General Practice and Primary Care - Research Publications
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ItemThe challenges of real-world implementation of web-based shared care software: the HopSCOTCH Shared-Care Obesity Trial in Children(BMC, 2014-07-24)BACKGROUND: E-health initiatives hold promise to improve shared-care models of health care. In 2008-2011 we developed and trialled web-based software to facilitate a randomised trial of a shared-care approach for childhood obesity involving General Practitioners (GPs) working with tertiary specialists. We describe the software's development, implementation and evaluation, and make recommendations for future e-health initiatives. The web-based software was designed with the goals of allowing both GPs and specialists to communicate and review patient progress; integrating with existing GP software; and supporting GPs to deliver the structured intervention. Specifically, we aimed to highlight the challenges inherent in this process, and report on the extent to which the software ultimately met its implementation and user aims. METHODS: The study was conducted at the Royal Children's Hospital and 22 general practices across Melbourne, Australia. Participants comprised 30 GPs delivering the shared-care intervention. Outcomes included the following. (1) GPs' pre-specified software requirements: transcribed from two focus groups and analysed for themes using content analysis. (2) Software implementation and performance based on the experience of the research team and GPs. (3) GP users' evaluation collected via questionnaire. (4) Software usage collected via GP questionnaire and qualified through visual inspection of the software meta-data. RESULTS: Software implementation posed difficult and at times disabling technological barriers (e.g. out-dated hardware, poor internet connections). The software's speed and inability to seamlessly link with day-to-day software was a source of considerable frustration. Overall, GPs rated software usability as poor, although most (68%) felt that the structure and functionality of the software was useful. Recommendations for future e-health initiatives include thorough scoping of IT systems and server speed, testing across diverse environments, automated pre-requisite checks and upgrades of processors/memory where necessary, and user-created usernames and passwords. CONCLUSIONS: GPs are willing to embrace novel technologies to support their practice. However, implementation remains challenging mainly for technical reasons, and this precludes further evaluation of potential user-specific barriers. These findings could inform future e-health ventures into shared-care, and highlight the need for an appropriate infrastructure. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN126080000553.
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ItemSt John's wort use in Australian general practice patients with depressive symptoms: their characteristics and use of other health services(BIOMED CENTRAL LTD, 2014-06-26)BACKGROUND: While depression is frequently managed by general practitioners, often patients self-manage these symptoms with alternative therapies, including St John's wort (SJW). We tested whether use of SJW was associated with different patterns of conventional and complementary health service use, strategies used for management of depression, or user dissatisfaction with or lack of trust in their general practitioner or clinic overall. METHODS: Secondary analysis of data collected from an Australian population screened for a longitudinal cohort study of depression. Main outcome measures were CES-D for depressive symptoms, satisfaction with their general practitioner (GPAQ), Trust in Physician scale, self-report of health services usage and strategies used to manage depression, stress or worries. RESULTS: Response rate was 7667/17,780 (43.1%). Of these, 4.3% (320/7,432) had used SJW in the past 12 months (recent 'SJW users'). SJW users were significantly more likely to be depressed and to have a higher CES-D score. There were no statistically significant differences between recent SJW users and non-SJW users in satisfaction with their general practice or in trust in their general practitioner (GP) when adjusted for multiple factors. SJW users were significantly more likely to use all health services, whether conventional or complementary, as well as other strategies used for mental health care. SJW users were also more likely to consider themselves the main carer for their depression. CONCLUSIONS: Primary care attendees with symptoms of depression who use SJW appear not to be rejecting conventional medicine. Rather, they may be proactive care seekers who try both conventional and complementary strategies to manage their depressive symptoms. If GPs enquire and find that their depressed patients are using SJW, this may indicate that they might explore for unrelieved symptoms of depression and also consider the issue of potential for interactions between SJW and other medicines.
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ItemImproving Population-Level Maternal Health: A Hard Nut to Crack? Long Term Findings and Reflections on a 16-Community Randomised Trial in Australia to Improve Maternal Emotional and Physical Health after Birth [ISRCTN03464021](PUBLIC LIBRARY SCIENCE, 2014-02-28)BACKGROUND: Community level interventions to improve maternal and child health have been supported and well evaluated in resource poor settings, but less so in developed countries. PRISM--Program of Resources, Information and Support for Mothers--was a primary care and community-based cluster-randomised trial in sixteen municipalities in Victoria, Australia, which aimed to reduce depression in mothers and improve their physical health. The aim of this paper is to report the longer term outcomes of PRISM and to reflect on lessons learned from this universal community intervention to improve maternal health. METHODS: Maternal health outcome data in PRISM were collected by postal questionnaire at six months and two years. At two years, the main outcome measures included the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36. Secondary outcome measures included the Experience of Motherhood Scale (EOM) and the Parenting Stress Index (PSI). A primary intention to treat analysis was conducted, adjusting for the randomisation by cluster. RESULTS: 7,169/18,424 (39%) women responded to the postal questionnaire at two years -3,894 (40%) in the intervention arm and 3,275 (38%) in the comparison arm. Respondents were mostly representative on available population data comparisons. There were no differences in depression prevalence (EPDS≥13) between the intervention and comparison arms (13.4% vs 13.1%; ORadj = 1.06, 95%CI 0.91-1.24). Nor did women's mental health (MCS: 48.6 vs 49.1) or physical health scores (PCS: 49.1 vs 49.0) on the SF-36 differ between the trial arms. CONCLUSION: Improvement in maternal mental and physical health outcomes at the population level in the early years after childbirth remains a largely unmet challenge. Despite the lack of effectiveness of PRISM intervention strategies, important lessons about systems change, sustained investment and contextual understanding of the workability of intervention strategies can be drawn from the experience of PRISM. Trial Registration. Controlled-Trials.com ISRCTN03464021.
