Burden of antimicrobial prescribing in primary care attributable to sore throat: a retrospective cohort study of patient record data

BACKGROUND

Reducing antibiotic use in Australia, and the subsequent impact on antimicrobial resistance, requires multiple, sustained approaches with appropriate resources and support. Additional strategies to reduce antibiotic prescribing include effective vaccines, against pathogens such as Streptococcus pyogenes, the most common bacterial cause of sore throat. As part of efforts towards assessing the benefits of introducing new strategies to reduce antimicrobial prescribing, we aimed to determine the burden of antimicrobial prescribing for sore throat in general practice.

METHODS

General practice activity data from 2013 - 2017 derived from the first 8 practices participating in the 'Primary Care Audit, Teaching and Research Open Network' (Patron) program were analysed according to reason for visit (upper respiratory tract infection, URTI, or sore throat) and antibiotic prescription. The main outcome measures were percentage of sore throat or URTI presentations with antibiotic prescription by age.

RESULTS

A total of 722,339 visits to general practice were made by 65,449 patients; 5.7% of visits were for URTI with 0.8% meeting the more specific criteria for sore throat. 66.1% of sore throat visits and 36.2% of URTI visits resulted in antibiotic prescription. Penicillin, the recommended antibiotic for sore throat when indicated, was the antibiotic of choice in only 52.9% of sore throat cases prescribed antibiotics. Broader spectrum antibiotics were prescribed more frequently in older age groups.

CONCLUSIONS

Frequency of antibiotic prescribing for sore throat is high and broad, despite Australian Therapeutic guideline recommendations. Multiple, sustained interventions to reduce prescribing, including availability of effective S. pyogenes vaccines that could reduce the incidence of streptococcal pharyngitis, could obviate the need to prescribe antibiotics and support ongoing efforts to promote antimicrobial stewardship.

Effect of the COVID-19 pandemic on mental health visits in primary care: an interrupted time series analysis from nine INTRePID countries

Background

The COVID-19 pandemic impacted mental health disorders, affecting both individuals with pre-existing conditions and those with no prior history. However, there is limited evidence regarding the pandemic's impact on mental health visits to primary care physicians. The International Consortium of Primary Care Big Data Researchers (INTRePID) explored primary care visit trends related to mental health conditions in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden, and the USA.

Methods

We conducted an interrupted time series analysis in nine countries to examine changes in rates of monthly mental health visits to primary care settings from January 1st, 2018, to December 31st, 2021. Sub-group analysis considered service type (in-person/virtual) and six categories of mental health conditions (anxiety/depression, bipolar/schizophrenia/other psychotic disorders, sleep disorders, dementia, ADHD/eating disorders, and substance use disorder).

Findings

Mental health visit rates increased after the onset of the pandemic in most countries. In Argentina, Canada, China, Norway, Peru, and Singapore, this increase was immediate ranged from an incidence rate ratio of 1·118 [95% CI 1.053-1.187] to 2.240 [95% CI 2.057-2.439] when comparing the first month of pandemic with the pre-pandemic trend. Increases in the following months varied across countries. Anxiety/depression was the leading reason for mental health visits in most countries. Virtual visits were reported in Australia, Canada, Norway, Peru, Sweden, and the USA, accounting for up to 40% of the total mental health visits.

Interpretation

Findings suggest an overall increase in mental health visits, driven largely by anxiety/depression. During the COVID-19 pandemic, many of the studied countries adopted virtual care in particular for mental health visits. Primary care plays a crucial role in addressing mental ill-health in times of crisis.

Funding

Canadian Institutes of Health Research grant #173094 and the Rathlyn Foundation Primary Care EMR Research and Discovery Fund.

Implementing a Sodium-Glucose Cotransporter 2 Inhibitor Module With a Software Tool (Future Health Today): Qualitative Study

BACKGROUND

Primary care plays a key role in the management of type 2 diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce hospitalization and cardiac and renal complications. Tools that optimize management, including appropriate prescribing, are a priority for treating chronic diseases. Future Health Today (FHT) is software that facilitates clinical decision support and quality improvement. FHT applies algorithms to data stored in electronic medical records in general practice to identify patients who are at risk of a chronic disease or who have a chronic disease that may benefit from intensification of management. The platform continues to evolve because of rigorous evaluation, continuous improvement, and expansion of the conditions hosted on the platform. FHT currently displays recommendations for the identification and management of chronic kidney disease, cardiovascular disease, type 2 diabetes, and cancer risk. A new module will be introduced to FHT focusing on SGLT2 inhibitors in patients with type 2 diabetes who have chronic kidney diseases, cardiovascular diseases, or risk factors for cardiovascular disease.

OBJECTIVE

The study aims to explore the barriers and enablers to the implementation of an SGLT2 inhibitor module within the Future Health Today software.

METHODS

Clinic staff were recruited to participate in interviews on their experience in their use of a tool to improve prescribing behavior for SGLT2 inhibitors. Thematic analysis was guided by Clinical Performance Feedback Intervention Theory.

RESULTS

In total, 16 interviews were completed. Identified enablers of use included workflow alignment, clinical appropriateness, and active delivery of the module. Key barriers to use were competing priorities, staff engagement, and knowledge of the clinical topic.

CONCLUSIONS

There is a recognized benefit to the use of a clinical decision support tool to support type 2 diabetes management, but barriers were identified that impeded the usability and actionability of the module. Successful and effective implementation of this tool could support the optimization of patient management of type 2 diabetes in primary care.

Interventions in adult patients with multimorbidity in low-income and middle-income countries: protocol for a mixed-methods systematic review

INTRODUCTION

Multimorbidity, the coexistence of two or more chronic conditions in the same individual, is a major public health problem in low-income and middle-income countries (LMICs). The use of single-disease guidelines contributes to polypharmacy, fragmented care and increased treatment burden. Health systems in LMICs are very different from those in high-income countries, and adapting interventions from one to the other may not be feasible. This review aims to systematically present the current evidence for interventions for multimorbidity in the LMIC setting.

METHODS AND ANALYSIS

In this mixed-methods systematic review, we will include all studies of interventions for the care of adults (>18 years of age) with multimorbidity (defined as the presence of two or more chronic illnesses in an individual) in any healthcare organisation (primary, secondary or tertiary care) in an LMIC (as defined by the World Bank), published between 2000 and March 2023. All primary study designs will be included. Studies reported in languages other than English and those describing interventions classified as 'financial' or 'governance arrangement' according to the Cochrane Effective Practice and Organisation of Care classification will be excluded. MEDLINE, PubMed, Cochrane Library, TRIP, SCOPUS and the 3ie databases will be searched. The titles will be screened by one author, and two authors will independently screen all included abstracts and full texts. A third author will resolve conflicts at every stage. Studies will be reviewed for quality of evidence using appropriate tools. Epidemiological, intervention and outcome data will be extracted and summarised. Outcomes of interest for LMICs defined by the Global Alliance for Chronic Diseases research group will be analysed. Subgroup analysis according to study types and study settings will be done.

ETHICS AND DISSEMINATION

No ethics approval is required for this systematic review. Results will be disseminated through publication in an open-access journal and presentation at conferences.

PROSPERO REGISTRATION NUMBER

CRD42023391897.

Global impacts of COVID-19 pandemic on sexual and reproductive health services: An international comparative study on primary care from the INTRePID Consortium

OBJECTIVE

To understand how the COVID-19 pandemic has impacted sexual and reproductive health (SRH) visits.

DESIGN

An ecological study comparing SRH services volume in different countries before and after the onset of the COVID-19 pandemic.

SETTING

Seven countries from the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID) across four continents.

POPULATION

Over 3.8 million SRH visits to primary care physicians in Australia, China, Canada, Norway, Singapore, Sweden and the USA.

METHODS

Difference in average SRH monthly visits before and during the pandemic, with negative binomial regression modelling to compare predicted and observed number of visits during the pandemic for SRH visits.

