General Practice Setting Research Articles

Facilitating advance care planning in the general practice setting for patients with a chronic, life-limiting illness: protocol for a phase-III cluster-randomized controlled trial and process evaluation of the ACP-GP intervention

BackgroundAdvance care planning (ACP), a process of communication about patients’ preferences for future medical care, should be initiated in a timely manner. Ideally situated for this initiation is the general practitioner (GP). The intervention to improve the initiation of ACP for patients with a chronic life-limiting illness in general practice (ACP-GP) includes an ACP workbook for patients, ACP communication training for GPs, planned ACP conversations, and documentation of ACP conversation outcomes in a structured template. We present the study protocol of a Phase-III randomized controlled trial (RCT) of ACP-GP that aims to evaluate its effects on outcomes at the GP, patient, and surrogate decision maker (SDM) levels; and to assess the implementation process of the intervention.MethodsThis RCT will take place in Flanders, Belgium. Thirty-six GPs, 108 patients with a chronic, life-limiting illness, and their (potential) SDM will be recruited, then cluster-randomized to the ACP-GP intervention or the control condition. The primary outcome for GPs is ACP self-efficacy; primary outcome for patients is level of ACP engagement. Secondary outcomes for GPs are ACP practices, knowledge and attitudes; and documentation of ACP discussion outcomes. Secondary outcomes for patients are quality of life; anxiety; depression; appointment of an SDM; completion of new ACP documents; thinking about ACP; and communication with the GP. The secondary outcome for the SDM is level of engagement with ACP. A process evaluation will assess the recruitment and implementation of the intervention using the RE-AIM framework.DiscussionWhile the general practice setting holds promise for timely initiation of ACP, there is a lack of randomized trial studies evaluating the effectiveness of ACP interventions implemented in this setting. After this Phase-III RCT, we will be able to present valuable evidence of the effects of this ACP-GP intervention, with the potential for offering a well-tested and evaluated program to be implemented in general practice. The results of the process evaluation will provide insight into what contributes to or detracts from implementation success, as well as how the intervention can be adapted to specific contexts or needs.Trial registrationProspectively registered at with ISRCTN (ISRCTN12995230); registered 19/06/2020.

Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia

BackgroundWith an ageing population and an increase in chronic disease burden in Australia, Patient Centred Medical Home (PCMH) models of care have been identified as potential options for primary care reform and improving health care outcomes. Adoption of PCMH models are not well described outside of North America. We examined the experiences of seven general practices in an Australian setting that implemented projects aligned with PCMH values and goals supported by their local Primary Health Network (PHN).MethodQualitative and quantitative data were collected over a twelve month period, including semi-structured interviews, participant observation, and practice data to present a detailed examination of a subject of study; the implementation of PCMH projects in seven general practices. We conducted 49 interviews (24 pre and 25 post) with general practitioners, practice managers, practice nurses and PHN staff. Framework analysis deploying the domains of a logic model was used to synthesis and analyse the data.ResultsFacilitators in implementing successful, sustainable change included the capacity and willingness of practices to undertake change; whole of practice engagement with a shared vision towards PCMH change; engaged leadership; training and support; and structures and processes required to provide team-based, data driven care. Barriers to implementation included change fatigue, challenges of continued engaged leadership and insufficient time to implement PCMH change.ConclusionsOur study examined the experiences of implementing PCMH initiatives in an Australian general practice setting, describing facilitators and barriers to PCMH change. Our findings provide guidance for PHNs and practices within Australia, as well as general practice settings internationally, that are interested in undertaking similar quality improvement projects.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis

ABSTRACT Background Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED. Methods Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.). Results A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm’s positive/negative predictive values (95% confidence interval) were 0.80 (0.28–0.99)/1.00 (0.92–1.00) and 0.75 (0.19–0.99)/0.98 (0.88–1.00) for detection of any DED and referral-warranted DED, respectively. Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI. Conclusions Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

Multilevel structures and human agency in relation to email consultations: A strong structuration theory analysis of the Danish general practice setting

