Tom Brett

Multimorbidity in patients attending 2 Australian primary care practices.

PURPOSE Multiple chronic conditions in a single patient can be a challenging health burden. We aimed to examine patterns and prevalence of multimorbidity among patients attending 2 large Australian primary care practices and to estimate disease severity burden using the Cumulative Illness Rating Scale (CIRS). METHODS Using published CIRS guidelines and a disease severity index calculated for each individual, we extracted data from the medical records of all 7,247 patients (58.5% female) seen over 6 months in 2008 who were rated for chronic conditions across 14 anatomical domains. RESULTS Fifty-two percent of patients had multimorbidity in 2 or more CIRS domains, ranging from 20.6% if younger than 25 years, 43.7% if aged 25 to 44 years, 75.5% if aged 45 to 64 years, 87.5% if aged 65 to 74 years, and 97.1% if aged 75 years and older. Using a cutoff of 3 or more CIRS domains, 34.5% had multimorbidity ranging from 4.8% if younger than 25 years, 22.3% if aged 25 to 44 years, 56.1% if aged 45 to 64 years, 74.6% if aged 65 to 74 years, and 92.0% if aged 75 years and older. Musculoskeletal, singularly or in combination with others, was the commonest morbidity domain. The moderate severity index category increased with increasing age. CONCLUSIONS Multimorbidity is a significant problem in men and women across all age-groups, and the moderate severity index increases with age. The musculoskeletal domain was most commonly affected. Mild and moderate severity index categories may underrepresent disease burden. Severity burden assessment in the primary care setting needs to take into account the severity index, as well as levels of domain severity within the index categories.

A new electronic screening tool for identifying risk of familial hypercholesterolaemia in general practice

Objective To evaluate the performance of a new electronic screening tool (TARB-Ex) in detecting general practice patients at potential risk of familial hypercholesterolaemia (FH). Methods Medical records for all active patients seen between 2012 and 2014 (n=3708) at a large general practice in Perth, Western Australia were retrospectively screened for potential FH risk using TARB-Ex. Electronic extracts of medical records for patients identified with potential FH risk (defined as Dutch Lipid Clinic Network Criteria (DLCNC) score ≥5) through TARB-Ex were reviewed by a general practitioner (GP) and lipid specialist. High-risk patients were recalled for clinical assessment to determine phenotypic FH diagnosis. Performance was evaluated against a manual record review by a GP in the subset of 360 patients with high blood cholesterol (cholesterol ≥7 mmol/L or low-density lipoprotein cholesterol ≥4.0 mmol/L). Results Thirty-two patients with DLCNC score ≥5 were identified through electronic screening compared with 22 through GP manual review. Sensitivity was 95.5% (95% CI 77.2% to 99.9%), specificity was 96.7% (95% CI 94.3% to 98.3%), negative predictive accuracy was 99.7% (95% CI 98.3% to 100%) and positive predictive accuracy was 65.6% (95% CI 46.9% to 8%). Electronic screening was completed in 10 min compared with 60 h for GP manual review. 10 of 32 patients (31%) were considered high risk and recalled for clinical assessment. Six of seven patients (86%) who attended clinical assessment were diagnosed with phenotypic FH on examination. Conclusions TARB-Ex screening is a time-effective and cost-effective method of systematically identifying potential FH risk patients from general practice records for clinical follow-up.

Multimorbidity in a marginalised, street-health Australian population: a retrospective cohort study.

Objectives Demographic and presentation profile of patients using an innovative mobile outreach clinic compared with mainstream practice. Design Retrospective cohort study. Setting Primary care mobile street health clinic and mainstream practice in Western Australia. Participants 2587 street health and 4583 mainstream patients. Main outcome measures Prevalence and patterns of chronic diseases in anatomical domains across the entire age spectrum of patients and disease severity burden using Cumulative Illness Rating Scale (CIRS). Results Multimorbidity (2+ CIRS domains) prevalence was significantly higher in the street health cohort (46.3%, 1199/2587) than age–sex-adjusted mainstream estimate (43.1%, 2000/4583), p=0.011. Multimorbidity prevalence was significantly higher in street health patients <45 years (37.7%, 615/1649) compared with age–sex-adjusted mainstream patients (33%, 977/2961), p=0.003 but significantly lower if 65+ years (62%, 114/184 vs 90.7%, 322/355, p<0.001). Controlling for age and gender, the mean CIRS Severity Index score for street health (M=1.4, SD=0.91) was significantly higher than for mainstream patients (M=1.1, SD=0.80), p<0.001. Furthermore, 44.2% (530/1199) of street health patients had at least one level 3 or 4 score across domains compared with 18.3% (420/2294) for mainstream patients, p<0.001. Street health population comprised 29.6% (766/2587) Aboriginal patients with 50.4% (386/766) having multimorbidity compared with 44.6% (813/1821) for non-Aboriginals, p=0.007. There were no comprehensive data on Indigenous status in the mainstream cohort available for comparison. Musculoskeletal, respiratory and psychiatric domains were most commonly affected with multimorbidity significantly associated with male gender, increasing age and Indigenous status. Conclusions Age–sex-adjusted multimorbidity prevalence and disease severity is higher in the street health cohort. Earlier onset (23–34 years) multimorbidity is found in the street health cohort but prevalence is lower in 65+ years than in mainstream patients. Multimorbidity prevalence is higher for Aboriginal patients of all ages.