MAIN OUTCOME MEASURES

Monthly number of visits to primary care physicians from 2018 to 2021.

RESULTS

During the pandemic, the average volume of monthly SRH visits increased in Canada (15.6%, 99% CI 8.1-23.0%) where virtual care was pronounced. China, Singapore, Sweden and the USA experienced a decline (-56.5%, 99% CI -74.5 to -38.5%; -22.7%, 99% CI -38.8 to -6.5%; -19.4%, 99% CI -28.3 to -10.6%; and -22.7%, 99% CI -38.8 to -6.5%, respectively); while Australia and Norway showed insignificant changes (6.5%, 99% CI -0.7 to -13.8% and 1.7%, 99% CI -6.4 to -9.8%). The countries that maintained (Australia, Norway) or surpassed (Canada) pre-pandemic visit rates had the greatest use of virtual care.

CONCLUSIONS

In-person SRH visits to primary care decreased during the pandemic. Virtual care seemed to counterbalance that decline. Although cervical cancer screening appeared insensitive to virtual care, strategies such as incorporating self-collected samples for HPV testing may provide a solution in a future pandemic.

Clinician- and Patient-Identified Solutions to Reduce the Fragmentation of Post-ICU Care in Australia

BACKGROUND

Critical care survivors experience multiple care transitions, with no formal follow-up care pathway.

RESEARCH QUESTION

What are the potential solutions to improve the communication between treating teams and integration of care following an ICU admission, from the perspective of patients, their caregivers, intensivists, and general practitioners (GPs) from diverse socioeconomic areas?

STUDY DESIGN AND METHODS

This study included a qualitative design using semi-structured interviews with intensivists, GPs, and patients and caregivers. Framework analysis was used to analyze data and to identify solutions to improve the integration of care following hospital discharge. Patients were previously mechanically ventilated for > 24 h in the ICU and had access to a video-enabled device. Clinicians were recruited from hospital networks and a state-wide GP network.

RESULTS

Forty-six interviews with clinicians, patients, and caregivers were completed (15 intensivists, 8 GPs, 15 patients, and 8 caregivers). Three higher level feedback loops were identified that comprised 10 themes. Feedback loop 1 was an ICU and primary care collaboration. It included the following: (1) developing collaborative relationships between the ICU and primary care; (2) providing interprofessional education and resources to support primary care; and (3) improving role clarity for patient follow-up care. Feedback loop 2 was developing mechanisms for improved communication across the care continuum. It included: (4) timely, concise information-sharing with primary care on post-ICU recovery; (5) survivorship-focused information-sharing across the continuum of care; (6) empowering patients and caregivers in self-management; and (7) creation of a care coordinator role for survivors. Feedback loop 3 was learning from post-ICU outcomes to improve future care. It included: (8) developing comprehensive post-ICU care pathways; (9) enhancing support for patients following a hospital stay; and (10) integration of post-ICU outcomes within the ICU to improve clinician morale and understanding.

INTERPRETATION

Practical solutions to enhance the quality of survivorship for critical care survivors and their caregivers were identified. These themes are mapped to a novel conceptual model that includes key feedback loops for health system improvements and foci for future interventional trials to improve ICU survivorship outcomes.

Have interventions aimed at assisting general practitioners in facilitating earlier diagnosis of type 1 diabetes in children been successful? A systematic review protocol

BACKGROUND

Early diagnosis of type 1 diabetes in children is critical to prevent deterioration to diabetic ketoacidosis (DKA), a state where the body's insulin levels are critically low resulting in the use of fat for fuel and the accumulation of ketones. DKA is a life-threatening emergency where dehydration and cerebral oedema can quickly develop and lead to death. Despite treatment, DKA also has harmful impacts on cognition and brain development. Most children admitted to a hospital with DKA see their general practitioner in the week leading up to their admission. A delay in referral from general practice can result in delays in commencing lifesaving insulin therapy. Prior systematic reviews have explored publicity campaign interventions aimed at recognising type 1 diabetes earlier; however, no reviews have explored these interventions targeted at reducing the delay after presentation to the general practitioner. This systematic review aims to summarise interventions that target the diagnostic delay emerging from general practice and to evaluate their effectiveness in reducing DKA admissions.

METHODS

Six databases (Ovid (MEDLINE), Web of Science, EMBASE, CINAHL, Evidence-Based Medicine Reviews (EBMR) and Google Scholar) will be searched to identify studies exploring interventions to reduce diagnostic delay in children with type 1 diabetes, and hence DKA, in general practice. The primary outcome will be the number of DKA admissions to a hospital following a delay in general practice. The secondary outcome will be the behaviour of general practitioners with respect to urgent referral of children with type 1 diabetes. Title, abstract and full-text screening for exclusion and inclusion of publications will be completed by two independent reviewers. Any risks of bias within individual studies will be assessed by two independent reviewers, using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Our confidence in the overall body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

The systematic review will be disseminated via publication and potentially in conference presentations. Ethics is not required for a systematic review of secondary data.

PROSPERO REGISTRATION NUMBER

CRD42023412504.

Informing the design of a digital intervention to support sexually transmissible infection care in general practice: a qualitative study exploring the views of clinicians

BACKGROUND

Strengthening sexually transmissible infection (STI) management in general practice is prioritised in Australian STI strategy. Digital interventions incorporating clinical decision support offer a mechanism to assist general practitioners (GPs) in STI care. This study explored clinicians' views towards a proposed digital intervention for supporting STI care in Australian general practice as a first step in the tool's design.

METHODS

Semi-structured one-to-one interviews were conducted during 2021 with sexual health physicians (n =2) and GPs (n =7) practicing in the state of Victoria, Australia. Interviews explored views on a proposed STI digital intervention for general practice. We applied the Theoretical Domains Framework (TDF), a behaviour change framework to our analysis. This involved: (1) directed content analysis of transcripts into TDF domains; and (2) thematic analysis to identify sub-themes within relevant TDF domains. Subthemes were subsequently categorised into enablers and barriers to the use and implementation of a STI computerised clinical decision support system (CDSS).

RESULTS

All interviewees viewed a digital intervention for STI care favourably, expressing confidence in its potential to improve care and support management. Within the relevant TDF domains (e.g. environmental context and resources), subthemes emerged as barriers (e.g. lack of sensitivity to patient context) or enablers (e.g. clear communication and guidance) to the use and implementation of a STI CDSS in primary care. Multiple subthemes (e.g. time constraints) have the potential to be a barrier or an enabler, and is largely dependent on end-user needs being met and clinical context being appropriately addressed.

CONCLUSIONS

A digital intervention incorporating clinical decision support was viewed favourably, indicating a possible role for such a tool in Australian general practice. Co-design with end-users and prototype evaluation with health consumers is recommended to ensure relevance and usefulness.

The impact on patients of the tertiary-primary healthcare interface in kidney failure: a qualitative study

BACKGROUND

Clinicians and patients have reported fragmentation in the primary and tertiary healthcare interface. However, perspectives of service navigation and the impacts of fragmentation are not well defined, particularly for patients transitioning to dialysis. This study aimed to define patient perspectives of the functioning of the health service interface and impacts on healthcare experiences and engagement, informing patient-centred and outcomes-focused service models.

METHODS

A qualitative study was conducted through semi-structured interviews with 25 dialysis patients (16 males) aged 34-78 receiving dialysis across a multi-site tertiary service. Transcripts were analysed thematically.

RESULTS

Three main themes were identified: (1) The Changing Nature of General Practitioner (GP) Patient Relationships; (2) Ownership and Leadership in Kidney Care; and (3) The Importance of Nephrologist-GP Communications. Patients perceived an unreliable primary-tertiary service interface which lacked coordinated care and created challenges for primary care continuity. These impacted perceptions of healthcare provider expertise and confidence in healthcare systems. Patients subsequently increased the healthcare sought from tertiary kidney clinicians. The fractured interface led some to coordinate communication between health sectors, to support care quality, but this caused additional stress.

