Susan Goode

Study protocol: The registrar clinical encounters in training (ReCEnT) study

BackgroundPatient encounters are the core learning activity of Australian general practice (family practice) training. Exposure to patient demographics and presentations may vary from one general practice registrar (vocational trainee) to another. This can affect comprehensiveness of training. Currently, there is no mechanism to systematically capture the content of GP registrar consultations. The aim of the Registrar Clinical Encounters in Training (ReCEnT) study is to document longitudinally the nature and associations of consultation-based clinical and educational experiences of general practice registrars.Methods/designThis is an ongoing prospective multi-site cohort study of general practice registrars’ consultations, entailing paper-based recording of consultation data. The study setting is general practices affiliated with three geographically-based Australian general practice regional training providers. Registrars record details of 60 consecutive consultations. Data collected includes registrar demographics, details of the consultation, patient demographics, reasons for encounter and problems managed. Problems managed are coded with the International Classification of Primary Care (second edition) classification system. Additionally, registrars record educational factors related to the encounter. The study will follow the clinical exposure of each registrar six-monthly over the 18 months to two years (full-time equivalent) of their general practice training program.ConclusionsThe study will provide data on a range of factors (patient, registrar and consultation factors). This data will be used to inform a range of educational decisions as well as being used to answer educational research questions. We plan to use ReCEnT as a formative assessment tool for registrars and help identify and address educational needs. The study will facilitate program evaluation by the participating training providers and thus improve articulation of educational programs with practice experience. From the research point of view it will address an evidence gap – the in-practice clinical and educational experience of general practice trainees, determinants of these experiences, and the determinants of registrars’ patterns of practice (for example, prescribing practice) over the course of their training.

A cross‐sectional study of psychological morbidity in patients with acne, psoriasis and atopic dermatitis in specialist dermatology and general practices

Background  There is considerable evidence for an association of skin diseases with psychological morbidity. This relationship is best established for acne, psoriasis and atopic eczema. Previous studies have mostly been performed in specialist dermatological practice, and there is a lack of studies that include patients from general practice and a lack of controlled studies employing multivariate analysis.

Correlation and agreement of self-assessed and objective skin disease severity in a cross-sectional study of patients with acne, psoriasis, and atopic eczema.

Background  Previous studies have shown variable correlation of patients’ self‐assessed skin severity measures and clinician‐assessed objective measures of severity. But, generally, correlation has not been as good as might be expected for conditions in which the objective physical extent of skin disease is apparent to the sufferer to an extent that is not applicable in many other diseases.

Occupational violence in general practice: a whole-of-practice problem. Results of a cross-sectional study.

OBJECTIVE To examine the experiences of occupational violence in general practitioner (GP) and non-GP staff. Further objectives were to compare prevalence of violence in GP and non-GP staff and to examine levels of apprehension and perceptions of control over violence. DESIGN Cross-sectional questionnaire-based study. SETTING A network of research general practices, New South Wales, Australia. PARTICIPANTS GPs and non-GP staff--receptionist, practice-management, nursing and allied health staff. MAIN OUTCOME MEASURE(S) Experience of occupational violence during the previous 12 months. Other outcomes examined were workplace apprehension regarding violence, perception of occupational violence as a problem in general practice, and perception of control over violence in the workplace. RESULTS A total of 125 questionnaire replies were received (response rate 55%), 59.3% of GPs and 74.6% of non-GPs had experienced work-related violence during the previous 12 months. The difference was not significant (OR 0.65, 95% CI 0.20-2.06). Subjects in rural practices were more likely than those in urban practices to have experienced violence (OR 3.79, 95% CI 1.15-12.5). Personal experience of violence (OR 35.9, 95% CI 6.24-207) and a perception that violence is increasing (OR 8.33, 95% CI 1.89-36.6) were associated with apprehension regarding violence at work.

Acne's relationship with psychiatric and psychological morbidity: results of a school-based cohort study of adolescents.

Background  There is a considerable number of studies linking acne with psychological and psychiatric morbidities, although this literature is not entirely consistent and is largely cross‐sectional in methodology.