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ItemWho uses Australian chiropractic services?(BIOMED CENTRAL LTD, 2013-09-26)BACKGROUND: The use of chiropractic services is widespread, however, little is known about the characteristics of people who seek chiropractic care in Australia. This study compared the characteristics of users and non-users of chiropractic services from a cohort of patients sourced from general medical practice in Victoria, Australia. METHODS: This is a secondary analysis of baseline screening data from a prospective adult cohort study beginning in 2005. Thirty randomly selected Australian general medical practices mailed out surveys to 17,780 of their patients. Differences were examined between chiropractic users and others, and between chiropractic users who reported a back problem to those who did not. RESULTS: Of 7,519 respondents, 15% indicated they had visited a chiropractor in the last 12 months. Chiropractic users were more likely to have their GP located in a rural location and to be born in Australia; they were less likely to be in the older age group (55-76), to be unemployed or to have a pension/benefit as their main source of income. Chiropractic users were more likely to: have a back problem; use complementary or alternative medication; visit another type of complementary health practitioner or a physiotherapist. They were less likely to take medication for certain health problems (e.g. for high blood pressure, high cholesterol or asthma). No important differences were seen between chiropractic users and non-users for other health problems. People who visited a chiropractor and reported a back problem were more likely to: be a current smoker; have a number of other chronic conditions, including arthritis, hypertension, chronic sinusitis, asthma, dermatitis, depression and anxiety; report taking medications, including antidepressants, analgesics (painkillers and arthritis medication) and complementary or alternative medications. CONCLUSIONS: This large cross-sectional study of general medical practice attendees suggests that chiropractors are the most commonly consulted complementary health profession. Chiropractors should ensure they are aware of their patients' health conditions other than musculoskeletal problems and should ensure they are appropriately managed.
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ItemEvaluation of the Social Participation Questionnaire in adult patients with depressive symptoms using Rasch analysis(SPRINGER, 2013-10)PURPOSE: The aim of this study was to explore the psychometric properties of the 22-item Social Participation Questionnaire (SPQ). METHODS: The SPQ was administered to 789 adult primary care patients with depressive symptoms. As the items were intended to be summed together to provide total score, Rasch analysis (partial credit model) was applied to assess the overall fit of the model, individual item fit, differential item functioning (DIF), targeting of persons, response dependency, unidimensionality and person separation. RESULTS: To improve the scale's fit, it was necessary to re-score the response format. Two items demonstrated some DIF for gender and eight items showed DIF for age. To support the assumption of unidimensionality post hoc principal component analysis was performed. The analysis showed two subtests of the residuals with positive and negative loadings, but the person estimates derived from these two subtests were not statistically different to that derived from all items taken together. The response dependence between two items was identified; however, the magnitude of difficulty was very small. Although the questionnaire appeared to have insufficient items to assess the full spectrum of informal social contact, the SPQ was reasonably well targeted. CONCLUSION: The SPQ is a promising questionnaire for the measurement of social participation although it could benefit from the inclusion of further items to measure informal social contact. This study found support for the internal validity, internal consistency reliability, and unidimensionality. A future study will investigate whether targeting can be improved when additional items are included.
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ItemNo Preview AvailableSelecting those to refer for joint replacement: Who will likely benefit and who will not?(ELSEVIER SCI LTD, 2014-02)Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms. Total joint replacement (TJR) is considered the most effective treatment for end-stage OA in those who have exhausted available conservative interventions. The demand for TJR is continually rising due to the ageing population; in the United States, more than 1 million TJRs were performed in 2010 and the number of procedures is projected to exceed 4 million in the US by 2030. It has been estimated that of all hip and knee replacements performed, approximately one quarter of the patients may be considered inappropriate candidates. Predicting who will benefit from TJR and who will not would seem critical in terms of containing the current and projected expenditure as well as improving satisfaction in TJR recipients. Few formal predictive tools are available to aid referring clinicians to determine those likely to be good or poor responders to surgery and current available tools tend to focus on disease severity alone with little consideration of risk factors that may predict a poor outcome or impede an effective response to surgery. This review examines the tools available to assist with assessing appropriateness for TJR; investigates the modifiable risk factors associated with poor outcome; and identifies areas for future research in selecting those appropriate for joint replacement.
