John Litt

The International Primary Care Respiratory Group (IPCRG) Research Needs Statement 2010

AIM Respiratory diseases are a public health issue throughout the world, with high prevalence and morbidity. This Research Needs Statement from the International Primary Care Respiratory Group (IPCRG) aims to highlight unanswered questions on the management of respiratory diseases that are of importance to practising primary care clinicians. METHODS An informal but inclusive consultation process was instigated in 2009. Draft statements in asthma, rhinitis, COPD, tobacco dependence, and respiratory infections were circulated widely to IPCRG members, other recognised experts, and representatives from a range of economic and healthcare backgrounds. An iterative process was used to generate, prioritise and refine research questions in each section. RESULTS Two overarching themes emerged. Firstly, there is a real need for research to be undertaken within primary care, which recruits patients representative of primary care populations, evaluates interventions realistically delivered within primary care, and draws conclusions that will be meaningful to professionals working within primary care. Secondly, international and national guidelines exist, but there is little evidence on the best strategies for implementing recommendations. Disease-specific research questions focus on effective and cost-effective ways to prevent disease, confirm the diagnosis, assess control, manage treatment, and empower selfmanagement. Practical questions about how to deliver this comprehensive agenda in diverse primary care settings are highlighted. CONCLUSIONS We hope that this Research Needs Statement will be used by clinicians and patients campaigning for answers to relevant questions, by researchers seeking funding to provide answers to these questions, and by funding bodies to enable them to prioritise research agendas.

What skills do primary health care professionals need to provide effective self-management support?: seeking consumer perspectives

This research aimed to identify the skills required by primary health care (PHC) professionals to provide effective chronic condition prevention and self-management support, according to the perceptions of a sample of Australian consumers and carers. Qualitative data were collected and integrated from a focus group, key informant interviews and National Stakeholder meetings and a National Workshop, supported by an extensive literature review. With the exception of health professionals specifically trained or currently working in this area, consumers and carers perceive there is a lack of understanding, competence and practice of chronic condition prevention and self-management support among PHC professionals. The PHC workforce appears not to have the full set of skills needed to meet the growing burden of chronic conditions on the health system. Recommendations include education and training that focuses on improved communication skills, knowledge of community support resources, identification of consumers’ strengths and current capacities, collaborative care with other health professionals, consumers and carers and psychosocial skills to understand the impact of chronic conditions from the person’s perspective.

SEARCH FOR T-VIOLATION IN THE INELASTIC SCATTERING OF ELECTRONS FROM A POLARIZED PROTON TARGET.

The authors have searched for an asymmetry in the inelastic scattering of electrons from a polarized proton target in the region of resonance excitation, at values of four-momentum transfer squared of 0.4, 0.6 and 1.0 (GeV/c){sup 2}. Data were also taken using an incident positron beam in order to distinguish any possible effect of time-reversal violation from that due to higher-order ({alpha}{sup 3}) contributions to the scattering. No sizeable violation of time-reversal invariance was found.

Preventive evidence into practice (PEP) study: implementation of guidelines to prevent primary vascular disease in general practice protocol for a cluster randomised controlled trial

BackgroundThere are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession.MethodsWe hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews.DiscussionWe plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.

Smoking termination opportunity for in patients (STOP): superiority of a course of varenicline tartrate plus counselling over counselling alone for smoking cessation: a 12-month randomised controlled trial for inpatients

Rationale Smoking cessation interventions in outpatient settings have been demonstrated to be cost effective. Given this evidence, we aimed to evaluate the effectiveness of varenicline tartrate plus Quitline-counselling compared with Quitline-counselling alone when initiated in the inpatient setting. Methods Adult patients (18–75 years) admitted with a smoking-related illness to three hospitals, were randomised to receive either 12-weeks of varenicline tartrate plus Quitline-counselling, (n=196) or Quitline-counselling alone, (n=196), with 12-months follow-up. Results For the primary analysis population (intention-to-treat), the proportion of subjects who remained continuously abstinent were significantly greater in the varenicline plus counselling arm (31.1%, n=61) compared with counselling alone (21.4%, n=42; RR 1.45, 95% CI 1.03 to 2.03, p=0.03). Conclusions The combined use of varenicline plus counselling when initiated in the inpatient setting has produced a sustained smoking cessation benefit at 12-months follow-up, indicating a successful opportunistic treatment for smokers admitted with smoking related illnesses. Trial registration http://www.clinicaltrials.gov/ ClinicalTrials.gov identification number: NCT01141855.

