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Background: To explore the perspectives of overweight and obese patients with diabetes from culturally and linguistically diverse, and disadvantaged backgrounds, as well as practice nurses (PNs) during implementation of a brief PN-supported self-regulation nutrition strategy for weight management in general practice settings serving disadvantaged populations., Methods: During intervention implementation, semi-structured interviews were conducted with 12 patients and four nurses in two general practices located in metropolitan suburbs in Sydney, Australia., Results: Patients and PNs found challenges related to cultural expectations and the requirement of patients to set and adhere to dietary change goals and behaviours. Although patients expressed high levels of satisfaction with PNs, the suitability of the intervention to this group was questioned by PNs. Obstacles were also encountered in delivering the intervention in a busy general practice setting., Conclusions: This pilot study provided initial evidence of the acceptability of a self-regulation nutrition intervention for weight management for overweight and obese patients with type 2 diabetes that was delivered by PNs. Cultural expectations of provider-patient roles, the type of intervention and flexibility in the workplace are important future considerations.

Background: Patients from culturally and linguistically diverse (CALD) backgrounds often face difficulties in accessing health and social care services. This study explored the feasibility and acceptability of involving community health workers (CHWs) as bilingual community navigators (BCNs) in general practice setting, to help patients from CALD backgrounds access health and social care services in Australia., Methods: This research was conducted in two general practices in Sydney where most patients are from specific CALD backgrounds (Chinese in one practice and Samoan in other). Three CHWs trained as BCNs were placed in these practices to help patients access health and social care service. A mixed-method design was followed to explore the feasibility and acceptability of this intervention including analysis of a record of services provided by BCNs and post-intervention qualitative interviews with patients, practice staff and BCNs exploring the feasibility and acceptability of the BCNs' role. The record was analyzed using descriptive statistics and interviews were audio-recorded, transcribed, and thematically analyzed., Results: BCNs served a total of 95 patients, providing help with referral to other services (52.6%), information about appointments (46.3%), local resources (12.6%) or available social benefits (23.2%). Most patients received one service from BCNs with the average duration of appointments being half an hour. Overall, BCNs fitted in well within the practices and patients as well as staff of participating practices accepted them well. Their role was facilitated by patients' felt need for and acceptance of BCNs' services, recruitment of BCNs from the patient community, as well as BCNs' training and motivation for their role. Major barriers for patients to access BCNs' services included lack of awareness of the BCNs' roles among some patients and practice staff, unavailability of information about local culture specific services, and inadequate time and health system knowledge by BCNs. Limited funding support and the short timeframe of the project were major limitations of the project., Conclusion: BCNs' placement in general practice was feasible and acceptable to patients and staff in these practices. This first step needs to be followed by accredited training, development of the workforce and establishing systems for supervision in order to sustain the program. Future research is needed on the extension of the intrevention to other practices and culture groups., (© 2023. The Author(s).)

Background: Australia has one of the highest rates of overweight and obesity in the developed world, and this increasing prevalence and associated chronic disease morbidity reinforces the importance of understanding the attitudes, views, and experiences of patients and health providers towards weight management interventions and programs. The purpose of this study was to investigate patients, family practitioners and family practice nurses' perceptions and views regarding the receipt or delivery of weight management within the context of the HeLP-GP intervention., Methods: A nested qualitative study design including semi-structured interviews with family practitioners (n = 8), family practice nurses (n = 4), and patients (n = 25) attending family practices in New South Wales (n = 2) and South Australia (n = 2). The patient interviews sought specific feedback about each aspect of the intervention and the provider interviews sought to elicit their understanding and opinions of the strategies underpinning the intervention as well as general perceptions about providing weight management to their patients. Interviews were recorded and transcribed verbatim, and coding and management conducted using NVivo 12 Pro. We analysed the interview data using thematic analysis., Results: Our study identified three key themes: long-term trusting and supportive relationships (being 'in it for the long haul'); initiating conversations and understanding motivations; and ensuring access to multi-modal weight management options that acknowledge differing levels of health literacy. The three themes infer that weight management in family practice with patients who are overweight or obese is challenged by the complexity of the task and the perceived motivation of patients. It needs to be facilitated by positive open communication and programs tailored to patient needs, preferences, and health literacy to be successful., Conclusions: Providing positive weight management in family practice requires ongoing commitment and an open and trusting therapeutic relationship between providers and patients. Behaviour change can be achieved through timely and considered interactions that target individual preferences, are tailored to health literacy, and are consistent and positive in their messaging. Ongoing support of family practices is required through funding and policy changes and additional avenues for referral and adjunctive interventions are required to provide comprehensive weight management within this setting., (© 2023. The Author(s).)

Background: General practitioners and general practice nurses are the most trusted and experienced sources of vaccine information for Australians and are the principal providers of routine immunisation in New South Wales, Australia. This study explored perceived barriers and challenges to the rollout of the COVID-19 immunisation program and continued provision of routine immunisation through general practice., Methods: Structured in-depth interviews were conducted between 29 April and 8 July 2021 with general practitionerss and general practice nurses working in accredited general practices in the Greater Sydney area. Interviews were transcribed verbatim and analysed thematically., Results: Fifteen participants (12 general practitioners and three general practice nurses) were interviewed. Participants considered the COVID-19 vaccine rollout to significantly burden general practice at the cost of delivery of routine preventative care. Patient fear and anxiety and vaccine hesitancy were perceived as major challenges to the provision of all immunisations, exacerbated by media coverage of shifting recommendations related to COVID-19 vaccine adverse events. Inadequate communication from government bodies contributed to a perceived erosion of patient trust in general practice. Participants considered routine immunisation to be minimally disrupted owing to robust practice-based recall and reminder systems and legislated immunisation requirements for children., Conclusion: The role of general practitioners and general practice nurses in the COVID-19 vaccine rollout was seen to be one of great burden and complexity. As the primary providers of immunisation in New South Wales, continued communication with and support for general practice, both financially and informationally, is pivotal to the sustained successful provision of routine and COVID-19 immunisation.

