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1.  An explorative qualitative study on acceptability of physical activity assessment instruments among primary care professionals in southern Sydney 
BMC Family Practice  2016;17:138.
There are a substantial number of instruments for primary-care clinicians to assess physical-activity (PA). However, there are few studies that have explored the views of clinicians regarding comparative acceptability and ease of use. A better understanding of how clinicians perceive instruments could help overcome barriers, and inform future interventions. This study explored the acceptability of five PA-assessment instruments amongst a sample of Australian primary-care clinicians, including family-physicians (FP) and practice-nurses (PN).
A purposive sample of FPs (N = 9) and PNs (N = 10) from eight family-practices in southern Sydney consented to participate. Stage-1 involved semi-structured interviews with participants to select preferred instruments. An analysis of the two preferred instruments was conducted as Stage-2, to identify differences in instrument purpose and content. Stage-3 involved participants using the two instruments, selected from Stage-1, for 12-weeks. At the end of this period, semi-structured interviews were repeated to explore clinician experience.
Clinicians indicated preferences for the GP-Physical-Activity-Questionnaire and 3-Questionnaire Physical-Activity-Questionnaire. These instruments demonstrated distinct variations in content, theoretical orientation, and outcome measures. Reasons for preference included; variations in individual clinician PA levels, knowledge in PA-assessment and instrument features.
Findings demonstrated two instruments as preferred. Reasons for preference related to internal characteristics of clinicians such as variations in the level of individual PA and external circumstances, such as instrument features.
PMCID: PMC5034541  PMID: 27658950
Acceptability; Family practice; General practitioner; Practice nurse; Physical activity; Physical activity assessment; Questionnaire
2.  Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis 
Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most.
Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models.
Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes.
Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.
PMCID: PMC5012618  PMID: 27621612
chronic obstructive pulmonary disease; individual patient data meta-analysis; self-management; subgroup analysis
3.  Prevalence of Risk Factors for Cardiovascular Diseases in Bangladesh: A Systematic Review and Meta-Analysis 
PLoS ONE  2016;11(8):e0160180.
Given the rising incidence of cardiovascular diseases (CVDs) in Bangladesh, an improved understanding of the epidemiology of CVD risk factors is needed. Therefore, we reviewed published studies on CVD modifiable risk factors e.g., Type 2 Diabetes Mellitus (T2DM), hypertension (HTN), dyslipidemia and smoking as well as studies on CVDs and conducted a meta-analysis of risk factors and disease prevalence.
We searched the GLOBAL HEALTH, MEDLINE, EMBASE ‘BanglaJol’ databases for all studies in English on CVDs and its associated modifiable risk factors. Random effects meta-analysis methods were used to estimate pooled prevalence.
There were 74 eligible studies (outcome: T2DM = 32, HTN = 24, dyslipidaemia = 8 and smoking = 25; CVDs = 10). Due to high between study heterogeneity (p<0.001, I2> 95%) in the prevalence of CVD risk factors, we presented median and interquartile range (IQR) instead of the pooled estimates as the summary measures. Median (IQR) prevalence of T2DM, HTN, dyslipidemia and smoking were 5.9% (1.97%-8.25%); 15.1% (10.52%-17.60%); 34.35% (10.66%-48.50%) and 40.56% (0.80%-55.95%), respectively. The prevalence of T2DM and dyslipidemia were significantly higher in urban compared to rural populations (13.5 vs 6%, p<0.001; 41.5 vs 30%, p = 0.007, respectively).
The prevalence of risk factors for CVDs is high in Bangladesh, more so in urban areas. Ageing of the population may be a factor but urbanization seems to have an influence, possibly related to changes in dietary and physical activity patterns. Further research, in particular longitudinal studies, is needed to explore the complex interaction of these factors and to inform policies and programs for the prevention and management of CVDs in Bangladesh.
PMCID: PMC4975457  PMID: 27494706
4.  Short-term predictive ability of selected cardiovascular risk prediction models in a rural Bangladeshi population: a case-cohort study 
Prediction of absolute risk of cardiovascular diseases (CVDs) has important clinical and public health significance, but the predictive ability of the available tools has not yet been tested in the rural Bangladeshi population. The present study was undertaken to test the hypothesis that both laboratory-based (Framingham equation and WHO/ISH laboratory-based charts) and non-laboratory-based tools may be used to predict CVDs on a short-term basis.
