Divisions Of General Practice Research Articles

Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia.

BackgroundChiropractic and osteopathy form a significant part of the healthcare setting in rural and regional Australia, with national registration of practitioners, public subsidies for services and high utilisation by the Australian public. However, despite their significant role in rural and regional Australia, there has been little exploration of the interface between chiropractic and osteopathy and conventional primary health care practitioners in this area. The study aim was to examine the referral practices and factors that underlie referral to chiropractors and osteopaths by rural and regional Australian general practitioners (GPs), by drawing on a sample of GPs in rural and regional New South Wales.MethodsA 27-item questionnaire was sent to all 1486 GPs currently practising in rural and regional Divisions of General Practice in New South Wales, Australia.ResultsA total of 585 GPs responded to the questionnaire, with 49 questionnaires returned as “no longer at this address” (response rate: 40.7%). The majority of GPs (64.1%) referred to a chiropractor or osteopath at least a few times per year while 21.7% stated that they would not refer to a chiropractor or osteopath under any circumstances. Patients asking the GP about CAM (OR=3.59; CI: 1.12, 11.55), GP’s use of CAM practitioners as a major source of information (OR=4.39; 95% CI: 2.04, 9.41), lack of other treatment options (OR=2.41; 95% CI: 1.18, 5.12), access to a wide variety of medical specialists (OR=12.5; 95% CI: 2.4, 50.0), GP’s belief in the efficacy of chiropractic and osteopathy services (OR=3.39; 95% CI: 2.19, 5.25) and experiencing positive results from patients using these services previously (OR=1.67; CI: 1.02, 2.75) were all independently predictive of increased referral to chiropractic and osteopathy services amongst the rural GPs.ConclusionsThere is a significant interface between chiropractic and osteopathy and Australian rural and regional general practice in New South Wales. Although there is generally high support for chiropractic and osteopathy among Australian GPs, this was not absolute and the heterogeneity of responses suggests that there remain tensions between the professions. The significant interface between chiropractic and osteopathy may be due in part to the inclusion of these professions in the publicly subsidised national healthcare delivery scheme. The significant impact of chiropractic and osteopathy and general practice in rural and regional Australian healthcare delivery should serve as an impetus for increased research into chiropractic and osteopathy practice, policy and regulation in these areas.

Innovations in primary mental healthcare

We review the evidence on innovations in Tier 2 of the Access to Allied Psychological Services (ATAPS) program, which is designed to facilitate the provision of primary mental healthcare to hard-to-reach and at-risk population groups (including women with perinatal depression, people at risk of self-harm or suicide, people experiencing or at risk of homelessness, people affected by the 2009 Victorian bushfires, people in remote locations, Aboriginal and Torres Strait Islanders and children with mental disorders) and the trialling of new modalities of service delivery (e.g. telephone-based or web-based CBT). The primary focus is on the uptake, outcomes and issues associated with the provision of ATAPS Tier 2. Drawing on data from an ongoing national ATAPS evaluation, including a national minimum dataset, key informant interviews and surveys, the impact of ATAPS innovations is analysed and illustrated through program examples. ATAPS Tier 2 facilitates access to, uptake of and positive clinical outcomes from primary mental healthcare for population groups with particular needs, although it requires periods of time to implement locally. Relatively simple innovations in mental health program design can have important practical ramifications for service provision, extending program reach and improving mental health outcomes for target populations. What is known about the topic? It is recognised that innovative approaches are required to tailor mental health programs for hard-to-reach and at-risk population groups. Divisions of General Practice have implemented innovations in the Access to Allied Psychological Services (ATAPS) program for several years. What does this paper add? Drawing on data from an ongoing national ATAPS evaluation, this paper presents a systematic analysis of the uptake, outcomes and issues associated with provision of the innovative ATAPS program. What are the implications for practitioners? The findings highlight the benefits of introducing innovations in primary mental healthcare in terms of increased access to care and positive consumer outcomes. They also identify challenges to and facilitators of the implementation process, which can inform innovation efforts in other primary care contexts.

