Dale Ford

Identification of depression in diabetes: the efficacy of PHQ-9 and HADS-D

BACKGROUND Clinical guidelines advise screening for depression in patients with diabetes. The Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) are commonly used in primary care. AIM To compare the efficacy of HADS-D and PHQ-9 in identifying moderate to severe depression among primary care patients with type 2 diabetes. DESIGN OF STUDY Self-report postal survey, clinical records assessed by GPs. SETTING Seven metropolitan and rural general practices in Victoria, Australia. METHOD Postal questionnaires were sent to all patients with diabetes on the registers of seven practices in Victoria. A total of 561 completed postal questionnaires were returned, giving a response rate 47%. Surveys included demographic information, and history of diabetes and depression. Participants completed both the PHQ-9 and HADS-D. Clinical data from patient records included glycosylated hemoglobin (HbA1c) levels and medications. RESULTS The proportion of the total sample completing HADS-D was 96.8% compared with 82.4% for PHQ-9. Level of education was unrelated to responses on the HADS-D but was related to completion of the PHQ-9. Using complete data (n = 456) from both measures, 40 responders showed HADS-D scores in the moderate to severe range, compared with 103 cases identified by PHQ-9. Only 35 cases were classified in the moderate to severe category by both the PHQ-9 and HADS-D. Items with the highest proportions of positive responses on the PHQ-9 were related to tiredness and sleeping problems and, on the HADS-D, feeling slowed down. CONCLUSION It may be that the items contributing to the higher prevalence of moderate to severe depression using the PHQ-9 are due to diabetes-related symptoms or sleep disorders.

Improving the quality of diabetes care in general practice

OBJECTIVE The evidence treatment gap for patients with type 2 diabetes. DESIGN A summary of convenience sample of seven general practices. SETTING Metropolitan and rural Victoria, Australia. PARTICIPANTS 561 patients of general practices (75% from rural general practices). MAIN OUTCOME MEASURES Demographic data, duration of diabetes, diabetes complications, HbA1c and lipid levels, blood pressure and score on PHQ-9. RESULTS Patients with depression show more severe, progressive and intensively treated diabetes. The prevalence of depression in diabetes is about twice that of the general population. CONCLUSION Australian guidelines for diabetes should recommend screening for depression.

General practices' perspectives on Medicare Locals' performance are critical lessons for the success of Primary Health Networks.

BACKGROUND Under a health reform after two decades, Primary Health Organisations (PHOs) in Australia were changed from Divisions of General Practice (DGP) to Medicare Locals (MLs). Following a review of Medicare Locals, in July 2015 Primary Health Networks (PHNs) replaced Medical Locals to potentially improve outcomes through supporting primary care and enhancing integration. AIMS The aim of this paper was to gather front-line staffs perspectives on MLs and identify any lessons applicable to PHNs. METHODS A national purposive sample of 22 high-performing general practices representing all Australian states and territories was selected for semi-structured, face-to-face interviews, and a thematic analysis conducted. RESULTS Fifty-three interviews were conducted: participants comprised 19 general practitioners (GPs), 18 practice managers (PMs), 15 practices nurses (PNs), and one community pharmacist. Most participants reflected on the difference between the DGP and MLs. Themes that emerged included ambiguity, community needs, professional development and education, communication and support, duplication in services and ignoring existing ones, recruitment and retention, and engagement and involvement. CONCLUSION Those MLs that did well continued in an expanded way the work DGP were doing beforehand and made a seamless transition. PHNs will need to build on the strengths of previous PHOs, and create locality structures and processes that maximise the potential for clinical engagement. They will actively guide the dialogue between related microsystems: to achieve this they will have to be clinically led, change management organisations.

What attributions do Australian high-performing general practices make for their success? Applying the clinical microsystems framework: a qualitative study

Objectives To identify the success attributions of high-performing Australian general practices and the enablers and barriers they envisage for practices wishing to emulate them. Design Qualitative study using semi-structured interviews and content analysis of the data. Responses were recorded, transcribed verbatim and coded according to success characteristics of high-performing clinical microsystems. Setting Primary healthcare with the participating general practices representing all Australian states and territories, and representing metropolitan and rural locations. Participants Twenty-two general practices identified as high performing via a number of success criteria. The 52 participants were 19 general practitioners, 18 practice managers and 15 practice nurses. Results Participants most frequently attributed success to the interdependence of the team members, patient-focused care and leadership of the practice. They most often signalled practice leadership, team interdependence and staff focus as enablers that other organisations would need to emulate their success. They most frequently identified barriers that might be encountered in the form of potential deficits or limitations in practice leadership, staff focus and mesosystem support. Conclusions Practice leaders need to empower their teams to take action through providing inclusive leadership that facilitates team interdependence. Mesosystem support for quality improvement in general practice should focus on enabling this leadership and team building, thereby ensuring improvement efforts are converted into effective healthcare provision.