Data from a case-cohort study (52989 cohort and 439 sub-cohort participants), conducted on a rural Bangladeshi population, were analysed using modified Cox PH model with a maximum follow-up of 2.5 years. The outcome variable, coronary heart diseases (CHDs), was assessed in 2014 using electrocardiography, and it was used as a surrogate marker for CVDs in Bangladesh. The predictive power of the models was assessed by calculating C-statistics and generating ROC curves with other measures of diagnostic tests.
All the models showed high negative prediction values (NPVs, 84 % to 92 %) and these did not differ between models or gender. The sensitivity of the models substantially changed based on the risk prediction thresholds (between 5–30 %); however, the NPVs and PPVs were relatively stable at various threshold levels. Hypertension and dyslipidaemia were significantly associated with CHD outcome in males and ABSI (a body shape index) in females. All models showed similar C-statistics (0.611–0.685, in both genders). Overall, the non-laboratory-based model showed better performance (0.685) in women but equal performance in men.
Existing CVD risk prediction tools may identify future CHD cases with fairly good confidence on a short-term basis. The non-laboratory-based tool, using ABSI as a predictor, may provide better predictive accuracy among women.
PMCID: PMC4937534  PMID: 27386836
Cardiovascular disease; Coronary heart disease; Myocardial infarction; Framingham risk scores; Case-cohort; CVD risk prediction; Bangladesh; NB-NCDP
5.  Improving the uptake of pre-travel health advice amongst migrant Australians: exploring the attitudes of primary care providers and migrant community groups 
BMC Infectious Diseases  2016;16:213.
Migrant travellers who return to their country of origin to visit family and friends (VFR) are less likely to seek travel-related medical care and are less likely to adhere to recommended medications and travel precautions. Through this study, we aimed to get an understanding of the views of stakeholders from community migrant centres and primary care providers on barriers for migrants, particularly from non-English speaking backgrounds, in accessing travel health advice and the strategies that could be used to engage them.
A qualitative study involving 20 semi-structured interviews was undertaken in Sydney, Australia between January 2013 and September 2014. Thematic analysis was undertaken.
Language barriers, a lower perceived risk of travel-related infections and the financial costs of seeking pre-travel health care were nominated as being the key barriers impacting on the uptake of pre-travel health advice and precautions. To overcome pre-existing language barriers, participants advocated for the use of bilingual community educators, community radio, ethnic newspapers and posters in the dissemination of pre-travel health information.
Travel is a major vector of importation of infectious diseases into Australia, and VFR travellers are at high risk of infection. Collaboration between the Government, primary care physicians, migrant community groups and migrants themselves is crucial if we are to be successful in reducing travel-related risks among this subgroup of travellers.
PMCID: PMC4870764  PMID: 27193512
Vaccination; Travel; Migrants; Attitudes; Visiting friends and relatives; Infectious diseases
6.  The impact of health literacy and life style risk factors on health-related quality of life of Australian patients 
Limited evidence exists regarding the relationship between health literacy and health-related quality of life (HRQoL) in Australian patients from primary care. The objective of this study was to investigate the impact of health literacy on HRQoL in a large sample of patients without known vascular disease or diabetes and to examine whether the difference in HRQoL between low and high health literacy groups was clinically significant.
This was a cross-sectional study of baseline data from a cluster randomised trial. The study included 739 patients from 30 general practices across four Australian states conducted in 2012 and 2013 using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) are derived using the standard US algorithm. Health literacy was measured using the Health Literacy Management Scale (HeLMS). Multilevel regression analysis (patients at level 1 and general practices at level 2) was applied to relate PCS-12 and MCS-12 to patient reported life style risk behaviours including health literacy and demographic factors.