In recent years and throughout the developed world, policymakers have encouraged the implementation of digital patient-clinician interaction. Our focus is on the Danish general practice setting where email consultations were implemented as a mandatory service in 2009 and now constitute 21% of all consultations in general practice. Drawing upon strong structuration theory (SST), our analysis sets out to explore how email consultations are represented in structures on macro, meso and micro-levels and how the interplay between structures and agents plays out with respect to possible alignments, tensions and adjustments. We analyze data from policy documents on the macro and meso-levels, data from clinics’ websites (meso-level) and data from interviews with GPs and patients (micro-level) (n = 53). Our findings show that the introduction of email consultation as a new health technology is a key site for development in email consultation practice, professional boundary setting and adjustments within the doctor-patient relationship. Our findings thus demonstrate that email consultation can be considered a dynamic component of a socio-technical network rather than a static medium for simple health transactions or information delivery. Based on these findings, we recommend that, for future implementation of patient-clinician digital communication it is important to investigate the multiple sources of influence on telecare practices and to see its intended users as agents who actively shape their own care motivated by opinions, relationships and values.

Rise in violence in general practice settings during the COVID-19 pandemic: implications for prevention.

Rise in violence in general practice settings during the COVID-19 pandemic: implications for prevention.

Exploring pharmacists' perceptions of integrating pharmacists into the general practice setting

BackgroundIn several countries worldwide, pharmacists have integrated into the general practice setting. This has resulted in enhanced medication management, a reduction in patients' appointments with general practitioners (GPs), and decreased medication costs. However, there is a paucity of research that has focused on exploring pharmacists' views of this emerging role prior to its implementation in countries where it is not yet commonplace. ObjectiveTo explore pharmacsists' perceptions of integrating pharmacists into the general practice setting, the proposed roles for such pharmacists, and the factors affecting integration. MethodsSemi-structured interviews were conducted with pharmacists in Ireland, who were sampled based on years of experience in community pharmacy and work location using convenience and snowball sampling. The interviews were audio-recorded and transcribed verbatim, which subsequently underwent thematic analysis. ResultsTwelve pharmacists – with a median of six years' experience as a community pharmacist – were interviewed between September and October 2019. Four main themes were generated:(i) expectations of integrated role (including the importance of role definition, pharmacist experience, and increased job satisfaction);(ii) altered pharmacist-patient dynamic in primary care (including patient trust, patient safety, and the impact on community pharmacist roles);(iii) GP-pharmacist relationship (including pre-existing relationships, autonomy, reducing GP workload, and individual GP attributes);(iv) logistical issues and financial implications (including practice characteristics, co-location time, and supporting evidence-based implementation). ConclusionThis study is unique as it has focused solely on exploring pharmacists' perceptions of integrating into general practice in a country where such roles are mostly non-existent. The attitudes of pharmacists in this study were primarily positive, for reasons such as intrinsic motivation, reducing GP workload, and improving patient health outcomes. However, the routine implementation of these roles will require funding and support from key stakeholders (other than pharmacists) and should be guided by the evidence from other countries.

Changes in Trunk Variability and Stability of Gait in Patients with Chronic Low Back Pain: Impact of Laboratory versus Daily-Living Environments.

BackgroundIndividuals with chronic low back pain (CLBP) experience changes in gait control due to pain and/or fear. Although CLBP patients’ gait has been performed in laboratory environments, changes in gait control as an adaptation to unstructured daily living environments may be more pronounced than the corresponding changes in laboratory environments. We investigated the impacts of the environment and pathology on the trunk variability and stability of gait in CLBP patients.MethodsCLBP patients (n=20) and healthy controls with no low-back pain history (n=20) were tasked with walking in a laboratory or daily-living environment while wearing an accelerometer on the low back. We calculated the stride-to-stride standard deviation and multiscale sample entropy as indices of “gait variability” and the maximum Lyapunov exponent as an index of “gait stability” in both the anterior-posterior and medial-lateral directions. The participants were assessed on the numerical rating scale for pain intensity, the Tampa Scale for Kinesiophobia, and the Roland–Morris Disability Questionnaire for quality of life (QOL).ResultsIn a repeated-measures ANOVA, the standard deviation was affected by environment in the anterior-posterior direction and by group and environment in the medial-lateral direction. Multiscale sample entropy showed no effect in the anterior-posterior direction and showed both effects in the medial-lateral direction. Maximum Lyapunov exponents showed both effects in the anterior-posterior direction, but none in the medial-lateral direction. These changes of trunk motor control by CLBP patients were found to be related to pain intensity, fear of movement, and/or QOL in the daily-living environment but not in the laboratory environment.ConclusionThese results revealed that CLBP patients exhibit changes in trunk variability and stability of gait depending on the environment, and they demonstrated that these changes are related to pain, fear, and QOL. We propose useful accelerometer-based assessments of qualitative gait in CLBP patients’ daily lives, as it would provide information not available in a general practice setting.

