General Practice and Primary Care - Theses
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ItemSupporting primary care practitioners to promote dementia risk reduction in Australian general practice: development and pilot evaluation of a practice change intervention and targeted implementation approach( 2023-10)Background. People in Australia have limited awareness of the potential for dementia risk reduction. General practice is an appropriate setting for promoting dementia risk reduction, yet it is not routinely discussed. The objectives of the Preventing Cognitive Impairment in Practice Project were to (1) develop an intervention for promoting dementia risk reduction in Australian general practice, (2) assess barriers to implementing the intervention, (3) develop an implementation approach in which strategies to mitigate assessed barriers were selected, operationalised, and introduced progressively, and (4) pilot the intervention and implementation approach in Australian general practices. Methods. The project was guided by a range of frameworks (eg, the Knowledge-to-Action Framework, the Consolidated Framework for Implementation Research). The project comprised six separate studies, including two scoping reviews, qualitative interviews with Australian primary care practitioners, retrospective analysis of discussion board posts from non-medically trained enrollees in a free online educational course about dementia risk reduction, development of an intervention and targeted implementation approach based on evidence and stakeholder consultation, and a pilot evaluation of implementation outcomes in five general practices in Melbourne, Australia. Results. The intervention comprised a patient survey to be completed in the waiting room and patient information cards to be used during consultations, both of which were designed to prompt specific practitioner actions. The implementation approach combined educational materials, outreach visits, local consensus discussions about whether dementia risk reduction was important and whether the proposed practice changes were appropriate, champions to drive implementation within general practices, and capturing and sharing knowledge across general practices. On piloting, implementation outcomes were mixed. Both the intervention and implementation approach were broadly acceptable and feasible, but penetration (‘reach’) was low. Discussion. The Preventing Cognitive Impairment in Practice Project led to an acceptable and feasible practice change intervention and targeted implementation approach that can support the promotion of dementia risk reduction in Australian general practices. Interpretation of the evaluation data identified opportunities for refinements to the intervention and implementation approach. Female participants and self-selected participants interested in DRR were overrepresented throughout the project. Future research could examine hypotheses about implementation outcomes arising from the pilot study, consider additional implementation outcomes, and adapt the intervention and targeted implementation approach for other contexts and populations.
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ItemAssessing and addressing diabetes distress during type 2 diabetes care: Design and implementation of a digital health solution in general practice( 2023-04)Background: Type 2 diabetes (T2D) affects 1.2 million (4.5%) Australians. It is estimated that up to 36% of people with T2D experience diabetes distress, the negative emotional experience resulting from the challenges of living with the demands of diabetes. Diabetes distress impacts diabetes self management and glycaemia. Healthcare professionals can assess diabetes distress using the Problem Areas In Diabetes (PAID) scale. Given that most people with T2D attend general practice, it is important to understand and optimise general practice approaches to assessing and addressing diabetes distress. Aim: This thesis aims to explore current practices for assessing and addressing diabetes distress in Australian general practice and develop an intervention to optimise these. Methods: Following a literature review, I conducted five related studies in two phases aligned with the Knowledge to Action framework. The first phase comprises three studies: a systematic review, interviews with people with T2D, and a survey of general practitioners (GPs). The first study was a systematic review of studies using a Patient Reported Outcome Measure (PROM) to assess depressive symptoms or diabetes distress during T2D care. In study two, I explored people with T2D experiences of emotional support in general practice using qualitative interviews. In study three, an online survey of GPs, I explored the current practices for assessing diabetes distress. In phase two of the thesis, I addressed key gaps identified in phase one in a series of design sessions and a case study to design and implement a digital health solution, PROM-GP. Results: There was a paucity of studies exploring if using the PAID scale during T2D care was associated with improvements in clinical and process outcomes in general practice. People with T2D do not recall completing the PAID scale in consultations with their GP. However, they acknowledged that the GP-patient relationship supported emotional health discussions. People with T2D speculated that the PAID scale would support the discussion if this relationship were absent. Three-quarters of GPs recognise their role in diabetes distress assessment. However, only a quarter GPs routinely ask about or assess for diabetes distress, and only 1.9% use the PAID scale. Health professionals key design preference was supportive language to minimise patients’ negative emotional responses when completing the PAID scale. Implementing PROM-GP was part of an ongoing relationship, with practices inviting people with T2D whom they deemed suitable. COVID-19 impacted healthcare professionals’ capacity to engage with the implementation of PROM-GP. Conclusions: Despite most GPs recognising their role, few routinely ask about or assess diabetes distress. When general practice healthcare professionals use the PAID scale, it is with a limited subset of people with T2D with an existing relationship. This limits the PAID scale use with people without an existing relationship who want to be asked. Healthcare professionals are concerned that asking and completing the PAID scale will elicit a negative emotional, unlike people with T2D who view it as a questionnaire. Competing interests hindered sustained implementation. Future research can focus on systematically implementing the PAID scale with automation during all T2D annual reviews.
