A woman with asthma: a whole systems approach to supporting self-management

A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient's goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient's asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

Effecting change in primary care management of respiratory conditions: a global scoping exercise and literature review of educational interventions to inform the IPCRG's E-Quality initiative

This discussion paper describes a scoping exercise and literature review commissioned by the International Primary Care Respiratory Group (IPCRG) to inform their E-Quality programme which seeks to support small-scale educational projects to improve respiratory management in primary care. Our narrative review synthesises information from three sources: publications concerning the global context and health systems development; a literature search of Medline, CINAHL and Cochrane databases; and a series of eight interviews conducted with members of the IPCRG faculty. Educational interventions sit within complex healthcare, economic, and policy contexts. It is essential that any development project considers the local circumstances in terms of economic resources, political circumstances, organisation and administrative capacities, as well as the specific quality issue to be addressed. There is limited evidence (in terms of changed clinician behaviour and/or improved health outcomes) regarding the merits of different educational and quality improvement approaches. Features of educational interventions that were most likely to show some evidence of effectiveness included being carefully designed, multifaceted, engaged health professionals in their learning, provided ongoing support, were sensitive to local circumstances, and delivered in combination with other quality improvement strategies. To be effective, educational interventions must consider the complex healthcare systems within which they operate. The criteria for the IPCRG E-Quality awards thus require applicants not only to describe their proposed educational initiative but also to consider the practical and local barriers to successful implementation, and to propose a robust evaluation in terms of changed clinician behaviour or improved health outcomes.

IPCRG Consensus statement: tackling the smoking epidemic - practical guidance for primary care

Tobacco use will become the world's foremost cause of premature death and disability within 20 years unless current trends are reversed. Many opportunities to reduce this epidemic are missed in primary care. This Discussion paper from the International Primary Care Respiratory Group (IPCRG) - which reflects the IPCRG's understanding of primary care practitioners' needs - summarises a new approach based on strong evidence for effective interventions. All primary care health professionals can increase smoking cessation rates among their patients, even when time and resources are limited. Medical and non-medical staff can support patients who choose to quit by providing information, referral to telephone counselling services, and behavioural counselling using motivational interviewing techniques, where resources permit. Drug therapy to manage nicotine dependence can significantly improve patients' chances of quitting successfully, and is recommended for people who smoke 10 or more cigarettes per day. All interventions should be tailored to the individual's circumstances and attitudes.

Safety and quality in primary care: The view from general practice

This article aims to provide a general practice perspective on quality and safety in primary health care. As the health care system has evolved over the past 50 years, so have approaches to ensuring it delivers high quality care. Traditional education has been joined by a range of initiatives from psychological, organisational, marketing, epidemiological and social disciplines. Most of these methods are successful in some situations, but need to be tailored to suit the specific context. There is still imperfect guidance in how to do this. Improvements in performance of 5% to 15% seem to be the best that have been achieved in randomised controlled trials. Quality initiatives in Australian general practice have changed considerably in keeping pace with these developments, moving from an educational paradigm to a more whole-of-system approach. They have been introduced or emerged in ways that are sometimes coherent, sometimes not. Australian general practice is a complex system that is hard to imagine organisationally as a well-oiled machine. The Royal Australian College of General Practitioners has developed a quality framework as a conceptual model to help make sense of the current pattern of quality activities and build a strategic awareness to guide future initiatives.

The impact of the UK General Practice Airways Group (GPIAG) — an international perspective

The impact of the UK General Practice Airways Group (GPIAG) over the past 20 years is discussed from an international perspective. The formation of the International Primary Care Respiratory Group (IPCRG) following the GPIAG conference in 2000, and the role of the Primary Care Respiratory Journal in publishing high quality primary care respiratory research, have been seminal elements in the development of the discipline of primary care respiratory medicine internationally. Research, guidelines development, education, and advocacy, are other areas where the GPIAG has provided a model or shown the way. At a more pragmatic level, the experience of the GPIAG in building a relationship with sponsors and in negotiating the regulatory maze in order to establish an incorporated legal company and charity saved the IPCRG much anguish. The differing roles of national and international organisations are contrasted to illustrate the constructive tension that has impacted on both organisations over the past five years. The IPCRG has built on the foundations of national organisations, particularly the GPIAG, but is charting the way internationally to support the delivery of better health outcomes for people with respiratory disease.

