Andrew Davey

Changing the Antibiotic Prescribing of general practice registrars: the ChAP study protocol for a prospective controlled study of a multimodal educational intervention.

BackgroundAustralian General Practitioners (GPs) are generous prescribers of antibiotics, prompting concerns including increasing antimicrobial resistance in the community. Recent data show that GPs in vocational training have prescribing patterns comparable with the high prescribing rate of their established GP supervisors. Evidence-based guidelines consistently advise that antibiotics are not indicated for uncomplicated upper respiratory tract infections (URTI) and are rarely indicated for acute bronchitis. A number of interventions have been trialled to promote rational antibiotic prescribing by established GPs (with variable effectiveness), but the impact of such interventions in a training setting is unclear. We hypothesise that intervening while early-career GPs are still developing their practice patterns and prescribing habits will result in better adherence to evidence-based guidelines as manifested by lower antibiotic prescribing rates for URTIs and acute bronchitis.Methods/designThe intervention consists of two online modules, a face-to-face workshop for GP trainees, a face-to-face workshop for their supervisors and encouragement for the trainee-supervisor dyad to include a case-based discussion of evidence-based antibiotic prescribing in their weekly one-on-one teaching meetings.We will use a non-randomised, non-equivalent control group design to assess the impact on antibiotic prescribing for acute upper respiratory infections and acute bronchitis by GP trainees in vocational training.DiscussionEarly-career GPs who are still developing their clinical practice and prescribing habits are an underutilized target-group for interventions to curb the growth of antimicrobial resistance in the community. Interventions that are embedded into existing training programs or are linked to continuing professional development have potential to increase the impact of existing interventions at limited additional cost.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12614001209684 (registered 17/11/2014).

Does brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners.

Abstract We aimed to evaluate the effect of pain education on opioid prescribing by early-career general practitioners. A brief training workshop was delivered to general practice registrars of a single regional training provider. The workshop significantly reduced “hypothetical” opioid prescribing (in response to paper-based vignettes) in an earlier evaluation. The effect of the training on “actual” prescribing was evaluated using a nonequivalent control group design nested within the Registrar Clinical Encounters in Training (ReCEnT) cohort study: 4 other regional training providers were controls. In ReCEnT, registrars record detailed data (including prescribing) during 60 consecutive consultations, on 3 occasions. Analysis was at the level of individual problem managed, with the primary outcome factor being prescription of an opioid analgesic and the secondary outcome being opioid initiation. Between 2010 and 2015, 168,528 problems were recorded by 849 registrars. Of these, 71% were recorded by registrars in the nontraining group. Eighty-two percentages were before training. Opioid analgesics were prescribed in 4382 (2.5%, 95% confidence interval [CI]: 2.40-2.63) problems, with 1665 of these (0.97%, 95% CI: 0.91-1.04) representing a new prescription. There was no relationship between the training and total prescribing after training (interaction odds ratio: 1.01; 95% CI: 0.75-1.35; P value 0.96). There was some evidence of a reduction in initial opioid prescriptions in the training group (interaction odds ratio: 0.74; 95% CI: 0.48-1.16; P value 0.19). This brief training package failed to increase overall opioid cessation. The inconsistency of these actual prescribing results with “hypothetical” prescribing behavior suggests that reducing opioid prescribing in chronic noncancer pain requires more than changing knowledge and attitudes.

Reducing general practice trainees' antibiotic prescribing for respiratory tract infections: an evaluation of a combined face-to-face workshop and online educational intervention.

Abstract Over-prescription of antibiotics for non-pneumonia respiratory tract infections (RTIs) is a major concern in general practice. Australian general practice registrars (trainees) have inappropriately high rates of prescription of antibiotics for RTIs. The ‘apprenticeship’ educational model and the trainee–trainer relationship are drivers of this inappropriate prescribing. We aimed to reduce registrars’ non-pneumonia RTI antibiotic prescribing via an educational intervention (a 90-min face-to-face workshop supported by online modules), complemented by delivery of the same intervention, separately, to their trainers. We conducted a pre- and post-intervention comparison of the registrars’ intention to prescribe antibiotics for common RTIs using McNemar’s test. We similarly tested changes in supervisors’ intended prescribing. Prescribing intentions were elicited by responses to six written clinical vignettes (upper respiratory tract infection, otitis media, sore throat and three acute bronchitis vignettes). We found that, for registrars, there were statistically significant reductions in antibiotic prescribing for the sore throat (24.0% absolute reduction), otitis media (17.5% absolute reduction) and two of the three acute bronchitis (12.0% and 18.0% absolute reduction) vignettes. There were significant reductions in supervisors’ antibiotic prescribing intentions for the same four vignettes. We conclude that our intervention produced a significant change in registrars’ intention to prescribe antibiotics for non-pneumonia RTIs.