Objectives: In this study, we aimed to describe and evaluate the codesign of an intervention in general practice setting to help address navigation problems faced by the patients from the culturally and linguistically diverse (CALD) community in Australia., Methods: An experience-based codesign (EBCD) methodology was adopted using the Double Diamond design process. Two codesign workshops were conducted online with 13 participants including patients, their caregivers, health service providers, researchers, and other stakeholders. Workshops were audio-recorded, transcribed, and thematically analyzed., Results: The codesign participants identified several navigation problems among CALD patients such as inadequate health literacy, cultural and language barriers, and difficulties with navigating health and social services. They believed that bilingual community navigators (BCNs; lay health workers from the same language or cultural background) could help them address these problems. However, this depended on BCNs being trained and supervised, with a clear role definition and manageable workloads, and not used as an interpreter. In undertaking the codesign process, we found that pre-workshop consultations were useful to ensure engagement, especially for consumers who participated more actively in group activities with service providers after these and their own separate small group discussions during the workshop., Conclusion: Overall, participants identified that BCNs could offer help in addressing the problems faced by the CALD patients in accessing care in general practice setting. The codesign process provided new insights into the navigation problems faced by CALD patients in accessing care and collaboratively developed a strategy for further testing and evaluation., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This research aimed to explore the needs, potential roles and implementation of Bilingual Community Navigators (BCNs) in providing navigation support for patients in general practice settings in Australia. A total of 19 participants (general practitioners, practice managers, practice nurses and receptionists) from five general practices in Sydney where most of the patients spoke a language other than English were interviewed about their views on needs, potential roles and implementation of BCNs in general practice settings. Data were collected between August 2019 and July 2020. The interview transcripts were inductively analysed for themes. Themes emerged across four broad categories: patients' barriers to access health and social care services; potential roles of BCNs; recruitment, training, and employment of BCNs and considerations and anticipated barriers to BCNs' role. Many barriers both at the patient and at the service provider levels in accessing healthcare and social care services were consistent with the Levesque et al. access framework including lack of understanding of the health system, language and cultural barriers, hesitancy to approach general practice and problems navigating services. Participants believed that BCNs would be able to help overcome these barriers through health education, support in booking appointments, arranging transport, providing language and cultural support and improving communication with the health services. Conditions for effective implementation of BCNs in practice included proper training of the navigators to ensure patient confidentiality and addressing organisational/system barriers such as lack of a funding mechanism, a clear role definition of BCNs and acceptance of BCNs by patients. BCNs potential role in facilitating access to appropriate care by culturally and linguistically diverse (CALD) patients in general practice warrants further evaluation in the context of the Australian healthcare system., (© 2022 John Wiley & Sons Ltd.)

Background: People with severe mental illness have a higher rate of premature death than the general population, largely due to primary care preventable diseases. There has been little research on the health profile of this population attending Australian general practices., Methods: In this nationwide cross-sectional study, MedicineInsight data for adult patients regularly attending general practices in 2018 were analysed to estimate the prevalence of schizophrenia or bipolar disorders (SBD) and investigate the health profile of people with SBD compared with other patients. Multilevel models clustered by practice (n  = 565) and patient, and practice characteristics were created., Results: The prevalence of recorded SBD was 1.91% (95% CI = 1.88%-1.94%) among the 618 849 patients included. Patients with recorded SBD were more likely than other patients to have records of health risk factors, particularly smoking (aOR = 3.8, 95% CI = 3.6-3.9) and substance use (aOR = 5.9, 95% CI = 5.6-6.3), and higher probabilities of comorbidities including cardiovascular diseases (aOR = 1.3, 95% CI = 1.2-1.4), cancer (aOR = 1.1, 95% CI = 1.0-1.2), diabetes mellitus type 2 (aOR = 2.2, 95% CI = 2.0-2.3), chronic kidney diseases (aOR = 1.7, 95% CI = 1.5-2.0), chronic liver diseases (aOR = 3.3, 95% CI = 2.6-4.0) and chronic respiratory diseases (aOR = 1.7, 95% CI = 1.7-1.8)., Conclusions: The higher prevalence of health risk factors and comorbidities among patients with recorded SBD underscores the need for proactive health risk monitoring and preventive care to address this health inequity.

Objective: Continuity and regularity of general practitioner (GP) contacts are associated with reduced hospitalisation in type 2 diabetes (T2DM). We assessed associations of these GP contact patterns with intermediate outcomes reflecting patient monitoring and health., Design: Observational longitudinal cohort study using general practice data 2011-2017., Setting: 193 Australian general practices in Western Australia and New South Wales participating in the MedicineInsight programme run by NPS MedicineWise., Participants: 22 791 patients aged 18 and above with T2DM., Interventions: Regularity was assessed based on variation in the number of days between GP visits, with more regular contacts assumed to indicate planned, proactive care. Informational continuity (claims for care planning incentives) and relational continuity (usual provider of care index) were assessed separately., Outcome Measures: Process of care indicators were glycosylated haemoglobin (HbA1c) test underuse (8 months without test), estimated glomerular filtration rate (eGFR) underuse (14 months) and HbA1c overuse (two tests within 80 days). The clinical indicator was T2DM control (HbA1c 6.5% (47.5 mmol/mol)-7.5% (58.5 mmol/mol))., Results: The quintile with most regular contact had reduced odds of HbA1c and eGFR underuse (OR 0.74, 95% CI 0.67 to 0.81 and OR 0.78, 95% CI 0.70 to 0.86, respectively), but increased odds of HbA1c overuse (OR 1.20, 95% CI 1.05 to 1.38). Informational continuity was associated with reduced odds of HbA1c underuse (OR 0.53, 95% CI 0.49 to 0.56), reduced eGFR underuse (OR 0.62, 95% CI 0.58 to 0.67) and higher odds of HbA1c overuse (OR 1.48, 95% CI 1.34 to 1.64). Neither had significant associations with HbA1c level. Results for relational continuity differed., Conclusions: This study provides evidence that regularity and continuity influence processes of care in the management of patients with diabetes, though this did not result in the recording of HbA1c within target range. Research should capture these intermediate outcomes to better understand how GP contact patterns may influence health rather than solely assessing associations with hospitalisation outcomes., Competing Interests: Competing interests: RM and MNH report grants from the National Health and Medical Research Council (Australia) during the conduct of the study. DY reports grants from the Research Training Programme (Australia) during the current study., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Evidence-based medicine (EBM) is a core skillset for enhancing the quality and safety of patients' care. Online EBM education could improve clinicians' skills in EBM, particularly when it is conducted during vocational training. There are limited studies on the impact of online EBM training on clinical practice among general practitioner (GP) registrars (trainees in specialist general practice). We aimed to describe and evaluate the acceptability, utility, satisfaction and applicability of the GP registrars experience with the online course. The course was developed by content-matter experts with educational designers to encompass effective teaching methods (e.g. it was interactive and used multiple teaching methods)., Methods: Mixed-method data collection was conducted after individual registrars' completion of the course. The course comprised six modules that aimed to increase knowledge of research methods and application of EBM skills to everyday practice. GP registrars who completed the online course during 2016-2020 were invited to complete an online survey about their experience and satisfaction with the course. Those who completed the course within the six months prior to data collection were invited to participate in semi-structured phone interviews about their experience with the course and the impact of the course on clinical practice. A thematic analysis approach was used to analyse the data from qualitative interviews., Results: The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted their practice. The students perceived the course increased their understanding of EBM with a Cohen's d of 1.6. Registrars identified factors that influenced the impact of the course. Of those, some were GP-related including their perception of EBM, and being comfortable with what they already learnt; some were work-place related such as time, the influence of supervisors, access to resources; and one was related to patient preferences., Conclusions: This study showed that GP registrars who attended the online course reported that it improved their knowledge, confidence, skill and practice of EBM over the period of three months. The study highlights the supervisor's role on GP registrars' ability in translating the EBM skills learnt in to practice and suggests exploring the effect of EBM training for supervisors., (© 2021. The Author(s).)

