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Home country re-entry from cross-cultural missionary work abroad may be associated with psychological distress. Re-entrants experience multiple losses including loss of identity which may be associated with personal/relational identity gaps and depersonalization/dehumanization. However, research suggests that some re-entrants are resilient with good mental health, while others are fragile with poor mental health. The aims of this paper are to explore the nature and frequency of re-entering missionaries' identity gaps and their depersonalization/dehumanization in resilient and fragile re-entrants. Fifteen re-entering adult Australian cross-cultural missionary workers from four interdenominational Australian mission organizations completed semi-structured interviews. Results were analysed using modified Consensual Qualitative Research methods. Links were established between personal/relational identity gaps, depersonalization/dehumanization and resilience on re-entry. Implications for re-entrants' care are discussed with suggestions for further research.

Background: Point-of-care testing is increasingly being used in general practice to assist GPs in their management of patients with chronic disease. However, patient satisfaction and acceptability of point-of-care testing in general practice has not been widely studied., Aim: To determine if patients are more satisfied with point-of-care testing than with pathology laboratory testing for three chronic conditions., Design of Study: As part of a large multicentre, randomised, controlled trial assessing the use of point-of-care testing in Australian general practice, satisfaction was measured for patients having pathology testing performed by point-of-care testing devices or pathology laboratories. Patients in the trial were managed by GPs for diabetes, hyperlipidaemia, and/or anticoagulant therapy., Method: Patient satisfaction was measured using level of agreement with a variety of statements at the end of the study with a patient satisfaction questionnaire for both the intervention and control groups. Analysis was performed using a mixed model analysis of variance (ANOVA) with allowance for clustering at the practice level following Box-Cox transformations of the data to achieve normality., Results: Overall, intervention patients reported that they were satisfied with point-of-care testing. In comparison with the control group, the intervention group had a higher level of agreement than control patients with statements relating to their satisfaction with the collection process (P<0.001) and confidence in the process (P<0.001). They also viewed point-of-care testing as strengthening their relationship with their GP (P = 0.010) and motivational in terms of better managing their condition (P<0.001)., Conclusion: The results from this trial support patient satisfaction and acceptability of point-of-care testing in a general practice setting.

Objective: To evaluate the association of characteristics of patients and general practices with patient assessment of quality of care., Design: Cross-sectional multi-practice study using the general practice assessment survey., Setting: General practices in Australia., Participants: Ninety-six general practices and 7505 chronic illness patients aged >or=18 years., Main Outcome Measures: Access of care and patient-centredness., Results: Two factors were identified in factor analysis: 'Access of care' and 'Patient-centredness'. Multilevel regression analysis showed significant associations between patients' assessments and patient and practice characteristics. Patients from smaller practices (one to three general practitioners) reported better access to care compared with larger practices. Patients from urban areas were more satisfied with patient-centredness than those from rural areas. Self-reported health status and age had a positive and home ownership, employment and education, and patients from non-English-speaking countries a negative relationship with both scores. Females were more satisfied with patient-centredness., Conclusions: Patient assessments of quality of care and patient-centredness were strongly associated with practice and patient characteristics. This has important implications for interpreting assessments of the quality of primary care, and for policy and practice measures designed to improve this.

Disenfranchised grief results from a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. This article aims to explain the concept and varying presentations of disenfranchised grief and outlines the importance of the general practitioner's role. Preliminary quantitative results of a study of 15 cross cultural workers re-entering Australia are presented, showing more than half experiencing grief during re-entry and all having some form of disenfranchised grief. Disenfranchised grievers present with various symptoms, however, primary care has focused on mental illness, with little recognition of loss and grief issues, especially disenfranchised grief. Further research is required and currently underway to design and formally test a model that can be implemented within an Australian fee-for-service setting.

Objective: Teamwork in primary healthcare is associated with patient care processes and staff outcomes. The ability of teams to be innovative is a hypothesized mechanism. We examined the characteristics of general practices with good team climate for innovation, and assessed the impact of climate on chronically ill patients' assessment of their care and on the job satisfaction of the staff., Design: Large cross-sectional study., Setting: Australian general practices., Participants: A total of 654 general practitioners and staff and 7505 chronically ill patients from 93 general practices in 6 Australian states and territories., Measures: The Team Climate Inventory and the Overall Job Satisfaction Scale, customized for use with general practices, were administered to general practitioners and practice staff, and the General Practice Assessment Survey was administered to patients. Practice characteristics were collected by survey from the principal doctor or practice manager., Results: Mean scores of team climate in Australian general practices were similar to those reported in the UK, except that in our study there was no association between the number of doctors in a practice and their team climate. Better team climate was found in practices with fewer non-clinical staff. Team climate predicted the job satisfaction of the general practitioners and staff, irrespective of the number of practice staff. Better team climate was associated with greater satisfaction by patients with their care., Conclusions: Team climate is important for patient and staff satisfaction. In large general practices, separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.