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ItemNo Preview AvailablePrimary care monitoring of depressive symptoms in young people(ROYAL AUSTRALIAN COLLEGE GENERAL PRACTITIONERS, 2014-03)BACKGROUND: Monitoring depressive symptoms and suicidality is essential in the management of depression in young people, yet routine monitoring is rare. This qualitative study sought to explore the experiences and beliefs of general practitioners about factors associated with monitoring youth depression in primary care settings. METHODS: Two focus groups with general practitioners (n = 12) were audio-recorded, transcribed verbatim and analysed using thematic analysis. A semi-structured interview schedule was used. RESULTS: In the primary care setting, monitoring was perceived as part of a continuum of care that begins with screening and diagnosis and as beneficial mostly in regards to informing treatment planning. Benefits and risks were reported, along with challenges and facilitators. DISCUSSION: Monitoring youth depression in primary care settings is perceived as both beneficial and potentially risky. Monitoring tools need to inform treatment planning, be brief and fit within existing electronic software used by general practitioners.
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ItemA trajectory-based approach to understand the factors associated with persistent depressive symptoms in primary care(ELSEVIER, 2013-06)BACKGROUND: Depression screening in primary care yields high numbers. Knowledge of how depressive symptoms change over time is limited, making decisions about type, intensity, frequency and length of treatment and follow-up difficult. This study is aimed to identify depressive symptom trajectories and associated socio-demographic, co-morbidity, health service use and treatment factors to inform clinical care. METHODS: 789 people scoring 16 or more on the CES-D recruited from 30 randomly selected Australian family practices. Depressive symptoms are measured using PHQ-9 at 3, 6, 9 and 12 months. RESULTS: Growth mixture modelling identified a five-class trajectory model as the best fitting (lowest Bayesian Information Criterion): three groups were static (mild (n=532), moderate (n=138) and severe (n=69)) and two were dynamic (decreasing severity (n=32) and increasing severity (n=18)). The mild symptom trajectory was the most common (n=532). The severe symptom trajectory group (n=69) differed significantly from the mild symptom trajectory group on most variables. The severe and moderate groups were characterised by high levels of disadvantage, abuse, morbidity and disability. Decreasing and increasing severity trajectory classes were similar on most variables. LIMITATIONS: Adult only cohort, self-report measures. CONCLUSIONS: Most symptom trajectories remained static, suggesting that depression, as it presents in primary care, is not always an episodic disorder. The findings indicate future directions for building prognostic models to distinguish those who are likely to have a mild course from those who are likely to follow more severe trajectories. Determining appropriate clinical responses based upon a likely depression course requires further research.
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ItemCharacteristics of People Who Use Telephone Counseling: Findings from Secondary Analysis of a Population-Based Study(Springer Verlag, 2014-09-19)The characteristics of people who use telephone counseling are not well understood. This secondary analysis used data from a nationally representative community survey of 8,841 Australian adults to compare callers and non-callers to telephone counseling services. Callers have a poorer clinical profile, including a higher risk of suicide, than people who do not use telephone counseling. They also use a variety of other mental health services. Repeat calls are associated with anxiety disorders, receipt of mental health care from general practitioners, and social disadvantage. All callers have a potential need for telephone counseling and further population studies that distinguish between telephone services intended to provide crisis (one-off) and ongoing counseling are warranted.
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ItemSystematic review of research into frequent callers to crisis helplines(SAGE PUBLICATIONS LTD, 2014-03)We conducted a systematic review of research into callers making multiple calls to crisis helplines. Two databases were searched, identifying 561 articles from 1960 until 2012, of which 63 were relevant. Twenty-one articles from 19 separate studies presented empirical data about callers making multiple calls to crisis helplines. Of the 19 studies, three were intervention studies, five were surveys of callers and 11 were call record audits. Most studies were conducted in the USA and defined frequent callers as people making two or more calls. Frequent callers were more likely to be male and unmarried compared to other callers. There were no reported differences between frequent callers and other callers with regard to age, mental health conditions or suicidality. Three studies tested interventions designed to better manage frequent callers. These studies, even though small, reported reductions in the number of calls made by frequent callers. Suggested techniques for responding to frequent callers included: limiting the number and duration of calls allowed, assigning a specific counsellor, implementing face to face contact, the service initiating contact with the caller instead of waiting for callers to contact the service, providing short term anxiety and depression treatment programmes by telephone, and creating a specific management plan for each frequent caller. Future work requires robust study design methods using larger sample sizes and validated measurements.