General Practice - Research Publications

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    Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis
    Cooke, G ; Tapley, A ; Holliday, E ; Morgan, S ; Henderson, K ; Ball, J ; van Driel, M ; Spike, N ; Kerr, R ; Magin, P (WILEY, 2017-12-01)
    CONTEXT: Tolerance for ambiguity is essential for optimal learning and professional competence. General practice trainees must be, or must learn to be, adept at managing clinical uncertainty. However, few studies have examined associations of intolerance of uncertainty in this group. OBJECTIVES: The aim of this study was to establish levels of tolerance of uncertainty in Australian general practice trainees and associations of uncertainty with demographic, educational and training practice factors. METHODS: A cross-sectional analysis was performed on the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study. Scores on three of the four independent subscales of the Physicians' Reaction to Uncertainty (PRU) instrument were analysed as outcome variables in linear regression models with trainee and practice factors as independent variables. RESULTS: A total of 594 trainees contributed data on a total of 1209 occasions. Trainees in earlier training terms had higher scores for 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose diagnosis/treatment uncertainty to patients'. Beyond this, findings suggest two distinct sets of associations regarding reaction to uncertainty. Firstly, affective aspects of uncertainty (the 'Anxiety' and 'Concern' subscales) were associated with female gender, less experience in hospital prior to commencing general practice training, and graduation overseas. Secondly, a maladaptive response to uncertainty (the 'Reluctance to disclose' subscale) was associated with urban practice, health qualifications prior to studying medicine, practice in an area of higher socio-economic status, and being Australian-trained. CONCLUSIONS: This study has established levels of three measures of trainees' responses to uncertainty and associations with these responses. The current findings suggest differing 'phenotypes' of trainees with high 'affective' responses to uncertainty and those reluctant to disclose uncertainty to patients. More research is needed to examine the relationship between clinical uncertainty and clinical outcomes, temporal changes in tolerance for uncertainty, and strategies that might assist physicians in developing adaptive responses to clinical uncertainty.
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    Referrals to dietitians/nutritionists: A cross-sectional analysis of Australian GP registrars' clinical practice
    Mulquiney, KJ ; Tapley, A ; van Driel, ML ; Morgan, S ; Davey, AR ; Henderson, KM ; Spike, NA ; Kerr, RH ; Watson, JF ; Catzikiris, NF ; Magin, PJ (WILEY, 2018-02-01)
    AIM: The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals. METHODS: This was a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six-month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010-2015). Independent variables were related to registrar, patient, practice and consultation. RESULTS: A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23-0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement. CONCLUSIONS: Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients' complex care needs.
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    Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis
    Magin, P ; Tapley, A ; Davey, A ; Morgan, S ; Henderson, K ; Holliday, E ; Ball, J ; Catzikiris, N ; Mulquiney, K ; Spike, N ; Kerr, R ; van Driel, M (WILEY, 2017-10-01)
    AIMS: Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of "non-symptomatic" PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars). METHODS: A cross-sectional analysis from the ReCEnT cohort study of registrars' consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an "asymptomatic" PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors. RESULTS: A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69 years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test). CONCLUSION: GP registrars frequently order "asymptomatic" PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted.
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    Older patients' consultations in an apprenticeship model-based general practice training program: A cross-sectional study
    Bonney, A ; Morgan, S ; Tapley, A ; Henderson, K ; Holliday, E ; Davey, A ; van Driel, M ; Spike, N ; Regan, C ; Ball, J ; Magin, P (WILEY, 2017-03-01)
    OBJECTIVE: To investigate older patients' encounters with general practice registrars (GPRs) to inform training and clinical practice. METHODS: Cross-sectional analysis of data from GPR consultations across five regional training providers in Australia. Data were analysed using simple and multiple logistic regression models. RESULTS: Our analysis included details of 118 831 consultations, 20 555 (17.6%, 95% CI 17.4-17.8) with patients aged ≥65 years. Older patient encounters had an increased likelihood of including chronic disease (OR 1.77, 95% CI 1.70, 1.86) and more problems (OR 1.24, 95% CI 1.20, 1.27). However, in-consultation information or advice was less likely to be sought (OR 0.92, 95% CI 0.88, 0.97), and consultations were briefer (OR 0.99, 95% CI 0.99, 1.00). CONCLUSION: Our results suggest relatively limited GPR exposure to older patients coupled with less complex consultations than expected. Solutions will need to be carefully constructed not only to increase caseloads, but also to address training and supervision concerns.