Background: This article describes the development and psychometric evaluation of an interview instrument to assess provider-reported quality of general practice care for patients with diabetes, cardiovascular disease and asthma--the Australian General Practice Clinical Care Interview (GPCCI)., Methods: We administered the GPCCI to 28 general practitioners (family physicians) in 10 general practices. We conducted an item analysis and assessed the internal consistency of the instrument. We next assessed the quality of care recorded in the medical records of 462 of the general practitioners' patients with Type 2 diabetes, ischaemic heart disease/hypertension and/or moderate to severe asthma. This was then compared with results of the GPCCI for each general practice., Results: Good internal consistency was found for the overall GPCCI (Cronbach's alpha = 0.75). As far as the separate sub-scales were concerned, diabetes had good internal consistency (0.76) but the internal consistency of the heart disease and asthma subscales was not strong (0.49 and 0.16 respectively). There was high inter-rater reliability of the adjusted scores of data extracted from patients' medical notes for each of the three conditions. Correlations of the overall GPCCI and patients' medical notes audit, combined across the three conditions and aggregated to practice level, showed that a strong relationship (r = 0.84, p = 0.003) existed between the two indices of clinical care., Conclusion: This study suggests that the GPCCI has good internal consistency and concurrent validity with patients' medical records in Australian general practice and warrants further evaluation of its properties, validity and utility.

Although we are rapidly improving our understanding of how to manage patients with chronic illness in Australian general practice, many patients are still receiving suboptimal care. General practices have limited organisational capacity to provide the structured care that is required for managing chronic conditions: regular monitoring, decision support, patient recall, supporting patient self management, team work, and information management. This requires a shift away from episodic, acute models. Overseas research has shown that areas such as team work, clinical information systems, decision support, linkages and leadership are also important in managing chronic illness, but we do not know which of these are most important in Australia.

Background: Clinical audit is recognised worldwide as a useful tool for quality improvement., Methods: A feedback report profiling capacity for chronic disease care was sent to 97 general practices. These practices were invited to complete a clinical audit activity based on that feedback. Data were analysed quantitatively and case studies were developed based on the free text responses., Results: Eighty-two (33%) of 247 general practitioners participated in the clinical audit process, representing 57 (59%) of 97 general practices. From the data in their feedback report, 37 (65%) of the 57 practices recognised the area most in need of improvement. This was most likely where the need related to clinical practice or teamwork, and least likely where the need related to linkages with other services, and business and finance. Only 25 practices (46%) developed an action plan related to their recognised area for improvement, and 22 (39%) practices implemented their chosen activity. Participating GPs judged that change activity focused on teamwork was most successful., Discussion: The clinical audit process offered participating GPs and practices an opportunity to reflect on their performance across a number of key areas and to implement change to enhance the practice's capacity for quality chronic disease care. The relationship between need and action was weak, suggesting a need for greater support to overcome barriers.

Background: Re-entry adjustment affects Australian cross cultural workers returning home; and for many, loss and grief issues arise. General practitioners are often the first point of contact in the health care system and are well placed to deal with these issues., Objective: This article examines strategies that GPs can use to support the Australian cross cultural worker on re-entry, and focuses on recognition of re-entry adjustment, the role of loss and grief issues, and the importance of dealing with these issues., Discussion: Australian cross cultural workers are valued members of their communities. However, their loss and grief issues associated with re-entry adjustment on return are often unrecognised and may lead to significant morbidity. Acknowledgment of their disenfranchised grief and appropriate therapy may be part of the role of their GP. Further research is needed to equip GPs to manage this important group in the Australian community.

Background: The relationship between the performance of opportunistic preventive activities in general practice consultations and characteristics of patients, general practitioners, consultations and preventive opportunities is poorly understood., Methods: We recorded the performance of 11 preventive care activities by 10 GPs in one practice and examined the associations of performance of the preventive activities and the characteristics of the patients, GPs, consultations and preventive opportunities., Results: Every patient, GP, consultation and preventive opportunity characteristic studied was independently significantly associated with the performance of at least two of the preventive activities., Discussion: These findings suggest ways of designing more effective reminders, particularly for patients least likely to receive prevention counselling.