CONCLUSIONS

A fragmented primary-tertiary healthcare interface creates challenges for patient service navigation and can negatively impact patient experiences, leading to primary care disengagement, reduced confidence in health care quality and increased stress. Future studies are imperative for assessing initiatives facilitating health system integration, including communication technologies, healthcare provider training, patient empowerment, and specific outcomes in health, economic and patient experience measures, for patients transitioning to dialysis.

Assessment of a primary care e-support package of automated case finding, simplified treatment algorithm and decision support to increase hepatitis B treatment uptake in primary care clinics in Australia (SIMPLY-B Study): protocol for a pilot evaluation

INTRODUCTION

Despite the availability of effective, subsidised hepatitis B treatment, linkage to care and treatment rates remain very low globally. In Australia, specially trained primary care physicians (general practitioner, GPs) can prescribe hepatitis B treatment, however, most hepatitis B care occurs in specialist clinics. Increasing hepatitis B management by GPs in primary care clinics is essential to achieve national hepatitis B linkage to care and treatment targets by 2030.This pilot study determines the feasibility, acceptability and effectiveness of Simply B, a novel GP hepatitis B e-support package designed to increase hepatitis B management by GPs in primary care clinics.

METHODS AND ANALYSIS

This study will be conducted in three parts:Part A: A prospective open-label pilot intervention study, comparing the proportion of people with hepatitis B who are managed by their GP in primary care clinics before, 12 months and 24 months after implementation of the Simply B electronic hepatitis B support package.Part B: A nested qualitative health services feasibility study using semistructured interviews and thematic analysisPart C: Cost-effectiveness analysis.

ETHICS AND DISSEMINATION

This study has received ethics approval by St Vincent's Hospital. Data management and analysis will be centralised through the Department of Gastroenterology, St Vincent's Hospital.

TRIAL REGISTRATION NUMBER

NCT05614466.

The development of Future Health Today: piloting a new platform for identification and management of chronic disease in general practice

Chronic disease identification and management is a significant issue in Australia, with general practice being the primary contact point for those at risk of, or living with, chronic disease. However, there is a well-described gap between guideline recommendations for chronic disease management and translation in the general practice setting. In 2018, a group of researchers, clinicians and software developers collaborated to develop a tool to support the identification and management of chronic disease in general practice, with the aim to create a platform that met the needs of general practice. The co-design process drew together core principles and expectations for the establishment of a technological platform, called Future Health Today (FHT), which would sit alongside the electronic medical record (EMR) management system within general practice. FHT used algorithms applied to EMR data to identify patients with, or at risk of, chronic disease and requiring review. Using chronic kidney disease as a clinical focus, the FHT prototype was piloted in a large, metropolitan general practice, and a large regional general practice. Based on user feedback, the prototype was further developed and improved. This paper provides a report on the key features and functionalities that participants identified and implemented in practice.

Chronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial

Background

Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases.

Methods

Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts.

Results

At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables.

Conclusions

This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.

The impact of structured self-monitoring of blood glucose on clinical, behavioral, and psychosocial outcomes among adults with non-insulin-treated type 2 diabetes: a systematic review and meta-analysis

Background

Self-monitoring of blood glucose (SMBG) is considered of little clinical benefit for adults with non-insulin-treated type 2 diabetes, but no comprehensive review of a structured approach to SMBG has been published to date.

Purpose

To conduct a systematic review and meta-analysis of the impact of sSMBG on HbA1c, treatment modifications, behavioral and psychosocial outcomes, and; examine the moderating effects of sSMBG protocol characteristics on HbA1c.

Data sources

Four databases searched (November 2020; updated: February 2022).

Study selection

Inclusion criteria: non-randomized and randomized controlled trials (RCTs) and prospective observational studies; reporting effect of sSMBG on stated outcomes; among adults (≥18 years) with non-insulin-treated type 2 diabetes. Studies excluded if involving children or people with insulin-treated or other forms of diabetes.

Data extraction and analysis

Outcome data extracted, and risk of bias/quality assessed independently by two researchers. Meta-analysis was conducted for RCTs, and moderators explored (HbA1c only).

Data synthesis

From 2,078 abstracts, k=23 studies were included (N=5,372). Risk of bias was evident and study quality was low. Outcomes assessed included: HbA1c (k=23), treatment modification (k=16), psychosocial/behavioral outcomes (k=12). Meta-analysis revealed a significant mean difference favoring sSMBG in HbA1c (-0·29%, 95% CI: -0·46 to -0·11, k=13) and diabetes self-efficacy (0.17%, 95% CI: 0.01 to 0.33, k=2). Meta-analysis revealed no significant moderating effects by protocol characteristics.

Limitations

Findings limited by heterogeneity in study designs, intervention characteristics, and psychosocial assessments.

Conclusion

A small positive effect of sSMBG on HbA1c and diabetes self-efficacy was observed. Narrative synthesis of sSMBG intervention characteristics may guide future implementation.

PROSPERO registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020208857, identifier CRD42020208857.

Factors impacting COVID-19 vaccine decision making in older adults and people with underlying conditions in Victoria, Australia: A cross-sectional survey

Australia's COVID-19 vaccine rollout included prioritizing older adults and those with underlying conditions. However, little was known around the factors impacting their decision to accept the vaccine. This study aimed to assess vaccine intentions, information needs, and preferences of people prioritized to receive the COVID-19 vaccine at the start of the Australian vaccine rollout. A cross-sectional online survey of people aged ≥70 years or 18-69 with chronic or underlying conditions was conducted between 12 February and 26 March 2021 in Victoria, Australia. The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework and items informed the survey design and framing of results. Bivariate logistic regression was used to investigate the association between intention to accept a COVID-19 vaccine and demographic characteristics. In total, 1828 eligible people completed the survey. Intention to vaccinate was highest among those ≥70 years (89.6%, n = 824/920) versus those aged 18-69 years (83.8%, n = 761/908), with 91% (n = 1641/1803) of respondents agreeing that getting a COVID-19 vaccine was important to their health. Reported vaccine safety (aOR 1.4, 95% CI 1.1 to 1.8) and efficacy (aOR 1.9, 95% CI 1.5 to 2.3) were associated with intention to accept a COVID-19 vaccine. Concerns around serious illness, long-term effects, and insufficient vaccine testing were factors for not accepting a COVID-19 vaccine. Preferred communication methods included discussion with healthcare providers, with primary care providers identified as the most trusted information source. This study identified factors influencing the prioritized public's COVID-19 vaccine decision-making, including information preferences. These details can support future vaccination rollouts.

Exploring the appropriateness of antibiotic prescribing for dental presentations in Australian general practice-A pilot study

AIMS

Dental pain is a common presentation in general medical practice for which patients are often prescribed antibiotics. The aim of this pilot study was to assess prescriptions by general medical practitioners (GPs) for dental presentations in Australia.

METHODS

Anonymised electronic medical data relating to antibiotic prescribing across 2 periods (3 August-30 November 2019 and 3 August-30 November 2020) were extracted from 8 general practices in Victoria that contributed data to the University of Melbourne's Data for Decisions programme. Extracted de-identified data included antibiotics prescribed for dental presentations, practice site number, visit date, patient age, sex, reason for prescription, reason for visit and the regimen of the antibiotic. Appropriateness of the prescribed antibiotic was assessed against the Australian national dental guidelines Therapeutic Guidelines Oral and Dental.

RESULTS

From 13 641 recorded prescriptions, 178 were recorded for dental presentations, representing 1.3% of all antibiotic prescriptions. When assessed against the guidelines, 23.6% (n = 42) were considered appropriate. The top 3 most commonly prescribed antibiotics were amoxicillin (n = 84, 47.2%), amoxicillin/clavulanic acid (n = 52, 29.2%) and metronidazole (n = 15, 8.4%). The reasons for inappropriate prescribing were as follows: third-line treatment being chosen, inappropriate spectrum, incorrect regimen or prescribing an antibiotic not recommended in the guidelines.

