Neil Spike

Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial

Introduction This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. Methods General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. Results 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN012606000098538

Changes in longer consultations for children in general practice

To determine if the duration of general practitioner (GP) consultations, or the proportional distribution of item numbers associated with longer consultations, with children has changed in association with the demographic changes in Australia.

Problems managed by Australian general practice trainees: results from the ReCenT (Registrar Clinical Encounters in Training) study.

UNLABELLED BACKGROUND Previous studies have found that general practitioner (GP) trainees (registrars) see a different spectrum of clinical problems compared to trainers, including less chronic disease and more acute minor illness. Our aim was to describe the case mix of first-term Australian GP trainees. METHODS This was a cross-sectional analysis of trainee consultations. Descriptive analyses were used to report patient demographics and the number and type of problems managed. RESULTS Two-hundred-and-three trainees provided data on 36182 consultations and 55740 problems. Overall, 60.7% of patients seen were female and 56.2% were new to the trainee. Trainees managed a mean of 154.1 problems per 100 encounters. Problems managed most commonly were respiratory (23.9 per 100 encounters), general/unspecified (21.8) and skin (16.4). New problems comprised 51.5% of the total, and 22.4% of problems were chronic diseases. CONCLUSION Trainees gain reasonably broad exposure overall in terms of patient demographics and problems managed. In comparison to established GPs, trainees managed the same mean number of problems, but the nature of problems managed was different, with more new patients, more new problems and less chronic disease. Our findings have significant implications for GP training in Australia.

Actual availability of general practice appointments for mildly ill children.

Objective: To determine actual availability and cost of general practitioner appointments for children with conditions of low acuity and low urgency, from the perspective of the childs family.

Family medicine trainees’ clinical experience of chronic disease during training: a cross-sectional analysis from the registrars’ clinical encounters in training study

BackgroundA broad case-mix in family physicians’ (general practitioners’, GPs’) vocational trainee experience is deemed essential in producing competent independent practitioners. It is suggested that the patient-mix should include common and significant conditions and be similar to that of established GPs. But the content of contemporary GP trainees’ clinical experience in training is not well-documented. In particular, how well trainees’ experience reflects changing general practice demographics (with an increasing prevalence of chronic disease) is unknown. We aimed to establish levels of trainees’ clinical exposure to chronic disease in training (and associations of this exposure) and to establish content differences in chronic disease consultations (compared to other consultations), and differences in trainees’ actions arising from these consultations.MethodsA cross-sectional analysis from the Registrars’ Clinical Encounters in Training (ReCEnT) study, a cohort study of GP registrars’ (trainees’) consultations in four Australian GP training organisations. Trainees record detailed data from 60 consecutive consultations per six-month training term. Diagnoses/problems encountered are coded using the International Classification of Primary Care-2 PLUS (ICPC-2 PLUS). A classification system derived from ICPC-2 PLUS was used to define diagnoses/problems as chronic/non-chronic disease. The outcome factor for analyses was trainees’ consultations in which chronic disease was encountered. Independent variables were a range of patient, trainee, practice, consultation and educational factors.ResultsOf 48,112 consultations (of 400 individual trainees), 29.5% included chronic disease problems/diagnoses. Associations of a consultation including chronic disease were the patient being older, male, and having consulted the trainee previously, and the practice routinely bulk-billing (not personally charging) patients. Consultations involving a chronic disease lasted longer, dealt with more problems/diagnoses, and were more likely to result in specialist referrals and trainees generating a personal learning goal. They were associated with less pathology tests being ordered.ConclusionsTrainees saw chronic disease less frequently than have established GPs in comparable studies. The longer duration and more frequent generation of learning goals in chronic disease-containing consultations suggest trainees may find these consultations particularly challenging. Our findings may inform the design of measures aimed at increasing the chronic disease component of trainees’ patient-mix.

Continuity of care in general practice vocational training: prevalence, associations and implications for training

Abstract Continuity of care is a defining characteristic of general practice. Practice structures may limit continuity of care experience for general practice registrars (trainees). This study sought to establish prevalence and associations of registrars’ continuity of care. We performed an analysis of an ongoing cohort study of Australian registrars’ clinical consultations. Primary outcome factors were ‘Upstream’ continuity (having seen the patient prior to the index consultation) and ‘Downstream’ continuity (follow-up organised post-index consultation). Independent variables were registrar, practice, patient, consultation and educational factors. 400 registrars recorded 48,114 consultations. 43% of patients had seen the registrar pre-index consultation, and 49% had follow-up organised. ‘Upstream’ continuity associations included registrar seniority, Australian medical qualification, practice billing policy, smaller practice size, registrar’s previous training in the practice, chronic disease and older, female patients (but not registrar full-time/part-time status). Associations of ‘Downstream’ continuity included non-Australian qualification, billing, chronic disease and the patient having seen the registrar previously. Consultations prompting follow-up were more complex: longer duration, involving more problems and generating more learning goals. There was, however, evidence for limited educational utility of this ‘continuity’. In our study, continuity of care in Australian registrars’ training experience is modest. Associations are complex, but may inform initiatives to increase in-training continuity.

Does brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners.