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    Anticholinergic medicines in an older primary care population: a cross-sectional analysis of medicines' levels of anticholinergic activity and clinical indications
    Magin, PJ ; Morgan, S ; Tapley, A ; McCowan, C ; Parkinson, L ; Henderson, KM ; Muth, C ; Hammer, MS ; Pond, D ; Mate, KE ; Spike, NA ; McArthur, LA ; van Driel, ML (WILEY, 2016-10-01)
    WHAT IS KNOWN AND OBJECTIVES: Adverse clinical outcomes have been associated with cumulative anticholinergic burden (to which low-potency as well as high-potency anticholinergic medicines contribute). The clinical indications for which anticholinergic medicines are prescribed (and thus the 'phenotype' of patients with anticholinergic burden) have not been established. We sought to establish the overall prevalence of prescribing of anticholinergic medicines, the prevalence of prescribing of low-, medium- and high-potency anticholinergic medicines, and the clinical indications for which the medicines were prescribed in an older primary care population. METHODS: This was a cross-sectional analysis of a cohort study of Australian early-career general practitioners' (GPs') clinical consultations - the Registrar Clinical Encounters in Training (ReCEnT) study. In ReCEnT, GPs collect detailed data (including medicines prescribed and their clinical indication) for 60 consecutive patients, on up to three occasions 6 months apart. Anticholinergic medicines were categorized as levels 1 (low-potency) to 3 (high-potency) using the Anticholinergic Drug Scale (ADS). RESULTS: During 2010-2014, 879 early-career GPs (across five of Australia's six states) conducted 20 555 consultations with patients aged 65 years or older, representing 35 506 problems/diagnoses. Anticholinergic medicines were prescribed in 10·4% [95% CIs 9·5-10·5] of consultations. Of the total anticholinergic load of prescribed medicines ('community anticholinergic load') 72·7% [95% CIs 71·0-74·3] was contributed by Level 1 medicines, 0·8% [95% CIs 0·5-1·3] by Level 2 medicines and 26·5% [95% CIs 24·8-28·1] by Level 3 medicines. Cardiac (40·0%), Musculoskeletal (16·9%) and Respiratory (10·6%) were the most common indications associated with Level 1 anticholinergic prescription. For Level 2 and 3 medicines (combined data), Psychological (16·1%), Neurological (16·1%), Musculoskeletal (15·7%) and Urological (11·1%) indications were most common. WHAT IS NEW AND CONCLUSION: Anticholinergic medicines are frequently prescribed in Australian general practice, and the majority of the 'community' anticholinergic burden is contributed by 'low'-anticholinergic potency medicines whose anticholinergic effects may be largely 'invisible' to prescribing GPs. Furthermore, the clinical 'phenotype' of the patient with high anticholinergic burden may be very different to common stereotypes (patients with urological, psychological or neurological problems), potentially making recognition of risk of anticholinergic adverse effects additionally problematic for GPs.
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    General practice trainees' clinical experience of dermatology indicates a need for improved education: A cross-sectional analysis from the Registrar Clinical Encounters in Training Study.
