The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

OBJECTIVE:To quantify the burden of cardiovascular diseases (CVD) in older adults using community and residential care services.METHODS:The study population comprised people aged 45+ from the 45 and Up Study (2006-09, n = 266,942) in Australia linked with records for hospital stays, aged care service and deaths for the period 2006-14. Follow-up time for each person was allocated to three categories of service use: no aged care, community care and residential care, with censoring at date of death. We calculated the prevalence at baseline and entry to aged care, and incidence rates for major CVD and six cardiovascular diagnoses, seven cardiovascular interventions (collectively CV interventions), cardiovascular-related intensive care unit stays and cardiovascular death.RESULTS:The prevalence of major CVD at entry into community care and residential care was 41% and 58% respectively. Incidence per 1,000 person-years of all major CVD hospitalisations and CV interventions, respectively, was 182.8 (95% CI: 180.0-185.8) and 37.0 (95% CI: 35.6-38.4) for people using community care, and 280.7 (95% CI: 272.2-289.4) and 11.7 (95% CI: 9.8-13.9) for people using residential care. Similar trends were observed for each of the CVD diagnoses and interventions. Crude incidence rates for cardiovascular deaths per 1,000 person-years were 1.4 (95% CI: 1.3-1.5) in no aged care, 13.3 (95% CI: 12.6-14.1) in community care, and 149.7 (95% CI: 144.4-155.2) in residential care.CONCLUSION:Our findings demonstrate the significant burden of CVD in people using both community-based and residential aged care services and highlights the importance of optimising cardiovascular care for older adults.

In the Central Coast Local Health District of New South Wales, Australia, childhood immunisation (CI) rates are around 95%, but pockets of underimmunisation exist. Using the World Health Organization's Tailoring Immunization Programmes, we identified areas of potential low vaccine coverage using Australian Immunisation Register (AIR) data (2016-18) and investigated factors that influence CI. Individual and group interviews with carers, community members and service providers (n = 52 participants) were conducted. Data were analysed thematically and the themes presented to stakeholders for feedback before finalisation. During 2018, Umina had 218 children at least 1 month overdue for at least one vaccination. Five themes emerged: (1) broader socioeconomic factors may apply pressures that influence CI; (2) parents largely supported immunisation and knew of its benefits to their children and the community; (3) immunisation service providers are committed, experienced and collaborate with community partners; (4) there is potential to increase access to free immunisation services in Umina; and (5) AIR data and reminder systems could be better used to inform service delivery and prompt parents before immunisations are due. This study identified opportunities to improve CI coverage in Umina and new information useful in developing a tailored immunisation strategy. Awareness of the pressures socioeconomic factors may have on families could help plan and deliver supportive primary health care that includes equitable access to immunisation.

Introduction: Integrated care has been posited as an important strategy for overcoming service fragmentation problems and achieving the Quadruple Aim of health care. This paper describes the Central Coast Integrative Care Program (CCICP) a complex, multi-component intervention addressing 3 target populations and more than 40 sub-projects of different scale, priority and maturity. Details are provided of the implementation including activities undertaken for each target population, in the context of the Central Coast Local Health District (CCLHD) strategies and priorities. Key lessons are drawn from the formative evaluation. Methods: A mixed methods approach to the formative evaluation was taken. Key stakeholders, professional staff with an in-depth knowledge of the program, were invited to complete surveys (n = 27) and semi-structured interviews (n = 23). The evaluation employed co-design principles with dialogue between CCICP partners and researchers throughout the process and sought to achieve a shared understanding of the dynamic context of the program, and the barriers and enablers for the various interventions. Key lessons and conclusion: Seven interdependent key lessons have been identified. These distil down to the setting of clear objectives aligning with all the goals of partners, developing strong relationships, leadership at multiple levels and communication and the building of a common language.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Introduction: The health sector is activity focused; it is counted, valued and bought. Is this sustainable and should alternative constructs be considered? This case study from Integrated Care on the Central Coast of NSW, Australia outlines the journey of building an Outcomes Based Commissioning Framework to support vulnerable older people.Practice Change Implemented: The approach applied new thinking around funding outcomes to develop an innovative funding to drive improved care.Aim and theory of change: The aim is to deliver care coordination for vulnerable population group, engage community based providers and pilot an alternative funding model.Targeted population and stakeholders: The project encompassed needs assessment and predictive risk stratification for a population at risk of hospitalisation in the next twelve-months and experiencing health and socioeconomic disadvantage.Timeline: Twelve-months.Highlights: The project brought together essential components of care – identifying a population at future risk, collaboratively designing new models of care through care design, assessing the local community’s capability to support the vulnerable and creating outcome based payment and contracting models. An outcome focus was developed through reducing hospitalisations and this provided the basis for an alternative funding model.The model focused on care and ensured funding was available where care was required (at the hospital to pay for bed days or to pay providers for supporting people in their community). This shifted the focus and reimbursement from service activity to delivering on patient outcomes.Sustainability and Transferability: This approach, drawing on existing funding, has potential to be sustainable into the future and challenges traditional funding of care. Transferability could be country wide, and the outcomes approach has implications in integrated care in all settings. It expands significantly on international outcome models by increasing payments to providers that successfully support patients to avoid unnecessary hospitalisations. Hybrid models of activity based and outcomes based funding have potential into the future of health funding.Conclusions: Potentially this care model is agreeable to providers, sits within existing health budgets, is transparent and allows care to follow the patient.Discussion: An alternative care model has been trialed within an Outcomes Based Commissioning Framework. It incorporates new approaches to considering funding, engaging the market and fundamentally challenging the traditional approach to core business.Lessons Learned: This new way of thinking challenges both the system and the people that work in it. It is a journey of change and needs support and guidance along the way. Political scrutiny adds an extra dimension to work of this type and the right stakeholders must be engaged. A number of secondary outcomes have emerged including:Development of new contracts and KPIsImproving links between clinical and financial performance staffEstablishing frameworks for care coordinators and general practitioners to work closer together

