General Practice and Primary Care - Research Publications
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ItemNo Preview AvailableWill a fee-for-service payment for a young people's health assessment in general practice increase the detection of health risk behaviours and health conditions? Protocol for a cluster randomised controlled trial (RAd Health Trial)(BMJ PUBLISHING GROUP, 2023-08)INTRODUCTION: Adolescence is a period of major transition in physical, cognitive, social and emotional development, and the peak time for the onset of mental health conditions, substance use disorders and sexual and reproductive health risks. Prevention and treatment during this time can improve health and well-being now and into the future. However, despite clinical guidelines recommending annual preventive health assessments for young people, health professionals cite lack of consultation time and adequate funding as key barriers. This trial aims to determine whether a specific fee-for-service ('rebate payment') for a young person's health assessment, is effective and cost-effective at increasing the detection and management of health risk behaviours and conditions among young people. METHODS AND ANALYSIS: This cluster randomised controlled trial will be conducted in Australian general practice. 42 general practices (clusters) will be randomly allocated 1:1 to either an intervention arm where general practitioners receive a rebate payment for each annual health assessment undertaken for 14-24-year-olds during a 2 year study period, or a control arm (no rebate). The rebate amount will be based on the Medical Benefits Schedule (Australia's list of health professional services subsidised by the Australian Government) currently available for similar age-based assessments. Our primary outcome will be the annual rate of risk behaviours and health conditions recorded in the patient electronic health record (eg, alcohol/drug use, sexual activity and mental health issues). Secondary outcomes include the annual rate of patient management activities related to health risks and conditions identified (eg, contraception prescribed, sexually transmitted infection tests ordered). A process evaluation will assess acceptability, adoption, fidelity and sustainability of the rebate; an economic evaluation will assess its cost-effectiveness. Analyses will be intention-to-treat. ETHICS AND DISSEMINATION: Ethics approval has been obtained from University of Melbourne Human and Research Ethics Committee (2022-23435-29990-3). Findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12622000114741.
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ItemStrengthening Care for Children (SC4C): protocol for a stepped wedge cluster randomised controlled trial of an integrated general practitioner-paediatrician model of primary care(BMJ PUBLISHING GROUP, 2022-09)INTRODUCTION: Australia's current healthcare system for children is neither sustainable nor equitable. As children (0-4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child's care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home. METHODS AND ANALYSIS: SC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children's (0-<18 years) GP appointments that result in a hospital referral, compared with the control period. Secondary outcomes include GP quality of care; GP experience and confidence in providing paediatric care; family trust in and preference for GP care; and the sustainability of the intervention. An implementation evaluation will assess the model to inform acceptability, adaptability, scalability and sustainability, while a health economic evaluation will measure the cost-effectiveness of the intervention. ETHICS AND DISSEMINATION: Human research ethics committee (HREC) approval was granted by The Royal Children's Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry 12620001299998.
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ItemIdentifying primary care datasets and perspectives on their secondary use: a survey of Australian data users and custodians(BMC, 2022-04-06)BACKGROUND: Most people receive most of their health care in in Australia in primary care, yet researchers and policymakers have limited access to resulting clinical data. Widening access to primary care data and linking it with hospital or other data can contribute to research informing policy and provision of services and care; however, limitations of primary care data and barriers to access curtail its use. The Australian Health Research Alliance (AHRA) is seeking to build capacity in data-driven healthcare improvement; this study formed part of its workplan. METHODS: The study aimed to build capacity for data driven healthcare improvement through identifying primary care datasets in Australia available for secondary use and understand data quality frameworks being applied to them, and factors affecting national capacity for secondary use of primary care data from the perspectives of data custodians and users. Purposive and snowball sampling were used to disseminate a questionnaire and respondents were invited to contribute additional information via semi-structured interviews. RESULTS: Sixty-two respondents collectively named 106 datasets from eclectic sources, indicating a broad conceptualisation of what a primary care dataset available for secondary use is. The datasets were generated from multiple clinical software systems, using different data extraction tools, resulting in non-standardised data structures. Use of non-standard data quality frameworks were described by two-thirds of data custodians. Building trust between citizens, clinicians, third party data custodians and data end-users was considered by many to be a key enabler to improve primary care data quality and efficiencies related to secondary use. Trust building qualities included meaningful stakeholder engagement, transparency, strong leadership, shared vision, robust data security and data privacy protection. Resources to improve capacity for primary care data access and use were sought for data collection tool improvements, workforce upskilling and education, incentivising data collection and making data access more affordable. CONCLUSIONS: The large number of identified Australian primary care related datasets suggests duplication of labour related to data collection, preparation and utilisation. Benefits of secondary use of primary care data were many, and strong national leadership is required to reach consensus on how to address limitations and barriers, for example accreditation of EMR clinical software systems and the adoption of agreed data and quality standards at all stages of the clinical and research data-use lifecycle. The study informed the workplan of AHRA's Transformational Data Collaboration to improve partner engagement and use of clinical data for research.