Managing high frequency users of an electronic consultation system in primary care: a quality improvement project

The COVID-19 pandemic prompted a rapid change in primary care provision. There was a significant shift from face-to-face appointments to remote methods such as electronic consultation (e-consultation). Patients from a...

The role of clinical signs and spirometry in the diagnosis of obstructive airway diseases: a systematic analysis adapted to general practice settings.

BackgroundIn general practice (GP), the diagnosis of obstructive airway diseases much relies on diagnostic questions, in view of the limited availability of lung function. We systematically assessed the relative importance of such questions for diagnosing asthma and chronic obstructive pulmonary disease (COPD), either without or with information from spirometry.MethodsWe used data obtained in a pulmonary practice to ensure the validity of diagnoses and assessments. Subjects with a diagnosis of COPD (n=260), or asthma (n=433), or other respiratory diseases (n=230), and subjects without respiratory diseases (n=364, controls) were included. The diagnostic questions comprised eight items, covering smoking history, self-attributed allergic rhinitis, dyspnea, cough, phlegm and wheeze. Optionally standard parameters of the flow-volume-curve were included. Decision trees for the diagnosis of COPD and asthma were constructed, moreover a probabilistic diagnostic network based on the results of path analyses describing the relationship between variables.ResultsIn the decision trees, age, sex, current smoking, wheezing, dyspnea upon mild exertion, self-attributed allergic rhinitis, phlegm, forced expiratory volume in one second (FEV1), and expiratory flow rates were relevant, depending on the diagnostic comparison, while cough, dyspnea upon strong exertion and ex-smoker status were not relevant. In contrast, the probabilistic network for the diagnosis of COPD and asthma versus controls incorporated all diagnostic questions, i.e., dyspnea upon mild or strong exertion, current smoking, ex-smoking, wheezing, cough and phlegm but from spirometry only FEV1. Depending on the individual pattern, the probability for COPD could raise from 25% to 81%, while the diagnostic gain for asthma was lower.ConclusionsThe study developed simple diagnostic algorithms for asthma and COPD that take into account the relative importance of clinical signs and history, as well as spirometric data if available. The diagnostic accuracy was especially high for COPD. These algorithms may be helpful as a starting point in the standardisation of diagnostic strategies in GP practices.Trial registrationThe study is registered under DRKS00013935 at German Clinical Trials Register (DRKS, Date of registration 01/03/2018).

Achilles tendon rupture: A diagnosis not to be missed

The Achilles tendon (AT) is the largest tendon in the human body, connecting the gastrocnemius, soleus and plantaris muscles to the calcaneus. Together with these muscles, the AT causes plantarflexion of the foot at the ankle joint and flexion at the knee, which are vital functions within the gait cycle. The AT also prevents excessive dorsiflexion of the foot. Whilst AT ruptures present more commonly in the emergency department, it is still a common presentation in general practice. In the general practice setting, delayed presentations and missed diagnoses are common. An increase in presentations following the recent COVID – 19 pandemic is anticipated, as people return to sport following a lengthy lay-off. Despite an awareness of the seriousness of this injury, many clinicians are unaware of how best to manage patients. This article will focus on the aetiology of AT ruptures, presentation in general practice and how best to diagnose and manage an AT rupture.

SARS-CoV-2 infection in general practice in Ireland: a seroprevalence study.

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing in community settings may help us better understand the immune response to this virus and, therefore, help guide public health efforts.AimTo conduct a seroprevalence study of immunoglobulin G (IgG) antibodies in Irish GP clinics.Design & settingParticipants were 172 staff and 799 patients from 15 general practices in the Midwest region of Ireland.MethodThis seroprevalence study utilised two manufacturers’ point-of-care (POC) SARS-CoV-2 immunoglobulin M (IgM)—IgG combined antibody tests, which were offered to patients and staff in general practice from 15 June to 10 July 2020.ResultsIgG seroprevalence was 12.6% in patients attending general practice and 11.1% in staff working in general practice, with administrative staff having the lowest seroprevalence at 2.5% and nursing staff having the highest at 17.6%. Previous symptoms suggestive of COVID-19 and history of a polymerase chain reaction (PCR) test were associated with higher seroprevalence. IgG antibodies were detected in approximately 80% of participants who had a previous PCR-confirmed infection. Average length of time between participants’ positive PCR test and positive IgG antibody test was 83 days.ConclusionPatients and healthcare staff in general practice in Ireland had relatively high rates of IgG to SARS-CoV-2 compared with the national average between 15 June and 10 July 2020 (1.7%). Four-fifths of participants with a history of confirmed COVID-19 disease still had detectable antibodies an average of 12 weeks post-infection. While not proof of immunity, SARS-CoV-2 POC testing can be used to estimate IgG seroprevalence in general practice settings.

Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations.

BackgroundSystems to detect and minimise unwarranted variation in clinician practice are crucial to ensure increasingly multidisciplinary healthcare workforces are supported to practise to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care.AimTo evaluate the benefits and limitations of a continuous, risk-based, consultation peer-review system used for 10 years by an out-of-hours general practice service in Bristol, UK.Design and settingA qualitative study in South West England.MethodSemi-structured interviews with intervention users (clinicians, peer reviewers, and clinical management), analysed by inductive thematic analysis and integrated into a programme theory.ResultsTwenty clinicians were interviewed between September 2018 and January 2019. Interviewees indicated that the intervention supported clinician learning through improved peer feedback, highlighting learning needs and validating practice. It was compared favourably with existing structures of ensuring clinician competence, supporting standardisation of supervision, clinical governance, and learning culture. These benefits were potentially limited by intervention factors such as differential feedback quality between clinician groups, the efficiency of methods to identify learning needs, and limitations of assessments based on written clinical notes. Contextual factors such as clinician experience, motivation, and organisational learning culture influenced the perception of the intervention as a support or a stressor.ConclusionThe findings demonstrate the potential of continuous, risk-based, consultation peer review to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practise to their full potential. The programme theory provides a theoretical basis to maximise the benefits and accommodate the potential limitations of this methodology

Personal, provider and system level barriers and enablers for hepatitis C treatment in the era of direct-acting antivirals: Experiences of patients who inject drugs accessing treatment in general practice settings in Australia

Direct acting antiviral (DAA) treatment has made the elimination of hepatitis C virus (HCV) a realisable global public health goal and people who inject drugs are a key target population. This study investigates barriers and enablers to DAA treatment of HCV in general practice settings in Australia, from the patient perspective. Semi-structured interviews were conducted with 28 patients; of these patients, seventeen participants were currently on opioid agonist therapy, and four were currently injecting drugs. Thematic data analysis was undertaken and a personal, provider and systems framework was used to describe the barriers and enablers to DAA treatment. Results suggest a range of initiatives are required to support the uptake of DAA in general practice settings. These include the provision of formalised peer information and support, and increasing the accessibility of blood tests and liver assessment on-site. Further, there remains a need to address stigma and discrimination affecting people who inject drugs in community healthcare settings.

Interrelationships Between Serum Levels of Procalcitonin and Inflammatory Markers

Abstract Various laboratory markers are utilized in general practice to detect inflammation, and procalcitonin (PCT) has also been routinely measured in many patients as a marker of bacterial infection and sepsis. An increase in PCT starts before an increase in C-reactive protein (CRP), and PCT level is useful not only for the diagnosis of bacterial infection, sepsis, as an indicator of the severity and prognosis of systemic inflammatory diseases, and is also useful for determination of the response to individual treatment. PCT is a precursor of calcitonin and PCT is not produced in a healthy state but is produced by various tissues in septic conditions. Since there are many patients with elevated levels of PCT due to nonbacterial causes, the levels of serum PCT have been apt to be used for a marker for the early detection of not only bacterial infection but also many inflammatory and/or febrile disorders including fever of unknown origin (FUO) in the clinical setting of general medicine. Here we attempted to clarify the differences and similarities of inflammatory markers for a clinical setting. We retrospectively reviewed 359 patients in whom serum PCT had been measured. According to our earlier study, the patients were categorized into 7 groups: bacterial, non-bacterial infection, non-specific inflammation, neoplasm, connective tissue disease (CTD), drug-induced diseases, and unidentified causes. Data for 332 PCT-positive cases including cases of bacterial infection (20.5%), non-specific inflammation (20.8%), neoplasm (9.9%), CTD (8.4%), and non-bacterial infection (7.2%) were used for analysis. Serum PCT level was highest in the bacterial infection group (1.94 ng/ml) followed by the non-specific inflammatory group (0.58 ng/ml) and neoplastic diseases group (0.34 ng/ml). Of note, serum PCT level was positively correlated with serum levels of C-reactive protein (R2=0.39), soluble interleukin-2 receptor (sIL-2R; R2=0.48), and ferritin, plasma level of D-dimer level and white blood cell count, whereas it was negatively correlated with serum albumin level (R2=0.27), hemoglobin concentration and platelet count. The result of the strongly positive correlation with serum level of sIL-2R suggested that an increased serum PCT level may indicate not only an inflammatory state but also a neoplastic state such as malignant lymphomas in the diagnostic process of various inflammatory disorders in a clinical setting of general practice for diagnosing febrile conditions.

