General Practice - Research Publications
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Item'Is Insulin Right for Me?' Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy in type 2 diabetes(BMJ PUBLISHING GROUP, 2021-09-01)OBJECTIVE: To develop a theory and evidence-based web intervention to reduce psychological barriers towards insulin therapy among adults with non-insulin-treated type 2 diabetes (T2D). METHODS: Salient psychological barriers towards insulin were identified from the literature and classified using the Theoretical Domains Framework (TDF). Relevant TDF domains were mapped to evidence-based behaviour change techniques (BCTs), which informed the content for each barrier. Acceptability was explored using cognitive debriefing interviews (n=6 adults with T2D). RESULTS: 'Is Insulin Right for Me' addresses eight barriers, phrased as common questions: Does insulin mean my diabetes is more serious? Do insulin injections cause complications? Is it my fault I need to inject insulin? Will I gain weight? Will injecting hurt? What about hypos? Will injecting insulin be a burden? What will others think of me? BCTs, including persuasive communication and modelling/demonstration, were delivered using appropriate methods (eg, demonstration of the injection process). Participant suggestions for improvement included clear and direct messages, normalising insulin and avoiding confronting images. CONCLUSIONS: 'Is Insulin Right for Me' is the first theory and evidence-based, web intervention designed to reduce psychological barriers towards insulin therapy for adults with T2D. Evaluation is needed to determine its impact on negative appraisals and receptiveness towards insulin.
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ItemThe CORE study-An adapted mental health experience codesign intervention to improve psychosocial recovery for people with severe mental illness: A stepped wedge cluster randomized-controlled trial(WILEY, 2021-08-04)BACKGROUND: Mental health policies outline the need for codesign of services and quality improvement in partnership with service users and staff (and sometimes carers), and yet, evidence of systematic implementation and the impacts on healthcare outcomes is limited. OBJECTIVE: The aim of this study was to test whether an adapted mental health experience codesign intervention to improve recovery-orientation of services led to greater psychosocial recovery outcomes for service users. DESIGN: A stepped wedge cluster randomized-controlled trial was conducted. SETTING AND PARTICIPANTS: Four Mental Health Community Support Services providers, 287 people living with severe mental illnesses, 61 carers and 120 staff were recruited across Victoria, Australia. MAIN OUTCOME MEASURES: The 24-item Revised Recovery Assessment Scale (RAS-R) measured individual psychosocial recovery. RESULTS: A total of 841 observations were completed with 287 service users. The intention-to-treat analysis found RAS-R scores to be similar between the intervention (mean = 84.7, SD= 15.6) and control (mean = 86.5, SD= 15.3) phases; the adjusted estimated difference in the mean RAS-R score was -1.70 (95% confidence interval: -3.81 to 0.40; p = .11). DISCUSSION: This first trial of an adapted mental health experience codesign intervention for psychosocial recovery outcomes found no difference between the intervention and control arms. CONCLUSIONS: More attention to the conditions that are required for eight essential mechanisms of change to support codesign processes and implementation is needed. PATIENT AND PUBLIC INVOLVEMENT: The State consumer (Victorian Mental Illness Awareness Council) and carer peak bodies (Tandem representing mental health carers) codeveloped the intervention. The adapted intervention was facilitated by coinvestigators with lived-experiences who were coauthors for the trial and process evaluation protocols, the engagement model and explanatory model of change for the trial.
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ItemWomen, clinician and IT staff perspectives on telehealth for enhanced gestational diabetes mellitus management in an Australian rural/regional setting(COLL MEDICINE & DENTISTRY JAMES COOK UNIV TOWNSVILLE, 2021-01-01)INTRODUCTION: Women in rural and regional areas encounter challenges when accessing care for gestational diabetes mellitus (GDM). A telehealth initiative for GDM care in an urban setting demonstrated positive effects on achieving glycaemic targets without compromising quality of care, but consumer and health service staff perspectives have not been explored. This research aimed to identify the profiles of women accessing care for GDM in a large regional hospital with a rural catchment in Victoria, Australia as well as gain insight into the views of the women with GDM, clinicians and IT staff on the acceptability and feasibility of a GDM telehealth in this setting. METHODS: Clinical and demographic characteristics of women accessing the GDM service between October 2016 and October 2017 were audited. Semi-structured interviews were completed with nine patients, three clinical staff and two IT service staff. Quantitative and qualitative data were analysed descriptively and thematically, respectively. RESULTS: Telehealth was viewed favourably by women and staff, with many perceived benefits identified around mitigating challenges of accessing care, and service capacity and provision. Concerns were raised around potential costs incurred by women and health services in accessing telehealth initiatives. Staff highlighted that moderation of workloads and coordination of telehealth services would be essential to the success of a future telehealth initiative. CONCLUSION: This article contributes important knowledge around GDM care in rural and regional settings and the perspectives of women with GDM, clinicians and technical support staff. Women and health services staff consider telehealth a feasible and acceptable alternative to current GDM care and address many of the barriers and impacts of attending care in person. Perceived benefits to patients and health services need to be balanced against the concerns around the work and costs to deliver GDM telehealth services.
