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Addressing the educational barriers of radiation therapists to facilitate the use of the PROMPT-Care electronic symptom and distress screening tool within Illawarra and Shoalhaven cancer care centres.(2021) Arnold, BelindaThesisWith the high prevalence of distress in people diagnosed with cancer, it has been widely recognised that routine screening for symptoms and distress at critical points of the disease trajectory is an essential component of best practice cancer care. Radiation therapists (RTs) are one of the primary care providers present at stages identified as increased times of anxiety and distress during the radiation therapy pathway; and they see approximately 50% of patients who are diagnosed with cancer, who require radiation therapy. Whilst RTs believe psychosocial care is important and integral to their role, it is unknown whether they have the required education to perform this role confidently. The research reported in this dissertation documents RTs’ baseline opinions of barriers, knowledge, attitudes, confidence and roles in the psychosocial care of patients. Evaluation of the impact of a communication skills training (CST) program, RT Prepare CST, on these variables and on RTs’ symptom and distress screening practices (behaviour change) post-intervention will be presented. A single-arm, pre-post intervention design was implemented. All RTs (n=39) attended the educational intervention (RT Prepare CST). RTs at two radiation therapy departments completed a paper-based questionnaire to assess their demographic and workplace characteristics, perceptions of barriers, knowledge, attitudes, confidence, and opinion of their role in symptom and distress screening. The questionnaire was completed at three-time points: pre-intervention (T1); immediately post (T2) and, three months post-intervention (T3). Interviews with RTs were conducted six months after the training to supplement the quantitative results. Data were extracted from the electronic medical record (EMR) to determine any change in the number of patients screened for symptoms and distress in the six months before compared to the six months after training to assess the impact on RTs’ screening behaviour. At baseline, RTs lacked knowledge and confidence whilst performing screening, and identified numerous barriers to performing this role. Providing education increased the knowledge, attitudes and confidence of RTs when providing emotional care to patients; and resulted in RT behaviour change, through significantly increased number of assessments completed with patients post-training. RTs’ perceptions of their role and barriers in performing psychosocial care of patients did not change post-training, with qualitative interviews with RTs highlighting the need for organisational direction, peers and supervisors' influence in performing roles, and their desire to be more actively involved in the follow-up to screening to provide more holistic care to patients. This research has provided the foundations for the future development and evaluation of a CST program that meets the educational needs of Australian RTs when performing symptom and distress screening. Attending RT Prepare CST has afforded new opportunities for RTs within these radiation therapy departments, enhancing their ability to care for patients holistically, equipping them with skills to potentially be included within a psychosocial model of care. For this to occur, organisations and leadership teams need to provide clear direction and create an environment that promotes discussion of the potential of RTs and their role in the psychosocial care of patients within radiation therapy departments.
Therapeutic drug monitoring to optimise treatment of inflammatory bowel disease with tumour necrosis factor inhibitors(2021) Wu, YangThesisINTRODUCTION Anti-Tumour Necrosis Factor-α inhibitors, infliximab (IFX) and adalimumab (ADA) have proven clinical efficacy in inflammatory bowel disease (IBD), however the annual risk of loss of response is estimated to be 13% per patient year. Therapeutic drug monitoring (TDM) is a useful tool in guiding patient management in the reactive setting, however there is controversy about its value in the proactive setting. The aim of this dissertation is to examine the ability of proactive and reactive anti-TNFα TDM to influence clinical practice and generate cost savings. METHODS In study 1, IFX and ADA drug levels measured for patients with Crohn s disease (CD) were collected from Liverpool and Royal Adelaide Hospitals, as well as the subsequent real-life management decisions. The decision was compared to a consensus decision from a panel of three gastroenterologists based on the clinical and laboratory results without the drug level. When the two decisions were discrepant, TDM was deemed to have changed management. In study 2, consecutive IFX level measurements performed at Liverpool Hospital, were prospectively collected. An IFX TDM algorithm was used to identify unnecessary IFX use. Cost analysis was performed by comparing the cost of performing IFX TDM with the cost of avoiding one IFX infusion or reducing IFX dosage. RESULTS Knowledge of anti-TNFα levels changed management in 85/181 (46.9%) of instances, with a greater proportion of decisions being altered in the reactive setting than the proactive setting (63% versus 36%; p = 0.001). The indication associated with the highest proportion of decisions changed by TDM results was in the proactive indication of consideration of drug withdrawal, 10/12 (83%). IFX TDM helped to identify unnecessary use of IFX in 30.6% of the TDM test samples, with an associated drug cost saving of $531.38 per IFX TDM test episode. Unnecessary IFX use was identified in 96/247 (38.9%) of reactive IFX TDM tests and in 35/181 (19.3%) of proactive testing. CONCULSION These results support the clinical value of anti-TNFα TDM as it alters management decisions in CD in both proactive and reactive settings. IFX TDM is also cost-effective for IBD management as it reduces unnecessary IFX use.
