Care In Australian General Practice Research Articles

Factors influencing referral to maternity models of care in Australian general practice.

In the Australian maternity system, general practitioners play a vital role in advising and directing prospective parents to maternity models of care. Optimising model of care discussions and the decision-making process avoids misaligning women with over or under specialised care, reduces the potential for disruptive care transitions and unnecessary healthcare costs, and is critical in ensuring consumer satisfaction. Current literature overwhelmingly focusses on women's decision-making around model of care discussions and neglects the gatekeeping role of the General Practitioner (GP). This study aimed to explore and describe the factors influencing Australian GPs decision-making when referring pregnant women to maternity models of care. This study used a qualitative descriptive approach. General practitioners (N = 12) with experience referring women to maternity models of care in Australia participated in a semi-structured interview. Interviews occurred between October and November 2021 by telephone or videoconference. Reflexive thematic analysis was facilitated by NVivo-12 data management software to codify and interpret themes from the data. Two broad themes were interpreted from the data. The first theme entitled 'GP Factors', incorporated three associated sub-themes including '1) GPs Previous Model of Care Experience', '2) Gaps in GP Knowledge' and '3) GP Perception of Models of Care'. The second theme, entitled 'Woman's Factors', encapsulated two associated sub-themes including the '4) Woman's Preferences' and '5) Access to Models'. This study provides novel evidence regarding general practitioner perspectives of the factors influencing model of care decision-making and referral. Predominant findings suggest that gaps in GP knowledge regarding the available models of care are present and are largely informed by prior personal and professional experience. Most GPs described referring to models of care they perceive positively and centring their model of care discussions on the woman's preferences and accessibility. The exploration and description of factors influencing model of care decisions provide unique insight into the ways that all stakeholders can experience access to a broader range of models of care including midwifery-led continuity of care models aligned with consumer-demand. In addition, the role of national primary health networks is outlined as a means to achieving this.

Interconception care in Australian general practice: a qualitative study.

GPs provide care for women across the lifespan. This care currently includes preconception and postpartum phases of a woman's life. Interconception care (ICC) addresses women's health issues between pregnancies that then have impact on maternal and infant outcomes, such as lifestyle and biomedical risks, interpregnancy intervals, and contraception provision. However, ICC in general practice is not well established. To explore GP perspectives about ICC. Qualitative interviews were undertaken with GPs between May and July 2018. Eighteen GPs were purposively recruited from South-Eastern Australia. Audiorecorded semi- structured interviews were transcribed verbatim and analysed thematically using the Framework Method. Most participants were unfamiliar with the concept of ICC. Delivery was mainly opportunistic, depending on the woman's presenting need. Rather than a distinct and required intervention, participants conceptualised components of ICC as forming part of routine practice. GPs described many challenges including lack of clarity about recommended ICC content and timing, lack of engagement and perceived value from mothers, and time constraints during consultations. Facilitators included care continuity and the availability of patient education material. Findings indicate that ICC is not a familiar concept for GPs, who feel that they have limited capacity to deliver such care. Further research to evaluate patient perspectives and potential models of care is required before ICC improvements can be developed, trialled, and evaluated. These models could include the colocation of multidisciplinary services and services in combination with well-child visits.

Informing the design of a digital intervention to support sexually transmissible infection care in general practice: a qualitative study exploring the views of clinicians.

Strengthening sexually transmissible infection (STI) management in general practice is prioritised in Australian STI strategy. Digital interventions incorporating clinical decision support offer a mechanism to assist general practitioners (GPs) in STI care. This study explored clinicians' views towards a proposed digital intervention for supporting STI care in Australian general practice as a first step in the tool's design. Semi-structured one-to-one interviews were conducted during 2021 with sexual health physicians (n =2) and GPs (n =7) practicing in the state of Victoria, Australia. Interviews explored views on a proposed STI digital intervention for general practice. We applied the Theoretical Domains Framework (TDF), a behaviour change framework to our analysis. This involved: (1) directed content analysis of transcripts into TDF domains; and (2) thematic analysis to identify sub-themes within relevant TDF domains. Subthemes were subsequently categorised into enablers and barriers to the use and implementation of a STI computerised clinical decision support system (CDSS). All interviewees viewed a digital intervention for STI care favourably, expressing confidence in its potential to improve care and support management. Within the relevant TDF domains (e.g. environmental context and resources), subthemes emerged as barriers (e.g. lack of sensitivity to patient context) or enablers (e.g. clear communication and guidance) to the use and implementation of a STI CDSS in primary care. Multiple subthemes (e.g. time constraints) have the potential to be a barrier or an enabler, and is largely dependent on end-user needs being met and clinical context being appropriately addressed. A digital intervention incorporating clinical decision support was viewed favourably, indicating a possible role for such a tool in Australian general practice. Co-design with end-users and prototype evaluation with health consumers is recommended to ensure relevance and usefulness.