Background: Language is a barrier to many patients from refugee backgrounds accessing and receiving quality primary health care. This paper examines the way general practices address these barriers and how this changed following a practice facilitation intervention., Methods: The OPTIMISE study was a stepped wedge cluster randomised trial set within 31 general practices in three urban regions in Australia with high refugee settlement. It involved a practice facilitation intervention addressing interpreter engagement as one of four core intervention areas. This paper analysed quantitative and qualitative data from the practices and 55 general practitioners from these, collected at baseline and after 6 months during which only those assigned to the early group received the intervention., Results: Many practices (71 %) had at least one GP who spoke a language spoken by recent humanitarian entrants. At baseline, 48 % of practices reported using the government funded Translating and Interpreting Service (TIS). The role of reception staff in assessing and recording the language and interpreter needs of patients was well defined. However, they lacked effective systems to share the information with clinicians. After the intervention, the number of practices using the TIS increased. However, family members and friends continued to be used to interpret with GPs reporting patients preferred this approach. The extra time required to arrange and use interpreting services remained a major barrier., Conclusions: In this study a whole of practice facilitation intervention resulted in improvements in procedures for and engagement of interpreters. However, there were barriers such as the extra time required, and family members continued to be used. Based on these findings, further effort is needed to reduce the administrative burden and GP's opportunity cost needed to engage interpreters, to provide training for all staff on when and how to work with interpreters and discuss and respond to patient concerns about interpreting services., (© 2021. The Author(s).)

Objective: This paper describes the process of developing a shared cancer care approach in follow-up, and identifies the e-health options that support an interactive e-care plan shared between a public cancer service, general practitioners (GPs) and cancer survivors. Type of program/service: The cancer service improvement initiative for shared care in follow-up targets colorectal cancer patients who have completed active treatment and who agree to shared care between specialists, GPs and other care team members. The intiative is supported by an agreed shared care pathway and an interactive e-care plan that is dynamic, can be shared and has functionalities that support collaboration. Design and development: A consultative process with stakeholders (local and state health services, a Primary Health Network, GPs and a consumer) was undertaken. Responses from individual consultations (25 stakeholders) were collated and commonalities identified to inform a workshop with 13 stakeholders to obtain consensus on the care pathway and e-health solution. Implications for policy and practice were identified throughout the process., Outcomes: The stakeholders agreed to a shared care pathway, which included assessment and consent, GP engagement, tailoring the care plan and communicating results and information as tasks are completed. The nurse coordinator monitored care. No interactive e-care plans were available at national, state or local health service levels. A web-based GP interactive e-care plan was selected. The main concerns raised were uncertainty about the security of e-health systems not controlled by the local health service and sharing clinical information with external health providers, engaging GPs, and patient anxiety about the capacity of general practice to provide care. The e-care plan provided a low-risk solution to sharing patient information and supported collaborative care. Challenges to share e-care plans have implications for policy and practice., Lessons Learnt: Stakeholders and the project team agreed that finding an e-health system that supported shared cancer care in follow-up and addressed the security and information sharing concerns could not all be adequately addressed at the local level. A GP interactive e-care plan provides a promising solution to a number of the barriers., Competing Interests: None declared.

Background: More than half of Australian adults manage one or more chronic conditions through ongoing interactions with general practitioners (GPs). Their experience of general practice interactions has important implications for their health outcomes and is thus important to explore in-depth. Consumer expectations have emerged as a key consideration in this regard. How well they met in care settings can inform consumers' satisfaction and response to the care received. However, consumer expectations in Australian general practice are not well researched., Objective: To identify key consumer expectations in clinical interactions in Australian general practice based on consumer and GP perspectives., Design: Qualitative, phenomenological approach using thematic analysis of semi-structured interviews., Setting and Participants: Thirty-one participants: 18 patients with one or more chronic (persisting > 6 months) conditions, 10 GPs and 3 GP registrars in Sydney, Australia., Results: Consumer expectations were strongly related to the context of their ongoing therapeutic relationship with a regular GP. Themes relating to some of the most commonly reported consumer expectations were as follows: (a) the importance of longevity and continuity; (b) having good rapport; (c) GP's respect for consumer opinions and expertise; (d) having effective communication; and (e) addressing mental health., Conclusion: Australian GPs and consumers prioritize a positive, long-term clinical relationship in which they respect one another and can communicate their expectations freely. This has implications for consumer satisfaction and in turn ensuring relational continuity, which is particularly relevant to the ongoing care and management of consumers with chronic conditions., (© 2020 The Authors Health Expectations published by John Wiley & Sons Ltd.)