CONCLUSION

These results indicate a need to better understand the potential patient drivers for antibiotic prescription for GPs and patients, and resources GPs need to manage dental presentations. These results will inform the codesign of targeted interventions to address any educational gaps and barriers to accessing dental treatment and thus improving antibiotic prescribing.

Assessing and addressing diabetes distress among adults with type 2 diabetes: An online survey of Australian general practitioners

AIM

Diabetes distress is experienced by up to 36% of adults with type 2 diabetes. Australian type 2 diabetes guidelines recommend annual assessment of diabetes distress in general practice. This study explores general practitioners' knowledge, current practice, and factors influencing implementation of guidelines, including Person Reported Outcome Measure (PROM) use.

METHODS

A cross-sectional online survey was disseminated via e-mail to 4776 Australian general practitioners listed on the Australasian Medical Publishing Company database.

RESULTS

264 (5%) surveys were returned. 75% indicated that general practitioners were the most appropriate professionals to assess diabetes distress. Sixteen percent reported asking about diabetes distress during type 2 diabetes consultations more than half the time, with 13% using a PROM more than half the time: 64% use the Kessler-10, and 1.9% use the Problem Areas in Diabetes (PAID) scale. While general practitioners had positive beliefs about the consequences of assessing and addressing diabetes distress, they also reported barriers in motivation, environment, and knowledge of guidelines.

CONCLUSION

Most respondents endorsed general practitioners' role in assessing diabetes distress, but few ask about or assess diabetes distress in routine consultations. To support uptake of guideline recommendations for diabetes-specific PROM use, environmental factors, specifically time, need to be addressed.

Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study

Background

The most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority.

Objective

This study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial.

Methods

GPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach.

Results

A total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs’ perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients’ worries.

Conclusions

There was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.

Process mining-driven analysis of COVID-19's impact on vaccination patterns

Process mining is a discipline sitting between data mining and process science, whose goal is to provide theoretical methods and software tools to analyse process execution data, known as event logs. Although process mining was originally conceived to facilitate business process management activities, research studies have shown the benefit of leveraging process mining in healthcare contexts. However, applying process mining tools to analyse healthcare process execution data is not straightforward. In this paper, we show a methodology to: i) prepare general practice healthcare process data for conducting a process mining analysis; ii) select and apply suitable process mining solutions for successfully executing the analysis; and iii) extract valuable insights from the obtained results, alongside leads for traditional data mining analysis. By doing so, we identified two major challenges when using process mining solutions for analysing healthcare process data, and highlighted benefits and limitations of the state-of-the-art process mining techniques when dealing with highly variable processes and large data-sets. While we provide solutions to the identified challenges, the overarching goal of this study was to detect differences between the patients' health services utilization pattern observed in 2020-during the COVID-19 pandemic and mandatory lock-downs -and the one observed in the prior four years, 2016 to 2019. By using a combination of process mining techniques and traditional data mining, we were able to demonstrate that vaccinations in Victoria did not drop drastically-as other interactions did. On the contrary, we observed a surge of influenza and pneumococcus vaccinations in 2020, as opposed to other research findings of similar studies conducted in different geographical areas.

Effect of routinely assessing and addressing depression and diabetes distress on clinical outcomes among adults with type 2 diabetes: a systematic review

OBJECTIVES

This study examined the effect of using patient-reported outcome measures (PROMs) routinely to assess and address depressive symptoms and diabetes distress among adults with type 2 diabetes.

DESIGN

A systematic review of published peer-reviewed studies.

DATA SOURCES

Medline, Embase, CINAHL Complete, PsycINFO, The Cochrane Library and Cochrane Central Register of Controlled Trials were searched.

ELIGIBILITY CRITERIA

Studies including adults with type 2 diabetes, published in English, from the inception of the databases to 24 February 2022 inclusive; and where the intervention included completion of a PROM of depressive symptoms and/or diabetes distress, with feedback of the responses to a healthcare professional.

DATA EXTRACTION AND SYNTHESIS

Using Covidence software, screening and risk of bias assessment were conducted by two reviewers independently with any disagreements resolved by a third reviewer.

RESULTS

The search identified 4512 citations, of which 163 full-text citations were assessed for eligibility, and nine studies met the inclusion criteria. Five studies involved assessment of depressive symptoms only, two studies assessed diabetes distress only, and two studies assessed both. All studies had an associated cointervention. When depressive symptoms were assessed (n=7), a statistically significant between-group difference in depressive symptoms was observed in five studies; with a clinically significant (>0.5%) between-group difference in HbA1c in two studies. When diabetes distress was assessed (n=4), one study demonstrated statistically significant difference in depressive symptoms and diabetes distress; with a clinically significant between-group difference in HbA1c observed in two studies.

CONCLUSION

Studies are sparse in which PROMs are used to assess and address depressive symptoms or diabetes distress during routine clinical care of adults with type 2 diabetes. Further research is warranted to understand how to integrate PROMs into clinical care efficiently and determine appropriate interventions to manage identified problem areas.

PROSPERO REGISTRATION NUMBER

CRD42020200246.

Changes in primary care visits arising from the COVID-19 pandemic: an international comparative study by the International Consortium of Primary Care Big Data Researchers (INTRePID)

INTRODUCTION

Through the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID), we compared the pandemic impact on the volume of primary care visits and uptake of virtual care in Australia, Canada, China, Norway, Singapore, South Korea, Sweden, the UK and the USA.

METHODS

Visit definitions were agreed on centrally, implemented locally across the various settings in INTRePID countries, and weekly visit counts were shared centrally for analysis. We evaluated the weekly rate of primary care physician visits during 2019 and 2020. Rate ratios (RRs) of total weekly visit volume and the proportion of weekly visits that were virtual in the pandemic period in 2020 compared with the same prepandemic period in 2019 were calculated.

RESULTS

In 2019 and 2020, there were 80 889 386 primary care physician visits across INTRePID. During the pandemic, average weekly visit volume dropped in China, Singapore, South Korea, and the USA but was stable overall in Australia (RR 0.98 (95% CI 0.92 to 1.05, p=0.59)), Canada (RR 0.96 (95% CI 0.89 to 1.03, p=0.24)), Norway (RR 1.01 (95% CI 0.88 to 1.17, p=0.85)), Sweden (RR 0.91 (95% CI 0.79 to 1.06, p=0.22)) and the UK (RR 0.86 (95% CI 0.72 to 1.03, p=0.11)). In countries that had negligible virtual care prepandemic, the proportion of visits that were virtual were highest in Canada (77.0%) and Australia (41.8%). In Norway (RR 8.23 (95% CI 5.30 to 12.78, p<0.001), the UK (RR 2.36 (95% CI 2.24 to 2.50, p<0.001)) and Sweden (RR 1.33 (95% CI 1.17 to 1.50, p<0.001)) where virtual visits existed prepandemic, it increased significantly during the pandemic.

CONCLUSIONS

The drop in primary care in-person visits during the pandemic was a global phenomenon across INTRePID countries. In several countries, primary care shifted to virtual visits mitigating the drop in in-person visits.

Identifying primary care datasets and perspectives on their secondary use: a survey of Australian data users and custodians

Background

Most people receive most of their health care in in Australia in primary care, yet researchers and policymakers have limited access to resulting clinical data. Widening access to primary care data and linking it with hospital or other data can contribute to research informing policy and provision of services and care; however, limitations of primary care data and barriers to access curtail its use. The Australian Health Research Alliance (AHRA) is seeking to build capacity in data-driven healthcare improvement; this study formed part of its workplan.

Methods

The study aimed to build capacity for data driven healthcare improvement through identifying primary care datasets in Australia available for secondary use and understand data quality frameworks being applied to them, and factors affecting national capacity for secondary use of primary care data from the perspectives of data custodians and users. Purposive and snowball sampling were used to disseminate a questionnaire and respondents were invited to contribute additional information via semi-structured interviews.

