General Practice and Primary Care - Research Publications
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ItemDevelopments in Australian general practice 2000-2002: what did these contribute to a well functioning and comprehensive Primary Health Care System?(Springer Science and Business Media LLC, 2006-01-15)BACKGROUND: In recent years, national and state/territory governments have undertaken an increasing number of initiatives to strengthen general practice and improve its links with the rest of the primary health care sector. This paper reviews how far these initiatives were contributing to a well functioning and comprehensive primary health care system during the period 2000-2002, using a normative model of primary health care and data from a descriptive study to evaluate progress. RESULTS: There was a significant number of programs, at both state/territory and national level. Most focused on individual care, particularly for chronic disease, rather than population health approaches. There was little evidence of integration across programs: each tended to be based in and focus on a single jurisdiction, and build capacity chiefly within the services funded through that jurisdiction. As a result, the overall effect was patchy, with similar difficulties being noted across all jurisdictions and little gain in overall system capacity for effective primary health care. CONCLUSION: Efforts to develop more effective primary health care need a more balanced approach to reform, with a better balance across the different elements of primary health care and greater integration across programs and jurisdictions. One way ahead is to form a single funding agency, as in the UK and New Zealand, and so remove the need to work across jurisdictions and manage their competing interests. A second, perhaps less politically challenging starting point, is to create an agreed framework for primary health care within which a collective vision for primary health care can be developed, based on population health needs, and the responsibilities of different sectors services can be negotiated. Either of these approaches would be assisted by a more systematic and comprehensive program of research and evaluation for primary health care.
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ItemLeaders, leadership and future primary care clinical research(BMC, 2008-09-29)BACKGROUND: A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base. METHODS: Review of recent developments supporting primary care clinical research. RESULTS: Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output. CONCLUSION: Primary care research is now well placed to lead a broad re-vitalisation of academic medicine, answering questions of relevance to practitioners, patients, communities and Government. Key areas for future primary care research leaders to focus on include exposing undergraduates early to primary care research, integrating this early exposure with doctoral and postdoctoral research career support, further expanding cross disciplinary approaches, and developing useful measures of output for future primary care research investment.
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ItemQuit in General Practice: a cluster randomised trial of enhanced in-practice support for smoking cessation(BMC, 2010-08-12)BACKGROUND: This study will test the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by the practice nurse (PN) and tailored to meet the needs of a diversity of patients. METHODS/DESIGN: This study is a cluster randomised trial, with practices allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline referral 3) GP usual care. PNs from practices randomised to the intervention group will receive a training course in smoking cessation followed by access to mentoring. GPs from practices randomised to the Quitline referral group will receive information about the study and the process of written referral and GPs in the usual care group will receive information about the study. Eligible patients are those aged 18 and over presenting to their GP who are daily or weekly smokers and who are able to give informed consent. Patients on low incomes in all three groups will be able to access free nicotine patches.Primary outcomes are sustained abstinence and point prevalence abstinence at the three month and 12 month follow-up points; and incremental cost effectiveness ratios at 12 months. Process evaluation on the reach and acceptability of the intervention approached will be collected through Computer Assisted Telephone Interviews (CATI) with patients and semi-structured interviews with PNs and GPs.The primary analysis will be by intention to treat. Cessation outcomes will be compared between the three arms at three months and 12 month follow-up using multiple logistic regression. The incremental cost effectiveness ratios will be estimated for the 12 month quit rate for the intervention groups compared to usual care and to each other. Analysis of qualitative data on process outcomes will be based on thematic analysis. DISCUSSION: High quality evidence on effectiveness of practice nurse interventions is needed to inform health policy on development of practice nurse roles. If effective, flexible support from the PN in partnership with the GP and the Quitline could become the preferred model for providing smoking cessation advice in Australian general practice. TRIAL REGISTRATION: ACTRN12609001040257.