Spiritual care in Australian general practice nursing: An interpretive descriptive study.

Spiritual care as an aspect of holistic or person-centered care has been well documented. Studies on spirituality and spiritual care in nursing have taken place in various countries and contexts. Studies about spiritual care from the nurse perspective in the primary healthcare setting of Australian General Practice are not evident. Using an interpretive description study design, data about views on spirituality, spiritual care experiences, and descriptions about any spiritual care provided were collected from eight practice nurses. Four themes were drawn from the findings: the personal importance of spirituality and spiritual care to nurses and patients, spiritual care as an aspect of person-centered care, spiritual care practices, and barriers and enablers to addressing spiritual needs. Participants identified that practice nurses require improved education about spirituality to adequately address spiritual needs as expressed by patients, as well as the tools to be able to provide spiritual care. They also identified that documentation templates used in general practice should include prompts to address spiritual and/or religious needs.

Improving the provision of preconception care in Australian general practice through task-sharing with practice nurses.

Preconception care (PCC) is effective in reducing modifiable risk factors and optimising maternal health. Primary care services such as general practices in Australia are an appropriate setting to provide PCC. However, PCC is not routinely provided in most of these settings, and many reproductive-aged women and men are not aware of the need for PCC. In this forum article, we discuss the factors that hinder PCC provision in Australian general practices and make recommendations on how access to PCC services can be broadened in Australia, including the potential opportunity for general practice nurses to contribute to the provision of PCC.

End-of-life care in general practice: clinic-based data collection

BackgroundThere are no processes that routinely assess end-of-life care in Australian general practice. This study aimed to develop a data collection process which could collect observational data on end-of-life care...

What matters to people with chronic conditions when accessing care in Australian general practice? A qualitative study of patient, carer, and provider perspectives

BackgroundResearch underpinning the patient experience of people with chronic conditions in Australian general practice is not well developed. We aimed to ascertain the perspectives of key stakeholders on aspects of patient experience, more specifically with regards to accessing general practice in Australia.MethodsUsing a qualitative design, semi-structured interviews were conducted by telephone and face-to-face with people living with one or more chronic conditions, informal carers, and primary care providers between October 2016 and October 2017. Participants were recruited and selected from three demographically representative primary health networks across Sydney, Australia. Interview transcripts and researcher’s reflective fieldnotes were coded and analyzed for key themes of access. Analysis and interpretation of data were guided by Levesque’s model of access, a conceptual framework to evaluate access broadly and from corresponding patient- and provider-side dimensions.ResultsA total of 40 interviews were included in the analysis. Most participants had attended their general practices for 10 years or more and had regular primary care providers. People with chronic conditions reported access barriers predominantly in their ability to reach services, which were related to illness-related disabilities (limited mobility, chronic pain, fatigue, frailty) and limitations in the availability and accommodation of health services to address patient preferences (unavailability of after-hours services, lack of alternative modes of service delivery). While cost was not a major barrier, we found a lack of clarity in the factors that determined providers’ decisions to waive or reduce costs for some patients and not others.ConclusionsPeople managing chronic conditions with a long-term primary care provider experienced access barriers in general practice, particularly in their ability to physically reach care and to do so on a timely basis. This study has important policy and practice implications, as it highlights patients’ experiences of accessing care and possible areas for improvement to appropriately respond to these experiences. Themes identified may be useful in the design of a patient experience survey tool specific to this population. While it incorporates perspectives from patients, carers and providers, this study could be further strengthened by including perspectives from culturally and linguistically underrepresented patient groups and more carers.

Men's preconception health care in Australian general practice: GPs' knowledge, attitudes and behaviours.

Potentially modifiable factors can affect male fertility and reproductive outcomes, including smoking, obesity, and older paternal age. This study surveyed GPs' knowledge about, attitudes towards, and needs for promoting fertility and preconception health to male patients. The survey, conducted February to June 2018 and completed by 304 GPs, included questions relating to men's preconception health, the potential barriers and enablers to discussing preconception health with male patients, and the types of resources that would enable GPs to discuss parenthood intentions with men of reproductive age. Most GPs (90%) did not feel confident in their knowledge about modifiable factors that affect male fertility. Two-thirds agreed that it was their role to discuss these factors with male patients, but nearly 80% practised this only occasionally. Lack of knowledge, the sensitivity of the subject and fertility being perceived as a female issue, were identified as barriers to discussing fertility and preconception health with male patients. To facilitate discussions, GPs wanted trustworthy websites and factsheets to refer patients to. Men do not typically receive fertility or preconception health advice in general practice. A national framework for preconception health care that includes men, GP education and training, and reproductive health resources for men is needed.

