Iqbal Hasan

Postgraduate education for doctors in smoking cessation.

INTRODUCTION AND AIMS Smoking cessation advice from doctors helps improve quit rates but the opportunity to provide this advice is often missed. Postgraduate education is one strategy to improve the amount and quality of cessation support provided. This paper describes a sample of postgraduate education programs for doctors in smoking cessation and suggests future directions to improve reach and quality. DESIGN AND METHODS Survey of key informants identified through tobacco control listserves supplemented by a review of the published literature on education programs since 2000. Programs and publications from Europe were not included as these are covered in another paper in this Special Issue. RESULTS Responses were received from only 21 key informants from eight countries. Two further training programs were identified from the literature review. The following components were present in the majority of programs: 5 As (Ask, Advise, Assess, Assist and Arrange) approach (72%), stage of change (64%), motivational interviewing (72%), pharmacotherapies (84%). Reference to clinical practice guidelines was very common (84%). The most common model of delivery of training was face to face. Lack of interest from doctors and lack of funding were identified as the main barriers to uptake and sustainability of training programs. DISCUSSION AND CONCLUSIONS Identifying programs proved difficult and only a limited number were identified by the methods used. There was a high level of consistency in program content and a strong link to clinical practice guidelines. Key informants identified limited reach into the medical profession as an important issue. New approaches are needed to expand the availability and uptake of postgraduate education in smoking cessation

Feasibility and effectiveness of nurse‐delivered smoking cessation counselling combined with nicotine replacement in Australian general practice

INTRODUCTION AND AIMS Practice nurses (PN) are an alternative workforce for cessation support in primary care, but their role and effectiveness is underdeveloped and underresearched. This study evaluated a model of smoking cessation intervention in Australian general practice based on PNs. Smokers were identified by their general practitioner (GP) and referred to the PN for cessation support over four counselling visits and offered free nicotine patches. DESIGN AND METHODS Pre- and post-study using mixed quantitative and qualitative methods. Cessation outcomes were collected by patient self-report at 6 months. Semistructured interviews were conducted with PNs and GPs to provide qualitative data on the acceptability of the model. RESULTS The project involved 31 PNs, 35 GPs and 498 patients from 19 general practices in Sydney. Mean age of participating patients was 46 years and 61% were female. Mean number of PN counselling visits was 3.1. At 6 month follow up the point prevalence abstinence rate was 22% and continuous abstinence rate was 16%. Participants who had attended for four or more counselling visits with the PN were significantly more likely to quit. PNs and GPs expressed enthusiasm for the PN role in smoking cessation and belief in its value and feasibility. DISCUSSION AND CONCLUSIONS Substantial rates of cessation were found in this uncontrolled study and the role was well accepted by PNs and GPs. The model shows promise as a means of providing cessation support in Australian primary care and further research in a randomised trial is warranted.

A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol

BackgroundChronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care.DesignA pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD.The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities.The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups.DiscussionThis study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care.Trial registrationACTRN12610000592044\

Barriers and facilitators to influenza vaccination among high-risk groups aged less than 65 years – views from general practitioners and practice nurses

Objectives: To explore the views of general practitioners and practice nurses about barriers to influenza vaccination among under 65 high‐risk patients and strategies to overcome those barriers.

COPD Diagnostic Questionnaire (CDQ) for selecting at-risk patients for spirometry: a cross-sectional study in Australian general practice.

Background:Using the COPD Diagnostic Questionnaire (CDQ) as a selection tool for spirometry could potentially improve the efficiency and accuracy of chronic obstructive pulmonary disease (COPD) diagnosis in at-risk patients.Aim:To identify an optimal single cut point for the CDQ that divides primary care patients into low or high likelihood of COPD, with the latter group undergoing spirometry.Methods:Former or current smokers aged 40–85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse at various general practices in Sydney, Australia. The CDQ was collected and pre- and post-bronchodilator spirometry was performed. Cases with complete CDQ data and spirometry meeting quality standards were analysed (1,054 out of 1,631 patients). CDQ cut points were selected from a receiver operating characteristic (ROC) curve.Results:The area under the ROC curve was 0.713. A cut point of 19.5 had the optimal combination of sensitivity (63%) and specificity (70%) with two-thirds below this cut point. A cut point of 14.5 corresponded to a sensitivity of 91%, specificity of 35% and negative predictive value of 96%, and 31% of patients below this cut point.Conclusions:The CDQ can be used to select patients at risk of COPD for spirometry using one cut point. We consider two possible cut points. The 19.5 cut point excludes a higher proportion of patients from undergoing spirometry with the trade-off of more false negatives. The 14.5 cut point has a high sensitivity and negative predictive value, includes more potential COPD cases but has a higher rate of false positives.