An Evaluation of the Prescription of Opioids for Chronic Nonmalignant Pain by Australian General Practitioners

Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). An anonymous, cross-sectional questionnaire-based survey. The setting was five Australian divisions of general practice (geographically based associations of GPs). A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (±8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions.

Referral to Chinese medicine practitioners in Australian primary care: a survey of New South Wales rural and regional general practitioners

BackgroundChinese medicine practitioners (CMPs) play an important part in rural and regional Australian healthcare. A survey was conducted to investigate referral practices between Chinese medicine (CM) and conventional primary health care practitioners in this region.MethodsA 27-item questionnaire was sent to all 1486 general practitioners (GPs) currently practising in rural and regional Divisions of General Practice in New South Wales, Australia. This survey explored GP opinions, perceptions and practices in relation to complementary and alternative medicine or Chinese medicine specifically.ResultsA total of 585 GPs completed the questionnaire. Forty-nine were returned as ‘no longer at this address’, resulting in an adjusted response rate of 40.7%. One in ten GPs (9.9%) had referred their patients to CMPs at least a few times over the past 12 months, one in five GPs (17.4%) could not locate a CMP to refer to in their local area, and over one-third of GPs (37.7%) stated they would not refer to a CMP under any circumstances. GPs that had graduated from an Australian medical college (OR = 3.71; CI: 1.22, 11.23), GPs observing positive responses previously in patients using CM (OR = 2.53; 95% CI: 1.12, 8.58), GPs perceiving a lack of other options for patients (OR = 3.10; 95% CI: 1.12, 8.58), GPs reporting satisfactory or higher levels of CM knowledge (OR = 15.62; 95% CI: 5.47, 44.56), and GPs interested in increasing their complementary and alternative medicine knowledge (OR = 3.28; 95% CI: 1.17, 9.21) referred to CMPs more frequently than did other groups of GPs amongst the rural GPs included in this study.ConclusionThere has been little interaction between CMPs and Australian rural and regional GPs.

Factors influencing participant enrolment in a diabetes prevention program in general practice: lessons from the Sydney diabetes prevention program

BackgroundThe effectiveness of lifestyle interventions in reducing diabetes incidence has been well established. Little is known, however, about factors influencing the reach of diabetes prevention programs. This study examines the predictors of enrolment in the Sydney Diabetes Prevention Program (SDPP), a community-based diabetes prevention program conducted in general practice, New South Wales, Australia from 2008–2011.MethodsSDPP was an effectiveness trial. Participating general practitioners (GPs) from three Divisions of General Practice invited individuals aged 50–65 years without known diabetes to complete the Australian Type 2 Diabetes Risk Assessment tool. Individuals at high risk of diabetes were invited to participate in a lifestyle modification program. A multivariate model using generalized estimating equations to control for clustering of enrolment outcomes by GPs was used to examine independent predictors of enrolment in the program. Predictors included age, gender, indigenous status, region of birth, socio-economic status, family history of diabetes, history of high glucose, use of anti-hypertensive medication, smoking status, fruit and vegetable intake, physical activity level and waist measurement.ResultsOf the 1821 eligible people identified as high risk, one third chose not to enrol in the lifestyle program. In multivariant analysis, physically inactive individuals (OR: 1.48, P = 0.004) and those with a family history of diabetes (OR: 1.67, P = 0.000) and history of high blood glucose levels (OR: 1.48, P = 0.001) were significantly more likely to enrol in the program. However, high risk individuals who smoked (OR: 0.52, P = 0.000), were born in a country with high diabetes risk (OR: 0.52, P = 0.000), were taking blood pressure lowering medications (OR: 0.80, P = 0.040) and consumed little fruit and vegetables (OR: 0.76, P = 0.047) were significantly less likely to take up the program.ConclusionsTargeted strategies are likely to be needed to engage groups such as smokers and high risk ethnic groups. Further research is required to better understand factors influencing enrolment in diabetes prevention programs in the primary health care setting, both at the GP and individual level.