Introduction: Predictive analytics have been used to identify people who are at high risk of a health event, and then offer a preventive intervention to avoid or delay that event. Health care systems in the UK, US, Europe facilitate the linkage of health data to allow predictive algorithms to be developed and applied. Data linkage in Australia can be challenging, with state funded public hospitals, private hospitals and federally funded independent general practices.Problem statement – Is predictive modelling using hospital and general practice data feasible in the Australian setting? What is the utility of these predictive models?Methods: Two general practices were approached to take part in this quality improvement project. Principal GPs were interested and willing to participate, and the practices used the same clinical practice software.Central Coast hospital admission data for people from these practices were extracted from the hospital information systems and provided to the two practices. An extract of each practice’s clinical system was taken for all active patients. These two datasets were combined at the general practice site, de-identified, and then provided to the researchers for analyses and predictive modelling.This project was approved by the health service research office as a quality improvement activityResults: Data extraction and linkage were achieved at both sites for over 3000 people.Predictive models were developed for each site, with mostly the same variables, and minor differences in the estimates of effect. Models developed had a c-statistic of 0.74 to 0.77, and when applied to a practice population, were found to have a positive predictive value of about 25%.Discussion: The usefulness of these models when applied to the practice population raises important questions. What is the intervention at the practice level? Do model results need to be incorporated into a staged selection process that leads to a more specific intervention? How will this operate in a treatment oriented fee for service primary health care system?Conclusions: Predictive modelling using hospital and general practice data was feasible.There are challenges in the transferability and sustainability of modelling, and how results are used to improve outcomes for people.Lessons learned: It required a multiple stage process to address privacy and ethics concerns.It is complex – there is variability in general practice clinical software, versions of software, versions of operating systems, individual use of clinical structures within software, and expertise of practice staff and IT support staff.Predictive analytics are the first step. Perhaps more importantly, how will each person’s risk estimate be used to improve their care, and prevent or minimise adverse health outcomes?Limitations: This was a resource intensive process, requiring high level data management skills to address IT variability.Practice and practitioner approach to the use of clinical software – how hospital, specialist and other services were recorded limited the scope for using this information.Suggestions for future research: What are the likely quantifiable benefits of these approaches? (in Australia)Are there other opportunities for this type of work in existing linkage projects?