Low health literacy patients were more likely to be smokers (12 % vs 6 %, P = 0.005), do insufficient physical activity (63 % vs 47 %, P < 0.001), be overweight (68 % vs 52 %, P < 0.001), and have lower physical health and lower mental health with large clinically significant effect sizes of 0.56 (B (regression coefficient) = −5.4, P < 0.001) and 0.78(B = -6.4, P < 0.001) respectively after adjustment for confounding factors. Patients with insufficient physical activity were likely to have a lower physical health score (effect size = 0.42, B = −3.1, P < 0.001) and lower mental health (effect size = 0.37, B = −2.6, P < 0.001). Being overweight tended to be related to a lower PCS-12 (effect size = 0.41, B = −1.8, P < 0.05). Less well-educated, unemployed and smoking patients with low health literacy reported worse physical health. Health literacy accounted for 45 and 70 % of the total between patient variance explained in PCS-12 and MCS-12 respectively.
Addressing health literacy related barriers to preventive care may help reduce some of the disparities in HRQoL. Recognising and tailoring health related communication to those with low health literacy may improve health outcomes including HRQoL in general practice.
PMCID: PMC4855442  PMID: 27142865
Quality of life; Health literacy; Life style risk factors; SF-12 version 2; Physical component score; Mental component score; Multilevel regression analysis
7.  Implementing guidelines to routinely prevent chronic vascular disease in primary care: the Preventive Evidence into Practice cluster randomised controlled trial 
BMJ Open  2015;5(12):e009397.
To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease.
32 urban general practices in 4 Australian states.
Stratified randomisation of practices.
122 general practitioners (GPs) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness.
The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information.
Outcome measures
Primary: 1. Change in proportion of patients aged 40–69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45–69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor.
change in self-reported frequency and confidence of GPs and PNs in assessment.
Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPs and PNs in the intervention group improved in the assessment of some risk factors.
This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit.
Trial registration number
Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000578808, results.
PMCID: PMC4679885  PMID: 26656984
PRIMARY CARE; PREVENTIVE MEDICINE; practice facilitation; chronic disease; quality improvement
8.  Application of two versions of the WHO/international society of hypertension absolute cardiovascular risk assessment tools in a rural Bangladeshi population 
BMJ Open  2015;5(10):e008140.
To estimate the absolute cardiovascular disease (CVD) risk burden in a remote rural Bangladeshi population using the ‘With’ and ‘Without’ Cholesterol versions of the WHO/International Society of Hypertension (WHO/ISH) CVD risk assessment chart (particularly suitable for low and middle-income countries due to less reliance on laboratory testing) and to evaluate the agreement between the two approaches.
Cross-sectional study using data from a large prospective cohort of the North Bengal Non-Communicable Disease Programme (NB-NCDP) of Bangladesh.
General rural population from Thakurgaon district of Bangladesh.
563 individuals who were categorised as having ‘no CVDs’ on screening by a questionnaire-based survey using the ‘WHO CVD-Risk Management Package’ developed in 2002.
Main outcome measures
Absolute CVD risk burden assessed using two versions of the WHO/ISH risk assessment charts for the South-East Asian Region-D.
10-year risk (moderate, high and very high) positivity was present among 21.5% and 20.2% of participants, respectively, using with and without cholesterol versions of the tool. The overall concordance rate for the two versions was 89.5% and they did not differ significantly in estimating the proportion of overall participants having higher levels of CVD. The projected drug requirement, however, showed a significant overestimation in the proportion of participants at both the threshold levels (p<0.002) on using ‘without’ as compared to ‘with’ cholesterol versions.
About one-fifth of the adult population in Bangladesh, even in a remote rural area, seem to be at risk of developing CVDs (25% of them at high risk and 25% at very high risk) within 10 years with males and females being almost equally vulnerable.
PMCID: PMC4606419  PMID: 26463220
Cardiovascular diseases; risk assessment; Cholesterol; Bangladesh
9.  Clinical and biochemical characterization of high risk and not high risk for cardiovascular disease adults in a population from peripheral region of Bangladesh 
BMC Public Health  2015;15:559.