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ItemAssociations between multimorbidity and glycaemia (HbA1c) in people with type 2 diabetes: cross-sectional study in Australian general practice(BMJ PUBLISHING GROUP, 2020-01-01)OBJECTIVES: To explore the prevalence of multimorbidity as well as individual and combinations of long-term conditions (LTCs) in people with type 2 diabetes (T2D) attending Australian general practice, using electronic health record (EHR) data. We also examine the association between multimorbidity condition count (total/concordant(T2D related)/discordant(unrelated)) and glycaemia (glycated haemoglobin, HbA1c). DESIGN: Cross-sectional study. SETTING: Australian general practice. PARTICIPANTS: 69 718 people with T2D with a general practice encounter between 2013 and 2015 captured in the MedicineInsight database (EHR Data from 557 general practices and >3.8 million Australian patients). PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of multimorbidity, individual and combinations of LTCs. Multivariable linear regression models used to examine associations between multimorbidity counts and HbA1c (%). RESULTS: Mean (SD) age 66.42 (12.70) years, 46.1% female and mean (SD) HbA1c 7.1 (1.4)%. More than 90% of participants with T2D were living with multimorbidity. Discordant conditions were more prevalent (83.4%) than concordant conditions (69.9 %). The three most prevalent discordant conditions were: painful conditions (55.4%), dyspepsia (31.6%) and depression (22.8%). The three most prevalent concordant conditions were hypertension (61.4%), coronary heart disease (17.1%) and chronic kidney disease (8.5%). The three most common combinations of conditions were: painful conditions and hypertension (38.8%), painful conditions and dyspepsia (23.1%) and hypertension and dyspepsia (22.7%). We found no associations between any multimorbidity counts (total, concordant and discordant) or combinations and HbA1c. CONCLUSIONS: Multimorbidity was common in our cohort of people with T2D attending Australian general practice, but was not associated with glycaemia. Although we did not explore mortality in this study, our results suggest that the increased mortality in those with multimorbidity and T2D observed in other studies may not be linked to glycaemia. Interestingly, discordant conditions were more prevalent than concordant conditions with painful conditions being the second most common comorbidity. Better understanding of the implications of different patterns of multimorbidity in people with T2D will allow more effective tailored care.
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ItemThe assertive cardiac care trial: A randomised controlled trial of a coproduced assertive cardiac care intervention to reduce absolute cardiovascular disease risk in people with severe mental illness in the primary care setting(ELSEVIER SCIENCE INC, 2020-10-01)BACKGROUND: Cardiovascular disease (CVD) accounts for 40% of the excess mortality identified in people with severe mental illness (SMI). Modifiable CVD risk factors are higher and can be exacerbated by the cardiometabolic impact of psychotropic medications. People with SMI frequently attend primary care presenting a valuable opportunity for early identification, prevention and management of cardiovascular health. The ACCT Healthy Hearts Study will test a coproduced, nurse-led intervention delivered with general practitioners to reduce absolute CVD risk (ACVDR) at 12 months compared with an active control group. METHODS/DESIGN: ACCT is a two group (intervention/active control) individually randomised (1:1) controlled trial (RCT). Assessments will be completed baseline (pre-randomisation), 6 months, and 12 months. The primary outcome is 5-year ACVDR measured at 12 months. Secondary outcomes include 6-month ACVDR; and blood pressure, lipids, HbA1c, BMI, quality of life, physical activity, motivation to change health behaviour, medication adherence, alcohol use and hospitalisation at 6 and 12 months. Linear mixed-effects regression will estimate mean difference between groups for primary and secondary continuous outcomes. Economic cost-consequences analysis will be conducted using quality of life and health resource use information and routinely collected government health service use and medication data. A parallel process evaluation will investigate implementation of the intervention, uptake and outcomes. DISCUSSION: ACCT will deliver a coproduced and person-centred, guideline level cardiovascular primary care intervention to a high need population with SMI. If successful, the intervention could lead to the reduction of the mortality gap and increase opportunities for meaningful social and economic participation. Trial registration ANZCTR Trial number: ACTRN12619001112156.