    Whiting, G ; Magin, P ; Morgan, S ; Tapley, A ; Henderson, K ; Oldmeadow, C ; Ball, J ; van Driel, M ; Spike, N ; McArthur, L ; Scott, J ; Stocks, N (Wiley, 2017-11)
    BACKGROUND/OBJECTIVES: Skin conditions are commonly encountered in general practice but dermatology is underrepresented in undergraduate medical courses. Australian and international studies have shown that the dermatological diagnostic ability of general practitioners (GPs) is suboptimal, contributing to increased dermatology outpatient referrals. Dermatological experience in GP vocational training is thus of particular importance. We aimed to document the prevalence of skin disease presentations and the range of skin diseases encountered by GP trainees. We also sought to establish associations of GP trainee's skin disease experience, including their personal characteristics, consultation factors, and the actions arising from the consultation. METHODS: This study took place in the Registrars Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, prospective, multi-site cohort study of Australian GP trainees' consultations. A descriptive cross-sectional analysis was performed on trainees' consultation data. RESULTS: In total, 645 individual trainees contributed data from 84 615 consultations. Altogether, 11% of all problems managed were skin problems. Infections, dermatitis, injury and wounds were the most common presentations. Associations of consultations for skin problems (compared with all other problems) included seeking in-consultation advice, planning patient follow up and generating learning goals. CONCLUSIONS: These findings suggest GP trainees find skin problems challenging and may indicate a need for more and better targeted undergraduate and GP trainee education.
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    The pattern of anxiolytic and hypnotic management by Australian general practice trainees
    Holliday, SM ; Morgan, S ; Tapley, A ; Henderson, KM ; Dunlop, AJ ; van Driel, ML ; Spike, NA ; McArthur, LA ; Ball, J ; Oldmeadow, CJ ; Magin, PJ (WILEY, 2017-03-01)
    INTRODUCTION AND AIMS: Guidelines recommend anxiolytics and hypnotics (A/H) as second-line, short-term medications. We aimed to establish prevalence and associations of A/H prescribing by Australian general practice (GP) trainees. DESIGN AND METHODS: A cross-sectional analysis from a cohort study of vocational trainees from four GP Regional Training Providers during 2010-2013. General practice trainees act as independent practitioners (including for prescribing purposes) while having recourse to advice from a GP supervisor. Practice and trainee demographic data were collected as well as patient, clinical and educational data from 60 consecutive consultations of each trainee each training term. Analysis was at the level of individual problem managed, with the outcome factor being prescription of any anxiolytic or hypnotic. RESULTS: Overall, 645 registrars (response rate 94.0%) prescribed 68 582 medications in 69 621 consultations (with 112 890 problems managed). A/Hs were prescribed for 1.3% of problems managed and comprised 2.2% of all prescriptions. They were prescribed particularly for insomnia (28.2%) or anxiety (21.8%), but also for many 'off-label' indications. Significant associations of A/H prescriptions were: patient-level (greater age, Aboriginal and Torres Strait Islander status, English-speaking background, being new to the trainee but not to the practice); trainee-level (male) and consultation-level (longer duration, pre-existing problem, specialist referral not being made). Prescribing was significantly lower in one of the four Regional Training Providers. DISCUSSION AND CONCLUSIONS: GP trainees, inconsistent with most guideline recommendations, prescribe A/Hs mainly as maintenance therapy to unfamiliar and older patients. Our results suggest that changes in management approaches are needed which may be facilitated by support for psychotherapeutic training. [Holliday SM, Morgan S, Tapley A, Henderson KM, Dunlop AJ, van Driel ML, Spike NA, McArthur LA, Ball J, Oldmeadow CJ, Magin PJ. The pattern of anxiolytic and hypnotic management by Australian general practice trainees. Drug Alcohol Rev 2017;36:261-269].