Results

Sixty-two respondents collectively named 106 datasets from eclectic sources, indicating a broad conceptualisation of what a primary care dataset available for secondary use is. The datasets were generated from multiple clinical software systems, using different data extraction tools, resulting in non-standardised data structures. Use of non-standard data quality frameworks were described by two-thirds of data custodians. Building trust between citizens, clinicians, third party data custodians and data end-users was considered by many to be a key enabler to improve primary care data quality and efficiencies related to secondary use. Trust building qualities included meaningful stakeholder engagement, transparency, strong leadership, shared vision, robust data security and data privacy protection. Resources to improve capacity for primary care data access and use were sought for data collection tool improvements, workforce upskilling and education, incentivising data collection and making data access more affordable.

Conclusions

The large number of identified Australian primary care related datasets suggests duplication of labour related to data collection, preparation and utilisation. Benefits of secondary use of primary care data were many, and strong national leadership is required to reach consensus on how to address limitations and barriers, for example accreditation of EMR clinical software systems and the adoption of agreed data and quality standards at all stages of the clinical and research data-use lifecycle. The study informed the workplan of AHRA’s Transformational Data Collaboration to improve partner engagement and use of clinical data for research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01830-9.

People with type 2 diabetes experiences and needs of emotional support in Australian general practice: A qualitative study

Context: Diabetes distress is the negative emotional response to the burden of living with and managing diabetes. It is associated with sub-optimal glycemia and diabetes self-management, with up to 40% of people with type 2 diabetes experiencing diabetes distress. Australian guidelines specifically recommend using Patient Reported Outcome Measures such as Problem Areas In Diabetes (PAID) scale to assess diabetes distress and discuss sources of distress with people with diabetes. However, use of the PAID scale in Australian general practice is low. Objective: Explore the experiences of people with type 2 diabetes, their needs and expectations of emotional support in general practice, and barriers and facilitators to completing the PAID scale. Study Design: Qualitative study with semi-structured interviews conducted via Zoom or telephone. Guided by Richie's framework thematic analysis, following familiarisation with the data, an initial thematic framework was developed using inductive and deductive approach. Data were coded using the thematic framework. Setting: General practices in Victoria, Australia. Participants: Adults >18 years with type 2 diabetes who primarily attend general practice for diabetes care. Outcomes to be reported: Themes and subthemes related to experiences, needs and expectations of emotional support of people with type 2 diabetes attending general practice are reported. Results: Twelve adults with type 2 diabetes participated. Seven women and five men participated; age range from 27-79 years. Participants considered the pre-existing general practitioner (GP)-patient relationship important when exploring emotional health during diabetes care. Key themes identified that influenced experiences of care were: (1) biomedical focus of diabetes care; (2) the GP-patient relationship; (3) importance of communication. No participants recalled completing the PAID scale with their GP to assess emotional health. They believed that the PAID scale could promote an understanding from the GP about issues impacting their life beyond the biomedical aspects of diabetes. Conclusions: Our findings indicate people with type 2 diabetes have no experience of using the PAID scale during diabetes care but perceive the use of the PAID scale could improve communication with their GP due to pre-identification of emotional issues. The findings will be used to develop a tool to implement the PAID scale in general practices in Victoria, Australia.

Primary care consumers' experiences and opinions of a telehealth consultation delivered via video during the COVID-19 pandemic

This study examined consumers' experiences and opinions of a videoconference with a primary healthcare professional, and estimated the value of travel and time savings for consumers compared with face-to-face consultations. The online survey was conducted in Melbourne, Australia, between October 2020 and May 2021. The sample (n = 499) was highly educated (Bachelor degree or higher, 79%; 393/499), predominately female (70%; 347/499), mainly spoke English at home (78%; 390/499) and had a mean age of 31.8 years (s.d. 11.40). Reduced travel time (27%; 271/499) and avoiding exposure to COVID-19 (23%; 228/499) were the main reasons consumers chose a videoconference. Mental health and behavioural issues were the main reason for the consultation (38%; 241/499) and 69% (346/499) of consultations were with a general practitioner. Perceptions of the quality of care were uniformly high, with 84% (419/499) of respondents believing videoconference was equivalent to a face-to-face consultation. No association was found between reporting that telehealth was equivalent to a face-to-face consultation and education, language, health status, reason for consultation or provider type. The average time saved per consultation was 1 h and 39 min, and the average transport-related saving was A$14.29. High rates of acceptance and substantial cost savings observed in this study warrant further investigation to inform the longer-term role of videoconferences, and telehealth more broadly, in the Australian primary care system.

Cost-effectiveness of professional-mode flash glucose monitoring in general practice among adults with type 2 diabetes: Evidence from the GP-OSMOTIC trial

AIM

To assess the cost-effectiveness of professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice compared with usual clinical care.

METHODS

An economic evaluation was conducted as a component of the GP-OSMOTIC trial, a pragmatic multicentre 12-month randomised controlled trial enrolling 299 adults with type 2 diabetes in Victoria, Australia. The economic evaluation was conducted from an Australian healthcare sector perspective with a lifetime horizon. Health-related quality of life (EQ-5D) and total healthcare costs were compared between the intervention and the usual care group within the trial period. The 'UKPDS Outcomes Model 2' was used to simulate post-trial lifetime costs, life expectancy and quality-adjusted life years (QALYs).

RESULTS

No significant difference in health-related quality of life and costs was found between the two groups within the trial period. Professional-mode flash glucose monitoring yielded greater QALYs (0.03 [95% CI: 0.02, 0.04]) and a higher cost (A$3807 [95% CI: 3604, 4007]) compared with usual clinical care using a lifetime horizon under the trial-based monitoring frequency, considered not cost-effective (incremental cost-effectiveness ratio = A$120,228). The intervention becomes cost-effective if sensor price is reduced to lower than 50%, or monitoring frequency is decreased to once per year while maintaining the same treatment effect on HbA_1c .

CONCLUSIONS

Including professional-mode flash glucose monitoring every 3 months as part of a management plan for people with type 2 diabetes in general practice is not cost-effective, but could be if the sensor price or monitoring frequency can be reduced.

Using electronic medical record data to assess chronic kidney disease, type 2 diabetes and cardiovascular disease testing, recognition and management as documented in Australian general practice: a cross-sectional analysis

Objectives

To evaluate the capacity of general practice (GP) electronic medical record (EMR) data to assess risk factor detection, disease diagnostic testing, diagnosis, monitoring and pharmacotherapy for the interrelated chronic vascular diseases—chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease.

Design

Cross-sectional analysis of data extracted on a single date for each practice between 12 April 2017 and 18 April 2017 incorporating data from any time on or before data extraction, using baseline data from the Chronic Disease early detection and Improved Management in PrimAry Care ProjecT. Deidentified data were extracted from GP EMRs using the Pen Computer Systems Clinical Audit Tool and descriptive statistics used to describe the study population.

Setting

Eight GPs in Victoria, Australia.

Participants

Patients were ≥18 years and attended GP ≥3 times within 24 months. 37 946 patients were included.

Results

Risk factor and disease testing/monitoring/treatment were assessed as per Australian guidelines (or US guidelines if none available), with guidelines simplified due to limitations in data availability where required. Risk factor assessment in those requiring it: 30% of patients had body mass index and 46% blood pressure within guideline recommended timeframes. Diagnostic testing in at-risk population: 17% had diagnostic testing as per recommendations for CKD and 37% for T2D. Possible undiagnosed disease: Pathology tests indicating possible disease with no diagnosis already coded were present in 6.7% for CKD, 1.6% for T2D and 0.33% familial hypercholesterolaemia. Overall prevalence: Coded diagnoses were recorded in 3.8% for CKD, 6.6% for T2D, 4.2% for ischaemic heart disease, 1% for heart failure, 1.7% for ischaemic stroke, 0.46% for peripheral vascular disease, 0.06% for familial hypercholesterolaemia and 2% for atrial fibrillation. Pharmaceutical prescriptions: the proportion of patients prescribed guideline-recommended medications ranged from 44% (beta blockers for patients with ischaemic heart disease) to 78% (antiplatelets or anticoagulants for patients with ischaemic stroke).

