Disease Management In General Practice Research Articles

Optimising a clinical decision support tool to improve chronic kidney disease management in general practice

BackgroundEarly identification and treatment of chronic disease is associated with better clinical outcomes, lower costs, and reduced hospitalisation. Primary care is ideally placed to identify patients at risk of, or in the early stages of, chronic disease and to implement prevention and early intervention measures. This paper evaluates the implementation of a technological intervention called Future Health Today that integrates with general practice EMRs to (1) identify patients at-risk of, or with undiagnosed or untreated, chronic kidney disease (CKD), and (2) provide guideline concordant recommendations for patient care. The evaluation aimed to identify the barriers and facilitators to successful implementation.MethodsFuture Health Today was implemented in 12 general practices in Victoria, Australia. Fifty-two interviews with 30 practice staff were undertaken between July 2020 and April 2021. Practice characteristics were collected directly from practices via survey. Data were analysed using inductive and deductive qualitative analysis strategies, using Clinical Performance - Feedback Intervention Theory (CP-FIT) for theoretical guidance.ResultsFuture Health Today was acceptable, user friendly and useful to general practice staff, and supported clinical performance improvement in the identification and management of chronic kidney disease. CP-FIT variables supporting use of FHT included the simplicity of design and delivery of actionable feedback via FHT, good fit within existing workflow, strong engagement with practices and positive attitudes toward FHT. Context variables provided the main barriers to use and were largely situated in the external context of practices (including pressures arising from the COVID-19 pandemic) and technical glitches impacting installation and early use. Participants primarily utilised the point of care prompt rather than the patient management dashboard due to its continued presence, and immediacy and relevance of the recommendations on the prompt, suggesting mechanisms of compatibility, complexity, actionability and credibility influenced use. Most practices continued using FHT after the evaluation phase was complete.ConclusionsThis study demonstrates that FHT is a useful and acceptable software platform that provides direct support to general practice in identifying and managing patients with CKD. Further research is underway to explore the effectiveness of FHT, and to expand the conditions on the platform.

Health professionals’ views of the first national GP payment scheme for structured type 2 diabetes care in Ireland: a qualitative study

Background: Payment schemes are widely used to improve chronic disease management in general practice. Although stakeholder views of such schemes could provide valuable learning regarding aspects that work and those which are more difficult to implement, there is a paucity of such data. We explored health professionals’ views of the implementation of the first national general practice payment scheme for type 2 diabetes (T2DM) care in Ireland, the ‘cycle of care’. Methods: Qualitative data were drawn from a multiple case study evaluating the implementation of a National Clinical Programme for Diabetes, collected from April 2016 to June 2017. Interview and focus group transcripts from participants involved in providing diabetes management in general practice and who referenced the cycle of care were eligible for inclusion in the current analysis. Data were analysed using reflective thematic analysis. Results: We analysed data from 28 participants comprising general practitioners (GPs) (n=8), practice nurses (n=9) and diabetes nurse specialists (DNS) (n=11). Participants perceived the cycle of care as “not adequate, but…a good start” to improve T2DM care in general practice in Ireland. Perceived benefits were greater financial viability for T2DM management in general practice, fostering a more proactive approach to T2DM care, delivery of T2DM care closer to patients’ homes, and increased use of other community diabetes services e.g., DNS and podiatry. Participants identified the limited resource for practice nurse time, inflexibility to provide care based on patient need and issues with data submission as drawbacks of the cycle of care. Conclusions: The cycle of care was viewed as a positive first step to increase and improve T2DM care delivered in general practice in Ireland. The implementation issues identified in this study should be considered in the design of future payment schemes targeting chronic disease management in general practice.

A snapshot of chronic obstructive pulmonary disease management in general practice in Ireland

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability. Its diagnosis, classification and management are complex. There is a paucity of data on the standard of COPD management in Irish general practice. We studied whether COPD diagnosis and management was in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We investigated if patients who were smokers had received smoking cessation advice. We examined whether influenza and pneumococcal vaccination had been given. Ten general practices affiliated with the Irish Mid-West Specialist Training Programme in General Practice (GP) were searched, to determine which patients had a diagnosis of COPD. A data-collection audit tool was developed using GOLD 2019 guidelines. Results were tabulated in SPSS. Descriptive statistics were used. Of 482 patients studied, 91.7% were eligible for free GP care. In 49.4%, the diagnosis of COPD had been made appropriately. In 56.2%, there was no evidence that the stage of COPD had been formally assessed. Of the patients studied, 33.2% were deemed to be receiving appropriate therapy. Smoking status was documented in 99.6% of cases studied and 59.9% were ex-smokers, while 25.9% were current smokers. Appropriate smoking cessation advice had been offered to 71% of eligible patients. Influenza vaccine had been given to 66.2% in the previous 12 months. A total of 53.9% had ever received pneumococcal vaccination. This study provides a comprehensive snapshot of care in Irish general practice for patients with COPD prior to introduction of the Chronic Disease Management programme (CDM).

