Clare Bayram

Integrating evidence and individual preferences using a web-based multi-criteria decision analytic tool: An application to prostate cancer screening

AbstractBackground: Annalisa© (AL) is a web-based decision-support template grounded in multi-criteria decision analysis (MCDA). It uses a simple expected value algorithm to calculate a score for each option by taking into account the individual’s preferences for different criteria (as importance weights) and the evidence of the performance of each option on each criterion. Given the uncertainty surrounding the trade offs between benefits and harms for prostate cancer screening, this topic was chosen as the vehicle to introduce this new decision-support template. Objective: The aim of the study was to introduce a new decision-support template, AL, and to develop and pilot a decision-support tool for prostate cancer screening using it. Methods: A decision-support tool for prostate cancer screening (ALProst) was implemented in the AL template. ALProst incorporated evidence on both the benefits and the potential harms of prostate cancer screening (the ‘attributes’) from published randomized controlled trials (RCTs). Individual weights for each attribute were elicited during interviews. By combining the individual’s preferences and the evidence, the best option for the user was identified on the basis of quantified scores.A convenience sample of computer-proficient primary-care physicians (general practitioners [GPs] in Australia) from the Sydney Metropolitan area (Australia) were invited to complete a face-to-face interview involving the decision-support tool. Preference for undergoing prostate-specific antigen testing for prostate cancer, both personally and for their patients, was sought prior to seeing the tool. After gaining hands-on experience with using the tool, GPs were asked to comment on the merits of the template and the tool. Preference for presenting the benefits of prostate cancer screening as the relative or absolute risk reduction in prostate cancer-specific mortality was also sought. Results: Of 60 GPs approached, ten (six men and four women) completed an interview (16.7% response rate). Most GPs agreed/strongly agreed with positive statements about the ease with which they could use AL (seven GPs), and understand the information in, and format of, AL (nine and eight, respectively). Eight agreed/strongly agreed that ALProst would be a useful tool for discussing prostate cancer screening with their patients. GPs were also asked to nominate difficult clinical decisions that they, and their patients, have had to make; responses included cancer screening (including prostate cancer); treating patients with multiple illnesses/diseases; managing multiple cardiovascular disease risk factors; and managing patients who are receiving multiple medications. The common element was the need to consider multiple factors in making these complex decisions. Conclusions: AL is distinguishable from most other decision-support templates available today by its underlying conceptual framework, MCDA, and its power to combine individual preferences with evidence to derive the best option for the user quantitatively. It therefore becomes potentially useful for all decisions at all levels in the healthcare system. Moreover, it will provide a universal graphic ‘language’ that can overcome the burden to patients of encountering a plethora of widely varying decision aids for different conditions during their lifetime.

Drugs causing adverse events in patients aged 45 or older: a randomised survey of Australian general practice patients

Objective To determine prevalence of adverse drug events (ADEs) in patients aged 45 years or older presenting to Australian general practitioners (GPs) and identify drug groups related to ADEs, their severity and manifestation. Design Substudy of the Bettering the Evaluation and Care of Health continuous survey of Australian GP clinical activity in which randomly selected GPs collected survey data from patients. Data are reported with 95% CIs. Setting General practice in Australia. Main outcome measures Prevalence in the preceding 6 months, type, implicated drugs, severity (including hospitalisation) and manifestation of ADEs. Participants From three survey samples, January–October 2007, and two samples, January–March 2010, responses were received from 482 GPs about 7561 patients aged 45 years or older. Results Of a final sample of 7518 patients (after duplicate patients removed), 871 (11.6%) reported ADEs in the previous 6 months. The type of ADE was recognised side effect (75.8%, 95% CI 72.0 to 79.7), drug sensitivity (9.9%, 95% CI 7.2 to 12.7) and drug allergy (7.4%, 95% CI 4.7 to 10.1). Drug interaction (1.0%, 95% CI 0.1 to 1.8), overdose (0.8%, 95% CI 0.0 to 1.5) and contraindications (0.2%, 95% CI 0.0 to 0.6) were very infrequent. A severity rating was provided for 846 patients. Almost half (45.9%, 95% CI 42.0 to 49.7) were rated as ‘mild’ events, 42.2% (95% CI 38.8 to 45.6) ‘moderate’, 11.8% (95% CI 9.5 to 14.1) severe and 5.4% (95% CI 3.8 to 7.0) had been hospitalised as a result of the most recent ADE. Thirteen commonly prescribed drug groups accounted for 58% of all ADEs, opioids being the group most often implicated. Conclusion ADEs in patients aged 45 or older are frequent and are associated with significant morbidity. Most of ADEs result from commonly prescribed drugs at therapeutic dosage. The list of causative agents bears little relationship to published lists of ‘inappropriate medications’.

Management of Whiplash Associated Disorders in Australian general practice

BackgroundWhiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments.MethodsWe analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters.Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines.ResultsOf 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8).ConclusionsGPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

Estimating non-billable time in Australian general practice

Objectives: To quantify the time that general practitioners spend on patient care that is not claimable from Medicare (non‐billable) and the monetary value of this work were it claimable, and to identify variables independently associated with non‐billable time.

Assessing patients' and GPs' ability to recognise overweight and obesity

Objective: To assess the ability of GPs and patients to recognise overweight and obesity, determine factors associated with accurate weight perception, and identify methods used by patients and GPs to manage patient overweight and obesity.

Gp-initiated pathology testing: data from the beach program

The BEACH study is a continuous national study of general practice activity. Each year approximately 1000 randomly sampled GPs provide data about 100 000 encounters. It contains data about pathology ordered at these encounters. In 2009-2010, GPs ordered 45.0 pathology tests/batteries per 100 encounters or 29.3 per 100 problems. At least one pathology test order was recorded at 17.7% of encounters (for 13.2% of problems managed), chemistry tests accounting for more than half of all pathology tests. Since 2000, rises in the number of tested problems and the number of problems managed at GP encounters contributed to overall increases in the proportion of encounters involving a pathology test, and the number of tests ordered by GPs. BEACH pathology data have been used to investigate: • the problems responsible for the highest volume and growth of testing in primary care and how GPs’ testing behaviour in the management of these problems has changed; • the extent to which GP-ordered pathology for type 2 diabetes, hypertension, lipid disorders, weakness/tiredness, ‘health checks’ and overweight/obesity aligned with testing recommended in inter/national guidance; • expected volume of GP-ordered testing in 2020 using patient age-sex-specific test rates, extrapolated using GP-attendance rates and national population projections.