The aim of this study was to compare the walkability of neighborhood environments of older adults (65 years and above) living in the general community and retirement village settings, and to describe associations between walkability and the physical activity of participants. The study was conducted in a coastal region of Australia largely characterized by urban sprawl. In 2011-2012, 292 participant neighborhoods (400 m radius around each home) were audited using the Irvine-Minnesota Inventory. Having validated a local adaptation of this tool, we compared neighborhood environments in the two settings. We found no association between walkability of the built environment and walking behavior of participants. Although retirement village residents lived in more highly walkable environments, they did not walk more and their overall levels of physical activity were lower than those of community residents.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Internationally, sophisticated risk stratification models have been developed using routinely collected data from large organisations that provide care in both community and hospital settings. This paper outlines a simple approach in the Australian context, where federal and state governments have separate data for community and hospital care, with limited opportunities for data linkage. On the NSW Central Coast, just north of Sydney, the Central Coast Local Health District, CCLHD, is embarking on a 10 year program to integrate primary health and social care for vulnerable older people in the community. A key action is to provide integrated care for people at greatest risk of some deterioration in their health state. Practice change Aim: To assess the utility of routinely collected hospital data for risk stratification. In the first year of the program, the risk is defined as a person with a high risk of being hospitalised in the next 12 months. Target Population: The Central Coast area of New South Wales, Australia, has a population of about 330,000 people, with 19% aged 65 years and over. Each year, about 10,000 people of this age have at least one unplanned hospital admission to a CCLHD hospital. There are over 400 General Practitioners, GPs, on the Central Coast, working from about 100 practice locations - with some solo practices to large group practices, operating as separate small business entities. People do not register for a GP, though nearly all people by 75 years of age have a regular GP. General practices also vary by the number and age profile of the patients they see in a year. Key Findings: The analysis of 5 years of hospital data demonstrated patterns in service delivery for the older age group eg for each year’s cohort of 10,000 people with at least one admission, about 2700 people (27%) have at least one hospital admission in the following year. Knowing each person’s nominated GP allowed some exploration of patterns of service use by GP. Some GPs had few patients admitted each year, and some GPs had many. It is likely this variability reflects differences in practice profiles of age distribution. There was consistency in these patterns of service use by GP over time, and also by general practice. The analysis of comorbidities allowed categorisation of the age group into those with 2 or more comorbidities - about 3500 people from a one year cohort have 2 or more chronic diseases. For this group of 3500 people, about 1500 people, or 40%, have a hospital admission in the following year. This approach was used to identify a small number of general practices in a low socio-economic status area, with an initial total cohort of about 600 people for a proof of concept of integrated care. Discussion : A risk stratification model needs to be linked with an effective intervention to improve the health of a population. Regression to the mean, when assessing whether a trial worked – it is important to have an understanding of patterns of service delivery over time, if they exist. Analysing hospital data, by general practice, allows contemporaneous analyses of other practices with similar activity and socio-economic profiles for comparison. Risk stratification models and c-statistics – the c-statistic is a useful measure of goodness of fit available for some regression models. It is not the only measure, and others should be considered. This approach using hospital data does not have a goodness of fit measure per se. Positive Predictive Value – Of equal importance is how well the model works when it is applied to the population of interest. If a model selects 100 people considered at high risk of hospitalisation, and 25 people are actually admitted to hospital, this represents a positive predictive value, PPV, of 25%. The PPV is influenced by the underlying risk of hospitalisation in your target population. Our 40% prediction of hospitalisation can be compared with the PPV of other risk stratification models. Conclusion : Further work is underway to apply a regression model to hospital data to facilitate comparisons with other risk stratification models reported in the literature, and quantify the incremental gains from increasingly sophisticated approaches to patient selection. Further work will also explore the gains from linking hospital data with primary care data. Using hospital data compares well with other models, and is an easily transferable, low tech approach to patient selection. A series of criteria for patient selection is a familiar way of doing business in many clinical settings.

The Local Government Area of Gosford implemented a water fluoridation scheme in 2008. Therefore the opportunity was taken to record the dental health of primary school children aged 5–7 years prior to the fluoridation and compare the results with other communities in NSW with different access to fluoridated water. The aim was to compare the oral health of New South Wales (Australia)s 5–7 year olds living in fluoridated, and non- fluoridated communities. One of the areas was due to implement water fluoridation and is termed the pre-fluoridation site.

OBJECTIVE:To estimate influenza and pneumococcal immunisation rates by self-report and validate this with immunisation providers.METHOD:A random population telephone survey. This was followed by contacting immunisation providers of those reporting having an influenza vaccination (2009 or 2010 only) and/or pneumococcal vaccination to confirm vaccination or not.RESULTS:A total of 680 people aged 65 and older responded to the telephone survey. Seventy-five per cent of respondents self-reported influenza vaccination in 2010 and 26% self-reported having ever had the pneumococcal vaccination. Following up with immunisation providers, we found recall for influenza vaccination was confirmed in 96% of cases. For the pneumococcal vaccination, recall for vaccination was confirmed in 87% of cases. People saying they were not vaccinated for pneumococcal were subsequently confirmed as vaccinated in 77% of cases.CONCLUSIONS:In this study, self-reported influenza vaccination was reliable. The term 'pneumococcal vaccination or Pneumovax' was poorly recognised by our telephone survey respondents as evident by the low rate of self-reported pneumococcal vaccination compared to a much higher rate of pneumococcal vaccinations recorded by GPs.IMPLICATIONS:While pneumococcal vaccination is an accurate term, researchers should be aware of the terminology used in general practice and the community when designing their survey.