Chronic Kidney Disease Management in General Practice: A Focus on Inappropriate Drugs Prescriptions.

Nephrotoxic drugs prescriptions are often prescribed inappropriately by general practitioners (GPs), increasing the risk of chronic kidney disease (CKD). The aim of this study was to detect inappropriate prescriptions in patients with CKD and to identify their predictive factors. A retrospective study on patients with creatinine values recorded in the period 2014–2016 followed by 10 GPs was performed. The estimated glomerular filtration rate (eGFR) was used to identify CKD patients. The demographic and clinical characteristics and drugs prescriptions were collected. A descriptive analysis was conducted to compare the characteristics and logistic regression models to estimate the predictive factors of inappropriate prescriptions. Of 4098 patients with creatinine values recorded, 21.9% had an eGFR <60 mL/min/1.73 m2. Further, 56.8% received inappropriate prescriptions, with a significantly lower probability in subjects with at least a nephrologist visit (Adj OR 0.54 (95% CI 0.36–0.81)) and a greater probability in patients treated with more active substances (1.10 (1.08–1.12)), affected by more comorbidities (1.14 (1.06–1.230)), or with serious CKD (G4/G5 21.28 (7.36–61.57)). Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most used contraindicated drugs (48.5%), while acetylsalicylic acid was the most inappropriately prescribed (39.5%). Our results highlight the inappropriate prescriptions for CKD authorized by GPs and underline the need of strategies to improve prescribing patterns.

A quick reference guide for rare disease: supporting rare disease management in general practice

A rare disease is defined as any life-limiting or chronically debilitating disease affecting <1 person in 2000, with many rare diseases affecting <1 person per 100 000. There are approximately 8000 rare diseases, with recent analysis suggesting a conservative prevalence of 3.5–5.9%.1 Over the last decade, tremendous advances have been made in rare disease identification, treatment, and support. This has been largely driven by an increasingly vehement consolidated patient voice and an EU directive (2009) that all member states required a rare disease plan/strategy by 2013. In 2013, the UK strategy for rare disease was published,2 followed by the launch of rare disease implementation plans for the devolved nations (Scotland in 2014;3 Northern Ireland in 2015;4 Wales in 20175). Rare diseases have major unmet medical needs. Healthcare professionals and rare disease charities often hear tragic stories of patients with rare life-threatening diseases where responsible doctors have been unable to help as they have never heard of the condition, nor seen a similar case presentation, nor found relevant knowledge and expertise online. More than 80% of individuals report difficulty in accessing relevant information and >70% of GPs struggle to identify or manage rare diseases. A long diagnostic odyssey is common, with patients often feeling misunderstood, isolated, vulnerable, receiving …

Factors associated with relational coordination between health professionals involved in insulin initiation in the general practice setting for people with type 2 diabetes.

To examine associations between characteristics of general practice settings and primary healthcare providers (general practitioners and practice nurses) and the degree of relational coordination for the task of insulin initiation for type 2 diabetes between primary healthcare providers and diabetes specialists. Relational coordination is a component of effective chronic disease management and can be used to measure collaboration and communication between health professionals. High levels of relational coordination may be important to support insulin initiation in general practice. Cross-sectional study. Surveys were completed by general practitioners and practice nurses participating in the Stepping Up trial. Data on demographics, practice characteristics and relational coordination were collected between October 2012-June 2014. Univariate and multivariate analyses examined factors associated with relational coordination. General practitioners (n = 174) and 115 practice nurses from 78 general practices were included in the analysis. General practice characteristics associated with relational coordination were geographical location and number of administrative staff. Female general practitioners and older practice nurses reported lower relational coordination. Practice nurses with diabetes educator qualifications and experience in insulin initiation reported higher relational coordination. An expanded role and experience of practice nurses in diabetes care increased relational coordination and has the potential to deliver more effective chronic disease management in general practice. Practice and health professional characteristics should be taken into account when designing models of care to increase insulin initiation.

Effect of an educational program in primary care: the case of lipid control in cardio-cerebrovascular prevention.