A group of 63708 Bangladeshi adults from a rural area were screened in 2011–12 for cardiovascular diseases (CVD) risk using a questionnaire based tool developed as part of the ‘WHO CVD-RISK Management Package for low-and medium resource setting’. In the current study participants who were found to be high risk and a sample of the not high risk participants from the screening were further characterized clinically and biochemically to explore the burden and determinants of CVD risk factors in a remote rural Bangladeshi population.
The high risk participants comprised all 1170 subjects who screened positive in 2011–12 and the not high risk group comprised 563 randomly sampled participants from the 62538 who screened negative. Socio-demographic, behavioral, anthropometric, clinical and biochemical data (glucose and lipids) were collected by standardized procedures. Body Mass Index (BMI) was classified following Asian BMI criteria. Data was analyzed using univariable and multivariable methods.
On univariable analysis in high risk and not high risk participants respectively, age in years (M ± SD) was 50 ± 11 for both groups, ratio of male: female was 40:60 and 66:44, current smoking 28.5 % and 50.6 %; smokeless tobacco use 37.1 % and 34.8 %; overweight and obesity measured by body mass index (BMI) was 39.1 % and 20.5 %; high waist circumference (WC) 36.1 % and 11.9 %; high waist to hip ratio (WHR) 53.8 % and 26.3 %; and with high waist to height ratio (WHtR) 56.4 % and 28.4 %, existence of hypertension (HTN) was 15.8 % and 3.6 %, pre-HTN 43.8 % and 12.1 %, diabetes (DM) 14.0 % and 10.5 %, pre-DM 16.9 % and 12.1 % and dyslipidaemia 85.8 % and 89.5 %. In multivariable logistic regression analysis female sex, BMI, WC, WHR and WHtR, HTN and dyslipidaemia remain significantly more common among high risk participants (p < 0.05 and p < 0.001).
The prevalence of clinical and biochemical risk factors of CVDs are quite high even in this rural population and this may be related to the socioeconomic and cultural transition in Bangladeshi society. Surprisingly more of the high risk group was female and there were fewer smokers. Obesity and hypertension were more frequent in high risk participants.
PMCID: PMC4471932  PMID: 26084331
Prevalence; Cardiovascular disease; Hypertension; Diabetes; Risk factors; Obesity; Bangladesh
10.  Evaluating the Guideline Enhancement Tool (GET): an innovative clinical training tool to enhance the use of hypertension guidelines in general practice 
BMC Medical Education  2014;14:1046.
This project aims to evaluate the effectiveness of an innovative educational intervention in enhancing clinical decision making related to the management of hypertension in general practice. The relatively low level of uptake of clinical practice guidelines by clinicians is widely recognised as a problem that impacts on clinical outcomes. This project addresses this problem with a focus on hypertension guidelines. Hypertension is the most frequently managed problem in general practice but evidence suggests that management of Hypertension in general practice is sub-optimal.
This study will explore the effectiveness of an educational intervention named the ‘Guideline Enhancement Tool (GET)’. The intervention is designed to guide clinicians through a systematic process of considering key decision points related to the management of hypertension and provides a mechanism for clinicians to engage with the hypertension clinical guidelines.
The intervention will be administered within the Australian General Practice Training program, via one of the regional training providers. Two cohorts of trainees will participate as the intervention and delayed intervention groups.
This process is expected to improve clinicians’ engagement with the hypertension guidelines in particular, and enhance their clinical reasoning abilities in general. The effectiveness of the intervention in improving clinical reasoning will be evaluated using the ‘Script Concordance Test’.
The study design presented in this protocol aims to achieve two major outcomes. Firstly, the trial and evaluation of the educational intervention can lead to the development of a validated clinical education strategy that can be used in GP training to enhance the decision-making processes related to the management of hypertension. This has the potential to be adapted to other clinical conditions and training programs and can benefit clinicians in their clinical decision-making. Secondly, the study explores features that influence the effective use of clinical practice guidelines. The study thus addresses a significant problem in clinical education.