Background: Variable and poor care quality are important causes of preventable patient harm. Many patients receive less than recommended care, but the extent of the problem remains largely unknown. The CareTrack Kids (CTK) research programme sought to address this evidence gap by developing a set of indicators to measure the quality of care for common paediatric conditions. In this study, we focus on one clinical area, 'preventive care' for pre-school aged children. Our objectives were two-fold: (i) develop and validate preventive care quality indicators and (ii) apply them in general medical practice to measure adherence., Methods: Clinical experts (n = 6) developed indicator questions (IQs) from clinical practice guideline (CPG) recommendations using a multi-stage modified Delphi process, which were pilot tested in general practice. The medical records of Australian children (n = 976) from general practices (n = 80) in Queensland, New South Wales and South Australia identified as having a consultation for one of 17 CTK conditions of interest were retrospectively reviewed by trained paediatric nurses. Statistical analyses were performed to estimate percentage compliance and its 95% confidence intervals., Results: IQs (n = 43) and eight care 'bundles' were developed and validated. Care was delivered in line with the IQs in 43.3% of eligible healthcare encounters (95% CI 30.5-56.7). The bundles of care with the highest compliance were 'immunisation' (80.1%, 95% CI 65.7-90.4), 'anthropometric measurements' (52.7%, 95% CI 35.6-69.4) and 'nutrition assessments' (38.5%, 95% CI 24.3-54.3), and lowest for 'visual assessment' (17.9%, 95% CI 8.2-31.9), 'musculoskeletal examinations' (24.4%, 95% CI 13.1-39.1) and 'cardiovascular examinations' (30.9%, 95% CI 12.3-55.5)., Conclusions: This study is the first known attempt to develop specific preventive care quality indicators and measure their delivery to Australian children in general practice. Our findings that preventive care is not reliably delivered to all Australian children and that there is substantial variation in adherence with the IQs provide a starting point for clinicians, researchers and policy makers when considering how the gap between recommended and actual care may be narrowed. The findings may also help inform the development of specific improvement interventions, incentives and national standards.

Background: The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years., Methods: This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006-2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage., Results: Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years., Conclusions: The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.

Background: Linking process of care data from general practice (GP) and hospital data may provide more information about the risk of hospital admission and re-admission for people with type-2 diabetes mellitus (T2DM). This study aimed to extract and link data from a hospital, a diabetes clinic (DC). A second aim was to determine whether the data could be used to predict hospital admission for people with T2DM., Methods: Data were extracted using the GRHANITE™ extraction and linkage tool. The data from nine GPs and the DC included data from the two years prior to the hospital admission. The date of the first hospital admission for patients with one or more admissions was the index admission. For those patients without an admission, the census date 31/03/2014 was used in all outputs requiring results prior to an admission. Readmission was any admission following the index admission. The data were summarised to provide a comparison between two groups of patients: 1) Patients with a diagnosis of T2DM who had been treated at a GP and had a hospital admission and 2) Patients with a diagnosis of T2DM who had been treated at a GP and did not have a hospital admission., Results: Data were extracted for 161,575 patients from the three data sources, 644 patients with T2DM had data linked between the GPs and the hospital. Of these, 170 also had data linked with the DC. Combining the data from the different data sources improved the overall data quality for some attributes particularly those attributes that were recorded consistently in the hospital admission data. The results from the modelling to predict hospital admission were plausible given the issues with data completeness., Conclusion: This project has established the methodology (tools and processes) to extract, link, aggregate and analyse data from general practices, hospital admission data and DC data. This study methodology involved the establishment of a comparator/control group from the same sites to compare and contrast the predictors of admission, addressing a limitation of most published risk stratification and admission prediction studies. Data completeness needs to be improved for this to be useful to predict hospital admissions.

Objective: To assess the association between continuity of provider-adjusted regularity of general practitioner (GP) contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation., Design: Cross-sectional study., Setting: Individual-level linked self-report and administrative health service data from New South Wales, Australia., Participants: 27 409 survey respondents aged ≥45 years with a prior history of diabetes and at least three GP contacts between 1 July 2009 and 30 June 2015., Main Outcome Measures: Unplanned diabetes-related hospitalisations or ED presentations, associated costs and bed days., Results: Twenty-one per cent of respondents had an unplanned diabetes-related hospitalisation or ED presentation. Increasing regularity of GP contact was associated with a lower probability of hospitalisation or ED presentation (19.9% for highest quintile, 23.5% for the lowest quintile). Conditional on having an event, there was a small decrease in the number of hospitalisations or ED presentations for the low (-6%) and moderate regularity quintiles (-8%), a reduction in bed days (ranging from -30 to -44%) and a reduction in average cost of between -23% and -41%, all relative to the lowest quintile. When probability of diabetes-related hospitalisation or ED presentation was included, only the inverse association with cost remained significant (mean of $A3798 to $A6350 less per individual, compared with the lowest regularity quintile). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome., Conclusions: Higher regularity of GP contact-that is more evenly dispersed, not necessarily more frequent care-has the potential to reduce secondary healthcare costs and, conditional on having an event, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine whether the Ways of Thinking and Ways of Doing (WoTWoD) cultural respect framework improves clinically appropriate anticipatory care in general practice and the cultural respect levels of medical practice staff., Design: Mixed methods, cluster randomised controlled trial with a participatory action research approach., Setting, Participants: Fifty-six general practices in Sydney and Melbourne, 2014-2017., Intervention: WoTWoD encompasses a toolkit (ten scenarios illustrating cross-cultural behaviour in clinical practice), one half-day workshop, cultural mentor support for practices, and a local care partnership between participating Medicare locals/primary health networks and local Aboriginal Community Controlled Health Services for guiding the program and facilitating community engagement. The intervention lasted 12 months at each practice., Major Outcomes: Rates of claims for MBS item 715 (health assessment for Aboriginal and Torres Strait Islander People) and recording of chronic disease risk factors; changes in cultural quotient (CQ) scores of practice staff., Results: Complete results were available for 28 intervention (135 GPs, 807 Indigenous patients) and 25 control practices (210 GPs, 1554 Indigenous patients). 12-Month rates of MBS item 715 claims and recording of risk factors for the two groups were not statistically significantly different, nor were mean changes in CQ scores, regardless of staff category and practice attributes., Conclusion: The WoTWoD program did not increase the rate of Indigenous health checks or improve cultural respect scores in general practice. Conceptual, methodologic, and contextual factors that influence cultural mentorship, culturally respectful clinical practice, and Indigenous health care require further investigation., Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12614000797673., (© 2019 AMPCo Pty Ltd.)