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ItemGPimED: General Practice: improving management of Eating Disorders: Can a one hour online educational intervention improve the detection and management of patients with Eating Disorders by General Practice Trainees?( 2020)GPimED: Can a one- hour on-line learning module improve early diagnosis and management of Eating Disorders by General Practice Trainees? PROBLEM STATEMENT Eating disorders are a serious and potentially life-threatening group of illnesses within the community. The literature shows that diagnosis and management of these illnesses are inadequately covered during medical school and subsequent General Practice training. This can result in a delay in diagnosis and appropriate referral thus significantly contributing to patient morbidity and mortality plus increased financial burden on the community. The literature demonstrates that patients with ED present repeatedly to General Practice (GP) with a myriad of signs and symptoms There is often delay in diagnosis due to varied reasons. The literature also finds that this delay coupled with lack of appropriate management can greatly exacerbate the morbidity and potential mortality. For example, within this group of disorders, Anorexia Nervosa (AN) has the highest mortality rate of any psychiatric illness with suicide rates 32 times higher than the general population and a mortality rate of 10%. General Practitioners (GPs) are often time poor and lack the knowledge to adequately manage patients with ED Online education for GPs is becoming more popular as it is cost effective, convenient and allows rural and remote GPs access to educational material they might not otherwise be able to access if it is available only via face to face delivery AIM The aim of this study is to determine whether a one-hour online learning module developed to upskill General Practitioners in the recognition and management of Eating Disorders improves the performance of GP trainees. SIGNFICANCE This study will shed light on the effectiveness of online education in upskilling GP trainees and if the ED module is successful, it may lead to improved treatment of patients with evolving or established eating disorders in the General Practice setting. It will potentially reduce the rates of delayed diagnosis resulting in improved outcomes. The literature indicates that patients with an ED present up to 5 times more frequently to primary care than demographically matched peers. General Practice is thus ideally placed to recognize these patients, to make a timely diagnosis and initiate appropriate investigation, management and referrals. The literature also indicates when diagnosis and appropriate intervention occurs within the first three years of the disorder developing, there is a greater than 40% chance of complete recovery. On November 1st 2019, the Federal Government initiated $110 million in extra funding for increased support for patients with a serious ED. This support can only be accessed if the patient as an Eating Disorder Plan completed is be done by the GP who has performed appropriate screening and provided the requisite history, examination and investigations. METHODS The trial design was a randomized, parallel-group study. Participants were recruited from the Victorian General Practice Training Consortia MCCC and EVGPT. The comparator was a general Youth Mental health module. Baseline surveys including demographic details plus a clinical case designed to assess baseline competence in recognising a probable eating disorder case and management thereafter. Following randomisation to either the ED module arm (intervention) or control arm, follow up surveys were completed after 6 weeks, quantitative evaluation was conducted using clinical scenarios presented as case studies in the format of Key Feature Problems (KFPs) which are a component of the FRACGP examination. RESULTS Despite our best efforts, there were only small number of recruits- 15 respondents with 8 completing all components of the study. Despite the small sample, there was measurable improvement in many parameters assessed cross both arms of the trial. In particular, an increase in the identification of ED as a differential diagnosis and improved referrals to health professionals considered integral to the evidence based best practice multidisciplinary team approach to ED management.