Lowering blood cholesterol levels reduces the risk of coronary heart disease. However, the effect of interventions depends on the patients' adherence to treatment. Primary care plays an important role in the detection, treatment and monitoring of disease, therefore different educational programs (EP) have been implemented to improve disease management in general practice. The present study is aimed to assess whether a general practitioner auditing and feedback EP may improve dyslipidaemia management in a primary care setting and to evaluate patients' adherence to prescribed lipid-lowering treatment. The quality of cardiovascular and cerebrovascular disease prevention before and after the implementation of an EP offered to 25 general practitioners (GPs), was evaluated. Clinical and prescription data on patients receiving at least one lipid-lowering treatment was collected. To evaluate the quality of the healthcare service provided, clinical and biochemical outcomes, and drug-utilization, process indicators were set up. Adherence was evaluated before and after the EP as the "Medication Possession Ratio" (MPR). A correlation analysis was carried out to estimate the effect of the MPR in achieving pre-defined clinical end-points. Prescription data for lipid-lowering drugs was collected in a sample of 839 patients. While no differences in the achievement of blood lipid targets were observed, a slight but significant improvement of the MPR was registered after the EP (MPR >0.8=64.2% vs 60.6%, p=0.0426). Moreover, high levels of statin adherence were associated with the achievement of total blood cholesterol target (OR=3.3 for MPR >0.8 vs MPR <0.5, 95% CI:1.7-6.7) or LDL therapeutic goal (OR=3.3 for MPR >0.8 vs MPR <0.5, 95% CI:1.5-7.2). The EP partially improved the defined clinical targets; probably, a more patient-based approach could be more appropriate to achieve the defined target. Further studies are needed to identify how healthcare services can be improved.

Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative

This paper draws on the implementation experience of the South Australian GP Plus Practice Nurse Initiative in order to establish what is needed to support the development of the chronic disease management role of practice nurses. The Initiative was delivered between 2007 and 2010 to recruit, train and place 157 nurses across 147 General Practices in Adelaide. The purpose was to improve chronic disease management in General Practice, by equipping nurses to work as practice nurses who would coordinate care and establish chronic disease management systems. Secondary analysis of qualitative data contained in the Initiative evaluation report, specifically drawing on quarterly project records and four focus groups conducted with practice nurses, practice nurse coordinators and practice nurse mentors. As evidenced by the need to increase the amount of support provided during the implementation of the Initiative, nurses new to General Practice faced challenges in their new role. Nurses described a big learning curve as they dealt with role transition to a new work environment and learning a range of new skills while developing chronic disease management systems. Informants valued the skills development and support offered by the Initiative, however the ongoing difficulties in implementing the role suggested that change is also needed at the level of the Practice. While just over a half of the placement positions were retained, practice nurses expressed concern with having to negotiate the conditions of their employment. In order to advance the role of practice nurses as managers of chronic disease support is needed at two levels. At one level support is needed to assist practice nurses to build their own skills. At the level of the Practice, and in the wider health workforce system, support is also needed to ensure that Practices are organisationally ready to include the practice nurse within the practice team.

The feasibility, acceptability and sustainability of nurse‐led chronic disease management in Australian general practice: The perspectives of key stakeholders

This was the first Australian study investigating the acceptability, feasibility and sustainability of a nurse-led model of chronic disease management in general practice. A concurrent mixed-methods design was used within a 12-month intervention of nurse-led care in three general practices. Adult patients with type 2 diabetes, hypertension and/or stable ischaemic heart disease were randomized into nurse-led or standard care. Semi-structured interviews explored perceptions of key stakeholders towards this model including patients in the nurse-led arm, and all practice staff pre- and posttrial. The data were thematically analysed and the emergent themes were: importance of time; collaborative relationships; nurse job satisfaction, confidence and competence; patient self-management and choice. Our findings showed that nurses provided chronic disease management that was acceptable, feasible and sustainable. The collaborative involvement of doctors was intrinsic to patient acceptability of nurse-led care that facilitated job satisfaction, and therefore retention and growth within this nursing speciality.

Pharmacists’ perceived integration into practice of over-the-counter simvastatin five years post reclassification

Simvastatin 10 mg was reclassified in 2004 to over-the-counter (OTC) status in the UK, indicated for the prevention of a first major coronary event in individuals at moderate risk of the event. The primary reason behind the reclassification was to reduce the burden of disease management in general practice. Community pharmacists' adoption of OTC simvastatin into practice immediately post reclassification was reported to below but there has been no systematic update on current practice. The aim was to investigate pharmacists' adoption into practice, and attitudes to, OTC simvastatin 5 years post reclassification in the UK. Community pharmacists at all community pharmacies in Scotland. A pre-piloted postal questionnaire was distributed to all community pharmacies in Scotland (N = 1138). Self rated adoption was measured on a five point scale. Factors associated with decision making were investigated using a 24-item Likert-type agreement scale. Pharmacists' perceived integration of reclassified simvastatin; factors associated with decision making. Response rate was 49.5 % (n = 563). A high majority reported not supplying the reclassified medicine mainly owing to a perceived lack of evidence, low patient demand, customer complaints about the retail price and lack of access to patient medical records. A minority agreed to reclassification being an opportunity for their role development. Community Pharmacists' views of reclassified simvastatin supply 5 years post reclassification, as compared to the time it was newly reclassified, suggest low uptake. This lack of progress over time suggests that, against policy initiatives, OTC availability is unlikely to have impacted on the level of general practice led management of patients at risk of coronary events.