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ItemAn International Society and Journal for Equity in Health: 10 years on(BioMed Central, 2011)
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ItemParticipant demographics reported in "Table 1" of randomised controlled trials: a case of "inverse evidence"?(BMC, 2012-03-19)INTRODUCTION: Data supporting external validity of trial results allows clinicians to assess the applicability of a study's findings to their practice population. Socio-economic status (SES) of trial participants may be critical to external validity given the relationship between social and economic circumstances and health. We explored how this is documented in reports of RCTs in four major general medical journals. METHODS: The contents lists of four leading general medical journals were hand searched to identify 25 consecutive papers reporting RCT results in each journal (n = 100). Data on demographic characteristics were extracted from each paper's Table 1 only (or equivalent). RESULTS: Authors infrequently reported key demographic characteristics relating to SES of RCT participants. Age and gender of participants were commonly reported. Less than 10% reported occupational group, employment status, income or area based measures of disadvantage. CONCLUSIONS: Without adequate reporting of key indicators of SES in trial participants it is unclear if lower SES groups are under-represented. If such groups are systematically under-recruited into trials, this may limit the external validity and applicability of study findings to these groups. This is in spite of the higher health-care need in more disadvantaged populations. Under-representation of low SES groups could underestimate the reported effect of an intervention for those with a higher baseline risk. The marginal benefit identified in a trial with poor or no representation of lower SES participants could significantly underestimate the potential benefit to a low SES community. More transparency in this reporting and greater attention to the impact of SES on intervention outcomes in clinical trials is needed. This could be considered in the next revision of the CONSORT statement.
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ItemThe ethics of everyday practice in primary medical care: responding to social health inequities.(Springer Science and Business Media LLC, 2010-05-03)BACKGROUND: Social and structural inequities shape health and illness; they are an everyday presence within the doctor-patient encounter yet, there is limited ethical guidance on what individual physicians should do. This paper draws on a study that explored how doctors and their professional associations ought to respond to the issue of social health inequities. RESULTS: Some see doctors as bound by a notion of care that is blind to a patient's social position, while others respond to this issue through invoking notions of justice and human rights where access to care is a prime focus. Both care and justice orientations however conceal important tensions linked to the presence of bioethical principles underpinning these. Other normative ethical theories like deontology, virtue ethics and utilitarianism do not provide adequate guidance on the problem of social health inequities either. CONCLUSION: This paper explores if Bauman's notion of "forms of togetherness" provides the basis of a relational ethical theory that can help to develop a response to social health inequities of relevance to individual physicians. This theory goes beyond silence on the influence of social position of health and avoids amoral regulatory approaches to monitoring equity of care provision.
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ItemEquity of access to quality of care in family medicine.(Hindawi Limited, 2011)
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ItemThe "cost" of treating to target: cross-sectional analysis of patients with poorly controlled type 2 diabetes in Australian general practice(BMC, 2013-03-08)BACKGROUND: To describe the current treatment gap in management of cardiovascular risk factors in patients with poorly controlled type 2 diabetes in general practice as well as the associated financial and therapeutic burden of pharmacological treatment. METHODS: Cross-sectional analysis of data from the Patient Engagement and Coaching for Health trial. This totalled 473 patients from 59 general practices with participants eligible if they had HbA1c > 7.5%. Main outcome measures included proportions of patients not within target risk factor levels and weighted average mean annual cost for cardiometabolic medications and factors associated with costs. Medication costs were derived from the Australian Pharmaceutical Benefits Schedule. RESULTS: Average age was 63 (range 27-89). Average HbA1c was 8.1% and average duration of diabetes was 10 years. 35% of patients had at least one micro or macrovascular complication and patients were taking a mean of 4 cardio-metabolic medications. The majority of participants on treatment for cardiovascular risk factors were not achieving clinical targets, with 74% and 75% of patients out of target range for blood pressure and lipids respectively. A significant proportion of those not meeting clinical targets were not on treatment at all. The weighted mean annual cost for cardiometabolic medications was AUD$1384.20 per patient (2006-07). Independent factors associated with cost included age, duration of diabetes, history of acute myocardial infarction, proteinuria, increased waist circumference and depression. CONCLUSIONS: Treatment rates for cardiovascular risk factors in patients with type 2 diabetes in our participants are higher than those identified in earlier studies. However, rates of achieving target levels remain low despite the large 'pill burden' and substantial associated fiscal costs to individuals and the community. The complexities of balancing the overall benefits of treatment intensification against potential disadvantages for patients and health care systems in primary care warrants further investigation.
