Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis

Individuals from culturally and linguistically diverse backgrounds have more advanced prostate cancer at diagnosis in Victoria, Australia

INTRODUCTION

The Australian Cancer Plan prioritises individuals from culturally and linguistically diverse (CALD) backgrounds as a focus of interventions aimed at improving cancer care experiences and outcomes. We aimed to investigate differences in the National Comprehensive Cancer Network (NCCN) risk category classification at prostate cancer (PCa) diagnosis between CALD and non-CALD populations.

METHODS

We included Victorian Prostate Cancer Outcomes Registry registrants with a PCa diagnosis (February 2009-August 2022) and country-of-birth data. CALD status was defined as birth in a mainly non-English-speaking country (CALD) versus Australia or a mainly English-speaking country (MESC). CALD individuals were further sub-grouped by preferred spoken language: English-speaking and non-English-speaking. We estimated the effect of CALD status on NCCN risk categories using partial proportional ordinal logistic regression.

RESULTS

There were 25,951 individuals: 18,392 (71 %) Australian-born, 5046 (19 %) CALD and 2513 (10 %) MESC-born. Of 4872 CALD individuals with preferred-language data, 498 (10 %) preferred speaking a language other than English. Compared to Australian-born individuals, non-English-speaking CALD individuals presented with less low-risk (15 % vs 22 %) but more high-risk (32 % vs 21 %) and metastatic (18 % vs 8 %) disease. CALD individuals had significantly more advanced (regional or metastatic) disease than Australian-born individuals (adjusted odds ratio [aOR]=1.17, 95 % confidence interval [CI]=1.06-1.29). Non-English-speaking CALD individuals had significantly more advanced PCa (aOR=1.54, 95 % CI=1.23-1.94).

CONCLUSIONS

Individuals from CALD backgrounds had greater odds of presenting with high-risk or advanced PCa. Improving early detection of PCa for CALD individuals requires investigation of underlying factors to plan effective interventions.

'Low-value' clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs' practice

Nonevidence-based and 'low-value' clinical care and medical services are 'questionable' clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with their cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key nonevidence-based or low-value 'questionable' clinical practices. The study was nested in the Registrar Clinical Encounters in Training study-an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on Registrar Clinical Encounters in Training data from 2010 to 2020, was the score on the QUestionable In-Training Clinical Activities Index (QUIT-CAI), which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. A total of 3206 individual registrars (response rate 89.9%) recorded 406 812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15 560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training terms: incidence rate ratios (IRRs) of 0.91 [95% confidence interval (CI) 0.87, 0.95] and 0.85 (95% CI 0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12, 1.45), the patient being of non-English-speaking background (IRR 1.24; 95% CI 1.04, 1.47), the practice being in a higher socioeconomic area decile (IRR 1.01; 95% CI 1.00, 1.02), small practice size (IRR 1.05; 95% CI 1.00, 1.10), shorter consultation duration (IRR 0.99 per minute; 95% CI 0.99, 1.00), and fewer problems addressed in the consultation (IRR 0.84; 95% CI 0.79, 0.89) for each additional problem]. Senior registrars' clinical practice entailed less 'questionable' clinical actions than junior registrars' practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests that continuity should be supported and facilitated during GP training (and in established GPs' practice).

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

BACKGROUND

During vocational general practice training, the content of each trainee's (in Australia, registrars') in-consultation clinical experience is expected to entail a breadth of conditions that exemplify general practice, enabling registrars to gain competency in managing common clinical conditions and common clinical scenarios. Prior to the Registrar Clinical Encounters in Training (ReCEnT) project there was little research into the content of registrars' consultations despite its importance to quality of training. ReCEnT aims to document the consultation-based clinical and educational experiences of individual Australian registrars.

METHODS

ReCEnT is an inception cohort study. It is comprised of closely interrelated research and educational components. Registrars are recruited by participating general practice regional training organisations. They provide demographic information about themselves, their skills, and their previous training. In each of three 6-month long general practice training terms they provide data about the practice where they work and collect data from 60 consecutive patient encounters using an online portal. Analysis of data uses standard techniques including linear and logistic regression modelling. The ReCEnT project has approval from the University of Newcastle Human Research Ethics Committee, Reference H-2009-0323.

DISCUSSION

Strengths of the study are the granular detail of clinical practice relating to patient demographics, presenting problems/diagnoses, medication decisions, investigations requested, referrals made, procedures undertaken, follow-up arranged, learning goals generated, and in-consultation help sought; the linking of the above variables to the presenting problems/diagnoses to which they pertain; and a very high response rate. The study is limited by not having information regarding severity of illness, medical history of the patient, full medication regimens, or patient compliance to clinical decisions made at the consultation. Data is analysed using standard techniques to answer research questions that can be categorised as: mapping analyses of clinical exposure; exploratory analyses of associations of clinical exposure; mapping and exploratory analyses of educational actions; mapping and exploratory analyses of other outcomes; longitudinal 'within-registrar' analyses; longitudinal 'within-program' analyses; testing efficacy of educational interventions; and analyses of ReCEnT data together with data from other sources. The study enables identification of training needs and translation of subsequent evidence-based educational innovations into specialist training of general practitioners.