All Western countries are developing and implementing new models for managing asthma. In Australia, the Asthma 3+ Visit Plan was implemented in 2001-2002, with the aim of establishing a structured approach in general practice for people with moderate and severe asthma, within a fee-for-service system. Evidence is emerging that the uptake across general practice has been poor, with approximately 5% of eligible people being enrolled. The reasons for the poor uptake include such factors as an inability to identify people with asthma, general practitioners being too busy with other clinical priorities, and the lack of interest and understanding of the need for a structured approach for this disease. This mismatch between evidence and policy development needs to be rectified, if sustainable models of chronic disease care are to be firmly established in general practice.

Objective: To develop a process for improving the integration of care across the rural acute and primary care settings using asthma as a case study., Methods: Development of the process on the analysis of case note audit, survey, interviews and a workshop., Setting: A rural region of South Australia., Results: A work plan for improving general practitioner (GP)-hospital integration was developed that resulted from analysis of the defined problem, GPs and stakeholder involvement, communication between all stakeholders, provision of an incentive to bring all the stakeholders together, and identification of evidence-based solutions., Conclusions: Managing chronic disease in a community requires the integration of care across the primary and acute care setting. To be successful, GP-hospital integration initiatives require stakeholder involvement, locally developed solutions, engagement of GPs, communication and a well-developed plan. This project provides a process for achieving this.

Objective: [corrected] To determine whether routine electronic records are an accurate source of population health data in general practice through reviewing cervical smears rates in four South Australian practices., Methods: The cervical screening rate in a purposive sample of four general practices (three rural and one urban) was obtained using an audit of medical records and a telephone follow-up., Results: The cervical screening rate using only immediately available electronic medical records indicated an overall low rate for the participating practices (44.9%). However, telephone follow-up and adjustments to the denominator indicated the real rate to be 85.7%. The offer of appointments during the telephone follow-up further improved this rate for eligible women (93.8%)., Conclusions and Implications: Electronic medical records may be inadequate in preventive screening in general practice, without ensuring their accuracy. Updating records by telephone or personal follow-up produces a much more accurate denominator.

Background: Preventive care is an important role for general practitioners, yet opportunities for prevention are often missed., Method: We provided an automatic electronic record preventive care reminder system for 12 preventive care activities for one 10 doctor practice. All patients who attended were randomised by the terminal digit of their record number., Results: The control uptake of opportunistic prevention was low; ranging from 1.5% (tetanus immunisation) to 27% (influenza immunisation). The reminders increased this by significant but small amounts for four out of 12 activities (immunisation for tetanus and pneumococcus and recording of allergies and weight), insignificant increases for four (mumps, measles and rubella immunisation, recording of smoking, and taking of cervical smears and of blood pressure), and insignificantly decreased influenza immunisation, and screening for diabetes and hyperlipidaemia., Discussion: Opportunistic electronic reminders have the potential to increase preventive care in general practice.

Objective: To determine the association between rural undergraduate training, rural postgraduate training and medical school entry criteria favouring rural students, on likelihood of working in rural Australian general practice., Methods: National case-control study of 2414 rural and urban general practitioners (GPs) sampled from the Health Insurance Commission database. Participants completed a questionnaire providing information on demographics, current practice location and rural undergraduate and postgraduate experience., Results: Rural GPs were more likely to report having had any rural undergraduate training [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.32-1.95] than were urban GPs. Rural GPs were much more likely to report having had rural postgraduate training (OR 3.14, 95% CI 2.57-3.83). As the duration of rural postgraduate training increased so did the likelihood of working as a rural GP: those reporting that more than half their postgraduate training was rural were most likely to be rural GPs (OR 10.52, 95% CI 5.39-20.51). South Australians whose final high school year was rural were more likely to be rural GPs (OR 3.18, 95% CI 0.99-10.22)., Conclusions: Undergraduate rural training, postgraduate training and medical school entry criteria favouring rural students, all are associated with an increased likelihood of being a rural GP. Longer rural postgraduate training is more strongly associated with rural practice. These findings argue for continuation of rural undergraduate training opportunities and rural entry schemes, and an expansion in postgraduate training opportunities for GPs.