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Item'Is insulin right for me?': Feasibility of a pilot randomised controlled trial and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes(WILEY, 2021-12-15)AIMS: Acceptable and accessible interventions are needed to address 'psychological insulin resistance', which is a common barrier to insulin uptake among adults with type 2 diabetes (T2D). Our aim was to test the feasibility of a randomised controlled trial (RCT) study design and acceptability of a theoretically grounded, psycho-educational, web-based resource to reduce negative insulin appraisals among adults with T2D. METHODS: A double-blinded, parallel group, two-arm pilot RCT (1:1), comparing intervention with active control (existing online information about insulin). Eligible participants were Australian adults with T2D, taking oral diabetes medications. EXCLUSION CRITERIA: prior use of injectable medicines; being 'very willing' to commence insulin. Primary outcomes: study feasibility (recruitment ease, protocol fulfilment, attrition, data completeness); secondary outcomes: intervention acceptability (intervention engagement, user feedback) and likely efficacy (negative Insulin Treatment Appraisal Scale [ITAS] scores at follow-up). Online surveys completed at baseline and 2 weeks. RESULTS: During 4-week recruitment, 76 people expressed interest: 51 eligible and 35 enrolled (intervention = 17, control = 18; median[interquartile range] age = 62[53, 69] years; 17 women). Protocol fulfilment achieved by 26 (74%) participants (n = 13 per arm), with low participant attrition (n = 6, 17%). Intervention acceptability was high (>80% endorsement, except format preference = 60%). ITAS negative scores differed between-groups at follow-up (M diff = -6.5, 95% confidence interval: -10.7 to -2.4), favouring the intervention. CONCLUSIONS: This novel web-based resource ("Is insulin right for me?") is acceptable and associated with a likely reduction in negative insulin appraisals, relative to existing resources. This pilot shows the study design is feasible and supports conduct of a fully powered RCT.
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ItemCost-effectiveness of professional-mode flash glucose monitoring in general practice among adults with type 2 diabetes: Evidence from the GP-OSMOTIC trial(WILEY, 2021-11-27)AIM: To assess the cost-effectiveness of professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice compared with usual clinical care. METHODS: An economic evaluation was conducted as a component of the GP-OSMOTIC trial, a pragmatic multicentre 12-month randomised controlled trial enrolling 299 adults with type 2 diabetes in Victoria, Australia. The economic evaluation was conducted from an Australian healthcare sector perspective with a lifetime horizon. Health-related quality of life (EQ-5D) and total healthcare costs were compared between the intervention and the usual care group within the trial period. The 'UKPDS Outcomes Model 2' was used to simulate post-trial lifetime costs, life expectancy and quality-adjusted life years (QALYs). RESULTS: No significant difference in health-related quality of life and costs was found between the two groups within the trial period. Professional-mode flash glucose monitoring yielded greater QALYs (0.03 [95% CI: 0.02, 0.04]) and a higher cost (A$3807 [95% CI: 3604, 4007]) compared with usual clinical care using a lifetime horizon under the trial-based monitoring frequency, considered not cost-effective (incremental cost-effectiveness ratio = A$120,228). The intervention becomes cost-effective if sensor price is reduced to lower than 50%, or monitoring frequency is decreased to once per year while maintaining the same treatment effect on HbA1c . CONCLUSIONS: Including professional-mode flash glucose monitoring every 3 months as part of a management plan for people with type 2 diabetes in general practice is not cost-effective, but could be if the sensor price or monitoring frequency can be reduced.