A step-by-step model for a brief behavioural treatment for insomnia in Australian general practice.

Chronic insomnia is a prevalent and debilitating disorder managed in Australian general practice. The most effective and recommended first-line treatment for insomnia is cognitive behavioural therapy. This treatment has been translated to a condensed brief behavioural therapy for insomnia (BBTi), which is suitable for delivery in the general practice setting. There is evidence that BBTi improves insomnia, daytime functioning and quality of life, with effects persisting far beyond treatment cessation. BBTi appears to be a cost-effective treatment that is superior to sedative-hypnotic management. The aim of this article is to present a step-by-step approach for Australian general practitioners to administer BBTi. BBTi is an effective treatment for insomnia that may be administered in the Australian general practice setting. General practitioners may choose to use existing funding support to administer BBTi to treat chronic insomnia according to guideline recommendations.

Comparison of General Surgical Practice Size and Setting in 2017 vs 2013 in the US

As health care delivery markets have changed and new payment models have emerged, physicians in many specialties have consolidated their practices, but whether this consolidation has occurred in surgical practices is unknown. To examine changes in the size of surgical practices, market-level factors associated with this consolidation, and how place of service for surgical care delivery varies by practice size. A cross-sectional study of Medicare Data on Provider Practice and Specialty from January 1 to December 31, 2013, compared with January 1 to December 31, 2017, was conducted on all general surgeon practices caring for patients enrolled in Medicare in the US. Data analysis was performed from November 4, 2019, to January 9, 2020. Practice sizes in 2013 and 2017 were compared relative to hospital market concentration measured by the Herfindahl-Hirschman Index in the hospital referral region. The primary outcome was the change in size of surgical practices over the study period. Secondary outcomes included change in surgical practice market concentration and the place of service for provision of surgical care stratified by surgical practice size. From 2013 to 2017, the number of surgical practices in the US decreased from 10 432 to 8451. The proportion of surgeons decreased in practices with 1 (from 26.2% to 17.4%), 2 (from 8.3% to 6.6%), and 3 to 5 (from 18.0% to 16.5%) surgeons, and the proportion of surgeons in practices with 6 or more surgeons increased (from 47.6% to 59.5%). Hospital concentration was associated with an increase in the size of the surgical practice. Each 10% increase in the hospital market concentration was associated with an increase of 0.204 surgeons (95% CI, 0.020-0.388 surgeons; P = .03) per practice from 2013 to 2017. Similarly, a 10% increase in the hospital-level HHI was associated with an increase in the surgical practice HHI of 0.023 (95% CI, 0.013-0.033; P < .001). Large surgical practices increased their share of Medicare services provided from 36.5% in 2013 to 45.6% in 2017. Large practices (31.3% inpatient in 2013 to 33.1% in 2017) were much more likely than small practices (19.0% inpatient in 2013 to 17.7% in 2017) to be based in hospital settings and this gap widened over time. Surgeons have increasingly joined larger practices over time, and there has been a significant decrease in solo, small, and midsize surgical practices. The consolidation of surgeons into larger practices appears to be associated with hospital market concentration in the same market. Although overall care appears to be more hospital based for larger practices, the association between the consolidation of surgical practices and patient access and outcomes should be studied.

Identification of Important Factors Affecting Use of Digital Individualised Coaching and Treatment of Type 2 Diabetes in General Practice: A Qualitative Feasibility Study.

