Christine Holton

Management of asthma in Australian general practice: care is still not in line with clinical practice guidelines

OBJECTIVE AND BACKGROUND We investigated the quality of primary care asthma management in a sample of Australian general practices. METHODS 247 general practitioners (GPs) from 97 practices completed a structured interview about management of asthma, diabetes and hypertension/heart disease. A further structured interview with the senior practice principal and practice manager was used to collect information about practice capacity for chronic disease management. RESULTS Just under half of GPs (47%) had access to an asthma register and the majority (76%) had access to spirometry in their practice. In terms of routine management of asthma, 12% of GPs reported using spirometry routinely, 13% routinely reviewed written asthma action plans, 27% routinely provided education about trigger factors, 30% routinely reviewed inhaler technique, 24% routinely assessed asthma severity, and 29% routinely assessed physical activity. Practice characteristics such as practice size (p=1.0) and locality (rural/metropolitan) (p=0.7) did not predict quality of asthma management nor did indicators of practice capacity including Business maturity, IT/IM maturity, Multidisciplinary teamwork, and Clinical linkages. CONCLUSION Gaps remain in the provision of evidence-based care for patients with asthma in general practice. Markers of practice capacity measured here were not associated with guideline-based respiratory care within practices.

Chronic Care Team Profile: a brief tool to measure the structure and function of chronic care teams in general practice

AIM At a time when workforce shortages in general practices are leading to greater role substitution and skill-mix diversification, and the demand on general practices for chronic disease care is increasing, the structure and function of the general practice team is taking on heightened importance. To assist general practices and the organizations supporting them to assess the effectiveness of their chronic care teamworking, we developed an interview tool, the Chronic Care Team Profile (CCTP), to measure the structure and function of teams in general practice. This paper describes its properties and potential use. METHOD An initial pool of items was derived from guidelines of best-practice for chronic disease care and performance standards for general practices. The items covered staffing, skill-mix, job descriptions and roles, training, protocols and procedures within the practice. The 41-item pool was factor analysed, retained items were measured for internal consistency and the reduced instruments face, content and construct validity were evaluated. RESULTS A three-factor solution corresponding to non-general practitioner staff roles in chronic care, administrative functions and management structures provided the best fit to the data and explained 45% of the variance in the CCTP. Further analyses suggested that the CCTP is reliable, valid and has some utility. DISCUSSION The CCTP measures aspects of the structure and function of general practices which are independent of team processes. It is associated with the job satisfaction of general practice staff and the quality of care provided to patients with chronic illnesses. As such, the CCTP offers a simple and useful tool for general practices to assess their teamworking in chronic disease care.

Does spirometry training in general practice improve quality and outcomes of asthma care

OBJECTIVE Clinical asthma guidelines recommend spirometry for asthma diagnosis, but there is inconsistent evidence about benefits to patients in using it for ongoing management. Our aim was to determine whether training in the use of spirometry for management of asthma provided better health outcomes and improved the quality of care in the primary care setting. DESIGN Pragmatic, cluster randomized controlled trial. SETTING General practices in two states of Australia. PARTICIPANTS Forty practices and 397 adults with asthma. INTERVENTION The staff of 26 intervention practices received comprehensive spirometry training. Fourteen control practices provided usual care. MAIN OUTCOME MEASURES Primary outcome measures were quality of life, self-reported asthma symptoms and lung function. Secondary measures related to the process of care (e.g. performance of spirometry, preparation of a written asthma action plan) and patient and general practitioner rating of the acceptability and usefulness of spirometry. RESULTS There were no statistically significant differences between the groups at 12 months for quality of life (mean difference = -0.23; 95% CI: -0.44, -0.01), days off work (rate ratio = 1.52; 95% CI: 0.91, 2.54), exacerbations (rate ratio = 1.09; 95% CI: 0.85, 1.41), asthma on waking (rate ratio = 1.21; 95% CI: 0.79, 1.85), nocturnal asthma (rate ratio = 0.98; 95% CI: 0.63, 1.51) and post-bronchodilator FEV(1)/FVC ratio (mean difference = -0.01, 95% CI: -0.03, 0.02). There was no improvement in the quality of care provided. CONCLUSIONS Training in spirometry did not result in any measurable improvement in the use of spirometry, quality of management of asthma or patient outcomes in primary care.