Challenges in the care of familial hypercholesterolemia: a community care perspective

Familial hyperchoelsterolaemia (FH) remains under-diagnosed and under-treated in the community setting. Earlier evidence suggested a prevalence of 1:500 worldwide but newer evidence suggests it is more common. Less than 15% of FH patients are ever diagnosed, with children and young adults rarely tested despite having the most to gain given their lifetime exposure. Increasing awareness among primary care teams is critical to improve the detection profile for FH. Cascade testing in the community setting needs a sustainable approach to be developed to facilitate family tracing of index cases. The use of the Dutch Lipid Clinic Network Criteria score to facilitate a phenotypic diagnosis is the preferred approach adopted in Australia and eliminates the need to undertake genetic testing for all suspected FH cases.

An approach to functional abdominal pain in children and adolescents

For children with chronic abdominal pain, the early introduction of stress as a potential cause is likely to improve outcome. Parents underestimate their childs awareness of and capacity to worry about everyday events. Parents, children, and teachers need to be convinced that functional symptoms are a normal feature of life. The need for empathy and quality discussion between doctor, parents, and child concerning potential causes of stress is critical. All reinforcement should be removed including insistence on continued school attendance. Cognitive behavioural therapy appears to be helpful in resistant cases. Medication such as antidepressants should be avoided unless prescribed by a child psychiatrist.

Beyond cascade screening: detection of familial hypercholesterolaemia at childhood immunization and other strategies

Purpose of review Familial hypercholesterolaemia is a common genetic disorder that accelerates premature coronary heart disease. Although effective treatments are available, the majority of individuals remain undiagnosed. We review new evidence for improving the detection of familial hypercholesterolaemia. Recent findings Recent studies have demonstrated that universal screening of children for familial hypercholesterolaemia may be highly effective at the time of immunization if combined with reverse cascade testing of adult family members, who have a more immediate risk of a coronary event. Alerts on laboratory reports and the application of bioinformatics to electronic health records may also be useful for identifying familial hypercholesterolaemia in community settings. Effective detection, diagnosis, and codification of familial hypercholesterolaemia are essential for the development of registries. Summary Although the cost-effectiveness of screening programs for familial hypercholesterolaemia in childhood remains to be established, combining universal and reverse cascade screening, complemented by opportunistic identification of individuals in high-risk settings, use of laboratory alerts, and screening of electronic health records are likely to have a high yield in the detection of familial hypercholesterolaemia in the community.

Perceptions of barriers to discussing and testing for sexually transmitted infections in a convenience sample of general practice patients

We aimed to identify patient perceptions of barriers to discussing sexually transmitted infections (STIs) at the primary care level. An anonymous questionnaire was available to patients (16-70 years) in the waiting room of four metropolitan Perth general practices. Results are based on 370 participant views (9.5% of the potential target population). Patients felt comfortable discussing STIs with their general practitioner (GP) and their level of comfort would be enhanced if they knew their GP had a special interest or qualification in sexual health. Willingness to discuss issues increased or remained unchanged if the GP took time to explain it to them or was a good listener. Patients were willing to discuss STIs if they were a new patient and irrespective of the GPs gender and age. Fewer patients were willing to discuss STIs if they knew the GP socially. Patients who had sex with a new partner were willing to request a STI test from their GP. Patients were not embarrassed if discussion was initiated in a consultation unrelated to sexual health and did not mind discussing the topic in the presence of a partner or parent, though this depended on circumstances. Waiting room STI test advertising did not affect patient comfort level. Patients would involve their GP when seeking information about STIs. Patients have fewer barriers to discussing sexual health matters than perceived by GPs.