PMCID: PMC4318171  PMID: 25547621
Clinical decision making; Clinical reasoning; Clinical practice guidelines; Guideline Enhancement Tool (GET); General practice training; Clinical education; Hypertension
11.  A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation 
Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Despite the widespread availability of evidence-based clinical guidelines and validated risk predication equations for prevention and management of CVD, their translation into routine practice is limited. We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support, patient risk communication tools, computerised audit and feedback tools, and monthly, peer-ranked performance feedback via a web portal. The intervention was implemented in a cluster randomised controlled trial in 60 primary healthcare services in Australia. Overall, there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals, but it is unclear how this intervention was used in practice and what factors promoted or hindered its use. This information is necessary to optimise intervention impact and maximally implement it in a post-trial context. In this study protocol, we outline our methods to conduct a theory-based, process evaluation of the intervention. Our aims are to understand how, why, and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination.
We will conduct four discrete but inter-related studies taking a mixed methods approach. Our quantitative studies will examine (1) the longer term effectiveness of the intervention post-trial, (2) patient and health service level correlates with trial outcomes, and (3) the health economic impact of implementing the intervention at scale. The qualitative studies will (1) identify healthcare provider perspectives on implementation barriers and enablers and (2) use video ethnography and patient semi-structured interviews to understand how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention. We will also assess the costs of implementing the intervention in Australian primary healthcare settings which will inform scale-up considerations.
This mixed methods evaluation will provide a detailed understanding of the process of implementing a quality improvement intervention and identify the factors that might influence scalability and sustainability.
Trials registration
PMCID: PMC4279909  PMID: 25515217
Knowledge translation; Process evaluation; Quality improvement intervention; Clinical decision support systems; Cardiovascular prevention; Cardiovascular risk; Primary healthcare; Mixed methods; Theory-based
12.  Patients’ perspectives on the impact of a new COPD diagnosis in the face of multimorbidity: a qualitative study 
Chronic obstructive pulmonary disease (COPD), a major cause of morbidity and mortality worldwide, often occurs in the presence of comorbidities, which may influence experience and management of the disease. No prior research seems to have gained perspectives of newly diagnosed primary care COPD patients in the context of multimorbidity.
This qualitative study aimed to explore the impact of a new diagnosis of COPD in the context of multimorbidity and also sought to gain a better understanding of how patients react to the diagnosis and incorporate it into their lives.
Participants were identified from a cohort of primary care patients with multimorbidity recently diagnosed with COPD. Data was collected via semi-structured interviews from nine male and eight female participants. Thematic analysis was performed and the data interpreted from a constructivist perspective.
Five core themes regarding COPD were induced: (i) reaction to diagnosis, (ii) impact on function and health behaviour, (iii) factors influencing self-management capacity, (iv) healthcare utilisation and (v) interplay of comorbidities. Most participants had difficulty recognising the importance of COPD and its long-term implications. For many, the salience of another chronic condition outweighed COPD. Self-management capacity and utilisation of healthcare services were challenged by low prioritisation of COPD among other comorbidities.
This study provides an insight into how primary care patients feel about being diagnosed with COPD, as well as their prioritisation of the disease in the context of multimorbidity. It highlights the need for tailored education and personalised management incorporating patients’ perspectives in primary care.
PMCID: PMC4373407  PMID: 25119845
13.  COPD Diagnostic Questionnaire (CDQ) for selecting at-risk patients for spirometry: a cross-sectional study in Australian general practice 
Using the COPD Diagnostic Questionnaire (CDQ) as a selection tool for spirometry could potentially improve the efficiency and accuracy of chronic obstructive pulmonary disease (COPD) diagnosis in at-risk patients.
To identify an optimal single cut point for the CDQ that divides primary care patients into low or high likelihood of COPD, with the latter group undergoing spirometry.
Former or current smokers aged 40–85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse at various general practices in Sydney, Australia. The CDQ was collected and pre- and post-bronchodilator spirometry was performed. Cases with complete CDQ data and spirometry meeting quality standards were analysed (1,054 out of 1,631 patients). CDQ cut points were selected from a receiver operating characteristic (ROC) curve.
The area under the ROC curve was 0.713. A cut point of 19.5 had the optimal combination of sensitivity (63%) and specificity (70%) with two-thirds below this cut point. A cut point of 14.5 corresponded to a sensitivity of 91%, specificity of 35% and negative predictive value of 96%, and 31% of patients below this cut point.