Conclusions

Using GP EMR data, this study identified recorded diagnoses of chronic vascular diseases generally similar to, or higher than, reported national prevalence. It suggested low levels of extractable documented risk factor assessments, diagnostic testing in those at risk and prescription of guideline-recommended pharmacotherapy for some conditions. These baseline data highlight the utility of GP EMR data for potential use in epidemiological studies and by individual practices to guide targeted quality improvement. It also highlighted some of the challenges of using GP EMR data.

'For me, it didn't seem as drastic a step as being controlled by insulin': A qualitative investigation of expectations and experiences of non-insulin injectable therapy among adults with type 2 diabetes

AIMS

This qualitative study aims to explore beliefs, attitudes and experiences of injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs) use and discontinuation, as well as attitudes to further injectable treatment intensification, among adults with type 2 diabetes (T2D).

METHODS

Nineteen in-depth semi-structured interviews lasting (mean ± standard deviation) 45 ± 18 min were conducted, face-to-face (n = 14) or via telephone (n = 5). Transcripts were analysed using inductive template analyses. Eligible participants were English-speaking adults with T2D who had recently initiated (≤3 years) GLP-1RA treatment.

RESULTS

Participants were aged 28-72 years, who predominantly lived in metropolitan areas (n = 15), and had an experience of daily (n = 11) and/or once-weekly (n = 13) GLP-1RA formulations. Six participants had discontinued treatment and seven had trialled two or more formulations. Expectations and experiences of GLP-1RA were related to the perceived: (1) symbolism and stigma of injectable diabetes treatment; (2) ease of injectable administration and device preferences; (3) treatment convenience and social impact; (4) treatment efficacy and benefits, and; (5) negative treatment side effects. Some participants reported increased receptiveness to insulin therapy following their GLP-1RA experience, others emphasised unique concerns about insulin beyond injectable administration.

CONCLUSIONS

This study provides a novel understanding of expectations and experience of non-insulin injectables among Australian adults with T2D. Our data suggest expectations may be informed by attitudes to insulin therapy, while perceived treatment benefits (e.g. weight-related benefits, administration frequency) may motivate uptake and ongoing use despite concerns. Experience of GLP-1RA injections may impact receptiveness to future insulin use.

Antibiotic stewardship: A review of successful, evidence-based primary care strategies

BACKGROUND

Antibiotic resistance is a rising global threat with only two options for mitigation: 1) invent new antibiotics and/or 2) use current antibiotics more wisely. In Australia, the majority of antibiotic usage is in the community, hence primary care has a key role.  OBJECTIVE: With no single 'magic bullet', a range of approaches is needed. The aim of this article is to describe the options and evidence in three broad categories: 1) regulatory changes such as repeats and pack sizes, 2) policy initiatives such as public campaigns, academic detailing and education and 3) clinical strategies including delayed prescribing, clinical decision support tools, practice-based audit and feedback, and patient information sheets.

DISCUSSION

Australia has good antibiotic regulation and guidelines but must invest in sustained primary care stewardship programs, which should include surveillance, information for consumers, support for general practitioners and general practice training, and an ongoing evaluation and research program.

Clinical insights into appropriate choice of antimicrobials for acute respiratory tract infections

BACKGROUND AND OBJECTIVES

Australia has relatively high rates of antibiotic prescribing in the community. The aim of this study was to identify clinical insights regarding antibiotic prescribing choices for the management of common upper respiratory tract infections through analysis of anonymised primary care electronic medical records (EMRs).

METHOD

EMR data relating to 1926 antimicrobial prescriptions for tonsillitis, pharyngitis and acute rhinosinusitis in adults and acute otitis media (AOM) in children were extracted from 11 general practices in Victoria and analysed for consistency with Australian Therapeutic Guidelines recommendations.

RESULTS

The analysis suggests that underdosing of amoxicillin for AOM in children, prescription of phenoxymethylpenicillin at doses not consistent with Therapeutic Guidelines recommendations for tonsillitis and pharyngitis in adults, and potential overprescription of antibiotics for patients with acute rhinosinusitis are not infrequent in general practice.

DISCUSSION

Anonymised EMR data provide an opportunity to analyse antibiotic prescribing practices at scale and provide insights relevant to clinical practice.

Factors Influencing Australian Healthcare Workers' COVID-19 Vaccine Intentions across Settings: A Cross-Sectional Survey

Healthcare workers' COVID-19 vaccination coverage is important for staff and patient safety, workforce capacity and patient uptake. We aimed to identify COVID-19 vaccine intentions, factors associated with uptake and information needs for healthcare workers in Victoria, Australia. We administered a cross-sectional online survey to healthcare workers in hospitals, primary care and aged or disability care settings (12 February-26 March 2021). The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework informed survey design and framing of results. Binary regression results adjusted for demographics provide risk differences between those intending and not intending to accept a COVID-19 vaccine. In total, 3074 healthcare workers completed the survey. Primary care healthcare workers reported the highest intention to accept a COVID-19 vaccine (84%, 755/898), followed by hospital-based (77%, 1396/1811) and aged care workers (67%, 243/365). A higher proportion of aged care workers were concerned about passing COVID-19 to their patients compared to those working in primary care or hospitals. Only 25% felt they had sufficient information across five vaccine topics, but those with sufficient information had higher vaccine intentions. Approximately half thought vaccines should be mandated. Despite current high vaccine rates, our results remain relevant for booster programs and future vaccination rollouts.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Assessing the suitability of general practice electronic health records for clinical prediction model development: a data quality assessment

BACKGROUND

The use of general practice electronic health records (EHRs) for research purposes is in its infancy in Australia. Given these data were collected for clinical purposes, questions remain around data quality and whether these data are suitable for use in prediction model development. In this study we assess the quality of data recorded in 201,462 patient EHRs from 483 Australian general practices to determine its usefulness in the development of a clinical prediction model for total knee replacement (TKR) surgery in patients with osteoarthritis (OA).

METHODS

Variables to be used in model development were assessed for completeness and plausibility. Accuracy for the outcome and competing risk were assessed through record level linkage with two gold standard national registries, Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and National Death Index (NDI). The validity of the EHR data was tested using participant characteristics from the 2014-15 Australian National Health Survey (NHS).

RESULTS

There were substantial missing data for body mass index and weight gain between early adulthood and middle age. TKR and death were recorded with good accuracy, however, year of TKR, year of death and side of TKR were poorly recorded. Patient characteristics recorded in the EHR were comparable to participant characteristics from the NHS, except for OA medication and metastatic solid tumour.

CONCLUSIONS

In this study, data relating to the outcome, competing risk and two predictors were unfit for prediction model development. This study highlights the need for more accurate and complete recording of patient data within EHRs if these data are to be used to develop clinical prediction models. Data linkage with other gold standard data sets/registries may in the meantime help overcome some of the current data quality challenges in general practice EHRs when developing prediction models.

763Validity of algorithms for identifying five chronic conditions in MedicineInsight, Australian national primary care data

Background

MedicineInsight is a database containing de-identified electronic health records (EHRs) from over 700 Australian general practices. To support the trust placed in analyses of MedicineInsight data, additional evidence regarding the accuracy of the data is needed.

Methods

This study measures the validity of algorithms available in MedicineInsight that identify patients with depression, anxiety, asthma, type 2 diabetes and osteoporosis. Fifty practices met eligibility criteria regarding patient load and location, five were randomly selected and four agreed to participate. Within each practice, 250 patients aged ≥ 40 years were randomly selected. This age restriction increased the prevalence of the evaluated conditions, thereby optimising statistical power. Trained staff review the full EHR for these patients, including progress notes and correspondence, which are not available in MedicineInsight because they may contain identifiable information.

