Amanda Barnard

An action research protocol to strengthen system-wide inter-professional learning and practice [LP0775514]

BackgroundInter-professional learning (IPL) and inter-professional practice (IPP) are thought to be critical determinants of effective care, improved quality and safety and enhanced provider morale, yet few empirical studies have demonstrated this. Whole-of-system research is even less prevalent. We aim to provide a four year, multi-method, multi-collaborator action research program of IPL and IPP in defined, bounded health and education systems located in the Australian Capital Territory (ACT). The project is funded by the Australian Research Council under its industry Linkage Program.Methods/DesignThe program of research will examine in four inter-related, prospective studies, progress with IPL and IPP across tertiary education providers, professional education, regulatory and registration bodies, the ACT health systems streams of care activities and teams, units and wards of the provider facilities of the ACT health system. One key focus will be on push-pull mechanisms, ie, how the education sector creates student-enabled IPP and the health sector demands IPL-oriented practitioners. The studies will examine four research aims and meet 20 research project objectives in a comprehensive evaluation of ongoing progress with IPL and IPP.DiscussionIPP and IPL are said to be cornerstones of health system reforms. We will measure progress across an entire health system and the clinical and professional education systems that feed into it. The value of multi-methods, partnership research and a bi-directional push-pull model of IPL and IPP will be tested. Widespread dissemination of results to practitioners, policymakers, managers and researchers will be a key project goal.

Managing Glaucoma in those with Co-morbidity: Not as Easy as it Seems

Purpose: To identify the extent of use of medicines recommended to be used with caution in glaucoma patients with specified comorbidities and to determine evidence of associated harm. Methods: Retrospective cohort analysis from administrative claims data and prescription/event sequence symmetry analysis. Participants: Australian Government Department of Veterans’ Affairs treatment card holders dispensed glaucoma eye-drops. Main outcome measures: Proportion of veterans with glaucoma and diabetes, airways disease, heart failure, ischemic heart disease or depression, dispensed glaucoma eye drops which should be used with caution. For harms, outcome measures were hospitalizations for airways disease and heart disease. Results: The cohort analysis included 25,984 veterans. Of these, 88% with airways disease were dispensed glaucoma eye drops with the potential to aggravate airways disease, 43% with heart failure were dispensed topical beta-blockers and 49% with depression received glaucoma eye drops which should be used cautiously in those with depression. We found increased risk of initiation of inhaled beta-agonist following timolol (adjusted sequence ratio (ASR) 1.48, 99% CI 1.22–1.78) and latanoprost (ASR 1.24, 99% CI 1.11–1.38) initiation. We found increased risk of inhaled corticosteroid initiation following initiation of timolol (ASR 1.43, 99% CI 1.13–1.81). There was increased risk of antidepressant initiation following timolol initiation (ASR 1.24, 99% CI 1.07–1.43), and latanoprost (ASR 1.16, 99% CI 1.03–1.31). There was also increased risk of hospitalization for bradycardia following timolol initiation (ASR 2.22,99% CI 1.15–4.31). Conclusion: Use of glaucoma eye drops recommended to be used with caution in co-morbidities is common and was associated with adverse outcomes. Awareness of co-morbidities is required in the selection and prescription of glaucoma eye drops.

Utilisation of multidisciplinary services for diabetes care in the rural setting

Objective To quantify utilisation of allied health care services by diabetics in rural NSW and explore reasons for any underutilisation. Design Self-administered mail survey of 268 patients with diagnosed diabetes identified from practice registers. Setting Two rural general practices. Participants One hundred seventeen respondents with diabetes. Main outcome measure Annual frequency of visits to allied health practitioners. Results In the last year, 40.2% of patients had seen a diabetes educator (DE), 21.4% a dietitian and 47% a podiatrist. However, 25–40% of patients had never used each of the services. Reasons for nonutilisation were non-referral (35.9–68.0%) and lack of perceived need (40.6–59.0%). One third of patients who had not seen a DE in the last year thought their ‘general practitioner (GP) provides a similar service’. However, mean annual GP visits (5.6) were significantly lower than urban and rural comparisons. Patients with formal management plans were, in the last year, twice as likely to have seen a DE and podiatrist, and reported two extra visits to their GP compared to those without. Conclusions Rates of allied health service utilisation were not significantly lower than urban rates; however, there is room for increased uptake of multidisciplinary services. Patients who do not access these services may expect their GP to fulfil multiple roles within a limited number of visits and may not understand the role of other practitioners. Where allied health services are available locally, utilisation may be improved by increasing use of management plans and fostering awareness of the role of allied health practitioners in diabetes management.