Exploring levels and correlates of health literacy in Arabic and Vietnamese immigrant patients with cancer and their Anglo-Australian counterparts in Australia.(2020) Gerges, MarthaThesisIntroduction: Australia has the second largest immigrant population in the world. Health literacy is a crucial factor in enabling patients to manage their own health and wellbeing and improving their health outcomes, particularly in the context of an increasingly complex health care system. Individuals with lower health literacy can experience inferior health outcomes and higher mortality rates, higher health-related costs, and higher use of health services; and they are less likely to undergo cancer screening and have low levels of healthcare knowledge. Aims: This project aimed to explore health literacy profiles of two immigrant Australian populations affected by cancer - Arabic and Vietnamese - and their Anglo-Australian counterparts, using the validated Health Literacy Questionnaire (HLQ). The project aimed to identify potential correlates of poorer health literacy between the groups and identity implications of these relationships on future research and within a clinical setting. Methods: Patients were eligible to participate if: a) aged 18+ years; b) diagnosed with cancer in the last five years; c) identified English, Arabic or Vietnamese as their primary language; d) were born outside of Australia (for immigrant groups) or in a predominantly English-speaking country for the Anglo-Australian group; and e) were cognitively able to provide informed consent. Levels of health literacy were evaluated using a cross-sectional self-report questionnaire provided to consenting patients in their preferred language. Multiple regression analysis was utilised in order to identify differences between Anglo-Australian and immigrant populations while controlling for pre-determined variables (correlates). Results: Results indicate that the immigrant and Anglo-Australian patients display very similar health literacy and eHealth literacy profiles with the exception of their ‘ability to find good health information’. In addition to this, self-efficacy, as displayed through the ability to ‘understand and participate in care’, and education, displayed statistically significant relationships on several domains of health literacy, irrespective of immigrant status. ‘Understanding and participating in care’ was also the only domain to show a significant relationship with eHealth literacy, also irrespective of immigrant status. Implications: The health system needs to be better enabled to meet the information needs of immigrant cancer patients. It is recommended that health care professional training be undertaken so that clinicians and other health care professionals can develop and maintain a meaningful working relationship with their patients, regardless of their health literacy levels. Moreover, research into the types of information and availability of services within the healthcare setting should be undertaken to improve the health system and enable it to create a more informed and involved health consumer, who is empowered to actively participate in their own health and wellbeing, irrespective of their health literacy levels.
(2022) Thilakanathan, CynthujaThesisHBsAg quantification may be a potential surrogate marker for hepatitis B (HBV) DNA load in mothers with chronic hepatitis B (CHB) given the higher availability and cheaper cost. Although genotype is not routinely tested in clinical practice, there are no studies looking at whether a correlation between quantitative HBsAg (qHBsAg) and viral load is affected by genotype. HBeAg seroconversion is important as it is associated with reduced liver injury time and earlier HBeAg seroconversion confers better prognosis. There are currently no definitive predictors of HBeAg seroconversion postpartum. A retrospective cohort analysis of mothers with CHB was performed across two major liver tertiary centres in Sydney, Australian between the years 2006 to 2019. Baseline (second trimester) and post-partum variables were collected including qHBsAg, viral load, genotype and evidence of seroconversion. We found qHBsAg level > 4 log 10 IU/mL to have a weak positive correlation with high viral load >6 log 10 IU/mL. The sensitivity was 70.5%, specificity 91.0%, negative predictive value (NOV) 91.0% and positive predictive value 70.5%. HBeAg was a better test to predict high viral load with NPV 97.9%. However, quantitative HBV DNA still remains the gold standard. Genotype did not affect the correlation between quantitative HBsAg and viral load. We identified three positive predictors for HBeAg seroconversion post-partum. This was age <35 years, baseline ALT ≥50 U/L and baseline HBV DNA <8 log10IU/ml. Our SydPredScore, based on these three variables, estimates the probability of seroconversion at 2000 days as approximately 10%, 30%, 70% and 80% for 0, 1, 2, and 3 predictors respectively. For mothers with 0 predictors, the chance of HBeAg seroconversion is extremely low and consideration could be given to treat these women with antiviral therapy to prevent further liver injury.