This paper describes the public health investigation and response to a Salmonella Typhimurium outbreak in June 2010 in the Central Coast of New South Wales. Two complaints from people with acute gastrointestinal illness pointed to food from a kebab takeaway shop as the cause of their illness. Liaison between public health and food authorities ensured timely epidemiological and environmental investigations leading to prompt identification and elimination of the point source. A case series investigation identified 45 outbreak cases including 31 laboratory-confirmed and 14 epidemiologically-linked cases. The food vehicles identified were hommus and tabouli--93% of cases reported having one or both items in their kebab. S. Typhimurium with the same MLVA type was found in stool specimens from outbreak cases and in food (including hommus and tabouli) and environmental samples collected at the kebab takeaway shop. Education of commercial food handlers, reduction of poultry meat contamination and collaboration between public health and food authorities to ensure prompt identification and control of outbreaks are important strategies to reduce Salmonella related illness.

Background/Aims: 118 elderly participants (65–90 years) were assessed for any relationship between folate, related genes and hypertension. Methods: Six B-vitamin-related SNPs were genotyped in 80 normotensive and 38 hypertensive subjects. Results: Of six polymorphisms (677C>T-MTHFR, 1298A>C-MTHFR, 80G>A-RFC, 2756A>G-MS, 66A>G- MSR, 19bpDHFR and 1561C>T-GCPII), only 677C>T-MTHFR was a significant risk for hypertension: OR 1.89; 95% CI 1.07–3.32 (χ2 p = 0.038). Additionally, hypertensive subjects had a significantly lower intake of dietary folate than normotensive individuals (p = 0.0221), although this did not markedly alter blood metabolite levels. Several significant linear associations between dietary folate and related blood metabolites were found in normotensive subjects (p < 0.001 for Hcy, red cell and serum folate) and were as predicted on an a priori basis – generally weaker associations existed in hypertensive subjects (p < 0.05 for serum folate). This was true for data examined collectively or by genotype. Multiple-regression analysis for diastolic or systolic blood pressure showed significant interaction for gender and folate intake (p = 0.014 and 0.019, respectively). In both cases this interaction occurred only in females, with higher folate intake associated with decreased blood pressure. Regressing diastolic blood pressure and 677C>T-MTHFR genotype showed significance (males; p = 0.032) and borderline significance (all subjects). Conclusion: Dietary folate and 677C>T-MTHFR genotype may modify blood pressure.

Background/Aims: Folic acid mediates transfer of one-carbon units into methionine and DNA-thymine biosynthesis. Discretionary and mandatory use of synthetic folic acid (SFA) to reduce spina bifida is on the increase. We show that historically, the seasonal cycle of abundance of folate-rich foods may have regulated embryo viability by acting as a selection factor for a significant polymorphism within a gene encoding 5,10-methylenetetrahydrofolate reductase (677C→T-MTHFR). Methods: Blood was collected from 150 UK and 118 Australian subjects born prior to discretionary or mandatory use of SFA. 677C→T-MTHFR genotype was determined using PCR. Results: The highest prevalence for 677T-MTHFR occurred 9 months post-harvest in UK subjects and was significantly higher at this time of year (July–Sept.) compared with Jan.-Mar. (OR = 2.0, 95% CI 1.03–3.87, p = 0.039) and Oct.–Dec. (OR = 2.2, 95% CI 1.12–4.31, p = 0.021). This effect was not detected in an Australian population subject to more moderate seasonality. Conclusions: Dietary folate may confer significant genetic buffering within populations dependent upon seasonal food sources that modify an individual’s vitamin status at the time of conception.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 5-10% of women. It is characterised by androgenisation and anovulation, with sufferers being at increased risk of metabolic problems such as noninsulin dependent diabetes mellitus and dyslipidaemia. An increased risk of cardiovascular disease is speculated. Clinically, sufferers may experience acne, obesity, hirsutism and/or male pattern baldness.