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ItemA systematic review of interventions to enhance access to best practice primary health care for chronic disease management, prevention and episodic care(BIOMED CENTRAL LTD, 2012-11-21)BACKGROUND: Although primary health care (PHC) is a key component of all health care systems, services are not always readily available, accessible or affordable. This systematic review examines effective strategies to enhance access to best practice processes of PHC in three domains: chronic disease management, prevention and episodic care. METHODS: An extensive search of bibliographic data bases to identify peer and non-peer reviewed literature was undertaken. Identified papers were screened to identify and classify intervention studies that measured the impact of strategies (singly or in combination) on change in use or the reach of services in defined population groups (evaluated interventions). RESULTS: The search identified 3,148 citations of which 121 were intervention studies and 75 were evaluated interventions. Evaluated interventions were found in all three domains: prevention (n = 45), episodic care (n = 19), and chronic disease management (n = 11). They were undertaken in a number of countries including Australia (n = 25), USA (n = 25), and UK (n = 15). Study quality was ranked as high (31% of studies), medium (61%) and low (8%). The 75 evaluated interventions tested a range of strategies either singly (n = 46 studies) or as a combination of two (n = 20) or more strategies (n = 9). Strategies targeted both health providers and patients and were categorised to five groups: practice re-organisation (n = 43 studies), patient support (n = 29), provision of new services (n = 19), workforce development (n = 11), and financial incentives (n = 9). Strategies varied by domain, reflecting the complexity of care needs and processes. Of the 75 evaluated interventions, 55 reported positive findings with interventions using a combination of strategies more likely to report positive results. CONCLUSIONS: This review suggests that multiple, linked strategies targeting different levels of the health care system are most likely to improve access to best practice PHC. The proposed changes in the structure of PHC in Australia may provide opportunities to investigate the factors that influence access to best practice PHC and to develop and implement effective, evidence based strategies to address these.
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ItemThe emotional context of self-management in chronic illness: A qualitative study of the role of health professional support in the self-management of type 2 diabetes.( 2008-10-17)BACKGROUND: Support for patient self-management is an accepted role for health professionals. Little evidence exists on the appropriate basis for the role of health professionals in achieving optimum self-management outcomes. This study explores the perceptions of people with type 2 diabetes about their self-management strategies and how relationships with health professionals may support this. METHODS: Four focus groups were conducted with people with type 2 diabetes: two with English-speaking and one each with Turkish and Arabic-speaking. Transcripts from the groups were analysed drawing on grounded hermeneutics and interpretive description. RESULTS: We describe three conceptually linked categories of text from the focus groups based on emotional context of self management, dominant approaches to self management and support from health professionals for self management. All groups described important emotional contexts to living with and self-managing diabetes and these linked closely with how they approached their diabetes management and what they looked for from health professionals. Culture seemed an important influence in shaping these linkages. CONCLUSION: Our findings suggest people construct their own individual self-management and self-care program, springing from an important emotional base. This is shaped in part by culture and in turn determines the aims each person has in pursuing self-management strategies and the role they make available to health professionals to support them. While health professionals' support for self-care strategies will be more congruent with patients' expectations if they explore each person's social, emotional and cultural circumstances, pursuit of improved health outcomes may involve a careful balance between supporting as well as helping shift the emotional constructs surrounding a patient life with diabetes.