Implementing guidelines to routinely prevent chronic vascular disease in primary care: the Preventive Evidence into Practice cluster randomised controlled trial

Objective To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease. Setting 32 urban general practices in 4 Australian states. Randomisation Stratified randomisation of practices. Participants 122 general practitioners (GPs) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness. Intervention The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information. Outcome measures Primary: 1. Change in proportion of patients aged 40–69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45–69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor. Secondary change in self-reported frequency and confidence of GPs and PNs in assessment. Results Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPs and PNs in the intervention group improved in the assessment of some risk factors. Conclusions This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit. Trial registration number Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000578808, results.

Factors impacting on shared care working relationships between practice nurses and general practitioners: a literature review.

Abstract Practice nurses have worked in general practice for many years yet little is known or published in Australia about their work. Recent health care reforms in Australia, particularly the establishment of the Divisions of General Practice and various best-practice innovations linked to the National GP Strategy have seen an increase in the role of practice nurses. Despite this GPs in Australia are cautious about the role of practice nurses. Much of this caution arises from reform in general practice in Britain particularly the establishment of fund-holding for general practice. This article reviews the literature on practice nurses in Britain and Australia within the framework of the health reforms in general practice in both countries.

Teaching health science students foundation motivational interviewing skills: use of motivational interviewing treatment integrity and self-reflection to approach transformative learning.

BackgroundMany undergraduate and graduate-entry health science curricula have incorporated training in motivational interviewing (MI). However, to effectively teach skills that will remain with students after they graduate is challenging. The aims of this study were to find out self-assessed MI skills of health students and whether reflecting on the results can promote transformative learning.MethodsThirty-six Australian occupational therapy and physiotherapy students were taught the principles of MI, asked to conduct a motivational interview, transcribe it, self-rate it using the Motivational Interviewing Treatment Integrity (MITI) tool and reflect on the experience. Student MI skills were measured using the reported MITI subscores. Student assignments and a focus group discussion were analysed to explore the student experience using the MITI tool and self-reflection to improve their understanding of MI principles.ResultsStudents found MI challenging, although identified the MITI tool as useful for promoting self-reflection and to isolate MI skills. Students self-assessed their MI skills as competent and higher than scores expected from beginners.ConclusionsThe results inform educational programs on how MI skills can be developed for health professional students and can result in transformative learning. Students may over-state their MI skills and strategies to reduce this, including peer review, are discussed. Structured self-reflection, using tools such as the MITI can promote awareness of MI skills and compliment didactic teaching methods.

Safety of Varenicline Tartrate and Counseling Versus Counseling Alone for Smoking Cessation: A Randomized Controlled Trial for Inpatients (STOP Study)

INTRODUCTION Inpatient medical settings offer an opportunistic environment for initiating smoking cessation interventions to patients reflecting on their health. Current evidence has shown the superior efficacy of varenicline tartrate (VT) for smoking cessation compared with other tobacco cessation therapies; however, recent evidence also has highlighted concerns about the safety and tolerability of VT. Given these apprehensions, we aimed to evaluate the safety and effectiveness of VT plus quitline-counseling compared to quitline-counseling alone in the inpatient medical setting. METHODS Adult patients (n = 392, 20-75 years) admitted with a smoking-related illnesses to 3 hospitals were randomized to receive either 12 weeks of varenicline tartrate (titrated from 0.5mg daily to 1mg twice daily) plus quitline-counseling (VT+C), (n = 196) or quitline-counseling alone (n = 196). RESULTS VT was well tolerated in the inpatient setting among subjects admitted with acute smoking-related illnesses (mean age 52.8±2.89 and 53.7±2.77 years in the VT+C and counseling alone groups, respectively). The most common self-reported adverse event during the 12-week treatment phase was nausea (16.3% in the VT+C group compared with 1.5% in the counseling alone group). Thirteen deaths occurred during the study period (n = 6 were in the VT+C arm compared with n = 7 in the counseling alone arm). All of these subjects had known comorbidities or developed underlying comorbidities. CONCLUSIONS VT appears to be a safe and well-tolerated opportunistic treatment for inpatient smokers who have related chronic disease. Based on the proven efficacy of varenicline from outpatient studies and our recent inpatient evidence, we suggest it be considered as part of standard care in the hospital setting.

Self-management in Lifestyle medicine

Abstract Self-management is a core concept of Lifestyle Medicine. This is designed to ensure optimal outcomes from the interaction of a health team and patient over the extended time (maybe a lifetime) needed to manage chronic diseases and conditions. Prompts to self-management discussed here include: (1) being client centered, (2) being motivation focused, and (3) being health literacy oriented. Each of these has implications for counseling, the health care practice, and desired outcomes—the long-term goal being greater involvement of the patient or client in his or her own care.