRU managers and policymakers to guide decisions with regard to perceived priorities for research in rural health. Interpretation & conclusions This first-of-its-kind RPS exercise provides inputs towards a strategic roadmap for rural health research, ensuring that future studies align with the needs of rural populations, leading to improved health outcomes. These findings illustrate perceptions and priorities of a selection of respondents from different stakeholder groups and need to be taken into consideration by the Department of Health Research and at the local level by each of the MRHRUs.

Background/Objectives: In 2020, the National Nutrition Committee in Saudi Arabia launched a nutrient profile model, aiming to support the classification of foods and beverages in line with successful international approaches. The objective of this study was to compare the existing Saudi Arabian nutrient profile model to other established models to help inform diet-related policies in the country. Methods: Packaged food and beverage data were obtained from Mintel’s Global New Products Database. Products were evaluated under the Saudi Arabian nutrient profile model, Nutri-Score and Chile’s high fat, salt, sugar (HFSS) model. Agreement among the three nutrient profile models was examined using Fleiss’ kappa statistic. Results: There were 6940 products used in analysis. All three models showed a low proportion of eligible/healthy products, with 26% for Chile’s HFSS model, 28% for Nutri-Score and 25% for the Saudi Arabian nutrient profile model. There was substantial agreement (86%; k = 0.74) among all three models examined, with the highest agreement between the Saudi Arabian nutrient profile model and the Nutri-Score model. Conclusions: All three demonstrated a sub-optimal level of overall healthiness in the Saudi Arabian packaged food and beverage supply, with <30% of products under all models considered “healthy”. Given the substantial agreement among all three nutrient profiling approaches examined, it is likely that Saudi Arabia could benefit from the use of a categorical approach to nutrient profiling such as the Nutri-Score model, which allows for a more scaled view on product healthiness compared to a binary approach.

Objective To analyse the gendered experience of women and men living with type 2 diabetes mellitus (T2D) related to diagnosis, treatment, and control in rural and urban contexts of Mexico. Methodology Qualitative ethnographic study. Thirty-six adults (21 women and 15 men) with a confirmed diagnosis of T2D for more than five years residing in urban and rural localities in Baja California and Morelos participated in this qualitative study between November 2022 and February 2023. A semi-structured interview guide was used to explore lifestyle changes, social and community networks, work and living conditions, experience with the disease, health services and associated economic burden. The analysis was guided by four conceptual domains of gender influence: identity, norms and roles, relationships and institutionalised gender. Results Women were more likely to report difficulty in accepting the diagnosis of T2D and stress in coping with the disease and related lifestyle changes. Men were more likely to report impact of T2D on their job and role as household providers, and their inability to contribute to the care of other family members. Women were more likely to report leaving their jobs, taking on caregiving responsibilities for family members, experiencing difficulty in accessing healthcare, and prioritizing their health in comparison to men. Men reported receiving more support from their partners, faced fewer financial barriers to care access, and had more freedom to pay for their medications and seek treatment in private care. However, they were also less adherent to treatment and disease care measures. Conclusions Gender appears to substantially influence experience of living with T2D. Women were more likely to provide family support and less likely to receive it and reported greater financial barriers to care access in comparison to men. Men were more likely to experience stress in relation to their employment as primary providers for their family, and less likely to adhere to prescribed medical management of their condition. These findings should be considered in more targeted health policy interventions to promote greater gender equity in the care of those with T2D in Mexico.