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ItemHARMONY: a pragmatic cluster randomised controlled trial of a culturally competent systems intervention to prevent and reduce domestic violence among migrant and refugee families in general practice: study protocol(BMJ PUBLISHING GROUP, 2021)INTRODUCTION: Domestic violence and abuse (DVA) is prevalent, harmful and more dangerous among diaspora communities because of the difficulty accessing DVA services, language and migration issues. Consequently, migrant/refugee women are common among primary care populations, but evidence for culturally competent DVA primary care practice is negligible. This pragmatic cluster randomised controlled trial aims to increase DVA identification and referral (primary outcomes) threefold and safety planning (secondary outcome) among diverse women attending intervention vs comparison primary care clinics. Additionally, the study plans to improve recording of DVA, ethnicity, and conduct process and economic evaluations. METHODS AND ANALYSIS: Recruitment of ≤28 primary care clinics in Melbourne, Australia with high migrant/refugee communities. Eligible clinics need ≥1 South Asian general practitioner (GP) and one of two common software programmes to enable aggregated routine data extraction by GrHanite. Intervention staff undertake three DVA training sessions from a GP educator and bilingual DVA advocate/educator. Following training, clinic staff and DVA affected women 18+ will be supported for 12 months by the advocate/educator. Comparison clinics are trained in ethnicity and DVA data entry and offer routine DVA care. Data extraction of DV identification, safety planning and referral from routine GP data in both arms. Adjusted regression analysis by intention-to-treat by staff blinded to arm. Economic evaluation will estimate cost-effectiveness and cost-utility. Process evaluation interviews and analysis with primary care staff and women will be framed by Normalisation Process Theory to maximise understanding of sustainability. Harmony will be the first primary care trial to test a culturally competent model for the care of diverse women experiencing DVA. ETHICS AND DISSEMINATION: Ethical approval from La Trobe University Human Ethics Committee (HEC18413) and dissemination by policy briefs, journal articles and conference and community presentations. TRIAL REGISTRATION NUMBER: ANZCTR- ACTRN12618001845224; Pre-results.
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ItemTowards optimising chronic kidney disease detection and management in primary care: Underlying theory and protocol for technology development using an Integrated Knowledge Translation approach(SAGE PUBLICATIONS INC, 2021)Worldwide, Chronic Kidney Disease (CKD), directly or indirectly, causes more than 2.4 million deaths annually with symptoms generally presenting late in the disease course. Clinical guidelines support the early identification and treatment of CKD to delay progression and improve clinical outcomes. This paper reports the protocol for the codesign, implementation and evaluation of a technological platform called Future Health Today (FHT), a software program that aims to optimise early detection and management of CKD in general practice. FHT aims to optimise clinical decision making and reduce practice variation by translating evidence into practice in real time and as a part of quality improvement activities. This protocol describes the co-design and plans for implementation and evaluation of FHT in two general practices invited to test the prototype over 12 months. Service design thinking has informed the design phase and mixed methods will evaluate outcomes following implementation of FHT. Through systematic application of co-design with service users, clinicians and digital technologists, FHT attempts to avoid the pitfalls of past studies that have failed to accommodate the complex requirements and dynamics that can arise between researchers and service users and improve chronic disease management through use of health information technology.
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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)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.