The CDQ can be used to select patients at risk of COPD for spirometry using one cut point. We consider two possible cut points. The 19.5 cut point excludes a higher proportion of patients from undergoing spirometry with the trade-off of more false negatives. The 14.5 cut point has a high sensitivity and negative predictive value, includes more potential COPD cases but has a higher rate of false positives.
PMCID: PMC4373382  PMID: 25010522
14.  Australian general practitioner perceptions of the detection and screening of at-risk drinking, and the role of the AUDIT-C: a qualitative study 
BMC Family Practice  2013;14:121.
At-risk drinking is common in Australia. Validated screening tools such as the AUDIT-C have been promoted to general practitioners (GPs), but appear rarely used and detection of at-risk drinking in primary care remains low. We sought to describe Australian GP perceptions of the detection and screening of at-risk drinking; to understand their low uptake of alcohol screening questionnaires, and in particular, their attitude to the adoption of the AUDIT-C.
Semi-structured focus group interviews of four groups of GPs and GP trainees were conducted in metropolitan Sydney between August and October 2011. Audio recordings were transcribed and analysed using grounded theory methodology.
We identified four main themes: there was consensus that detecting at-risk drinking is important but difficult to do, social and cultural attitudes to alcohol consumption affect willingness to ask questions about its use, the dynamics of patient-doctor interactions are important, and alcohol screening questionnaires lack practical utility. Analysis suggests that the conceptual barriers to detecting at-risk drinking were: community stigma and stereotypes of “problem drinking”, GP perceptions of unreliable patient alcohol use histories, and the perceived threat to the patient-doctor relationship.
This small exploratory study found that the practice of, and barriers to, detecting at-risk drinking appear to be inextricably linked to the sociocultural beliefs surrounding alcohol use. Screening questionnaires such as the AUDIT-C are not designed to address these issues. In the current context, it is unlikely that approaches that focus on the use of these tools will be effective at improving detection of at-risk drinking by GPs.
PMCID: PMC3765703  PMID: 23961835
Alcohol drinking; Primary health care; General practitioners; Substance abuse detection; Health knowledge; Attitudes; Practice
15.  Healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice 
BMC Family Practice  2013;14:51.
Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens.
This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology.
The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives – re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices.
The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare.
PMCID: PMC3644498  PMID: 23617833
General practice; Quality improvement; Complexity; Organisational change
16.  The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study: intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare 
BMJ Open  2012;2(6):e002177.
Large gaps exist in the implementation of guideline recommendations for cardiovascular disease (CVD) risk management. Electronic decision support (EDS) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia. We have developed HealthTracker, a multifaceted EDS and quality improvement intervention to improve the management of CVD risk.
It is hypothesised that the use of HealthTracker over a 12-month period will result in: (1) an increased proportion of patients receiving guideline-indicated measurements of CVD risk factors and (2) an increased proportion of patients at high risk will receive guideline-indicated prescriptions for lowering their CVD risk. Sixty health services (40 general practices and 20 Aboriginal Community Controlled Health Services (ACCHSs) will be randomised in a 1:1 allocation to receive either the intervention package or continue with usual care, stratified by service type, size and participation in existing quality improvement initiatives. The intervention consists of point-of-care decision support; a risk communication interface; a clinical audit tool to assess performance on CVD-related indicators; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance. The control arm will continue with usual care without access to these intervention components. Quantitative data will be derived from cross-sectional samples at baseline and end of study via automated data extraction. Detailed process and economic evaluations will also be conducted.
Ethics and dissemination
The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee (HREC) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC. Formal agreements with each of the participating sites have been signed. In addition to the usual scientific forums, results will be disseminated via newsletters, study websites, face-to-face feedback forums and workshops.
Trial registration
The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910.
PMCID: PMC3533097  PMID: 23166140
Primary Care; Cardiology
17.  A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol 
Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care.
A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD.
The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities.
The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups.
This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care.
Trial registration
PMCID: PMC3457839  PMID: 22958678
18.  Supporting Treatment decision making to Optimise the Prevention of STROKE in Atrial Fibrillation: The STOP STROKE in AF study. Protocol for a cluster randomised controlled trial 
Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke.