GPs, medications and older people: A qualitative study of general practitioners' approaches to potentially inappropriate medications in older people

To explore the prescribing, and the rationale for this prescribing, of potentially inappropriate medications (PIMs) in older persons by Australian general practitioners (GPs).

Diagnosis and disclosure of a memory problem is associated with quality of life in community based older Australians with dementia.

BACKGROUND Identification of factors associated with quality of life (QoL) in people having dementia will help develop strategies for maintenance and improvement of patient QoL. This study examined the predictors of QoL in a community-dwelling population aged 75 years and over, with or without dementia. METHODS This was a cross-sectional study involving 169 GPs and 2,028 patients. Patients were interviewed to collect information on personal circumstances. Several instruments were administered including the WHOQOL-BREF (quality of life outcome measure), Geriatric Depression Scale, GPAQ (satisfaction with GP care), and the CAMCOG-R (cognitive function). Patients with a CAMCOG-R score < 80 were allocated to the dementia group. GPs provided an independent clinical judgment of cognitive function for each of their participating patients. RESULTS The dementia group had significantly lower QoL scores in all four domains of the WHOQOL-BREF (all p ≤ 0.002). The GDS score was negatively correlated with all four domains in the non-dementia group and with physical, psychological, and environmental QoL in the dementia group (all p < 0.001). Satisfaction with GP communication was positively associated with psychological QoL in the dementia group and all domains in the non-dementia group. Participants in the dementia group who had been given a diagnosis of a memory problem had significantly higher physical (2.05, 95% CI 0.36 to 3.74) and environmental (2.18, 95% CI 0.72 to 3.64) QoL. CONCLUSIONS Satisfaction with GP communication is associated with a higher QoL in their older patients. Diagnosis and disclosure of memory problems is associated with better QoL in people with dementia. Clinicians should not be deterred from discussing a memory diagnosis and plans for the future with patients.

An Evaluation of the Prescription of Opioids for Chronic Nonmalignant Pain by Australian General Practitioners

OBJECTIVE Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). DESIGN An anonymous, cross-sectional questionnaire-based survey. SETTING The setting was five Australian divisions of general practice (geographically based associations of GPs). METHODS A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. RESULTS We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (±8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. CONCLUSIONS In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions.

Reliability of skin‐type self‐assessment: agreement of adolescents’ repeated Fitzpatrick skin phototype classification ratings during a cohort study

Background  The Fitzpatrick Skin Phototype Classification (FSPC) is the most commonly used measure of skin type. In questionnaire‐based surveys, self‐rated FSPC is often used as a measure of respondents’ skin type.

Referral and triage of patients with transient ischemic attacks to an acute access clinic: risk stratification in an Australian setting.

Background Transient ischemic attacks and minor stroke entail considerable risk of completed stroke but this risk is reduced by prompt assessment and treatment. Risk can be stratified according to the ABCD2 prediction score. Current guidelines suggest specialist assessment and treatment within 24 h for high-risk event (ABCD2 score 4–7) and seven-days for low-risk event (ABCD2 score ≤ 3). Aims The study aims to establish paths to care and outcomes for patients referred by general practitioners and emergency departments to an Australian acute access transient ischemic attack service. Methods This is a prospective audit. Primary outcomes were time from event to referral, from referral to clinic appointment, and from event to appointment. ABCD2 score was calculated for each event. Time from event was modeled using Cox proportional hazards regression. Results There were 231 clinic attendees (general practitioner: 127; emergency department: 104). Mean time from event to referral was 9·2 days (SD 23·7, median 2), from referral to being seen in the clinic was 13·6 days (SD 19·0, median 7), and from event to being seen in the clinic was 17·2 days (SD 27·1, median 10). Of low-risk patients, 38·5% were seen within seven-days of event. Of high-risk patients, 36·7% were seen within one-day. ABCD2 score was not a significant predictor of any time interval from event to clinic attendance. There were no completed strokes prior to clinic attendance. Conclusions Times from event to clinic assessment were in excess of current recommendations and risk stratification was suboptimal, though short-term outcomes were good. Improvements in referral mechanisms may enhance risk-stratification and triage.