Improving primary care in Australia through the Australian Primary Care Collaboratives Program: a quality improvement report

ProblemEffective and affordable health systems have good primary care. Access, equity, care of chronic conditions and quality are key priorities in primary care in Australia.DesignA large-scale quality improvement collaborative addressing...

Qualitative evaluation of a diabetes electronic decision support tool: views of users

BackgroundQuality care of type 2 diabetes is complex and requires systematic use of clinical data to monitor care processes and outcomes. An electronic decision support (EDS) tool for the management of type 2 diabetes in primary care was developed by the Australian Pharmaceutical Alliance. The aim of this qualitative study was to evaluate the uptake and use of the EDS tool as well as to describe the impact of the EDS tool on the primary care consultation for diabetes from the perspectives of general practitioners and practice nurses.MethodsThis was a qualitative study of telephone interviews. General Practitioners and Practice Nurses from four Divisions of General Practice who had used the EDS tool for a minimum of six weeks were invited to participate. Semi-structured interviews were conducted and the interview transcripts were coded and thematically analysed using NVivo 8 software.ResultsIn total 15 General Practitioners and 2 Practice Nurses completed the interviews. The most commonly used feature of the EDS tool was the summary side bar; its major function was to provide an overview of clinical information and a prompt or reminder to diabetes care. It also assisted communication and served an educational role as a visual aide in the consultation. Some participants thought the tool resulted in longer consultations. There were a range of barriers to use related to the design and functionality of the tool and to the primary care context.ConclusionsThe EDS tool shows promise as a way of summarising information about patients’ diabetes state, reminder of required diabetes care and an aide to patient education.

Culturally and linguistically diverse general practitioners’ utilisation of practice nurses

Practice nurses are primarily employed by general practitioners, however little is known about the barriers to practice nurse employment from the perspective of general practitioners (GPs). This paper seeks to explore solo, culturally and linguistically diverse (CALD) general practitioners' perceptions of the practice nurse role, and to identify the barriers and facilitators of these doctors employing nurses within their practice. A descriptive study, using semi-structured interviews, was conducted from July to August 2010. Participants were CALD GPs working as solo practitioners who were members of a Division of General Practice in South Western Sydney. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using thematic analysis. The response rate was 51%, however no demographic differences were identified between responders and non-responders. The majority of participants (73%) agreed that practice nurses could perform vital sign measurements or spirometry. Fewer participants (52-63%) believed practice nurses could perform breast checks, pap smears, or assessment of medication regimes. Perceived barriers to employing a practice nurse included lack of space or equipment, legal implications, lack of a specific job description and language communication issues. Participants identified the need for greater financial rebates, assistance with training practice nurses and assistance with business modelling as facilitators to practice nurse employment. The feasibility of practice nurse employment in practices with solo, culturally and linguistically diverse general practitioners remains a challenge that needs further exploration. Employment of practice nurses may be a viable option for younger practitioners who have a desire to work in collaborative multidisciplinary models.

Does a primary care practice pharmacist improve the timeliness and completion of medication management reviews?

To describe the effect of integrating a pharmacist into the general practice team on the timeliness and completion of pharmacist-conducted medication reviews. A pharmacist was integrated into an Australian inner-city suburb general practice medical centre to provide medication reviews for practice patients. A retrospective analysis of medication reviews with two time periods was conducted: pre-integration of the practice pharmacist and post-integration of the practice pharmacist. In an effort to obtain a measure of external validity the data were compared to data from the Division of General Practice in which the medical centre is located. There were 70 patients referred for medication review in the pre-integration phase and 314 patients referred in the post-integration phase. The time to complete the medication review process was significantly reduced from a median of 56 days to 20 days with a practice pharmacist. Prior to having a practice pharmacist 52% of patients did not have the service billed by the general practitioner, which was reduced to 6% during the post-integration phase. The results from this trial show that the integration of a pharmacist into the general practice team was associated with an increase in the timeliness and completion rate of medication reviews.