Results

With data collection almost complete, the target sample size will not be attainable. Power calculations indicate the current sample of 479 should provide adequate precision. For each condition of interest, the sensitivity, specificity, positive predictive value and negative predictive value of the algorithm is calculated. The full EHR review is the gold standard against which the algorithms are benchmarked.

Conclusions

The findings will indicate whether these algorithms demonstrate adequate accuracy to be used for research and decision-making.

Key messages

This additional understanding regarding the accuracy of MedicineInsight data will facilitate the interpretation of analyses of MedicineInsight data and guide improvements to the algorithms.

Towards optimising chronic kidney disease detection and management in primary care: Underlying theory and protocol for technology development using an Integrated Knowledge Translation approach

Worldwide, Chronic Kidney Disease (CKD), directly or indirectly, causes more than 2.4 million deaths annually with symptoms generally presenting late in the disease course. Clinical guidelines support the early identification and treatment of CKD to delay progression and improve clinical outcomes. This paper reports the protocol for the codesign, implementation and evaluation of a technological platform called Future Health Today (FHT), a software program that aims to optimise early detection and management of CKD in general practice. FHT aims to optimise clinical decision making and reduce practice variation by translating evidence into practice in real time and as a part of quality improvement activities. This protocol describes the co-design and plans for implementation and evaluation of FHT in two general practices invited to test the prototype over 12 months. Service design thinking has informed the design phase and mixed methods will evaluate outcomes following implementation of FHT. Through systematic application of co-design with service users, clinicians and digital technologists, FHT attempts to avoid the pitfalls of past studies that have failed to accommodate the complex requirements and dynamics that can arise between researchers and service users and improve chronic disease management through use of health information technology.

Impact of quarterly professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice (GP-OSMOTIC): Secondary psychological and self-care outcomes of a pragmatic, open-label, 12-month, randomised controlled trial

AIMS

To investigate the impact of quarterly professional-mode flash glucose monitoring on psychological outcomes in adults with type 2 diabetes in primary care.

METHODS

The GP-OSMOTIC trial randomised 299 adults with type 2 diabetes in 25 general practices to quarterly use of professional-mode flash glucose monitoring (sensor worn for 14 days; data discussed at clinic visit) or usual care. At baseline and 12 months, participants completed validated measures: general emotional well-being (WHO-5), diabetes-specific quality of life (DIDP), satisfaction with glucose monitoring (GME-Q), self-care activities (SDSCA) and perceived involvement in clinical care (PICS). Linear mixed-effects models examined between-group differences at 12 months.

RESULTS

At 12 months, there were no clinically important between-arm differences in any secondary psychological or self-care outcomes. Per protocol analyses showed no clinically significant between-group differences.

CONCLUSIONS

The GP-OSMOTIC intervention had no significant impact, at 12 months, on general emotional well-being, diabetes-specific quality of life or satisfaction with glucose monitoring, suggesting no added psychological burden. Lack of positive impact on self-reported self-care activities or perceived involvement in clinical care may warrant closer attention to the fidelity of intervention delivery, the context (e.g. the nature of clinician-patient interactions) and/or the sensitivity of the measures, as these will help plan future studies.

Evaluating the Implementation of a Pilot Quality Improvement Program to Support Appropriate Antimicrobial Prescribing in General Practice

Inappropriate antimicrobial prescribing contributes to increasing antimicrobial resistance. An antimicrobial stewardship (AMS) program in the form of quality improvement activities that included audit and feedback, clinical decision support and education was developed to help optimise prescribing in general practice. The aim of this study was to evaluate the implementation of this program (Guidance GP) in three general practices in Melbourne, Australia, between November 2019 and August 2020. Thirty-one general practitioners (GPs) participated in the program, with 11 GPs and three practice managers participating in follow-up focus groups and interviews to explore the acceptability and feasibility of the program. Our findings showed that the quality improvement activities were acceptable to GPs, if they accurately fit GPs' decision-making process and workflow. It was also important that they provided clinically meaningful information in the form of audit and feedback to GPs. The time needed to coordinate the program, and costs to implement the program were some of the potential barriers identified. Facilitators of success were a "whole of practice" approach with enthusiastic GPs and practice staff, and an identified practice champion. The findings of this research will inform implementation strategies for both the Guidance GP program and AMS programs more broadly in Australian general practice, which will be critical for general practice participation and engagement.

Validity of algorithms for identifying five chronic conditions in MedicineInsight, an Australian national general practice database

BACKGROUND

MedicineInsight is a database containing de-identified electronic health records (EHRs) from over 700 Australian general practices. It is one of the largest and most widely used primary health care EHR databases in Australia. This study examined the validity of algorithms that use information from various fields in the MedicineInsight data to indicate whether patients have specific health conditions. This study examined the validity of MedicineInsight algorithms for five common chronic conditions: anxiety, asthma, depression, osteoporosis and type 2 diabetes.

METHODS

Patients' disease status according to MedicineInsight algorithms was benchmarked against the recording of diagnoses in the original EHRs. Fifty general practices contributing data to MedicineInsight met the eligibility criteria regarding patient load and location. Five were randomly selected and four agreed to participate. Within each practice, 250 patients aged ≥ 40 years were randomly selected from the MedicineInsight database. Trained staff reviewed the original EHR for as many of the selected patients as possible within the time available for data collection in each practice.

RESULTS

A total of 475 patients were included in the analysis. All the evaluated MedicineInsight algorithms had excellent specificity, positive predictive value, and negative predictive value (above 0.9) when benchmarked against the recording of diagnoses in the original EHR. The asthma and osteoporosis algorithms also had excellent sensitivity, while the algorithms for anxiety, depression and type 2 diabetes yielded sensitivities of 0.85, 0.89 and 0.89 respectively.

CONCLUSIONS

The MedicineInsight algorithms for asthma and osteoporosis have excellent accuracy and the algorithms for anxiety, depression and type 2 diabetes have good accuracy. This study provides support for the use of these algorithms when using MedicineInsight data for primary health care quality improvement activities, research and health system policymaking and planning.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

OBJECTIVE

To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Residents with T2DM and aged ≥60 years living in LTCFs.

MEASURES

Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.

RESULTS

Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.

CONCLUSIONS AND IMPLICATIONS

The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.

Prescribing and deprescribing in chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) rarely occurs in isolation; multimorbidity is the norm. As a result, polypharmacy is common in people with CKD. Some medications are indicated to reduce the risk of cardiovascular disease and progression of CKD. In contrast, some medications may require dose reduction or cessation as a result of advancing stages of CKD.

OBJECTIVE

The aim of this article is to describe broad principles of managing the challenges and necessities of polypharmacy in patients with CKD.

DISCUSSION

Medications such as angiotensin converting enzyme inhibitors, angiotensin receptor blockers, statins and sodium-glucose co-transporter-2 inhibitors may reduce cardiovascular disease risk and/or reduce CKD progression, and their use should be balanced by likelihood of benefit. Medication cessation or dose reduction may be required to prevent medication accumulation, adverse medication events and kidney injury. Polypharmacy can be addressed with a collaborative Home Medicines Review and use of deprescribing tools, using a shared decision-making approach.

Effect of routinely assessing and addressing depression and diabetes distress using patient-reported outcome measures in improving outcomes among adults with type 2 diabetes: a systematic review protocol

INTRODUCTION

Type 2 diabetes is a global health priority. People with diabetes are more likely to experience mental health problems relative to people without diabetes. Diabetes guidelines recommend assessment of depression and diabetes distress during diabetes care. This systematic review will examine the effect of routinely assessing and addressing depression and diabetes distress using patient-reported outcome measures in improving outcomes among adults with type 2 diabetes.

