Mahnaz Fanaian

Predictors of primary care referrals to a vascular disease prevention lifestyle program among participants in a cluster randomised trial

BackgroundCardiovascular disease accounts for a large burden of disease, but is amenable to prevention through lifestyle modification. This paper examines patient and practice predictors of referral to a lifestyle modification program (LMP) offered as part of a cluster randomised controlled trial (RCT) of prevention of vascular disease in primary care.MethodsData from the intervention arm of a cluster RCT which recruited 36 practices through two rural and three urban primary care organisations were used. In each practice, 160 eligible high risk patients were invited to participate. Practices were randomly allocated to intervention or control groups. Intervention practice staff were trained in screening, motivational interviewing and counselling and encouraged to refer high risk patients to a LMP involving individual and group sessions. Data include patient surveys; clinical audit; practice survey on capacity for preventive care; referral records from the LMP. Predictors of referral were examined using multi-level logistic regression modelling after adjustment for confounding factors.ResultsOf 301 eligible patients, 190 (63.1%) were referred to the LMP. Independent predictors of referral were baseline BMI ≥ 25 (OR 2.87 95%CI:1.10, 7.47), physical inactivity (OR 2.90 95%CI:1.36,6.14), contemplation/preparation/action stage of change for physical activity (OR 2.75 95%CI:1.07, 7.03), rural location (OR 12.50 95%CI:1.43, 109.7) and smaller practice size (1–3 GPs) (OR 16.05 95%CI:2.74, 94.24).ConclusionsProviding a well-structured evidence-based lifestyle intervention, free of charge to patients, with coordination and support for referral processes resulted in over 60% of participating high risk patients being referred for disease prevention. Contrary to expectations, referrals were more frequent from rural and smaller practices suggesting that these practices may be more ready to engage with these programs.Trial registrationACTRN12607000423415

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial

BackgroundPrevious research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care.MethodsThis concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program.ResultsA total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance.ConclusionBarriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals’ health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation.Trial registrationACTRN12607000423415

Assessment and management of lifestyle risk factors in rural and urban general practices in Australia

Prevention of cardiovascular disease is a major public health challenge. Many chronic health problems are amenable to lifestyle interventions, which can ameliorate progression of disease and contribute to primary prevention. Prior to a large randomised controlled trial we assessed preventive care in trial practices. General practitioners and practice nurses completed a preventive care questionnaire covering frequency of assessing and managing behavioural and physiological risk factors, which was developed from previously validated instruments. Factor analysis confirmed 10 scales. Scores for rural and urban respondents were contrasted using univariate statistics. Sixty-three general practitioners and practice nurses completed the questionnaire (27 urban and 36 rural). The clinicians reported high levels of assessment and advice for cardiovascular risk factors but less frequent referral. There were no differences between urban and rural practitioners in relation to assessment of risk or stage of change, referral or barriers to referral or management of high blood pressure. Rural practitioners had lower scores for frequency of advice, and management of obesity/overweight, pre-diabetes and high lipids. Although clinicians report frequently advising high risk patients to exercise more, there remain significant gaps in provision of dietary advice and referral. Greater attention to addressing these issues is required to maximise the potential benefits for cardiovascular disease prevention in general practice.

Improving services for people with personality disorders: views of experienced clinicians

People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence-based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole-service approach that enhances evidence-based practice in the community.

What predicts patient-reported GP management of smoking, nutrition, alcohol, physical activity and weight?

This study aimed to describe patient-reported management of behavioural risk factors in Australian general practice. Six hundred and ninety-eight eligible patients from 30 general practices in two rural and three urban Divisions of General Practice responded to a mailed invitation to participate and completed a questionnaire. Data were analysed using univariate and multi-level multivariate methods. The prevalence of risk factors varied between 12.6% for smoking and 72.6% for at-risk diet (56.2% were overweight). Most patients were at the action or maintenance phases of their readiness to change their risky behaviours. General practitioners (GPs) provided education or advice to between one-quarter and one-third of those at risk for each risk factor; 9.2% and 9.6% of patients reported having been referred for diet or physical activity interventions. Patient body mass index was associated with increased likelihood of receiving GP advice or referral for diet and physical activity interventions. Having poor diet or physical activity levels and being more ready for change were not associated with the likelihood of GP referral. The major challenge for general practice is to ensure that effective lifestyle interventions are provided to those who will most benefit. Patient-reported GP behavioural risk factor advice and referral is less frequent than is optimal. Priority needs to be given to those most at risk and ready to change their behaviour.