Development and validation of the GP frequency of interprofessional collaboration instrument (FICI-GP) in primary care

Existing validated measures of pharmacist–physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of interactions that comprise actual collaborative behavior. Therefore, the aim of this study was to develop and validate an instrument to measure the frequency of collaboration between general practitioners (GPs) and pharmacists from the GP's perspective. An 11-item Frequency of Interprofessional Collaboration Instrument for GPs (FICI-GP) was developed and administered to 1118 GPs in eight divisions of general practice in New South Wales, Australia. Two hundred and fifty-eight (23%) GP surveys were completed and returned. Principal component analysis suggested removal of one item for a final one-factor solution. The refined 10-item FICI-GP had a Cronbach's alpha of 0.87. After collapsing the original five-point response scale to a three-point response scale, the refined FICI-GP demonstrated fit to the Rasch model. Criterion validity of the FICI-GP was supported by the correlation of FICI-GP scores with scores on a previously validated physician–pharmacist collaboration instrument as well as by predicted differences in FICI-GP scores between subgroups of respondents stratified on age, co-location with pharmacists and interactions during residency. The refined 10-item FICI-GP was shown to have good internal consistency, criterion validity and fit to the Rasch model.

The Australian Experiment: How Primary Health Care Organizations Supported the Evolution of a Primary Health Care System

Primary health care in Australia has undergone 2 decades of change. Starting with a vision for a national health strategy with general practice at its core, Australia established local meso-level primary health care organizations--Divisions of General Practice--moving from focus on individual practitioners to a professional collective local voice. The article identifies how these meso-level organizations have helped the Australian primary health care system evolve by supporting the roll-out of initiatives including national practice accreditation, a focus on quality improvement, expansion of multidisciplinary teams into general practice, regional integration, information technology adoption, and improved access to care. Nevertheless, there are still challenges to ensuring equitable access and the supply and distribution of a primary care workforce, addressing the increasing rates of chronic disease and obesity, and overcoming the fragmentation of funding and accountability in the Australian system.

Increasing dietetic referrals: Perceptions of general practitioners, practice nurses and dietitians

AbstractAim: To examine Australian private practice dietitians' relationships with general practitioners and practice nurses as a factor that influences dietetic referrals.Methods: Semistructured telephone interviews and an online survey were conducted with Australian private practice dietitians (n = 52 and n = 90, respectively) between April and May 2008. Semistructured questionnaires were conducted with general practitioners (n = 11) and practice nurses (n = 12) from the ‘GP Access’ Division of General Practice between March and July 2007.Results: General practitioners' relationships with dietitians were believed to be the primary influencing factor on referral, provided by 81% of survey dietitians and 25% of interview dietitians. The most common means of initially forming relationships with general practitioners were face‐to‐face introduction (48%) and introductory letters (37%). Patient feedback via letter, fax or email was the most popular method of maintaining relationships with general practitioners (77%). Meeting with general practitioners in person was believed to be the most effective activity in building relationships with general practitioners and increasing referral rates (42%). Referral was made easier for general practitioners by providing paper (37%) or electronic (19%) referral forms and contact details (19%). The majority of general practitioners and dietitians believed that the ‘Allied Health Services Under Medicare’ made it easier to refer to a dietitian.Conclusions: Dietetic referrals can be encouraged through good relationships between general practitioners, practice nurses and dietitians. Private practice dietitians would benefit from cultivating relationships with general practitioners and practice nurses through personal contact and providing good patient feedback.