Many Australian adults with type 2 diabetes mellitus (T2DM) do not follow recommended self-management behaviours that could prevent or delay complications. This exploratory study aimed to investigate the factors influencing self-management of T2DM in general practice. Semi-structured qualitative interviews were conducted with patients with T2DM (n = 10) and their GPs (n = 4) and practice nurses (n = 3) in a low socioeconomic area of Sydney, New South Wales, Australia. The interviews were analysed thematically using the socio-ecological model as a framework for coding. Additional themes were derived inductively based on the explicitly stated meaning of the text. Factors influencing self-management occurred on four levels of the socio-ecological model: individual (e-health literacy, motivation, time constraints); interpersonal (family and friends, T2DM education, patient-provider relationship); organisational (affordability, multidisciplinary care); and community levels (culture, self-management resources). Multi-level strategies are needed to address this wide range of factors that are beyond the scope of single services or organisations. These could include tailoring health education and resources to e-health literacy and culture; attention to social networks and the patient-provider relationship; and facilitating access to affordable on-site allied health services.

The number of older people living with chronic health conditions is increasing in Australia. The Chronic Disease Management (CDM) items program was introduced to the Medicare Benefits Schedule (MBS) to encourage a more structured approach to managing patients with chronic conditions. Initial uptake was slow and recent research has suggested that uptake is decreasing. This paper examines: person MBS CDM claims in NSW between 2006 and 2014 - using baseline survey data (2006-09) from the Sax Institute's 45 and Up Study linked to MBS and Death Registry data (2006-14) - and MBS CDM claims per 100000 population - using billing data sourced from the Medicare Australia Statistics website - to systematically examine any changes in uptake using a time-series analysis. After age adjustment, claims for initial plans increased from 11.3% in 2006 to 22.4% in 2014. Increases were also seen for allied health service claims (from 4.1% in 2006 to 20.8% in 2014) and for plan reviews (from 5.9% in 2006 to 16.0% in 2014). These increases were consistent with the MBS summary claims data. There is evidence that these plans are appropriately targeting those in most need; however, there is limited evidence of their effect. Claims for plan reviews, although increasing, are suboptimal and may indicate poor continuity of care.

Background: When information on changes in address or migration of people to or from a study jurisdiction is unavailable in longitudinal studies, issues relating to loss-to-follow-up and misclassification bias may result. This study investigated how estimations of associations between general practitioner (GP) contact and hospital use were affected by incomplete address and migration data., Methods: This was a retrospective population-based cohort study of Western Australians from 1990 to 2004. Linked administrative data including mortality records, hospital admissions, primary care and Electoral Roll records were used. Regularity of GP contact, based on the variance of the number of days between GP visits, was calculated for each person-year. Outcomes were the number and costs (A$2014) of diabetes-related hospital admissions in the following year. Models were estimated separately for cohorts where (i) postcode was ascertained at study commencement and held constant, and (ii) postcode and residency within Western Australia were updated with each change of address recorded on the Electoral Roll over the study period., Results: Updating address data reduced total person-years by 11% and changed the distribution of covariates. Estimations of associations between patterns of GP contact and number of hospitalizations changed; the incidence rate ratios measuring the relationship with the most regular GP contact (baseline of those with <2 GP visits) changed from 0.81 [95% confidence interval (CI) 0.66-1.00] to 0.42 (95% CI 0.33-0.53) after updating postcode information. Impacts on cost models were smaller, though still statistically significant., Conclusions: Longitudinal studies using administrative data may report biased results if they ignore address changes and migration. Researchers should attempt to link to these data wherever possible, or choose study designs which these issues are less likely to affect. Custodians should be aware that such data can be vital to high quality research., (© The Author 2017; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association)

Background: Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care., Methods: PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores., Results: Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes., Conclusions: The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures., Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

Developed nations are implementing initiatives to transform the delivery of primary care. New models have been built around multidisciplinary teams, information technology and systematic approaches for chronic disease management (CDM). In Australia, the General Practice Super Clinic (GPSC) model was introduced in 2010. A case study approach was used to illustrate the development of inter-disciplinary CDM over 12 months in two new, outer urban GPSCs. A social scientist visited each practice for two 3-4-day periods. Data, including practice documents, observations and in-depth interviews (n=31) with patients, clinicians and staff, were analysed using the concept of organisational routines. Findings revealed slow, incremental evolution of inter-disciplinary care in both sites. Clinic managers found the facilitation of inter-disciplinary routines for CDM difficult in light of competing priorities within program objectives and the demands of clinic construction. Constraints inherent within the GPSC program, a lack of meaningful support for transformation of the model of care and the lack of effective incentives for collaborative care in fee-for-service billing arrangements, meant that program objectives for integrated multidisciplinary care were largely unattainable. Findings suggest that the GPSC initiative should be considered a program for infrastructure support rather than one of primary care transformation.

Background: Indigenous peoples experience worse health and die at younger ages than their non-indigenous counterparts. Ethnicity data enables health services to identify inequalities experienced by minority populations and to implement and monitor services specifically targeting them. Despite significant Government intervention, Australia's Indigenous peoples, the Aboriginal and Torres Strait Islander peoples, continue to be under identified in data sets. We explored the barriers to Indigenous status identification in urban general practice in two areas in Sydney., Methods: A mixed-methods multiple-site case study was used, set in urban general practice. Data collection included semi-structured interviews and self-complete questionnaires with 31 general practice staff and practitioners, interviews with three Medicare Local staff, and focus groups with the two local Aboriginal and Torres Strait Islander communities in the study areas. These data were combined with clinical record audit data and Aboriginal unannounced standardised patient visits to participating practices to determine the current barriers to Indigenous status identification in urban general practice., Results: Findings can be broadly grouped into three themes: a lack of practitioner/staff understanding on the need to identify Indigenous status or that a problem with identification exists; suboptimal practice systems to identify and/or record patients' Indigenous status; and practice environments that do not promote Indigenous status identification., Conclusion: Aboriginal and Torres Strait Islander peoples remain under-identified in general practice. There is a need to address the lack of practitioner and staff recognition that a problem with Indigenous status identification exists, along with entrenched attitudes and beliefs and limitations to practice software capabilities. Guidelines recommending Indigenous status identification and Aboriginal and Torres Strait Islander-specific Practice Incentive Payments have had limited impact on Indigenous status identification rates. It is likely that policy change mandating Indigenous status identification and recording in general practice will also be required.