Knowledge and information and the quality framework

BACKGROUND

The quality framework developed by The Royal Australian College of General Practitioners is described by Booth in this issue of Australian Family Physician. This article applies the framework to the 'knowledge and information' domain.

OBJECTIVE

This article draws on selected examples of immediate relevance to Australian general practitioners to demonstrate the value of such a framework.

DISCUSSION

The framework provides a mechanism for assessing policy and implementation initiatives in an Australian context that takes account of the realities of clinical practice. Management, implementation of guidelines, immunisation, electronic prescribing, and decision support are considered using descriptive or analytical approaches.

International Primary Care Respiratory Group (IPCRG) Guidelines: dissemination and implementation--a proposed course of action

There is growing evidence that good implementation of evidence-based guidelines can result in improvement in health outcomes. This paper on Dissemination and Implementation constitutes the final paper of the IPCRG Guidelines on the management of chronic respiratory diseases in primary care. It highlights the historical development of these guidelines following the formation of the International Primary Care Airways Group (IPAG) in 2001 together with its dissemination and implementation subgroup, and the subsequent transfer of this dissemination and implementation role to the IPCRG. It covers the main factors within the IPCRG workplan, including the issues of governance, launch, dissemination, implementation, and evaluation.

Scale Dissolver Application: Production Enhancement and Formation-Damage Potential

Summary

Sulfate scale dissolvers have been applied downhole for many years to remove barium and mixed sulfate scale deposits from the wellbore and from the near-wellbore formation. As well as dissolving mineral scales, these corrosive materials also have the potential to cause some degree of formation damage by the dissolution of reservoir minerals. In this study, three commercial scale dissolver formulations and two laboratory prepared amino carboxylic acid dissolvers (EDTA and DTPA) were tested to assess their comparative capacity to dissolve barium sulfate and, of more importance in the current study, their potential to cause damage in the near-wellbore formation. The potential formation damage capacity of various scale dissolvers has been assessed by measuring the levels of cation release in static tests on mineral separates and by studying the various effluent profiles from core floods using reservoir sand. Possible damage mechanisms include silicate dissolution, fines generation/migration, mechanical strength reduction and wettability changes. We conclude that, when testing sulfate scale dissolvers for field application, their formation damage potential should be assessed as well as their barite dissolution performance.

Introduction

The most effective way of avoiding the problem of oilfield scale formation is by using chemical scale inhibitors which prevent or delay scale formation at substoichiometric levels in solution.1,2 However, if scale formation cannot be prevented, or if the strategy to prevent its formation fails, remedial treatments may be required. The removal of mineral scale deposits is carried out using either chemical or mechanical means.3–5 In general, chemical removal treatments are preferred since they are usually considerably less expensive than mechanical methods and they may also help to remove scale from the near-wellbore formation.

In this paper, we focus on the application of scale dissolvers for the removal of barium and mixed sulfate scales which are the most difficult to remove chemically due to their thermodynamic stability. Carbonate scale removal by acid is a more straightforward problem and will not be discussed here. Certain commercial sulfate scale dissolvers based on amino-carboxylic acids, such as EDTA and DTPA, have been shown to lead to the successful dissolution of barium sulfate when applied appropriately.6–15 In such treatments, the dissolvers may be deliberately injected into the near-wellbore formation to remove scale which has formed there.7,10,12,14 However, in addition to causing reservoir stimulation, these packages also have the potential to cause mineral dissolution and formation damage.