Patient characteristics associated with GP referral to the Access to Allied Psychological Services Program: A case-control study

GPs have referred patients for psychological treatment under the Better Outcomes in Mental Health Care, Access to Allied Psychological Services (ATAPS) Program since 2003. It is not known how GPs might select patients for referral. We explored which characteristics identified ATAPS patients compared to usual GP patients. The study was conducted in GP Access, a Division of General Practice (Newcastle and Lower Hunter) in NSW, Australia. It was a case-control design with 63 cases (ATAPS patients), and 64 controls (GP patients never referred to ATAPS). Unadjusted and sequentially adjusted logistic regressions were used to identify independent predictors of being an ATAPS case based on official referral guidelines: ICD-10 diagnosis of depression or anxiety and scores on the K-10 (psychological distress) and DASS-21 (psychological symptoms). A multivariable logistic regression was also used to determine the best minimum set of predictor variables. Eight-three per cent of ATAPS cases had anxiety or depression. In unadjusted models, any mood disorder, OR 7.68 (95% CI: 3.47, 17.01), any anxiety disorder, OR 2.88 (95% CI: 1.37, 6.05), higher K-10 score, OR 1.06 (95% CI: 1.04, 1.14) and higher DASS-21 score, OR 1.06 (95% CI: 1.03, 1.09) were associated with being an ATAPS case. Any mood disorder, any anxiety disorder, K-10 score and DASS-21 scores remained significant in most adjusted analyses and all models showed change when adjusted for mental disability and physical disability. Three variables predicted being an ATAPS case in the multivariable regression: greater mental disability, lesser physical disability and greater number of substances misused. Cases had higher levels of mental disability and greater substance misuse, but lower levels of physical disability. This may reflect GP referral decision making and have implications for policy development.

Development and initial validation of the Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) in primary care

BackgroundExisting validated measures of pharmacist-physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of collaborative interactions. ObjectiveTo develop and validate an instrument to measure the frequency of collaboration between pharmacists and general practitioners (GPs) from the pharmacist’s perspective. MethodsAn 11-item Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) was developed and administered to 586 pharmacists in 8 divisions of general practice in New South Wales, Australia. The initial items were informed by a review of the literature in addition to interviews of pharmacists and GPs. Items were subjected to principal component and Rasch analyses to determine each item’s and the overall measure’s psychometric properties and for any needed refinements. ResultsTwo hundred and twenty four (38%) of pharmacist surveys were completed and returned. Principal component analysis suggested removal of 1 item for a final 1-factor solution. The refined 10-item FICI-P demonstrated internal consistency reliability at Cronbach’s alpha=0.90. After collapsing the original 5-point response scale to a 4-point response scale, the refined FICI-P demonstrated fit to the Rasch model. Criterion validity of the FICI-P was supported by the correlation of FICI-P scores with scores on a previously validated Physician-Pharmacist Collaboration Instrument. Validity was also supported by predicted differences in FICI-P scores between subgroups of respondents stratified on age, colocation with GPs, and interactions during the intern-training period. ConclusionThe refined 10-item FICI-P was shown to have good internal consistency, criterion validity, and fit to the Rasch model. The creation of such a tool may allow for the measure of impact in the evaluation of interventions designed to improve interprofessional collaboration between GPs and pharmacists.

What predicts patient-reported GP management of smoking, nutrition, alcohol, physical activity and weight?

This study aimed to describe patient-reported management of behavioural risk factors in Australian general practice. Six hundred and ninety-eight eligible patients from 30 general practices in two rural and three urban Divisions of General Practice responded to a mailed invitation to participate and completed a questionnaire. Data were analysed using univariate and multi-level multivariate methods. The prevalence of risk factors varied between 12.6% for smoking and 72.6% for at-risk diet (56.2% were overweight). Most patients were at the action or maintenance phases of their readiness to change their risky behaviours. General practitioners (GPs) provided education or advice to between one-quarter and one-third of those at risk for each risk factor; 9.2% and 9.6% of patients reported having been referred for diet or physical activity interventions. Patient body mass index was associated with increased likelihood of receiving GP advice or referral for diet and physical activity interventions. Having poor diet or physical activity levels and being more ready for change were not associated with the likelihood of GP referral. The major challenge for general practice is to ensure that effective lifestyle interventions are provided to those who will most benefit. Patient-reported GP behavioural risk factor advice and referral is less frequent than is optimal. Priority needs to be given to those most at risk and ready to change their behaviour.