Objective: To implement and evaluate a collaborative medication management service model., Design: Participatory action research., Setting and Participants: The study was conducted from March 1999 to March 2000; 1000 patients, 63 pharmacists and 129 general practitioners from six Divisions of General Practice in South Australia participated., Interventions: A collaborative service delivery model, involving a preliminary case conference, a home visit and a second case conference, was agreed through discussions with medical and pharmacy organisations and then implemented., Outcome Measures: Medication-related problems; actions recommended; actions implemented; and outcomes after actions taken., Results: Overall, 2764 problems were identified. The most common medication-related problem (17.5% of all problems) was the need for additional tests. Thirty-seven per cent of problems related to medicine selection, 20% to patient knowledge, and 17% to the medication regimen. Of 2764 actions recommended to resolve medication-related problems, 42% were implemented. Of the 978 problems for which action was taken and follow-up data were available, 81% were reported to be "resolved", "well managed" or "improving"., Conclusion: This implementation model was successful in engaging GPs and pharmacists and in assisting in the resolution of medication-related problems.

Objective: To determine the association between rural background on practice location of general practitioners (GPs) (rural or urban)., Design: Comparison of data from two postal surveys., Subjects: 268 rural and 236 urban GPs practising in South Australia., Main Outcome Measures: Association between practice location (rural or urban) and demographic characteristics, training, qualifications, and rural background., Results: Rural GPs were younger than urban GPs (mean age 47 versus 50 years, P < 0.01) and more likely to be male (81% versus 67%, P = 0.001), to be Australian-born (72% versus 61%, P = 0.01), to have a partner (95% versus 85%, P = 0.001), and to have children (94% versus 85%, P = 0.001). Similar proportions of rural and urban GPs were trained in Australia and were Fellows of the Royal Australian College of General Practitioners, but more rural GPs were vocationally registered (94% versus 84%, P = 0.001). Rural GPs were more likely to have grown up in the country (37% versus 27%, P = 0.02), to have received primary (33% versus 19%, P = 0.001) and secondary (25% versus 13%, P = 0.001) education there, and to have a partner who grew up in the country (49% versus 24%, P = 0.001). In multivariate analysis, only primary education in the country (odds ratio [OR], 2.43; 95% CI, 1.09-5.56) and partner of rural background (OR, 3.14; 95% CI, 1.96-5.10) were independently associated with rural practice., Conclusion: Our findings support the policy of promoting entry to medical school of students with a rural background and provide an argument for policies that address the needs of partners and maintain quality primary and secondary education in the country.

Objective: To ascertain the incidence of acupuncture claims and the characteristics of patients claiming for acupuncture., Design: Secondary analysis of Health Insurance Commission data on claims for acupuncture performed by a medical practitioner., Participants: A summary of all Medicare acupuncture claims for financial years 1984-85 to 1996-97 and a random sample of patients claiming a Medicare rebate in calendar year 1996., Main Outcome Measures: Claims for acupuncture by patients' State, sex, age, and the socioeconomic disadvantage index of patients' residences., Results: Between 1984-85 and 1996-97 the number of acupuncture claims increased, but declined as a proportion of total Medicare claims. In 1996, 1.16% of patients claimed for acupuncture, which constituted 0.5% of all Medicare claims. Adjusting for age and socioeconomic disadvantage, women were more likely than men to claim for acupuncture (odds ratio, 1.40; 95% confidence interval, 1.36-1.45). This sex difference is proportionately greater than that for all medical services. Propensity to claim for acupuncture increased with age, peaking at 65-69 years, then declining. Acupuncture claims were more likely in areas just above those assessed as having the greatest social disadvantage., Conclusion: The number of acupuncture claims has increased since 1984. As a proportion of all Medicare claims, acupuncture has remained stable since declining in 1991-92. This suggests that acupuncture is now an established complementary medical practice.

At this time innovation in general practice service delivery is being extensively explored and critically examined as a means of improving efficiency. It is important that general practitioners are actively involved in the debate and utilise techniques that allow detailed, logical and robust judgments to be formulated. Economic analysis is one important tool that can contribute to these judgments. The aim of this article is to provide a brief overview of the concepts and methods used.