Where There Is No Gold Standard: Mixed Method Research in a Cluster Randomised Trial of a Tool for Safe Prioritising of Patients by Medical Receptionists

Abstract Medical receptionists have been shown to play a key role in general practice as the first point of contact for patients. They frequently make decisions about appointment allocation which effectively prioritise access to medical care, but may have limited tools or structures to assist them with this. We report the methods of a study evaluating a customisable tool (POPGUNS – Prioritisation of Patients: A Guide for Non-clinical Staff ) to support safe prioritisation of patients. This paper reports methodological challenges in a study of this nature where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. We have attempted to respond to these challenges by: observing the determinants of inter-practice variation; developing a multi-member panel to constitute appropriate standards for practices; and monitoring self-reported prioritisation decisions by practice receptionists through the use of simulated patients.

The learner’s perspective in GP teaching practices with multi-level learners: a qualitative study

BackgroundMedical students, junior hospital doctors on rotation and general practice (GP) registrars are undertaking their training in clinical general practices in increasing numbers in Australia. Some practices have four levels of learner. This study aimed to explore how multi-level teaching (also called vertical integration of GP education and training) is occurring in clinical general practice and the impact of such teaching on the learner.MethodsA qualitative research methodology was used with face-to-face, semi-structured interviews of medical students, junior hospital doctors, GP registrars and GP teachers in eight training practices in the region that taught all levels of learners. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted using thematic analysis techniques aided by the use of the software package N-Vivo 9. Primary themes were identified and categorised by the co-investigators.Results52 interviews were completed and analysed. Themes were identified relating to both the practice learning environment and teaching methods used.A practice environment where there is a strong teaching culture, enjoyment of learning, and flexible learning methods, as well as learning spaces and organised teaching arrangements, all contribute to positive learning from a learners’ perspective.Learners identified a number of innovative teaching methods and viewed them as positive. These included multi-level learner group tutorials in the practice, being taught by a team of teachers, including GP registrars and other health professionals, and access to a supernumerary GP supervisor (also termed “GP consultant teacher”). Other teaching methods that were viewed positively were parallel consulting, informal learning and rural hospital context integrated learning.ConclusionsVertical integration of GP education and training generally impacted positively on all levels of learner. This research has provided further evidence about the learning culture, structures and teaching processes that have a positive impact on learners in the clinical general practice setting where there are multiple levels of learners. It has also identified some innovative teaching methods that will need further examination. The findings reinforce the importance of the environment for learning and learner centred approaches and will be important for training organisations developing vertically integrated practices and in their training of GP teachers.

Maximising student preparation for clinical teaching placements

Background:  With the increasing emphasis on ambulatory health care, clinical educators need to ensure that students are sufficiently prepared to maximise learning opportunities during placements in ambulatory settings.

Learning trajectories in longitudinal rural medical school placements

Background:  Rural longitudinal placements are now a key part of clinical medical education, and are part of workforce strategies to enhance the rural medical workforce. Learning trajectories (a map to guide student learning) have been recommended as a means of maximising student learning on placements, and have the potential to assist long‐term rural students and supervisors in adapting to a longitudinal clerkship.

Impact of clinical audit in the care of coronary heart disease: The experience of a rural general practice

Chronic disease accounts for a large burden of disease in Australia, and primary care is integral in its management. This study examined the use of clinical audit as a means to improve chronic disease management in a rural general practice. The study included: (i) evaluation of the impact of participation in a formal clinical audit program on the Practice’s short (during formal clinical audit) and longer-term (the year following completion of formal clinical audit) management of coronary heart disease (CHD), using predefined, evidence-based clinical indicators; and (ii) exploration of the experience of the Practice with clinical audit.