Chronic disease management in Australia: evidence and policy mismatch, with asthma as an example

All Western countries are developing and implementing new models for managing asthma. In Australia, the Asthma 3+ Visit Plan was implemented in 2001—2002, with the aim of establishing a structured approach in general practice for people with moderate and severe asthma, within a fee-for-service system. Evidence is emerging that the uptake across general practice has been poor, with approximately 5% of eligible people being enrolled. The reasons for the poor uptake include such factors as an inability to identify people with asthma, general practitioners being too busy with other clinical priorities, and the lack of interest and understanding of the need for a structured approach for this disease. This mismatch between evidence and policy development needs to be rectified, if sustainable models of chronic disease care are to be firmly established in general practice.

Practice nurse involvement in general practice clinical care: policy and funding issues need resolution

In Australia, primary care-based funding initiatives have been implemented to encourage general practices to employ practice nurses. The aim of this paper is to discuss limitations of the current funding and policy arrangements in enhancing the clinical role of practice nurses in the management of chronic conditions. This paper draws on the results of a real-world economic evaluation, the Primary Care Services Improvement Project (PCSIP). The PCSIP linked routinely collected clinical and resource use data to undertake a risk-adjusted cost-effectiveness analysis of increased practice nurse involvement in clinical-based activities for the management of diabetes and obesity. The findings of the PCSIP suggested that the active involvement of practice nurses in collaborative clinical-based activities is cost-effective, as well as addressing general practice workforce issues. Although primary healthcare organisations (e.g. Medicare Locals) can play a key role in supporting enhanced practice nurse roles, improvements to practice nurse funding models could further encourage more efficient use of an important resource.

A risk adjusted cost-effectiveness analysis of alternative models of nurse involvement in obesity management in primary care.

Controlled evaluations are subject to uncertainty regarding their replication in the real world, particularly around systems of service provision. Using routinely collected data, we undertook a risk adjusted cost‐effectiveness (RAC‐E) analysis of alternative applied models of primary health care for the management of obese adult patients. Models were based on the reported level of involvement of practice nurses (registered or enrolled nurses working in general practice) in the provision of clinical‐based activities.

A risk-adjusted economic evaluation of alternative models of involvement of practice nurses in management of type 2 diabetes.

To determine the cost‐effectiveness of alternative models of practice nurse involvement in the management of type 2 diabetes within the primary care setting.

Spirometry and impulse oscillometry (IOS) for detection of respiratory abnormalities in metropolitan firefighters

Background and objective:  As firefighters are at increased risk of adverse health effects, periodic examination of their respiratory health is important. The objective of this study was to establish whether the use of impulse oscillometry (IOS) reveals respiratory abnormalities in metropolitan firefighters that go undetected during routine respiratory health screening by spirometry and assessment of respiratory symptoms.

Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: cluster randomized controlled trials

To determine whether spirometry and regular medical review improved quality of life or other outcomes in children and adolescents with asthma.

Practice nurse involvement in primary care depression management: an observational cost-effectiveness analysis

BackgroundMost evidence on the effect of collaborative care for depression is derived in the selective environment of randomised controlled trials. In collaborative care, practice nurses may act as case managers. The Primary Care Services Improvement Project (PCSIP) aimed to assess the cost-effectiveness of alternative models of practice nurse involvement in a real world Australian setting. Previous analyses have demonstrated the value of high level practice nurse involvement in the management of diabetes and obesity. This paper reports on their value in the management of depression.MethodsGeneral practices were assigned to a low or high model of care based on observed levels of practice nurse involvement in clinical-based activities for the management of depression (i.e. percentage of depression patients seen, percentage of consultation time spent on clinical-based activities). Linked, routinely collected data was used to determine patient level depression outcomes (proportion of depression-free days) and health service usage costs. Standardised depression assessment tools were not routinely used, therefore a classification framework to determine the patient’s depressive state was developed using proxy measures (e.g. symptoms, medications, referrals, hospitalisations and suicide attempts). Regression analyses of costs and depression outcomes were conducted, using propensity weighting to control for potential confounders.ResultsCapacity to determine depressive state using the classification framework was dependent upon the level of detail provided in medical records. While antidepressant medication prescriptions were a strong indicator of depressive state, they could not be relied upon as the sole measure. Propensity score weighted analyses of total depression-related costs and depression outcomes, found that the high level model of care cost more (95% CI: -