Engaging participants in a complex intervention trial in Australian General Practice

BackgroundThe paper examines the key issues experienced in recruiting and retaining practice involvement in a large complex intervention trial in Australian General Practice.MethodsReflective notes made by research staff and telephone interviews with staff from general practices which expressed interest, took part or withdrew from a trial of a complex general practice intervention.ResultsRecruitment and retention difficulties were due to factors inherent in the demands and context of general practice, the degree of engagement of primary care organisations (Divisions of General Practice), perceived benefits by practices, the design of the trial and the timing and complexity of data collection.ConclusionThere needs to be clearer articulation to practices of the benefits of the research to participants and streamlining of the design and processes of data collection and intervention to fit in with their work practices. Ultimately deeper engagement may require additional funding and ongoing participation through practice research networks.Trial RegistrationCurrent Controlled Trials ACTRN12605000788673

Facilitating teamwork in general practice: moving from theory to practice

The aims of this paper are to describe the development of an intervention to improve teamwork and systems in general practice that support the care of patients with diabetes, ischaemic heart disease and hypertension and to identify the challenges to implementing the intervention. Effective teamwork in general practice encompasses general practitioners (GP), clinical and non-clinical staff, each with clearly defined roles and opportunities to provide feedback and input into how the practice is run and chronic disease managed. The intervention implemented in this study provided an opportunity for key members of general practice teams to work with a facilitator on changes to improve teamwork over three practice visits over 6–12 months. Facilitators had experience in practice support and goal setting, an understanding of the Medicare Items and knowledge about teamwork and systems. The visits focussed on the specific needs and capacities of each practice, assisting the team to set manageable goals and building systems that best utilise the systemic and human resources available. Successful implementation of sustained change depended on strong leadership in the practice and cooperation between team members as well as clear and achievable goals being set. Structured facilitation of teamwork in general practice should focus on goal setting and the development of leadership and communication rather than delivery of information or resources.

Routine use of clinical management guidelines in Australian general practice.

Significant gaps remain between recommendations of evidence-based guidelines and primary health care practice in Australia. This paper aims to evaluate factors associated with the use of guidelines reported by Australian GPs. Secondary analysis was performed on a survey of primary care practitioners which was conducted by the Commonwealth Fund in 2009: 1016 general practitioners responded in Australia (response rate 52%). Two-thirds of Australian GPs reported that they routinely used evidence-based treatment guidelines for the management of four conditions: diabetes, depression, asthma or chronic obstructive pulmonary disease and hypertension - a higher proportion than in most other countries. Having non-medical staff educating patients about self-management, and a system of GP reminders to provide patients with test results or guideline-based intervention or screening tests, were associated with a higher probability of guidelines use. Older GP age was associated with lower probability of guideline usage. The negative association with age of the doctor may reflect a tendency to rely on experience rather than evidence-based guidelines. The association with greater use of reminders and self-management is consistent with the chronic illness model.

Access to same day, next day and after-hours appointments: the views of Australian general practitioners

OBJECTIVE To evaluate factors associated with the availability of same or next day appointments and after-hours access reported by Australian general practitioners (GPs). METHODS Secondary analysis of a survey of primary care practitioners conducted by the Commonwealth Fund in 2009 in 11 countries. Analysis of factors likely to be associated with reported availability of same or next day appointments and after-hours access. FINDINGS Of 1016 Australian GPs, 78.8% reported that most patients in their practice had access to an appointment on the same or next day and 50% that their practice had arrangements for after-hours access. Access to same or next day care was better in practices where practitioners reported larger numbers of patients seen per GP per week and reviewed their performance against annual targets, but worse in rural areas and practices routinely reviewing outcomes data. Arrangements for after-hours care were more common among GPs who were planning to retire in the next 5 years; worked in practices with high electronic functioning information systems; and received and reviewed clinical outcome data and incentives for performance. CONCLUSIONS Improving after-hours access requires a comprehensive approach which includes incentives, improvements to information management and organised systems of care with review of data on clinical outcomes.

Socio-demographic factors, behaviour and personality: associations with psychological distress

Background: Anxiety, psychological distress and personality may not be independent risk factors for cardiovascular disease; however they may contribute via their relationship with unhealthy lifestyle behaviours. This study aimed to examine the association between psychological distress, risk behaviours and patient demographic characteristics in a sample of general practice patients aged 40–65 years with at least one risk factor for cardiovascular disease. Design: Cross-sectional analytic study. Methods: Patients, randomly selected from general practice records, completed a questionnaire about their behavioural risk factors and psychological health as part of a cluster randomized controlled trial of a general practice based intervention to prevent chronic vascular disease. The Kessler Psychological Distress Score (K10) was the main outcome measure for the multilevel, multivariate analysis. Results: Single-level bi-variate analysis demonstrated a significant association between higher K10 and middle age (p = 0.001), high neuroticism (p = 0), current smoking (p = 0), physical inactivity (p = 0.003) and low fruit and vegetable consumption (p = 0.008). Socioeconomic (SES) indicators of deprivation (employment and accommodation status) were also significantly associated with higher K10 (p = 0). No individual behavioural risk factor was associated with K10 on multilevel multivariate analysis; however indicators of low SES remained significant (p < 0.001). Conclusions: When all factors were considered, psychological distress was not associated with behavioural risk factors for cardiovascular disease. Other underlying factors, such as personality type and socioeconomic status, may be associated with both the behaviours and the distress.