Most type 2 diabetes patients are treated in general practice and there is a need of developing and implementing efficient lifestyle interventions. eHealth interventions have shown to be effective in promoting a healthy lifestyle. The purpose of this study was to test the feasibility, including the identification of factors of importance, when offering digital lifestyle coaching to type 2 diabetes patients in general practice. We conducted a qualitative feasibility study with focus group interviews in four general practices. We identified two overall themes and four subthemes: (1) the distribution of roles and lifestyle interventions in general practice (subthemes: external and internal distribution of roles) and (2) the pros and cons for digital lifestyle interventions in general practice (subthemes: access to real life data and change in daily routines). We conclude that for digital lifestyle coaching to be feasible in a general practice setting, it was of great importance that the general practitioners and practice nurses knew the role and content of the intervention. In general, there was a positive attitude in the general practice setting towards referring type 2 diabetes patients to digital lifestyle intervention if it was easy to refer the patients and if easily understandable and accessible feedback was implemented into the electronic health record. It was important that the digital lifestyle intervention was flexible and offered healthcare providers in general practice an opportunity to follow the type 2 diabetes patient closely.

The experience of Australian general practice patients at high risk of poor health outcomes with telehealth during the COVID-19 pandemic: a qualitative study

BackgroundThe emergence of the COVID-19 pandemic has raised concerns about the potential decrease in access and utilisation of general practice services and its impact on patient care. In March 2020, the Australian Government introduced telehealth services to ensure that people more vulnerable to COVID-19 do not delay routine care from their general practitioners. Evidence about patients’ experience of telehealth and its impact on patient care is scarce. This study aimed to investigate the experience with telehealth by Australian general practice patients at high risk of poor health outcomes during the COVID-19 pandemic.MethodsSemi-structured telephone interviews were conducted with 30 patients from nine general practices in metropolitan Adelaide (May–June 2020). Participants were identified by their regular doctor as being at high risk of poor health outcomes. Interviews sought participants’ perspectives and experiences about telehealth services in the general practice setting during COVID-19, and the value of offering continued telehealth services post pandemic. Interviews were recorded and transcribed verbatim. Data were analysed using a coding structure developed based on deductive codes derived from the research questions and any additional concepts that emerged inductively from interviews.ResultsParticipants expressed satisfaction with telehealth including convenient and timely access to general practice services. Yet, participants identified challenges including difficulties in expressing themselves and accessing physical exams. Prescription renewal, discussing test results and simple follow-ups were the most common reasons that telehealth was used. Telehealth was mainly via phone that better suited those with low digital literacy. Participants indicated that an existing doctor-patient relationship was important for telehealth services to be effective. Subjects believed that telehealth services should be continued but needed to be combined with opportunities for face-to-face consultations after the COVID-19 pandemic was over.ConclusionsThe expansion of telehealth supported access to general practice including chronic disease management during the COVID-19 pandemic. In the future, telehealth in Australia is likely to have a stronger place in primary healthcare policy and practice and an increased acceptance amongst patients.

Cross-sector pre-registration pharmacist placements in general practice in England: lessons from a national evaluation

Abstract Introduction In 2019/2020, the Pharmacy Integration Fund commissioned delivery of cross-sector pre-registration pharmacist training incorporating 3–6 month placements in general practice (GP). GP placements were managed by Health Education England (HEE) and organised as one (or more) blocks, or as spilt weeks/days across base sector (hospital/community) and GP. Trainees had a pharmacist tutor at base and in GP. Aim to evaluate the implementation of cross-sector pre-registration pharmacy placements in GP in England, and to identify barriers and enablers of a successful placement. Methods A qualitative approach was taken, with case study sites purposively sampled for maximum variation: pharmacy base (hospital/community), number of pre-registration pharmacist trainees in base doing GP placement, length of GP placement, organisation of GP placement and geographical location. With consent, trainees and tutors identified as meeting sampling criteria were emailed invitation letters and participant information sheets. Where the trainee and their tutor(s) agreed to participate, semi-structured telephone interviews were conducted January - July 2020. Questions developed from literature(1, 2) and the HEE handbook were tailored to understanding trainees’ and tutors’ views on the implementation of pre-registration pharmacist placements in GP, including benefits, unintended consequences and impacts. Thematic analysis across sites was undertaken with a focus on exploring inter and intra group themes. Results Thirty-four interviews were completed in 11 study sites (5 GP/hospital; 6 GP/community pharmacy). Trainees and tutors considered GP placements had been successful. Contributing factors were: placement planning (induction, contingency arrangements for cover should GP tutor be unavailable); tutors working together (good communication and collaboration); GP tutor support (regular contact, reflection; identifying learning needs; opportunities for learning); integration of GP placements within training year (specific learning/training activities at base during GP placement); and GP tutors having backing of their organisation to supervise effectively. A lack of these impacted negatively. Trainees completed a wide spectrum of activities and gradually moved from administrative to clinical tasks. They built up confidence to undertake patient-facing activities, with more direct supervision at the beginning moving to indirect supervision using debriefing. Thirteen weeks in GP was considered an appropriate minimum duration by all trainees and tutors; those based in community felt that 26 weeks in GP provided more opportunities for clinical and consultation skills learning. Cross-sector experience facilitated a better understanding of patient pathways and the importance of holistic patient care. All trainees considered working in GP in future but highlighted the lack of a cross-sector GP foundation programme. Base tutors felt the time commitment was comparable to single sector placements. Base and GP tutors felt that a clear set of competencies for GP placements and a broader governance framework would ensure standards and consistency. Conclusion This is the first national evaluation of cross-sector pre-registration pharmacists in general practice placements in England. Sampling as case studies enabled data triangulation and generated a multi-faceted understanding on factors impacting GP placements. A key limitation was the volunteer bias associated with recruitment. Key attributes of a successful pre-registration cross-sector training experience are highlighted and can inform policy reforms including change from pre-registration to foundation year training.