GP registrar consultations addressing menopause-related symptoms: a cross-sectional analysis

Objective: To investigate the prevalence and associations of general practitioner registrars’ (trainees’) management of women with menopause-related symptoms. Methods: A cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) cohort study. In ReCEnT registrars collected data of 60 consecutive consultations on three occasions during training. The outcome factor was menopause-related problems/diagnoses (compared with other problems/diagnoses). Associations of registrar, patient, practice, and consultation-independent variables were assessed by univariate and multivariable logistic regression. Results: In all, 1,333 registrars conducted 189,774 consultations involving 295,017 problems/diagnoses. Of these, there were 1,291 problems/diagnoses (0.44% of all problems/diagnoses) relating to menopause. Significant multivariable independent associations of a problem being menopause-related were registrar female sex (odds ratio [OR] 2.74, 95% confidence interval [CI] 2.30-3.26) and registrars working part-time (OR 0.84, 95% CI 0.72-0.98 for full-time work). Consultation-related associations included an increased number of problems addressed in the consultation (OR 1.29, 95% CI 1.21-1.37), and menopause-related problems/diagnoses not being new (OR 0.75, 95% CI 0.66-0.86). Significant educational associations were increased odds of recourse to in-consultation sources of information or assistance (OR 2.09, 95% CI 1.80-2.44) and of generating learning goals (OR 3.15, 95% CI 2.66-3.72). Conclusions: Registrars seek more assistance and further knowledge about menopause compared with other problems. Thus, they may find the area particularly challenging and could benefit from further education regarding managing menopause. Our findings may help inform the design of measures aimed at improving the delivery of menopause training for general practice registrars.

Clinical encounters of Australian general practice registrars with paediatric patients

Abstract Background: Whether general practitioner (GP) registrars have adequate exposure to, and feel confident in, managing children’s health during training is unknown. Objectives: To determine the prevalence and associations of GP registrars’ paediatric vs. non-paediatric consultations. Methods: Cross-sectional analysis from a cohort study of Australian GP registrars’ 2010–2014 consultations. Results: 889 registrars contributed details for 26,427 (21.8% (95% CI: 21.4–22.2) paediatric consultations. Paediatric patients were more likely to be male and new to the practice. Although paediatric patients were less likely to have a chronic disease (OR 0.38, 95% CI 0.36, 0.40) and presented with fewer problems (OR 0.59, 95% CI 0.57, 0.61), registrars were more likely to seek in-consultation advice (OR 1.25, 95% CI 1.19, 1.31) and generate learning goals (OR 1.12, 95% CI 1.07, 1.18) for paediatric consultations. Discussion: GP registrars appear to feel less confident in managing paediatric compared with adult consultations, suggesting an unmet training need.

Management of transient ischemic attacks diagnosed by early-career general practitioners: A cross-sectional study:

Background Transient ischemic attack incurs a risk of recurrent stroke that can be dramatically reduced by urgent guideline-recommended management at the point of first medical contact. Aims This study describes the prevalence and associations of new transient ischemic attack presentations to general practice registrars and the management undertaken. Methods A cross-sectional analysis of the Registrar Clinical Encounters in Training cohort study. General practice registrars from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of their three six-month training terms. The proportion of problems managed being new transient ischemic attacks and proportion of transient ischemic attacks with guideline-recommended management were calculated. Univariate and multivariable logistic regression established associations of patient, registrar, and practice factors with a problem being a new transient ischemic attack. Results A total 1331 general practice registrars contributed data (response rate 95.8%). Of the 250,625 problems, there were 65 new transient ischemic attacks diagnosed (0.03% [95% confidence interval: 0.02–0.03%]). General practice registrars were more likely to seek help, generate learning goals, and spend more time for a new transient ischemic attack compared to other problems. Compliance with management guidelines was modest: 15.4% ordered brain and arterial imaging, 36.9% prescribed antiplatelet medication, and 3.1% prescribed antihypertensive medication. Conclusions Transient ischemic attack is a very infrequent presentation for general practice registrars, giving little clinical opportunity to reinforce training program education regarding guideline-recommended management. General practice registrars found transient ischemic attacks challenging and management was not ideal. Since most transient ischemic attacks first present to general practice and urgent management is essential, an enhanced model of care utilizing rapid access to specialist transient ischemic attack support and follow-up could improve guideline compliance.

General practice registrars’ clinical exposure to dermatological procedures during general practice training: a cross-sectional analysis

ABSTRACT Australian general practitioners (GPs) commonly manage dermatological conditions requiring procedures. GP registrars have limited pre-vocational training exposure to dermatology and find skin problems challenging. We aimed to establish the prevalence, nature and associations of GP registrars’ performance of skin procedures. We conducted a cross-sectional analysis from the Registrar Clinical Encounters in Training cohort study. Multivariable logistic regression was used to establish associations of our outcome (skin procedures, both including and excluding cryotherapy). Independent variables included patient and doctor demographics, diagnoses/problems managed and registrars’ recourse to in-consultation assistance/information. A total of 1161 registrars provided data on 166,988 consultations, recording 2927 skin procedures (16.7% of all procedures; performed in 1.7% of consultations). Cryotherapy, excision, punch biopsy and shave biopsy were most common. More complex procedures were performed infrequently. Significant associations of performing procedures included rural/remote location (compared to major city), male patients, patient age 65+ (compared to age 15–34) and registrars seeking in-consultation information/assistance. Skin procedures were less likely for Aboriginal patients or those from non-English-speaking backgrounds. For non-cryotherapy procedures, rurality was not significantly associated, but significant differences were found between training regions. In summary, GP registrars perform fewer dermatological procedures compared to established GPs. Findings will inform GP vocational training in skin procedures.

Changes in pathology test ordering by early career general practitioners: a longitudinal study

Objective: To assess the number of pathology tests ordered by general practice registrars during their first 18–24 months of clinical general practice.

Prevalence and associations of general practitioners’ ordering of “non-symptomatic” prostate-specific antigen tests: A cross-sectional analysis

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).