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    General practice registrars' experiences of antenatal care: A cross-sectional analysis
    Pappalardo, E ; Magin, P ; Tapley, A ; Davey, A ; Holliday, EG ; Ball, J ; Spike, N ; FitzGerald, K ; Morgan, S ; van Driel, ML (WILEY, 2019-08-19)
    BACKGROUND: General practitioners play an important role in diagnosis and ongoing management of pregnancies. Some GP registrars entering GP training may have had no post-graduate experience in obstetrics and gynaecology. GP registrars' involvement in antenatal care is under-researched. AIMS: This study aimed to determine the prevalence and associations of Australian GP registrars' clinical consultations involving antenatal care. MATERIALS AND METHODS: A cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) cohort study. GP registrars record details of 60 consecutive consultations during each of three six-month training terms. Associations of managing pregnancy-related problems (compared to all other problems) were analysed using univariate and multivariable logistic regression. Independent variables included registrar, practice, patient, consultation and educational factors. RESULTS: Antenatal care comprised 3277 (1.1%) of registrar problems/diagnoses. Consultations involving pregnancy-related problems were significantly associated with registrars being female, in term three, younger, and having post-graduate qualifications in obstetrics/gynaecology. Patients were significantly more likely to be from a non-English speaking background. Pregnancy-related problems/diagnoses were more likely to be seen in lower socioeconomic areas. Consultation factors significantly associated with a pregnancy-related problem/diagnosis included ordering imaging, ordering pathology, arranging referrals, and a longer duration of consultation. Registrars were less likely to prescribe medication or generate learning goals. CONCLUSIONS: GP registrars see fewer antenatal problems compared to established GPs. Male registrars, especially, have significantly less exposure to antenatal care, suggesting potential limitation of opportunity to gain skills and experience in antenatal care.
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    Australian general practice registrars and their experience with postpartum consultations: A cross-sectional analysis of prevalence and associations
    Hill, S ; Tapley, A ; van Driel, ML ; Holliday, EG ; Ball, J ; Davey, A ; Patson, I ; Spike, N ; Fitzgerald, K ; Morgan, S ; Magin, P (WILEY, 2019-07-07)
    BACKGROUND: In Australia, general practitioners (GPs) are recognised as an essential source of postpartum care. However, there remains a paucity of research pertaining to this, and in particular, to that of GP trainees (in Australia, termed 'registrars'). Previous post-graduate experience in obstetrics and gynaecology (O&G) is not a prerequisite for GP training, and thus, it is imperative that vocational training provides adequate exposure to postpartum consultations. AIM: To investigate the prevalence and associations of Australian GP registrars' (trainees') experience in postpartum care. MATERIALS AND METHODS: A cross-sectional study employing data from the Registrar Clinical Encounters in Training (ReCEnT) project. ReCEnT is an ongoing cohort study where GP registrars record 60 consecutive consultations mid-way through each training term. The outcome variable was postpartum problem/diagnosis (compared to all other problems/diagnoses). The independent variables included registrar, practice, patient, consultation, clinical and educational factors. Analyses employed univariate and multivariable regression. RESULTS: Analysis included 2234 registrars (response rate 96.1%), 289 594 consultations, and 453 786 problems/diagnoses. Postpartum care (897) comprised 0.2% (95% CI: 0.19-0.21) of all problems/diagnoses in 0.3% (95% CI: 0.27-0.31) of all consultations. Significant multivariable associations included registrar's gender (female) and obtainment of post-graduate O&G qualifications. Postpartum consultations were longer and resulted in more learning goals being generated. DISCUSSION: An overall low prevalence was established. Both male registrars, and those without pre-existing O&G qualifications, may have particularly limited experience. These findings should inform educational policy and practice regarding postpartum care experience in general practice training.
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    Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial
    French, SD ; McKenzie, JE ; O'Connor, DA ; Grimshaw, JM ; Mortimer, D ; Francis, JJ ; Michie, S ; Spike, N ; Schattner, P ; Kent, P ; Buchbinder, R ; Page, MJ ; Green, SE ; Gagnier, JJ (PUBLIC LIBRARY SCIENCE, 2013-06-13)
    INTRODUCTION: This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. METHODS: General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. RESULTS: 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. CONCLUSIONS: The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN012606000098538.