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ItemAntiepileptic Drugs, Polypharmacy, and Quality of Life in People Living with Epilepsy Managed in General Practice(Georg Thieme Verlag KG, 2020-04-01)Abstract Objective Recently, instances of general practitioners (GPs) prescribing antiepileptic drugs (AEDs) have increased. We aimed to investigate the use of AEDs in a community sample of people with epilepsy and the effect on quality of life (QoL). Methods Responses from the Australian Epilepsy Longitudinal Study (AELS), Pharmaceutical Benefit Scheme (PBS), and Medicare Benefit Scheme (MBS) data were used. Linear regression was used to investigate the relationship between the numbers of AEDs and QoL. Results Fifty people with epilepsy were prescribed an average of two AEDs. The most common were lamotrigine, sodium valproate, and levetiracetam. Eighty-two percent were prescribed medications from two or more categories of medications. A lower QoL at wave 2 of the AELS was significantly associated with a higher number of AEDs. Conclusion Given the high number of people with epilepsy being cared for in general practice, GPs must understand the risks and benefits of epilepsy monotherapy, polytherapy, and polypharmacy.
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ItemMetabolic Score for Visceral Fat (METS-VF) Estimation - A Novel Cost-Effective Obesity Indicator for Visceral Adipose Tissue Estimation(DOVE MEDICAL PRESS LTD, 2020-01-01)BACKGROUND: Visceral adipose tissue (VAT) assessment is limited in clinical practice due to expensive, time consuming and limited availability of MRI and DXA machines. We explored the utility of a recently developed Metabolic Score for Visceral Fat (METS-VF) to assess VAT in south Asian individuals with morbid obesity. PATIENTS AND METHODS: Individuals with BMI ≥35 kg/m2 aged between 30 and 60 years were randomly selected from a database of individuals with morbid obesity, attending a multi-disciplinary bariatric clinic in a tertiary care teaching hospital in southern India. Body composition was assessed by using a Hologic Discovery A dual-energy X-ray absorptiometry (DXA) machine. METS-VF was used to estimate VAT by using a previously published algorithm. RESULTS: The mean age and body mass index of the study subjects (N=350) were 38.2 years and 40.1 kg/m2. The MET-VF score performed satisfactorily (AUC of 0.78 (95% CI 0.72-0.85)) for predicting an increased visceral adipose tissue (VAT area ≥ 163 cm2) as detected by DXA. A METS-VF value of 7.3 was found to have a good sensitivity and reasonable specificity in predicting elevated VAT in this population. CONCLUSION: This is the first study to validate the utility of METS-VF as a surrogate measure of visceral adiposity in south Indian individuals with morbid obesity. Given the simplicity, easy availability, reliability and inexpensive nature of this obesity indicator, it may find its widespread use in lower middle-income countries.
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ItemGuiding Glucose Management Discussions Among Adults With Type 2 Diabetes in General Practice: Development and Pretesting of a Clinical Decision Support Tool Prototype Embedded in an Electronic Medical Record(JMIR PUBLICATIONS, INC, 2020-09-01)BACKGROUND: Managing type 2 diabetes (T2D) requires progressive lifestyle changes and, sometimes, pharmacological treatment intensification. General practitioners (GPs) are integral to this process but can find pharmacological treatment intensification challenging because of the complexity of continually emerging treatment options. OBJECTIVE: This study aimed to use a co-design method to develop and pretest a clinical decision support (CDS) tool prototype (GlycASSIST) embedded within an electronic medical record, which uses evidence-based guidelines to provide GPs and people with T2D with recommendations for setting glycated hemoglobin (HbA1c) targets and intensifying treatment together in real time in consultations. METHODS: The literature on T2D-related CDS tools informed the initial GlycASSIST design. A two-part co-design method was then used. Initial feedback was sought via interviews and focus groups with clinicians (4 GPs, 5 endocrinologists, and 3 diabetes educators) and 6 people with T2D. Following refinements, 8 GPs participated in mock consultations in which they had access to GlycASSIST. Six people with T2D viewed a similar mock consultation. Participants provided feedback on the functionality of GlycASSIST and its role in supporting shared decision making (SDM) and treatment intensification. RESULTS: Clinicians and people with T2D believed that GlycASSIST could support SDM (although this was not always observed in the mock consultations) and individualized treatment intensification. They recommended that GlycASSIST includes less information while maintaining relevance and credibility and using graphs and colors to enhance visual appeal. Maintaining clinical autonomy was important to GPs, as they wanted the capacity to override GlycASSIST's recommendations when appropriate. Clinicians requested easier screen navigation and greater prescribing guidance and capabilities. CONCLUSIONS: GlycASSIST was perceived to achieve its purpose of facilitating treatment intensification and was acceptable to people with T2D and GPs. The GlycASSIST prototype is being refined based on these findings to prepare for quantitative evaluation.