Background: With increasing computerisation in general practice, national primary care networks are mooted as sources of data for health services and population health research and planning. Existing data collection programs - MedicinesInsight, Improvement Foundation, Bettering the Evaluation and Care of Health (BEACH) - vary in purpose, governance, methodologies and tools. General practitioners (GPs) have significant roles as collectors, managers and users of electronic health record (EHR) data. They need to understand the challenges to their clinical and managerial roles and responsibilities., Objective: The aim of this article is to examine the primary and secondary use of EHR data, identify challenges, discuss solutions and explore directions., Discussion: Representatives from existing programs, Medicare Locals, Local Health Districts and research networks held workshops on the scope, challenges and approaches to the quality and use of EHR data. Challenges included data quality, interoperability, fragmented governance, proprietary software, transparency, sustainability, competing ethical and privacy perspectives, and cognitive load on patients and clinicians. Proposed solutions included effective change management; transparent governance and management of intellectual property, data quality, security, ethical access, and privacy; common data models, metadata and tools; and patient/community engagement. Collaboration and common approaches to tools, platforms and governance are needed. Processes and structures must be transparent and acceptable to GPs.

Objective: To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease., Setting: 32 urban general practices in 4 Australian states., Randomisation: Stratified randomisation of practices., Participants: 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., Intervention: 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., Secondary: change in self-reported frequency and confidence of GPs and PNs in assessment., Results: 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., Conclusions: 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., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: To address the gap in access to healthcare between Aboriginal people and other Australians, we developed Ways of Thinking, Ways of Doing (WoTWoD) to embed cultural respect into routine clinical practice. WoTWoD includes a workshop, toolkit and cultural mentors in a partnership of general practice and Aboriginal organisations. The aim of this study was to examine the im-pact of WoTWoD on cultural respect, health checks and risk factor management for Aboriginal patients in general practice., Methods: A multi-methods and multi-perspective pre- and-post-intervention pragmatic study with 10 general practices was undertaken, using information from medical records, practice staff, cultural mentors and patients., Results: Cultural respect, service and clinical measures improved after implementing WoTWoD. Qualitative information confirmed and explained improvements. Knowledge of Aboriginal history needed further improvement., Discussion: The WoTWoD may improve culturally appropriate care in general practice. Further research requires adequately powered randomised controlled trials.

Aim: Approximately 20% of Australian pre-school children are overweight. Primary care providers have a crucial role in identifying children at risk of unhealthy weight gain and to offer advice and suggestions to parents. The Healthy 4 Life pilot study aimed to develop and test the feasibility of a practice nurse (PN)-led brief intervention into a healthy kid's check in general practice., Methods: A PN intervention was developed based on a needs assessment and existing literature. A workshop was conducted, and resources were provided to enable four PNs to deliver a brief obesity prevention intervention to parents. Nurses then incorporated the Healthy 4 Life components into the healthy kid's checks they conducted on the next 10 children. Medical records were reviewed and nurses interviewed to establish the feasibility of the intervention., Results: All of the nurses incorporated some Healthy 4 Life components into their healthy kid's checks. Body mass index was calculated and plotted for all children, and advice around healthy eating was offered in 60% of consultations; however, advice about limiting screen time provided in only 2% of consultations. Nurses reported that the intervention fitted well with their current practice, although time constraints were a concern for some nurses and some parents., Conclusion: The provision of a brief training workshop and resources can equip nurses in general practice to offer an obesity prevention intervention to parents of young children. Further research is required to examine the impact of such an intervention on parent and child behaviours and the sustainability of such practices for PNs., (© 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

General practice has experienced change over the past century driven by a variety of influences, the most important of which have been changes in the health needs of the population, the organisation of the workforce, and medicine itself. Over this time, general practice has developed as a profession through education and, ultimately, recognition of its specialist qualifications. There has been increasing organisational sophistication at the practice, regional and national levels. Despite contested scope of practice and vision of its future, general practice's place in the health system as a whole has been increasingly recognised and affirmed.

Significant gaps remain between recommendations of evidence-based guidelines and primary health care practice in Australia. This paper aims to evaluate factors associated with the use of guidelines reported by Australian GPs. Secondary analysis was performed on a survey of primary care practitioners which was conducted by the Commonwealth Fund in 2009: 1016 general practitioners responded in Australia (response rate 52%). Two-thirds of Australian GPs reported that they routinely used evidence-based treatment guidelines for the management of four conditions: diabetes, depression, asthma or chronic obstructive pulmonary disease and hypertension - a higher proportion than in most other countries. Having non-medical staff educating patients about self-management, and a system of GP reminders to provide patients with test results or guideline-based intervention or screening tests, were associated with a higher probability of guidelines use. Older GP age was associated with lower probability of guideline usage. The negative association with age of the doctor may reflect a tendency to rely on experience rather than evidence-based guidelines. The association with greater use of reminders and self-management is consistent with the chronic illness model.

Background: Screening for vascular disease, risk assessment and management are encouraged in general practice however there is limited evidence about the emotional impact on patients. The Health Improvement and Prevention Study evaluated the impact of a general practice-based vascular risk factor intervention on behavioural and physiological risk factors in 30 Australian practices. The primary aim of this analysis is to investigate the psychological impact of participating in the intervention arm of the trial. The secondary aim is to identify the mediating effects of changes in behavioural risk factors or BMI., Methods: This study is an analysis of a secondary outcome from a cluster randomized controlled trial. Patients, aged 40-65 years, were randomly selected from practice records. Those with pre-existing cardiovascular disease were excluded. Socio-demographic details, behavioural risk factors and psychological distress were measured at baseline and 12 months. The Kessler Psychological Distress Score (K10) was the outcome measure for multi-level, multivariable analysis and a product-of-coefficient test to assess the mediating effects of behaviour change., Results: Baseline data were available 384 participants in the intervention group and 315 in the control group. Twelve month data were available for 355 in the intervention group and 300 in the control group. The K10 score of patients in the intervention group (14.78, SD 5.74) was lower at 12 months compared to the control group (15.97, SD 6.30). K10 at 12 months was significantly associated with the score at baseline and being unable to work but not with age, gender, change in behavioural risk factors or change in BMI., Conclusions: The reduction of K10 in the intervention group demonstrates that a general practice based intervention to identify and manage vascular risk factors did not adversely impact on the psychological distress of the participants. The impact of the intervention on distress was not mediated by a change in the behavioural risk factors or BMI, suggesting that there must be other mediators that might explain the positive impact of the intervention on emotional wellbeing., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12607000423415.