Detection and management of familial hypercholesterolaemia in primary care in Australia: protocol for a pragmatic cluster intervention study with pre-post intervention comparisons

Introduction Familial hypercholesterolaemia (FH), an autosomal dominant disorder of lipid metabolism, results in accelerated onset of atherosclerosis if left untreated. Lifelong treatment with diet, lifestyle modifications and statins enable a normal lifespan for most patients. Early diagnosis is critical. This protocol trials a primary care-based model of care (MoC) to improve detection and management of FH. Methods and analysis Pragmatic cluster intervention study with pre-post intervention comparisons in Australian general practices. At study baseline, current FH detection practice is assessed. Medical records over 2 years are electronically scanned using a data extraction tool (TARB-Ex) to identify patients at increased risk. High-risk patients are clinically reviewed to provide definitive, phenotypic diagnosis using Dutch Lipid Clinic Network Criteria. Once an index family member with FH is identified, the primary care team undertake cascade testing of first-degree relatives to identify other patients with FH. Management guidance based on disease complexity is provided to the primary care team. Study follow-up to 12 months with TARB-Ex rerun to identify total number of new FH cases diagnosed over study period (via TARB-Ex, cascade testing and new cases presenting). At study conclusion, patient and clinical staff perceptions of enablers/barriers and suggested improvements to the approach will be examined. Resources at each stage will be traced to determine the economic implications of implementing the MoC and costed from health system perspective. Primary outcomes: increase in number of index cases clinically identified; reduction in low-density lipoprotein cholesterol of treated cases. Secondary outcomes: increase in the number of family cases detected/contacted; cost implications of the MoC. Ethics and dissemination Study approval by The University of Notre Dame Australia Human Research Ethics Committee Protocol ID: 0 16 067F. Registration: Australian New Zealand Clinical Trials Registry ID: 12616000630415. Information will be disseminated via research seminars, conference presentations, journal articles, media releases and community forums. Trial registration number Australian New Zealand Clinical Trials Registry ID 12616000630415; Pre-results.

Multimorbidity in patients enrolled in a community-based methadone maintenance treatment programme delivered through primary care

Background Multimorbidity, the co-existence of two or more (2+) long-term conditions in an individual, is common among problem drug abusers. Objective To delineate the patterns, multimorbidity prevalence, and disease severity in patients enrolled in a community-based primary care methadone maintenance treatment (MMT) programme. Design This was a retrospective cohort study (n=274). The comparator group consisted of mainstream primary care patients. Electronic medical record assessment was performed using the Cumulative Illness Rating Scale. Results Prevalence of multimorbidity across 2+ domains was significantly higher within the MMT sample at 88.7% (243/274) than the comparator sample at 51.8% (142/274), p<0.001. MMT patients were seven times more likely to have multimorbidity across 2+ domains compared with mainstream patients (OR 7.29, 95% confidence interval 4.68–11.34; p<0.001). Prevalence of multimorbidity was consistently high across all age groups in the MMT cohort (range 87.8–100%), while there was a positive correlation with age in the comparator cohort (r=0.29, p<0.001). Respiratory, psychiatric, and hepatic–pancreatic domains were the three most common domains with multimorbidity. Overall, MMT patients (mean±SD, 1.97±0.43) demonstrated significantly higher disease severity than mainstream patients (mean±SD, 1.18±0.78), p<0.001. Prevalence of moderate disease severity observed in the <45-year MMT age group was 50% higher than the ≥45-year comparator age group. Conclusions Prevalence of multimorbidity and disease severity in MMT patients was greater than in the age- and sex-matched comparators. Patients with a history of drug abuse require co-ordinated care for treatment of their addiction, and to manage and prevent chronic illnesses. Community-based programmes delivered through primary care help fulfil this need.

Screening for familial hypercholesterolaemia in primary care: Time for general practice to play its part

Fifty per cent of first-degree relatives of index cases with familial hypercholesterolemia (FH) inherit the disorder. Despite cascade screening being the most cost-effective method for detecting new cases, only a minority of individuals with FH are currently identified. Primary care is a key target area to increase identification of new index cases and initiate cascade screening, thereby finding close relatives of all probands. Increasing public and health professional awareness about FH is essential. In the United Kingdom and in Australia, most of the population are reviewed by a General Practitioner (GP) at least once over a three-year period, offering opportunities to check for FH as part of routine clinical consultations. Such opportunistic approaches can be supplemented by systematically searching electronic health records with information technology tools that identify high risk patients. GPs can help investigate and implement results of this data retrieval. Current evidence suggests that early detection of FH and cascade testing meet most of the criteria for a worthwhile screening program. Among heterozygous patients the long latent period before the expected onset of coronary artery disease provides an opportunity for initiating effective drug and lifestyle changes. The greatest challenge for primary care is to implement an efficacious model of care that incorporates sustainable identification and management pathways.