From Provider Continuity to Practice Integration. Changing Care in Australian General Practice

Introduction: Attempts to encourage integrated care in Australia are known be made difficult by complicated funding health funding streams that come through two layers of government (Federal and State) and differing constitutional responsibilities for hospitals and other health care. This paper discusses further potential barriers to integration at a primary care level. Description of context: Primary care is predominantly funded by the Federal Government through payments to general practitioners, but there are significant contributions through State-funded community health centres and through patient out of pocket expenses. This presentation will discuss the funding structure of primary care in Australia, as well as barriers to achieving integrated care. In particular, the Australian health system does not limit patients (by regulation or financial burden) from attending multiple general practices or general practitioners in meeting their primary health care needs. There is good capacity for sharing of electronic health records within practices, but limited capacity to do so between practices. This Australian context has potential implications for the fragmentation of care and decreased delivery of continuity of care and patient centred care. Key findings: This paper uses data from an Australian Study of over 50000 patients to understand how patient preferences for general practice care are changing, and reveals increasing patient preferences for seeking care from a regular practice, rather than a particular provider. There is also a trend for patients to seek care at larger practices. Conclusion: It is hypothesised that patients are seeking to identify with a regular general practice, in order to gain some of benefits of both personal continuity of care and integrated care. By attending a regular general practice and a larger practice, these benefits can be obtained without the decreased access associated with a sole provider, and without potential fragmentation from attending multiple practices which do not share information. There are limitations to the research due to the nature of the study sample, and the use of patient recall in service usage estimations.

Impact of nursing care in Australian general practice on the quality of care: A pilot of the Patient Enablement and Satisfaction Survey (PESS)

Nursing roles in general practice have undergone significant expansion, but as yet there are few tools to measure the quality of nursing care in general practice. This study piloted the Patient Enablement and Satisfaction Survey (PESS) to evaluate two aspects of quality of care in this setting. Participants were patients attending nurse-led general and chronic-disease clinics in two general practices The survey was posted to 180 consecutive patients attending these clinics over one week (response rate, 28% for general clinic, 40% chronic diseases clinic; n = 57). Scores were calculated for enablement and satisfaction and free text comments were analysed. Comparisons were made between patients who had attended the general clinic for influenza vaccination and for other conditions, and those who attended the chronic diseases clinic. Overall results indicate high levels of satisfaction (M = 68.3/75 SD = 8.1) and moderate enablement (M = 4.7/8 SD = 3.2). Significant differences were observed between satisfaction scores for patients attending the chronic disease clinic and the general clinic for influenza vaccinations alone, and between those attending the general clinic for influenza vaccinations versus treatment of other conditions. Patients attending the chronic disease clinic had higher enablement scores than patients receiving influenza vaccinations at the general clinic. Analysis of free-text comments in the survey supported these findings. All patients reported satisfaction with nursing care. Patients receiving chronic disease management reported high levels of enablement. This pilot indicated that the PESS can distinguish between two aspects of the quality of nursing care that may impact on patient outcomes.

Australian practice nursing: collaboration in context.

To explore whether or not the context of Australian practice nursing supports collaborative decision-making about organisation and delivery of patient care. Positive patient outcomes depend on Australian practice nurses participating in collaborative and interprofessional services, particularly for patients with chronic disease(s). It is unclear whether Australian practice nurses have the opportunity to collaborate in decision-making or how traditional organisational structures may support or hinder collaboration. This is a descriptive exploratory study. Semi-structured interviews were conducted using a purposive sample of practice nurses (n = 15). Thematic analysis was used to provide meaningful and contextual insights into how practice nurses participate in decision-making. An interview tool, based on available literature, was developed and consisted of thirty open-ended questions to direct discussion during telephone interviews. Transcribed data were imported into NVivo(tm) for analysis and interpretation. The collection, analysis and thematic interpretation of data were an iterative process. Participants fostered trusting interprofessional relationships, which enabled them to influence medical decision-making and thereby advocate for patient need. Trusting interprofessional relationships were perceived to alter the relative roles of the medical practitioner and practice nurse and enhance the opportunities for collaborative decision-making. Collaborative interprofessional care in Australian general practice must occur if increased demands for care are to be met. It is timely to consider how government policy, financial regulations and the organisation of Australian general practice can better support and enhance a collaborative contribution to care by practice nurses.