Background: Patients with multimorbidity are increasingly common in general practice. Multimorbidity is a challenge for both patients and practitioners because of the complexity of care and its impact on patients' lives. Single-disease-based guidelines are of limited use to providers managing patients with multimorbidity., Objective: The article aims to discuss how multimorbidity can be best managed in general practice. It does this within the framework of a patient-centred approach that recognises the importance of finding common ground with patients in setting priorities and assessing the impact of care., Discussion: Providing effective care for multimorbidity requires shared decision-making about goals with patients and more effective communication and coordination between providers. For this group of patients, our current single-disease-based models of care need to be replaced with more integrated ones in which the impact of all the patient's conditions on their quality of life are considered.

Background: Despite being at high risk, disadvantaged patients may be less likely to receive preventive care in general practice. This study aimed to explore self-reported preventive care received from general practitioners and the factors associated with this by healthy New South Wales (NSW) residents aged 45-74 years., Methods: A self-completed questionnaire was sent to 100,000 NSW residents in the 45 and Up cohort study. There was a 60% response rate. After exclusions there were 39,964 participants aged 45-74 years who did not report cardiovascular disease or diabetes. Dichotomised outcome variables were participant report of having had a clinical assessment of their blood pressure (BP), blood cholesterol (BC) or blood glucose (BG), or received advice to eat less high fat food, eat more fruit and vegetables or be more physically active from their GP in the last 12 months. Independent variables included socio-demographic, lifestyle risk factors, health status, access to health care and confidence in self-management., Results: Most respondents reported having had their BP (90.6%), BC (73.9%) or BG (69.4%) assessed. Fewer reported being given health advice to (a)eat less high fat food (26.6%), (b) eat more fruit and vegetables (15.5%) or (c) do more physical activity (19.9%). The patterns of association were consistent with recognised need: participants who were older, less well educated or overweight were more likely to report clinical assessments; participants who were overseas born, of lower educational attainment, less confident in their own self-management, reported insufficient physical activity or were overweight were more likely to report receiving advice. However current smokers were less likely to report clinical assessments; and rural and older participants were less likely to receive diet or physical activity advice., Conclusions: This study demonstrated a gap between reported clinical assessments and preventive advice. There was evidence for inverse care for rural participants and smokers, who despite being at higher risk of health problems, were less likely to report receiving preventive care. This suggests the need for greater effort to promote preventive care for these groups in Australian general practice.

Background: Diabetes can be effectively managed in general practice (GP). This study used record linkage to explore associations between diabetes care in GP and hospitalisation., Methods: Data on patients with type 2 diabetes were extracted from a Division of GP diabetes register (CARDIAB) for 2002-05 and were linked to the New South Wales Admitted Patient and Emergency Department (ED) Data Collection to create a unit record data collection containing demographic, clinical and health service records. Rates of admission and ED presentation per patient-year of follow up were calculated for the year following CARDIAB record., Results: The study included 1178 diabetic patients with 2959 patient-years of follow up. Their mean age was 65.7 years and duration of diabetes was 5.9 years. All-cause admission and ED presentation rates were 0.7 and 0.2 per patient-year of follow up respectively and length of admission 3.2 days (s.d. 11.7 days). Admission was associated with age, duration of diabetes and prior admission. The number of processes of care recorded for each patient-year was associated with admission. Admission and length of stay were not associated with achievement of clinical targets., Conclusions: These data suggest that receipt of processes of care, rather than clinical targets, will prevent admission. One explanation may be that continuity of care in GP provides opportunity for early intervention and treatment. WHAT IS KNOWN ABOUT THE TOPIC? Diabetes is a serious public health problem that is largely managed in primary care. Health care planners use health service use (hospital admissions) for diabetes as an indicator of primary care. Guidelines for diabetes care are known to be effective in reducing diabetes-related complications. WHAT DOES THIS PAPER ADD? This paper created a linked data collection comprising demographic and clinical data from general practice and administrative health records of hospital admissions and emergency department presentations. The paper explores the associations between processes of primary care and control of diabetes and cardiovascular risk factors, and use of health services for a general practice population with diabetes. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? The study suggests that processes of care and not technical control of diabetes and cardiovascular risk factors are important in preventing hospital admission. Continuity of care in general practice that ensures implementation of processes of care provides opportunity for early intervention and treatment.

Background: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession., Methods: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews., Discussion: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.

Background: This article explores the views of general practitioners on their referral of colorectal cancer patients following diagnosis to specialist surgeons., Methods: Sampling was purposive. Nineteen GPs representing urban and rural areas participated in four focus groups., Results: General practitioners viewed their relationship with surgeons to be of prime importance in the decision about whom to refer. This relationship allowed faster referrals and improved feedback from the specialist to the GP. General practitioners preferred referral to the private health services because they perceived delays in the public system and that referral and communication was easier with private specialists. Neither the volume of colorectal cancer work nor the availability of a multidisciplinary team influenced their decision making., Discussion: The relationship and communication between GP and surgeon are important in facilitating the referral pathway and the continuing role that many GPs would like to have in the care of their patients.