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ItemHow do general practitioners access guidelines and utilise electronic medical records to make clinical decisions on antibiotic use? Results from an Australian qualitative study(BMJ PUBLISHING GROUP, 2019-08)OBJECTIVE: This study aimed to explore how general practitioners (GPs) access and use both guidelines and electronic medical records (EMRs) to assist in clinical decision-making when prescribing antibiotics in Australia. DESIGN: This is an exploratory qualitative study with thematic analysis interpreted using the Theory of Planned Behaviour (TPB) framework. SETTING: This study was conducted in general practice in Victoria, Australia. PARTICIPANTS: Twenty-six GPs from five general practices were recruited to participate in five focus groups between February and April 2018. RESULTS: GPs expressed that current EMR systems do not provide clinical decision support to assist with antibiotic prescribing. Access and use of guidelines were variable. GPs who had more clinical experience were less likely to access guidelines than younger and less experienced GPs. Guideline use and guideline-concordant prescribing was facilitated if there was a practice culture encouraging evidence-based practice. However, a lack of access to guidelines and perceived patients' expectation and demand for antibiotics were barriers to guideline-concordant prescribing. Furthermore, guidelines that were easy to access and navigate, free, embedded within EMRs and fit into the clinical workflow were seen as likely to enhance guideline use. CONCLUSIONS: Current barriers to the use of antibiotic guidelines include GPs' experience, patient factors, practice culture, and ease of access and cost of guidelines. To reduce inappropriate antibiotic prescribing and to promote more rational use of antibiotic in the community, guidelines should be made available, accessible and easy to use, with minimal cost to practicing GPs. Integration of evidence-based antibiotic guidelines within the EMR in the form of a clinical decision support tool could optimise guideline use and increase guideline-concordant prescribing.
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ItemGathering data for decisions: best practice use of primary care electronic records for research(WILEY, 2019-03-31)In Australia, there is limited use of primary health care data for research and for data linkage between health care settings. This puts Australia behind many developed countries. In addition, without use of primary health care data for research, knowledge about patients' journeys through the health care system is limited. There is growing momentum to establish "big data" repositories of primary care clinical data to enable data linkage, primary care and population health research, and quality assurance activities. However, little research has been conducted on the general public's and practitioners' concerns about secondary use of electronic health records in Australia. International studies have identified barriers to use of general practice patient records for research. These include legal, technical, ethical, social and resource-related issues. Examples include concerns about privacy protection, data security, data custodians and the motives for collecting data, as well as a lack of incentives for general practitioners to share data. Addressing barriers may help define good practices for appropriate use of health data for research. Any model for general practice data sharing for research should be underpinned by transparency and a strong legal, ethical, governance and data security framework. Mechanisms to collect electronic medical records in ethical, secure and privacy-controlled ways are available. Before the potential benefits of health-related data research can be realised, Australians should be well informed of the risks and benefits so that the necessary social licence can be generated to support such endeavours.
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ItemImproving a Secondary Use Health Data Warehouse: Proposing a Multi-Level Data Quality Framework(Ubiquity Press, Ltd., 2019-08-02)Background: Data quality frameworks within information technology and recently within health care have evolved considerably since their inception. When assessing data quality for secondary uses, an area not yet addressed adequately in these frameworks is the context of the intended use of the data. Methods: After review of literature to identify relevant research, an existing data quality framework was refined and expanded to encompass the contextual requirements not present. Results: The result is a two-level framework to address the need to maintain the intrinsic value of the data, as well as the need to indicate whether the data will be able to provide the basis for answers in specific areas of interest or questions. Discussion: Data quality frameworks have always been one dimensional, requiring the implementers of these frameworks to fit the requirements of the data’s use around how the framework is designed to function. Our work has systematically addressed the shortcomings of existing frameworks, through the application of concepts synthesized from the literature to the naturalistic setting of data quality management in an actual health data warehouse. Conclusion: Secondary use of health data relies on contextualized data quality management. Our work is innovative in showing how to apply context around data quality characteristics and how to develop a second level data quality framework, so as to ensure that quality and context are maintained and addressed throughout the health data quality assessment process.