The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this ‘distance education’ program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit.
The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management.
Trial registration
Australian Clinical Trials Registry Registration Number: ACTRN12611000076976.
PMCID: PMC3443055  PMID: 22770423
Atrial fibrillation; General practice; Anticoagulation; Decisional support
19.  Qualitative evaluation of a diabetes electronic decision support tool: views of users 
Quality care of type 2 diabetes is complex and requires systematic use of clinical data to monitor care processes and outcomes. An electronic decision support (EDS) tool for the management of type 2 diabetes in primary care was developed by the Australian Pharmaceutical Alliance. The aim of this qualitative study was to evaluate the uptake and use of the EDS tool as well as to describe the impact of the EDS tool on the primary care consultation for diabetes from the perspectives of general practitioners and practice nurses.
This was a qualitative study of telephone interviews. General Practitioners and Practice Nurses from four Divisions of General Practice who had used the EDS tool for a minimum of six weeks were invited to participate. Semi-structured interviews were conducted and the interview transcripts were coded and thematically analysed using NVivo 8 software.
In total 15 General Practitioners and 2 Practice Nurses completed the interviews. The most commonly used feature of the EDS tool was the summary side bar; its major function was to provide an overview of clinical information and a prompt or reminder to diabetes care. It also assisted communication and served an educational role as a visual aide in the consultation. Some participants thought the tool resulted in longer consultations. There were a range of barriers to use related to the design and functionality of the tool and to the primary care context.
The EDS tool shows promise as a way of summarising information about patients’ diabetes state, reminder of required diabetes care and an aide to patient education.
PMCID: PMC3426492  PMID: 22759239
20.  A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors 
BMC Family Practice  2012;13:49.
To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).
A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.
We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).
Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.
Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).
Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.
52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.
Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.
PMCID: PMC3444864  PMID: 22656188
Health literacy; Behavioral risk factors
21.  Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis 
BMC Family Practice  2012;13:44.
People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes.
Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.
The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review.
52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.
Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients.
Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.
PMCID: PMC3515410  PMID: 22639799
Health literacy; Lifestyle risk factor modification; Primary health care
22.  Study protocol: the DESPATCH study: Delivering stroke prevention for patients with atrial fibrillation - a cluster randomised controlled trial in primary healthcare 
Compelling evidence shows that appropriate use of anticoagulation in patients with nonvalvular atrial fibrillation reduces the risk of ischaemic stroke by 67% and all-cause mortality by 26%. Despite this evidence, anticoagulation is substantially underused, resulting in avoidable fatal and disabling strokes.
DESPATCH is a cluster randomised controlled trial with concealed allocation and blinded outcome assessment designed to evaluate a multifaceted and tailored implementation strategy for improving the uptake of anticoagulation in primary care. We have recruited general practices in South Western Sydney, Australia, and randomly allocated practices to receive the DESPATCH intervention or evidence-based guidelines (control). The intervention comprises specialist decisional support via written feedback about patient-specific cases, three academic detailing sessions (delivered via telephone), practice resources, and evidence-based information. Data for outcome assessment will be obtained from a blinded, independent medical record audit. Our primary endpoint is the proportion of nonvalvular atrial fibrillation patients, over 65 years of age, receiving oral anticoagulation at any time during the 12-month posttest period.
Successful translation of evidence into clinical practice can reduce avoidable stroke, death, and disability due to nonvalvular atrial fibrillation. If successful, DESPATCH will inform public policy, providing quality evidence for an effective implementation strategy to improve management of nonvalvular atrial fibrillation, to close an important evidence-practice gap.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000074392
PMCID: PMC3121604  PMID: 21599901
23.  Annual influenza vaccination: coverage and attitudes of primary care staff in Australia 
Please cite this paper as: Ward et al. (2011) Annual influenza vaccination: coverage and attitudes of primary care staff in Australia. Influenza and Other Respiratory Viruses 5(2), 135–141.