Objective: This pilot study was undertaken to assess the need and acceptability of a theoretically based audit model to assist GPs improve their asthma care., Method: Seventeen GPs from two GP divisions conducted a chart audit and patient survey of asthma patients presenting during the 8 week audit period. Audit results were discussed at a workshop providing a forum for GP peer groups to review their asthma care against current guidelines. This workshop allowed the GPs to develop strategies to improve their asthma care in the context of the resources of their individual practice, GP division, local community and health services., Results: Of the 243 asthma patients audited 177 (72.8%) had a review of their asthma recorded in the past 12 months, 138 (56.8%) were prescribed regular preventive therapy and 118 (48.2%) had been given an asthma action plan. Despite the time commitment required to participate in the activity, 16 respondents who answered the audit evaluation questionnaire reported that the audit was a useful process and 15 (93.8%) stated that it had motivated them to change their practice., Conclusion: The results confirmed the need for improved asthma care in general practice and demonstrated the feasibility of the GP-peer led, regionally coordinated, audit-workshop model.

Objective: To determine if providing general practitioners (GPs) with costing information can change their clinical behaviour and reduce medical costs., Data Sources: MEDLINE, CINAHL, Health Plan and EMBASE and citations in review articles were searched for studies published between 1980 and 1996., Study Selection: Studies were included if they provided costing information to GPs with the aim of decreasing costs by changing behaviour, included an objective measure of GP performance or clinical care, and used a randomised or quasi-randomised controlled design, crossover design or a controlled time series., Data Extraction: Data extracted included study design, intervention used and measure of GP performance/clinical care (including test ordering, drug prescribing, hospital and primary care visits and costs)., Data Synthesis: Six studies met the inclusion criteria. Computerised feedback on drug costs increased generic prescribing, and "academic detailing" decreased inappropriate prescribing of target drugs. Providing costing information also decreased ordering of diagnostic tests. "Gatekeeper" physicians reduced use of hospital and specialist services. Only two studies found the changes were sustained for nine months or longer and only one evaluated health outcomes., Conclusion: The provision of costing information can change GP behaviour in all service areas. Sustainability of these changes and linking of cost savings to health outcomes have not been well studied.

Objective: To examine knowledge, attitudes and practices of South Australian general practitioners (GPs) in relation to screening for colorectal cancer., Design: A descriptive study in which data were collected by means of postal questionnaires., Main Outcome Measures: Use of screening tests for colorectal cancer, knowledge in relation to colorectal cancer prevention, opinions on organisation and delivery of colorectal cancer screening., Results: The response rate to the survey was 66.3%. GPs showed considerable variability in screening practices, particularly for individuals who are at no increased risk of colorectal cancer. Mass screening with the faecal occult blood test (FOBT), particularly if it is centrally coordinated, was not widely endorsed, in contrast with strategies which provide a central role for the GP. On the whole, GPs preferred patient-initiated, rather than doctor-initiated, screening. We found a number of knowledge deficits in relation to FOBT screening; many GPs felt they had inadequate training in this area., Conclusion: Clear and consistent guidelines for colorectal cancer screening are required. Medical education about colorectal cancer should also be addressed.

Diabetes mellitus is a chronic disease commonly managed in general practice. This article reviews the findings of a questionnaire survey of 173 randomly chosen South Australian general practitioners and their reported management in the areas of detection, diagnosis, assessment, monitoring and GP knowledge. Substantial differences between respondents were found in all areas, suggesting the need for improved educational methods aimed at all general practitioners.

Aim: This study, carried out in 1989, set out to assess general practitioners' knowledge of asthma management and their reported management practices., Method: Of 153 randomly selected South Australian general practitioners 127 (83%) completed a questionnaire designed to explore issues relating to the management of asthma., Results: The survey revealed substantial differences between general practitioners in their knowledge and management practices including the assessment of the severity of asthma, the need for objective monitoring, that is by the use of spirometry and peak flow meters, and the use of medication. Overall, the sampled general practitioners believed that patient-related factors were the main barriers to effective treatment of asthma., Conclusion: The findings of this study suggest that ideal asthma management was not being attained. More research is required to ascertain why such variability among practitioners exists and how best to remedy these differences.

Our results indicate that most demonstration practice grant holders in South Australia and the Northern Territory accept and regularly access facilitator services. Grant holders had little experience with granting body procedures and most frequently discussed administrative matters regarding their individual projects with the facilitator. Concerns about project progress and evaluation issues were other popular topics discussed during grant holder facilitator interactions. The present study did not seek to measure the impact of facilitation on the success of projects. A further study should be undertaken to examine the efficacy and effectiveness of facilitation on project outcome.

Some educational, training and politico-economic reasons for the decline in GP obstetrics in Adelaide, South Australia, are described. It is recommended that similar studies be done in other centres in Australia to evaluate the general nature of the findings.