Abstract We aimed to evaluate the effect of pain education on opioid prescribing by early-career general practitioners. A brief training workshop was delivered to general practice registrars of a single regional training provider. The workshop significantly reduced “hypothetical” opioid prescribing (in response to paper-based vignettes) in an earlier evaluation. The effect of the training on “actual” prescribing was evaluated using a nonequivalent control group design nested within the Registrar Clinical Encounters in Training (ReCEnT) cohort study: 4 other regional training providers were controls. In ReCEnT, registrars record detailed data (including prescribing) during 60 consecutive consultations, on 3 occasions. Analysis was at the level of individual problem managed, with the primary outcome factor being prescription of an opioid analgesic and the secondary outcome being opioid initiation. Between 2010 and 2015, 168,528 problems were recorded by 849 registrars. Of these, 71% were recorded by registrars in the nontraining group. Eighty-two percentages were before training. Opioid analgesics were prescribed in 4382 (2.5%, 95% confidence interval [CI]: 2.40-2.63) problems, with 1665 of these (0.97%, 95% CI: 0.91-1.04) representing a new prescription. There was no relationship between the training and total prescribing after training (interaction odds ratio: 1.01; 95% CI: 0.75-1.35; P value 0.96). There was some evidence of a reduction in initial opioid prescriptions in the training group (interaction odds ratio: 0.74; 95% CI: 0.48-1.16; P value 0.19). This brief training package failed to increase overall opioid cessation. The inconsistency of these actual prescribing results with “hypothetical” prescribing behavior suggests that reducing opioid prescribing in chronic noncancer pain requires more than changing knowledge and attitudes.

Anticholinergic medicines in an older primary care population: a cross-sectional analysis of medicines' levels of anticholinergic activity and clinical indications.

Adverse clinical outcomes have been associated with cumulative anticholinergic burden (to which low‐potency as well as high‐potency anticholinergic medicines contribute). The clinical indications for which anticholinergic medicines are prescribed (and thus the ‘phenotype’ of patients with anticholinergic burden) have not been established. We sought to establish the overall prevalence of prescribing of anticholinergic medicines, the prevalence of prescribing of low‐, medium‐ and high‐potency anticholinergic medicines, and the clinical indications for which the medicines were prescribed in an older primary care population.

How we use patient encounter data for reflective learning in family medicine training

Abstract Introduction: Consulting with patients is the core learning activity of Australian family medicine (general practice/GP) training, providing a rich source of reflective learning for trainees. We have developed a reflective learning program for postgraduate vocational trainees based on clinical encounters. Methods: The Registrar Clinical Encounters in Training (ReCEnT) program is an educational program documenting GP trainees’ consultations in five Australian GP training providers. Trainees record patient demographics, consultation details, problems managed, management practices and educational factors from sixty consecutive consultations per six-month training term. Trainees receive a detailed feedback report comparing individual data to aggregated trainee data and national GP data. Results: The patient encounter system provides multiple opportunities for reflective learning across a number of domains of exposure and practice. Reflection can occur during completion of the encounter form; as self-reflection on the feedback report; as facilitated reflection with the GP trainer and medical educator; and as part of integration of data into teaching. We have identified areas for further development, including enhancing the reflective skills of trainees and trainers. Conclusion: The ReCEnT patient encounter program provides a rich platform for reflective learning for vocational trainees and supports development of skills in lifelong learning.

Parental preferences for paediatric specialty follow-up care

Objective The aim of the present study was to examine factors associated with: (1) parental preference to receive follow-up care for their child from a general practitioner (GP); and (2) a decision to seek treatment when there is a slight worsening of their childs condition. Methods Parents presenting with their child at any one of five paediatric out-patient clinics at two public hospitals in Melbourne (Vic., Australia) were surveyed. We performed frequency distributions, bivariate analyses and multivariate logistic regression to evaluate associations with the preference for a GP for follow-up care and treatment in case of a slight worsening. Results In all, 606 parents were recruited to the study, 283 being new presentations and 323 presenting for review. GPs were selected as the preference for follow-up care by 23% (n=142) of respondents, and 26% (n=160) reported they would seek treatment from a GP if the condition of their child were to worsen slightly. There was an increased likelihood to prefer a GP for follow-up care for new patients (odds ratio (OR) 3.10; 95% confidence interval (CI) 1.99-4.83), those attending general paediatrics clinic (OR 1.73; 95% CI 1.11-2.70), and parents with a lower level of education (OR 1.74; 95% CI 1.09-2.78). For review patients, if during the previous visit a paediatrician suggested follow-up with a GP, parents were more likely to prefer a GP as a follow-up provider (OR 6.70; 95% CI 3.42-13.10) and to seek treatment from a GP in case of a slight worsening (OR 1.86; 95% CI 1.03-3.37). Conclusion Most parents attending paediatric out-patient appointments prefer to return for follow-up care; however, a paediatricians advice may have an important role in return of paediatric patients to primary care. What is known about the topic? In Australia, there has been a growing concern regarding long waiting times for specialist consultations in out-patient clinics and difficulties with access for new patients. This has occurred when the ratio of review attendees to new patients has tipped towards the review attendees. What does this paper add? Most parents of children attending paediatric out-patient clinics value follow-up care with paediatric specialists, even if the referring GP requested a return to their surgery. The advice of the consulting paediatrician in support of follow-up care with a GP contributes significantly to the willingness of parents to return to primary care and to seek treatment from their GP for a slight worsening of their childs condition. What are the implications for practitioners? The findings of the present study have significant implications for the discharge of patients from speciality care: paediatricians can have an important role in the return of paediatric patients to primary care.