When big isn't beautiful: lessons from England and Scotland on primary health care organisations

United Kingdom primary care trusts resembled the primary health care organisations (PHCOs) that have been proposed for Australia--for example, Medicare Locals. They resulted in a loss of innovation, creativity, motivation and morale among general practitioners and other front-line staff. English primary care trusts are being abolished and £80 billion will be handed over to GP commissioners. Management theory and practical experience shows repeatedly the dangers of reorganising into larger units. Lessons for Australia are to defer deciding on the size of PHCOs until their purposes are clear, to enshrine the principle of subsidiarity, and to opt for networking of the current Divisions of General Practice over mergers. So far, debate on the functions and structures of PHCOs has been muted. It is now time for vigorous debate.

Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: A step towards explaining high CAM use in rural health?

Complementary and alternative medicine (CAM) use is high in rural health and an agenda for research in the geography of CAM has been outlined. Unfortunately, no studies to date have mapped the geographic distribution of CAM practitioners in rural areas. For the first time we investigate CAM practitioner distributions across a large district/region in rural Australia. A CAM infrastructure audit of practitioners was performed in rural Divisions of General Practice in New South Wales, Australia. CAM providers form a significant part of the health care system in rural New South Wales with substantial representation across all degrees of rurality and in both under-serviced and well-serviced areas. CAM practitioners outnumbered GPs in four NSW Divisions of General Practice and in no Division numbered less than half of the total number of GPs. Given the challenges of access to and recruitment and retention of conventional health care providers in rural settings and the significant presence of CAM practitioners, it is possible to consider such practitioners as an untapped resource in rural health care delivery. Assuming appropriate regulatory and quality standards are in place this resource should attract careful attention as part of future rural health policy and planning. The significant presence and high prevalence of use of CAM practitioners should also serve as an impetus to reform CAM service delivery in Australia.

Handing over the reins – establishing long term strategies for embedding advance care planning in rural and remote communities in Australia

Establishing effective advance care planning (ACP) implementation programs in communities is challenging at the best of times – but when the region extends to over 166 000 square kilometres of...

A national survey of general practitioners’ experiences of patient‐initiated aggression in Australia

To determine the prevalence of patient-initiated aggression toward general practitioners in Australia. A cross-sectional national survey, conducted during February-May 2010, of 3090 GPs in 19 Divisions of General Practice, purposively sampled to represent urban, rural and remote areas. Proportion of GPs experiencing patient-initiated aggression. Eight-hundred and four GPs returned completed surveys (response rate, 26.3%). In the previous 12 months, 58% of GPs had experienced verbal abuse and 18% had experienced property damage or theft. Very few GPs had experienced physical abuse (6%), stalking (4%), sexual harassment (6%) or sexual assault (0.1%). After controlling for other demographic variables, GPs with fewer years of experience (P = 0.003), or who worked full-time or in larger practices (both P = 0.03) experienced significantly more verbal abuse than their counterparts, and GPs who worked full-time (P = 0.004) or in metropolitan areas (P = 0.01) experienced significantly more property damage or theft. Female GPs experienced significantly more sexual harassment than male GPs (P < 0.001). This is the first national evidence of the prevalence of patient aggression toward GPs in Australia, which could inform the development of policies and guidelines that aim to reduce the prevalence of patient aggression toward GPs.

Combining top-down and bottom-up change management strategies in implementation of ACP: the My Wishes program in South West Sydney, Australia

Attempts to introduce advance care planning (ACP) and make it a part of normal clinical practice present significant challenges and one way of approaching these is to utilise the change...