The Teamwork Study: enhancing the role of non-GP staff in chronic disease management in general practice

There is evidence for a team-based approach in the management of chronic disease in primary health care. However, the standard of care is variable, probably reflecting the limited organisational capacity of health services to provide the necessary structured and organised care for this group of patients. This study aimed to evaluate the impact of a structured intervention involving non-GP staff in GP practices on the quality of care for patients with diabetes or cardiovascular disease. A cluster randomised trial was undertaken across 60 GP practices. The intervention was implemented in 30 practices with staff and patients interviewed at baseline and at 12-15 months follow up. The change in team roles was evaluated using a questionnaire completed by practice staff. The quality of care was evaluated using the Patient Assessment of Chronic Illness Care questionnaire. We found that although the team roles of staff improved in the intervention practices and there were significant differences between practices, there was no significant difference between those in the intervention and control groups in patient-assessed quality of care after adjusting for baseline-level score and covariates at the 12-month follow up. Practice team roles were not significantly associated with change in Patient Assessment of Chronic Illness Care scores. Patients with multiple conditions were more likely to assess their quality of care to be better. Thus, although previous research has shown a cross-sectional association between team work and quality of care, we were unable to replicate these findings in the present study. These results may be indicative of insufficient time for organisational change to result in improved patient-assessed quality of care, or because non-GP staff roles were not sufficiently focussed on the aspects of care assessed. The findings provide important information for researchers when designing similar studies.

Understanding the process of patient satisfaction with nurse‐led chronic disease management in general practice

To investigate the process of patient satisfaction with nurse-led chronic disease management in Australian general practice. Nurses working in the primary care context of general practice, referred to as practice nurses, are expanding their role in chronic disease management; this is relatively new to Australia. Therefore, determining patient satisfaction with this trend is pragmatically and ethically important. However, the concept of patient satisfaction is not well understood particularly in relation to care provided by practice nurses. A grounded theory study underpinned by a relativist ontological position and a relativist epistemology. Grounded theory was used to develop a theory from data collected through in-depth interviews with 38 participants between November 2007-April 2009. Participants were drawn from a larger project that trialled a practice nurse-led, collaborative model of chronic disease management in three Australian general practices. Theoretical sampling, data collection, and analysis were conducted concurrently consistent with grounded theory methods. Patients undergo a cyclical process of Navigating Care involving three stages, Determining Care Needs, Forming Relationship, and Having Confidence. The latter two processes are inter-related and a feedback loop from them informs subsequent cycles of Determining Care Needs. If any of these steps fails to develop adequately, patients are likely to opt out of nurse-led care. Navigating Care explains how and why time, communication, continuity, and trust in general practitioners and nurses are important to patient satisfaction. It can be used in identifying suitable patients for practice nurse-led care and to inform the practice and organization of practice nurse-led care to enhance patient satisfaction.

Qualitative outcome assessment and research on chronic disease management in general practice. Highlights from a keynote lecture, EGPRN May 2011, Nice

At its 2011 conference in Nice, France, the European General Practice Research Network (EGPRN), considered the issue of Relevant Outcome Measures in General Practice Research into Chronic Diseases. This paper, which is adapted from a keynote lecture given during that conference, considers the role of qualitative outcome assessments in research. Such assessments have a great deal in common with the patient-centred approach of general practice as they can capture the overall state of a patient rather than capturing only certain aspects. Research suggests that patients can be categorized, based on qualitative outcome assessment, and over time might change category. This approach to assessment brings to our attention alternative ways of considering the future: future as currently being made or future as predictable, at least to some extent. Although general practice needs the evidence from research that predicts the future, it also needs to engage in research that seeks to understand patients as they make their future, and to understand the impact of clinical interventions on this process.

Register-Recall Systems: Tools for Chronic Disease Management in General Practice.

The Divisions Diabetes and Cardiovascular Disease Quality Improvement Project (DDCQIP) is a national project that aims to promote quality improvement initiatives among Divisions of General Practice. DDCQIP has investigated the growth of Division-based diabetes and cardiovascular disease register-recall systems and the role they play in promoting evidence-based structured care within general practice. In the period 2000-2002, an increase in the number of GPs using register-recall systems and the rise in the number of active registered patients have made it possible to monitor quality of care and health outcome indicators, and contributed to the growth of a Division-based population health program.