Objective: To evaluate the impact of a lifestyle intervention in Australian general practice to reduce the risk of vascular disease., Design, Setting and Participants: Stratified cluster randomised controlled trial among 30 general practices in New South Wales from July 2008 to January 2010. Patients aged 40-64 years were invited to participate. The subgroup who were 40-55 years of age were included only if they had either hypertension or dyslipidaemia., Intervention: A general practice-based health-check with brief lifestyle counselling and referral of high-risk patients to a program consisting of one to two individual visits with an exercise physiologist or dietitian, and six group sessions., Main Outcome Measures: Outcomes at baseline, 6 and 12 months included the behavioural and physiological risk factors for vascular disease - self-reported diet and physical activity, and measured weight, body mass index, waist circumference, blood lipid and blood sugar levels, and blood pressure., Results: Of the 3128 patients who were invited, 958 patients (30.6%) responded and 814 were eligible to participate. Of these, 699 commenced the study, and 655 remained in the study at 12 months. Physical activity levels increased to a greater extent in the intervention group than the control group at 6 and 12 months (P = 0.005). There were no other changes in behavioural or physiological outcomes or in estimated absolute risk of cardiovascular disease at 12 months. Of the 384 enrolled in the intervention group, 117 patients (30.5%) attended the minimum number of group program sessions and lost more weight (mean weight loss, 1.06 kg) than those who did not attend the minimum number of sessions (mean weight gain, 0.73 kg)., Conclusion: While patients who received counselling by their general practitioner increased self-reported physical activity, only those who attended the group sessions sustained an improvement in weight. However, more research is needed to determine whether group programs offer significant benefits over individual counselling in general practice., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12607000423415.

Three features are essential in designing the flexible funding payments and pay-for-performance elements.

Vascular disease is a leading cause of death and disability. While it is preventable, little is known about the feasibility or acceptability of implementing interventions to prevent vascular disease in Australian primary health care. We conducted a cluster randomised controlled trial assessing prevention of vascular disease in patients aged 40-65 by providing a lifestyle modification program in general practice. Interviews with 13 general practices in the intervention arm of this trial examined their views on implementing the lifestyle modification program in general practice settings. Qualitative study, involving thematic analysis of semi-structured interviews with 11 general practitioners, four practice nurses and five allied health providers between October 2009 and April 2010. Providing brief lifestyle intervention fitted well with routine health-check consultations; however, acceptance and referral to the program was dependent on the level of facilitation provided by program coordinators. Respondents reported that patients engaged with the advice and strategies provided in the program, which helped them make lifestyle changes. Practice nurse involvement was important to sustaining implementation in general practice, while the lack of referral services for people at risk of developing vascular disease threatens maintenance of lifestyle changes as few respondents thought patients would continue lifestyle changes without long-term follow up. Lifestyle modification programs to prevent vascular disease are feasible in general practice but must be provided in a flexible format, such as being offered out of hours to facilitate uptake, with ongoing support and follow up to assist maintenance. The newly formed Medicare Locals may have an important role in facilitating lifestyle modification programs for this target group.

This study aimed to describe patient-reported management of behavioural risk factors in Australian general practice. Six hundred and ninety-eight eligible patients from 30 general practices in two rural and three urban Divisions of General Practice responded to a mailed invitation to participate and completed a questionnaire. Data were analysed using univariate and multi-level multivariate methods. The prevalence of risk factors varied between 12.6% for smoking and 72.6% for at-risk diet (56.2% were overweight). Most patients were at the action or maintenance phases of their readiness to change their risky behaviours. General practitioners (GPs) provided education or advice to between one-quarter and one-third of those at risk for each risk factor; 9.2% and 9.6% of patients reported having been referred for diet or physical activity interventions. Patient body mass index was associated with increased likelihood of receiving GP advice or referral for diet and physical activity interventions. Having poor diet or physical activity levels and being more ready for change were not associated with the likelihood of GP referral. The major challenge for general practice is to ensure that effective lifestyle interventions are provided to those who will most benefit. Patient-reported GP behavioural risk factor advice and referral is less frequent than is optimal. Priority needs to be given to those most at risk and ready to change their behaviour.

Aim: This article aims to explore the factors contributing to sustained or nonsustained behaviour change following a lifestyle intervention in general practice., Methods: Twenty patients who had participated in a general practice health check and group lifestyle support program were interviewed by telephone after 12 months. The interviews were transcribed and analysed thematically., Results: Patients reported positive effects of the intervention on their behaviour change, especially the group peer support. However, their maintenance of these changes varied. Factors that contributed to sustained behaviour change included social support and self efficacy. Factors contributing to relapse included competing demands on time, comorbidity and stress., Discussion: Greater attention needs to be given to maintenance of behaviour change in lifestyle management programs. Following completion of the program, there needs to be greater support for relapse prevention and management and effective integration back into general practice.

Background: Prevention of vascular disease is an important and challenging role for general practice. Various professional bodies in Australia have published best practice guidelines that address the major behavioural and physiological risk factors for vascular disease. Although these guidelines provide consistent advice and have been widely disseminated, they have not been systematically implemented., Objective: This article presents findings from a literature review that identified effective strategies for implementing guidelines., Discussion: Interventions that support guideline implementation are informed by theory, are multifaceted, tailored to barriers (at the patient, provider and practice levels) and the local context, and involve the entire primary healthcare team. Effective strategies include small group education, clinician prompts and decision aids, audit and feedback and external facilitation. The effectiveness of these strategies in different contexts varies. New systems or tools must fit well within the usual work routines if they are to be successful.

Objectives: Chronic diseases require a multidisciplinary approach to provide optimal patient care in general practice. In Australian general practice, this usually involves referral to an allied health provider outside the practice. This study explored the patient and practice factors associated with referral of patients with diabetes, ischaemic heart disease (IHD) or hypertension to external allied health providers (AHPs)., Methods: A multilevel analysis of data collected as part of a quasi-experimental study was conducted in 26 practices in Sydney. The frequency of patient-reported referral to AHPs 6-months post-intervention was measured against patient and practice characteristics assessed by patients and practice staff questionnaires., Findings: Seven per cent of the total variance in the referrals was due to differences between practices and 93% attributed to differences between patients. Previous referral, age over 45 years, multiple conditions, longer illness duration, poor mental and physical health were associated with the likelihood of referral to AHPs but not socio-economic status, patient self-assessment of care and the intervention. Those attending practices with over three GPs were more likely to be referred., Conclusions: Referral to multidisciplinary care for patients with long term conditions was appropriately linked to the complexity, duration and impact of these conditions. The lack of association between the intervention and the frequency of referral suggests that factors other than knowledge and communication such as the accessibility of the allied health services may have been more important in determining referral., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice., Design and Setting: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics., Main Outcome Measures: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores., Results: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not., Conclusions: Findings were consistent with the purpose of TCAs--to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.