METHODS AND ANALYSIS

MEDLINE, Embase, CINAHL Complete, PsycInfo, The Cochrane Library and Cochrane Central Register of Controlled Trials will be searched using a prespecified strategy using a prespecified Population, Intervention, Comparator, Outcomes, Setting and study design strategy. The date range of the search of all databases will be from inception to 3 August 2020. Randomised controlled trials, interrupted time-series studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies published in peer-reviewed journals in the English language will be included. Two review authors will independently screen abstracts and full texts with disagreements resolved by a third reviewer, if required, using Covidence software. Two reviewers will undertake risk of bias assessment using checklists appropriate to study design. Data will be extracted using prespecified template. A narrative synthesis will be conducted, with a meta-analysis, if appropriate.

ETHICS AND DISSEMINATION

Ethics approval is not required for this review of published studies. Presentation of results will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidance. Findings will be disseminated via peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020200246.

Professional flash glucose monitoring and health service utilisation in type 2 diabetes: A secondary analysis of the GP-OSMOTIC study

AIM

Professional flash glucose monitoring involves people with diabetes wearing a glucose monitor for up to two weeks, with the data downloaded by their health professional, and the information used to help guide treatment. This study describes if professional flash glucose monitoring was associated with a change in health services utilisation.

METHODS

Administrative claims data from three data sources were linked to 288 participants from the GP-OSMOTIC study, a randomised controlled trial evaluating the use of professional flash glucose monitoring versus usual care in people with type 2 diabetes in primary care. Generalised linear models with the Poisson family specified and log link function were used to compare general practice consultations between the intervention and control groups at 0-6- and 6-12-month time points, with adjustment for baseline health services utilisation.

RESULTS

GP consultations increased in the flash glucose monitoring group in the 6 months following initial flash glucose monitoring sensor application from a median (IQR) 6 (4,9) to 8 (5,11); (P < 0.001). Participants in the professional FGM group were 1.2 times (95 % CI 1.1-1.4 (P = 0.0014)) more likely at 6-12 months to have GP consultation visits.

CONCLUSIONS

Administrative claims data identified changes in health services utilisation associated with professional flash glucose monitoring, despite minimal changes in glycaemic control.

Future Health Today: codesign of an electronic chronic disease quality improvement tool for use in general practice using a service design approach

OBJECTIVE

To codesign an electronic chronic disease quality improvement tool for use in general practice.

DESIGN

Service design employing codesign strategies.

SETTING

General practice.

PARTICIPANTS

Seventeen staff (general practitioners, nurses and practice managers) from general practice in metropolitan Melbourne and regional Victoria and five patients from metropolitan Melbourne.

INTERVENTIONS

Codesign sessions with general practice staff, using a service design approach, were conducted to explore key design criteria and functionality of the audit and feedback and clinical decision support tools. Think aloud interviews were conducted in which participants articulated their thoughts of the resulting Future Health Today (FHT) prototype as they used it. One codesign session was held with patients. Using inductive and deductive coding, content and thematic analyses explored the development of a new technological platform and factors influencing implementation of the platform.

RESULTS

Participants identified that the prototype needed to work within their existing workflow to facilitate automated patient recall and track patients with or at-risk of specific conditions. It needed to be simple, provide visual snapshots of information and easy access to relevant guidelines and facilitate quality improvement activities. Successful implementation may be supported by: accuracy of the algorithms in FHT and data held in the practice; the platform supporting planned and spontaneous interactions with patients; the ability to hide tools; links to Medicare Benefits Schedule; and prefilled management plans. Participating patients supported the use of the platform in general practice. They suggested that use of the platform demonstrates a high level of patient care and could increase patient confidence in health practitioners.

CONCLUSION

Study participants worked together to design a platform that is clear, simple, accurate and useful and that sits within any given general practice setting. The resulting FHT platform is currently being piloted in general practices and will continue to be refined based on user feedback.

Clinical Decision Support Systems and Medico-Legal Liability in Recall and Treatment: A Fresh Examination

Clinical decision support systems (CDSSs) provide a valuable tool for clinicians to aid in the care of patients with chronic disease. Various questions have emerged about their implications for the doctor's legal duty of care to their patients, in terms of recognition of risk, recall, testing and treatment. In this article, through an analysis of Australian legislation and international case law, we address these questions, considering the potential impact of CDSSs on doctors' liability in negligence. We conclude that the appropriate use of a well-designed CDSS should minimise, rather than heighten, doctor's potential liability. It should support optimal patient care without diminishing the capacity of the doctor to make individualised decisions about recall, testing and treatment for each patient. We foreshadow that in the future doctors in Australia may have a duty to use available well-established software systems in patient care.

Associations between multimorbidity and glycaemia (HbA1c) in people with type 2 diabetes: cross-sectional study in Australian general practice

OBJECTIVES

To explore the prevalence of multimorbidity as well as individual and combinations of long-term conditions (LTCs) in people with type 2 diabetes (T2D) attending Australian general practice, using electronic health record (EHR) data. We also examine the association between multimorbidity condition count (total/concordant(T2D related)/discordant(unrelated)) and glycaemia (glycated haemoglobin, HbA1c).

DESIGN

Cross-sectional study.

SETTING

Australian general practice.

PARTICIPANTS

69 718 people with T2D with a general practice encounter between 2013 and 2015 captured in the MedicineInsight database (EHR Data from 557 general practices and >3.8 million Australian patients).

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of multimorbidity, individual and combinations of LTCs. Multivariable linear regression models used to examine associations between multimorbidity counts and HbA1c (%).

RESULTS

Mean (SD) age 66.42 (12.70) years, 46.1% female and mean (SD) HbA1c 7.1 (1.4)%. More than 90% of participants with T2D were living with multimorbidity. Discordant conditions were more prevalent (83.4%) than concordant conditions (69.9 %). The three most prevalent discordant conditions were: painful conditions (55.4%), dyspepsia (31.6%) and depression (22.8%). The three most prevalent concordant conditions were hypertension (61.4%), coronary heart disease (17.1%) and chronic kidney disease (8.5%). The three most common combinations of conditions were: painful conditions and hypertension (38.8%), painful conditions and dyspepsia (23.1%) and hypertension and dyspepsia (22.7%). We found no associations between any multimorbidity counts (total, concordant and discordant) or combinations and HbA1c.

CONCLUSIONS

Multimorbidity was common in our cohort of people with T2D attending Australian general practice, but was not associated with glycaemia. Although we did not explore mortality in this study, our results suggest that the increased mortality in those with multimorbidity and T2D observed in other studies may not be linked to glycaemia. Interestingly, discordant conditions were more prevalent than concordant conditions with painful conditions being the second most common comorbidity. Better understanding of the implications of different patterns of multimorbidity in people with T2D will allow more effective tailored care.

Multimorbidity, glycaemic variability and time in target range in people with type 2 diabetes: A baseline analysis of the GP-OSMOTIC trial

AIMS

To explore associations between multimorbidity condition counts (total; concordant (diabetes-related); discordant (unrelated to diabetes)) and glycaemia (HbA1c; glycaemic variability (GV); time in range (TIR)) using data from a randomised controlled trial examining effectiveness of continuous glucose monitoring (CGM) in people with type 2 diabetes (T2D).

METHODS

Cross-sectional study: 279 people with T2D using baseline data from the General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC) trial from 25 general practices in Australia. Number of long-term conditions (LTCs) in addition to T2D used to quantify total/concordant/discordant multimorbidity counts. GV (measured by coefficient of variation (CV)) and TIR derived from CGM data. Multivariable linear regression models used to examine associations between multimorbidity counts, HbA1c (%), GV and TIR.

RESULTS

Mean (SD) age of participants 60.4 (9.9) years; 40.9% female. Multimorbidity was present in 89.2% of participants. Most prevalent comorbid LTCs: hypertension (57.4%), painful conditions (29.8%), coronary heart disease (22.6%) and depression (19.0%). No evidence of associations between multimorbidity counts, HbA1c, GV and TIR.

CONCLUSIONS

While multimorbidity was common in this T2D cohort, it was not associated with HbA1c, CV or TIR. Future studies should explore factors other than glycaemia that contribute to the increased mortality observed in those with multimorbidity and T2D.