Stepping up: a nurse-led model of care for insulin initiation for people with type 2 diabetes

Most people with type 2 diabetes (T2D) have glycaemic levels outside of target. Insulin is effective in improving glycaemia and most people with T2D eventually need this. Despite this, transition to insulin therapy is often delayed in primary care. To develop a model of care (Stepping Up) for insulin initiation in routine diabetes care in Australian general practice. To evaluate the model for feasibility of integration within routine general practice care. Drawing on qualitative work and normalisation process theory, we developed a model of care that included clarification of roles, in-practice systems and simple clinical tools. The model was introduced in an educational and practice system change intervention for general practitioners (GPs) and practice nurses (PNs). Five practices (seven GPs and five PNs) and 18 patients formed the feasibility study. Evaluation at 3 and 12 months explored experiences of GPs, PNs and patients. Fourteen patients commenced insulin, with average HbA1c falling from 8.4% (68.3 mmol/mol) to 7.5% (58.5 mmol/mol) at 3 months. Qualitative evaluation highlighted how the model of care supported integration of the technical work of insulin initiation within ongoing generalist GP care. Ensuring peer support for patients and issues of clinical accountability and flexibility, managing time and resources were highlighted as important. The Stepping Up model allowed technical care to be embedded within generalist whole-person care, supported clinicians and practice system to overcome clinical inertia and supported patients to make the timely transition to insulin. Testing of the model's effectiveness is now underway.

The views of mothers and GPs about postpartum care in Australian general practice.

BackgroundThe postpartum period is a time of increased morbidity for mothers and infants under 12 months, yet is an under-researched area of primary care. Despite a relatively clear framework for involving general practitioners (GPs) in antenatal care, the structure of maternity service provision in some Australian jurisdictions has resulted in highly variable roles of general practice in routine postpartum care. This study aimed to investigate the views and experiences of mothers and GPs about postpartum care in general practice.MethodsThis was a qualitative study of mothers and GPs in rural, regional and metropolitan areas of Queensland, Australia. Semi-structured interviews were conducted with 88 mothers and six general practitioners between September 2010 and February 2012. Interviews were recorded and transcribed verbatim. Data were analysed thematically and compared across groups.ResultsThree main themes emerged: The relationship between the mother and GP; practice management; and GP visits. This paper focuses on the theme GP visits and its subthemes: recommendations for GP visits; scope of practice; and content of a routine visit. Recommendations about GP visits given to mothers varied by birthing sector, obstetric provider and model of maternity care resulting in confusion amongst mothers about the timing and role of GPs in routine postpartum care. Similarly, GPs voiced concerns about a lack of consistent guidelines for their involvement in routine postpartum care. Although ideally placed to provide primary care to mothers and their infants in the postpartum period, the lack of consistent guidelines for the role of GPs is of concern to both the GPs and early parenting women.ConclusionGeneral practice is an important source of postpartum care for mothers and provides a basis for ongoing support for the family. More consistent guidelines and better coordination with other care providers would benefit both mothers and GPs.

A tool to evaluate patients’ experiences of nursing care in Australian general practice: development of the Patient Enablement and Satisfaction Survey

Australian health policy initiatives have increasingly supported the employment of nurses in general practice. An understanding of the impact of nursing care on patients in this setting is integral to assuring quality, safety and a patient-centred focus. The aim was to develop a survey to evaluate the satisfaction and enablement of patients who receive nursing care in Australian general practices. The survey was to be simple to administer and analyse, ensuring practicality for use by general practice nurses, doctors and managers. Two validated instruments formed the basis of the Patient Enablement and Satisfaction Survey (PESS). This survey was refined and validated for the Australian setting using focus groups and in-depth interviews with patients, and feedback from general practice nurses. Test-retest and alternate form methods were used to establish the survey's reliability. Feedback resulted in 14 amendments to the original draft survey. Questions that demonstrated a strong positive correlation for the test-retest and alternate form measures were included in the final survey. The PESS is a useful, practical tool for the evaluation of nursing care in Australian general practice, its validity and reliability established through a patient-centred research approach, reflective of the needs of patients accessing nursing services in this setting.

Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice

To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice. Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics. Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores. Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not. Findings were consistent with the purpose of TCAs--to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

Utilization of the CARDIAB®™ database system to promote quality of care in Australian general practice

This article describes quality of care and health outcome indicator data aggregated from seven Australian Divisions of General Practice, using the CARDIAB®™ register recall system, involving 4359 people with diabetes. Eighty-eight per cent of patients registered had type 2 diabetes. The process of care of these patients was evaluated in nine parameters critical to quality of care in diabetes: glycaemic control (HbA1c), blood pressure, body mass index, total cholesterol levels, triglyceride levels, high density lipoprotein levels (HDL), microalbumin level, foot checks and eye checks. The data provide important baseline information for program planning, service delivery, quality assurance and quality improvement at local, state and national levels. They demonstrate the potential of CARDIAB®™ to provide support to general practice in the management of diabetes. The reach of such registers will be facilitated by increased computerization of general practice records. A policy framework which addresses key concerns was central to recruitment to the project.