Background  Annual influenza vaccination is recommended for all Australian health care workers (HCWs) including those working in primary health care. There is limited published data on coverage, workplace provision, attitudes and personal barriers to influenza vaccination amongst primary health care staff. The aim of this study was to contribute to the limited literature base in this important area by investigating these issues in the primary health care setting in New South Wales (NSW), Australia.
Methods  A postal survey was sent to general practitioners (GPs) and practice nurses (PNs) from inner city, semi‐urban and rural areas of NSW, Australia. There were 139 responses in total (response rate 36%) from 79 GPs (response rate 30%) and 60 PNs (response rate 46%).
Results  Reported influenza vaccination coverage in both 2007 and 2008 was greater than 70%, with GPs reporting higher coverage than PNs in both years. The main barriers identified were lack of awareness of vaccination recommendations for general practice staff and concern about adverse effects from the vaccine.
Conclusions  Rates of influenza vaccination coverage reported in this study were higher than in previous studies of hospital and institutional HCWs, though it is possible that the study design may have contributed to these higher results. Nevertheless, these findings highlight that more needs to be done to understand barriers to vaccination in this group, to inform the development of appropriate strategies to increase vaccination coverage in primary health care staff, with a special focus on PNs.
PMCID: PMC4942009  PMID: 21306577
General practice; influenza; primary health care; vaccination
24.  Quit in General Practice: a cluster randomised trial of enhanced in-practice support for smoking cessation 
BMC Family Practice  2010;11:59.
This study will test the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by the practice nurse (PN) and tailored to meet the needs of a diversity of patients.
This study is a cluster randomised trial, with practices allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline referral 3) GP usual care. PNs from practices randomised to the intervention group will receive a training course in smoking cessation followed by access to mentoring. GPs from practices randomised to the Quitline referral group will receive information about the study and the process of written referral and GPs in the usual care group will receive information about the study. Eligible patients are those aged 18 and over presenting to their GP who are daily or weekly smokers and who are able to give informed consent. Patients on low incomes in all three groups will be able to access free nicotine patches.
Primary outcomes are sustained abstinence and point prevalence abstinence at the three month and 12 month follow-up points; and incremental cost effectiveness ratios at 12 months. Process evaluation on the reach and acceptability of the intervention approached will be collected through Computer Assisted Telephone Interviews (CATI) with patients and semi-structured interviews with PNs and GPs.
The primary analysis will be by intention to treat. Cessation outcomes will be compared between the three arms at three months and 12 month follow-up using multiple logistic regression. The incremental cost effectiveness ratios will be estimated for the 12 month quit rate for the intervention groups compared to usual care and to each other. Analysis of qualitative data on process outcomes will be based on thematic analysis.
High quality evidence on effectiveness of practice nurse interventions is needed to inform health policy on development of practice nurse roles. If effective, flexible support from the PN in partnership with the GP and the Quitline could become the preferred model for providing smoking cessation advice in Australian general practice.
Trial Registration
PMCID: PMC2931485  PMID: 20701812
25.  What evidence is there to support skill mix changes between GPs, pharmacists and practice nurses in the care of elderly people living in the community? 
Workforce shortages in Australia are occurring across a range of health disciplines but are most acute in general practice. Skill mix change such as task substitution is one solution to workforce shortages. The aim of this systematic review was to explore the evidence for the effectiveness of task substitution between GPs and pharmacists and GPs and nurses for the care of older people with chronic disease. Published, peer reviewed (black) and non-peer reviewed (grey) literature were included in the review if they met the inclusion criteria.
Forty-six articles were included in the review. Task substitution between pharmacists and GPs and nurses and GPs resulted in an improved process of care and patient outcomes, such as improved disease control. The interventions were either health promotion or disease management according to guidelines or use of protocols, or a mixture of both. The results of this review indicate that pharmacists and nurses can effectively provide disease management and/or health promotion for older people with chronic disease in primary care. While there were improvements in patient outcomes no reduction in health service use was evident.
When implementing skill mix changes such as task substitution it is important that the health professionals' roles are complementary otherwise they may simply duplicate the task performed by other health professionals. This has implications for the way in which multidisciplinary teams are organised in initiatives such as the GP Super Clinics.
PMCID: PMC2749853  PMID: 19744350

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