A systematic review of pharmacist-led audit and feedback interventions to influence prescribing behaviour in general practice settings

Abstract Introduction Audit and Feedback (A&amp;F) involves measuring data about practice, comparing it with clinical guidelines, professional standards or peer performance, and then feeding back the data to individuals/groups of health professionals to encourage change in practice (if required). A 2012 Cochrane review (1) found A&amp;F was effective in changing health professionals’ behaviour and suggested that the person who delivers the A&amp;F intervention influences its effect. Increasingly, pharmacists work in general practice and often have responsibility for medication review and repeat prescriptions. The effectiveness of pharmacist-led A&amp;F in influencing prescribing behaviour is uncertain. Aim This secondary analysis from an ongoing update of the original Cochrane review aims to identify and describe pharmacist-led A&amp;F interventions and evaluate their impact on prescribing behaviour in general practice compared with no intervention. Methods This sub-review is registered with PROSPERO: CRD42020194355 and complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (2). For the updated Cochrane review, the Cochrane Effective Practice and Organization of Care Group searched MEDLINE (1946 to present), EMBASE, CINAHL and Cochrane Library (March 2019) to identify randomised trials featuring A&amp;F interventions. For this sub-review, authors screened titles and abstracts (May 2020) to identify trials involving pharmacist-led A&amp;F interventions in primary care, extracted data, and assessed risk of bias (RoB) in eligible studies. Review results are summarised descriptively. Heterogeneity will be assessed and a random-effects meta-analysis is planned. Publication bias for selected outcomes and the certainty of the body of evidence will be evaluated and presented. Sub-group analyses will be conducted. Results Titles and abstracts of 295 studies identified for inclusion in the Cochrane A&amp;F review update were screened. Eleven studies (all cluster-randomised trials) conducted in 9 countries (Denmark, Italy, Netherlands, Norway, Republic of Ireland, UK, Australia, Malaysia, USA) were identified for inclusion (Figure 1). Six studies had low RoB, two had high risk due to dissimilarities between trial arms at baseline and/or insufficient detail about randomisation, and three studies had unclear RoB. Studies examined the effect of A&amp;F on prescribing for specific conditions (e.g. hypertension), medications (e.g. antibiotics), populations (e.g. patients &amp;gt;70), and prescribing errors (e.g. inappropriate dose). The pharmacist delivering A&amp;F was a colleague of intervention participants in five studies. Pharmacists’ levels of skill and experience varied; seven studies reported details of pharmacist training undertaken for trial purposes. A&amp;F interventions in nine studies demonstrated changes in prescribing, including reductions in errors or inappropriate prescribing according to the study aims and smaller increases in unwanted prescribing compared with the control group. Data analyses are ongoing (results will be available for the conference). Conclusion The preliminary results demonstrate the effectiveness of pharmacist-led A&amp;F interventions in different countries and health systems with influencing prescribing practice to align more closely with guidance. Studies measured different prescribing behaviours; meta-analysis is unlikely to include all 11 studies. Further detailed analysis including feedback format/content/frequency and pharmacist skill level/experience, work-base (external/internal to recipients), will examine the impact of specific features on intervention effectiveness.