Validation of the COPD Diagnostic Questionnaire in an Australian general practice cohort: a cross-sectional study.

Background: The gold standard for the diagnosis of chronic obstructive pulmonary disease (COPD) is spirometry, but there are barriers to its use in primary care. Aims: To externally validate the COPD Diagnostic Questionnaire (CDQ) as a diagnostic tool in patients at increased risk in Australian general practice and to compare its performance with other CDQ validation studies. Methods: Patients were recruited from 36 general practices in Sydney, Australia. Former or current smokers aged 40–85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse. The CDQ was collected and pre- and postbronchodilator spirometry was performed. Cases for whom complete CDQ data were present and the spirometry met quality standards were analysed. Results: Of 1,631 patients who attended case-finding recruitment, 1,054 (65%) could be analysed. Spirometry showed 13% had COPD. The ability of the CDQ to discriminate between patients with and without COPD was fair, represented by the area under the receiver operating characteristic curve of 0.713. With a CDQ cut-off point value of 16.5 the sensitivity was 80% and specificity 47% and, at a cut-off point value of 19.5, the sensitivity was 63% and specificity 70%. Conclusions: The CDQ did not discriminate between patients with and without COPD accurately enough to use as a diagnostic tool in patients at increased risk of COPD in Australian general practice. Further research is needed on the value of the CDQ as a tool for selecting patients for spirometry.

A systematic review of chronic disease management interventions in primary care

BackgroundPrimary and community care are key settings for the effective management of long term conditions. We aimed to evaluate the pattern of health outcomes in chronic disease management interventions for adults with physical health problems implemented in primary or community care settings.MethodsThe methods were based on our previous review published in 2006. We performed database searches for articles published from 2006 to 2014 and conducted a systematic review with narrative synthesis using the Cochrane Effective Practice and Organisation of Care taxonomy to classify interventions and outcomes. The interventions were mapped to Chronic Care Model elements. The pattern of outcomes related to interventions was summarized by frequency of statistically significant improvements in health care provision and patient outcomes.ResultsA total of 9589 journal articles were retrieved from database searches and snowballing. After screening and verification, 165 articles that detailed 157 studies were included. There were few studies with Health Care Organization (1.9% of studies) or Community Resources (0.6% of studies) as the primary intervention element. Self-Management Support interventions (45.8% of studies) most frequently resulted in improvements in patient–level outcomes. Delivery System Design interventions (22.6% of studies) showed benefits in both professional and patient-level outcomes for a narrow range of conditions. Decision Support interventions (21.3% of studies) had impact limited to professional-level outcomes, in particular use of medications. The small number of studies of Clinical Information System interventions (8.9%) showed benefits for both professional- and patient-level outcomes.ConclusionsThe published literature has expanded substantially since 2006. This review confirms that Self-Management Support is the most frequent Chronic Care Model intervention that is associated with statistically significant improvements, predominately for diabetes and hypertension.

Experiences and views of a brokerage model for primary care for Aboriginal people

OBJECTIVE A mixed methods study was conducted to determine the views of Aboriginal people on their experiences of a brokerage model for access to community-based health services in an urban setting. METHODS A broad range of approaches, using surveys, semi-structured interviews and community forums with Aboriginal people were used to find out peoples views and experiences of using the brokerage service. RESULTS Of the 1304 people invited to participate, only 127 people provided feedback on the brokerage service model for Aboriginal people. Of these, 120 people identified as being Aboriginal. Participants said that the service helped them to navigate the system and access health care. Participants felt that the health professionals involved with the service were respectful of their needs. The service was not able to improve access to dental care. CONCLUSIONS The brokerage model implemented in this area appears to have been well received and is supporting urban Aboriginal people to access some of the health care needed.