In this paper, we present results from an experimental study of the effect of barium sulfate scale dissolvers on both crystalline barite (BaSO4) and various reservoir minerals. The initial results show the comparative levels of barite dissolution obtained for various scale dissolvers. Further results from bottle tests on the effects of scale dissolvers on individual rock mineral separates, quartz, feldspar and kaolinite, are then described. Finally, the effects of scale dissolvers on unconsolidated core material from a North Sea reservoir is assessed by performing core flooding under simulated reservoir treatment conditions. Recommendations are made concerning the application of scale dissolver treatments taking into account the effect that they may have on the near-wellbore formation.

Experimental Materials and Procedures

Barite Dissolution Bottle Tests.

Conditions and Scale Dissolvers Studied.

In these tests, three commercial scale dissolvers, denoted SD1, SD2 and SD3, were examined for their comparative performance on small chips of mineralogical barite. Dissolution experiments were conducted in synthetic seawater (SW) and formation water (FW) compositions listed in Table 1 using the method outlined below. Further tests then measured the level of dissolution obtained with SD3 compared with laboratory prepared samples of diethylene triamine penta acetic acid (DTPA) and ethylene diamine tetra acetic acid (EDTA). All experimental details are given below.

Experimental Procedure.

The method used to measure the level of barite scale dissolution was as follows.One hundred mL of a scale dissolver solution at the appropriate concentration was poured into a 150 mL polypropylene bottle and placed in a water bath at the test temperature (50 or 80°C) for >1 hour in order to allow equilibration. [Appropriate concentrations being SD1 through SD3 as 50% solutions in SW or, for SD3 in one case, as 50% solution in distilled water (DW) for comparison with 10% solutions of DTPA and EDTA in DW.]Ten g of the prepared barite chips was accurately weighed and placed into a second polypropylene bottle.The scale dissolver solution was then added to the barite chips and shaken vigorously. The bottles were replaced in the water bath at test temperature (50 and 80°C) and a stop clock was started (t=0).At t=30 minutes, the sample bottles were shaken (inverted ~10 times).At t=1 a 1 mL sample of the supernatant was withdrawn through an automatic pipette and added to a test tube containing 9 mL of stabilizing solution, described below.Following sampling, the bottles were shaken as described above and replaced in the water bath.Step 5 was then repeated at t=2, 4, 6, 8, and 12 hours.Further samples were withdrawn at t=24 and 48 hours. For these final samples, the bottles were shaken 1 hour prior to sampling.For the samples collected at 24 and 48 hours, a separate portion of the supernatant was filtered through 0.2 µm syringe filters prior to being sampled in the normal manner (1 mL filtered supernatant to 9 mL stabilizing solution). This filtration procedure for the final sample was used purely for quality assurance purposes to ensure effective sampling. No effect in the observed extent of dissolution was observed as a result of sample filtration.

Randomised controlled trial of effect of feedback on general practitioners' prescribing in Australia

OBJECTIVE

To evaluate the effect on general practitioners' prescribing of feedback on their levels of prescribing.

DESIGN

Randomised controlled trial.

SETTING

General practice in rural Australia.

PARTICIPANTS

2440 full time recognised general practitioners practising in non-urban areas.

INTERVENTION

Two sets of graphical displays (6 months apart) of their prescribing rates for 2 years, relative to those of their peers, were posted to participants. Data were provided for five main drug groups and were accompanied by educational newsletters. The control group received no information on their prescribing.

MAIN OUTCOME MEASURES

Prescribing rates in the intervention and control groups for the five main drug groups, total prescribing and potential substitute prescribing and ordering before and after the interventions.

RESULTS

The intervention and control groups had similar baseline characteristics (age, sex, patient mix, practices). Median prescribing rates for the two groups were almost identical before and after the interventions. Any changes in prescribing observed in the intervention group were also seen in the control group. There was no evidence that feedback reduced the variability in prescribing nor did it differentially affect the very high or very low prescribers.

CONCLUSIONS

The form of feedback evaluated here-mailed, unsolicited, centralised, government sponsored, and based on aggregate data-had no impact on the prescribing levels of general practitioners.