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Uncertainty surrounding the risk of developing and dying from Thrombosis and Thromobocytopenia Syndrome (TTS) associated with the AstraZeneca (AZ) COVID-19 vaccine may contribute to vaccine hesitancy. A model is urgently needed to combine and effectively communicate the existing evidence on the risks versus benefits of the AZ vaccine. We developed a Bayesian network to consolidate the existing evidence on risks and benefits of the AZ vaccine, and parameterised the model using data from a range of empirical studies, government reports, and expert advisory groups. Expert judgement was used to interpret the available evidence and determine the structure of the model, relevant variables, data to be included, and how these data were used to inform the model.The model can be used as a decision support tool to generate scenarios based on age, sex, virus variant and community transmission rates, making it a useful for individuals, clinicians, and researchers to assess the chances of different health outcomes. Model outputs include the risk of dying from TTS following the AZ COVID-19 vaccine, the risk of dying from COVID-19 or COVID-19-associated atypical severe blood clots under different scenarios. Although the model is focused on Australia, it can be easily adaptable to international settings by re-parameterising it with local data. This paper provides detailed description of the model-building methodology, which can used to expand the scope of the model to include other COVID-19 vaccines, booster doses, comorbidities and other health outcomes (e.g., long COVID) to ensure the model remains relevant in the face of constantly changing discussion on risks versus benefits of COVID-19 vaccination.

Thrombosis and Thromobocytopenia Syndrome (TTS) has been associated with the AstraZencea (AZ) COVID-19 vaccine. Australia has reported low TTS incidence of 3000 deaths prevented under high transmission. Risks versus benefits varied significantly between age groups and transmission levels. Under high transmission, deaths prevented by AZ vaccine far exceed deaths from TTS (by 8 to >4500 times depending on age). Probability of dying from COVID-related atypical severe blood clots was 58-126 times higher (depending on age and sex) than dying from TTS. To our knowledge, this is the first example of the use of Bayesian networks for risk-benefit analysis for a COVID-19 vaccine. The model can be rapidly updated to incorporate new data, adapted for other countries, extended to other outcomes (e.g., severe disease), or used for other vaccines.HIGHLIGHTSAZ vaccination risk-benefit analysis must consider age/community transmission levelAZ vaccine benefits far outweigh risks in older age groups and during high transmissionAZ vaccine-associated TTS lower fatality than COVID-related atypical blood clotsBayesian networks utility for risk-benefit analysis of rapidly evolving situationsBNs allow integrating multiple data sources when large datasets are not available

Herpes zoster (shingles) is a painful condition resulting from reactivation of latent varicella zoster virus (VZV). The Australian National Shingles Vaccination Program (commenced November 2016) provides free herpes zoster vaccination for eligible adults aged 70 years, with a 5-year catch-up program (until October 2021) for adults aged 71–79 years. Patterns and impact of the program were evaluated by analysis of vaccine distribution and delivery data and specific antiviral prescription data from the Pharmaceutical Benefits Scheme. During the first 2 years, uptake of funded live attenuated shingles vaccine ZOSTAVAX® (Zoster Virus Vaccine Live; ZVL) was high across the ongoing and catch-up programs. Before program implementation (2006–2016), herpes zoster coded antiviral prescription rates increased by 2.2% per year (95% CI: 1.5, 2.9) in the 70–79 years age group. In the two years since program launch, herpes zoster antiviral prescription rates declined substantially in this age group, by an average of 13.6% per year (95% CI: 1.5, 24.2). These results indicate that the National Shingles Vaccination Program has been highly successful in vaccinating a considerable proportion of Australian adults aged 70–79 years against herpes zoster and suggest that vaccine uptake was associated with decreased incidence of herpes zoster.

IntroductionVarenicline tartrate is superior for smoking cessation to other tobacco cessation therapies by 52 weeks, in the outpatient setting. We aimed to evaluate the long-term (104 week) efficacy following a standard course of inpatient-initiated varenicline tartrate plus Quitline-counselling compared to Quitline-counselling alone.MethodsAdult patients (n = 392, 20-75 years) admitted with a smoking-related illnesses to one of three hospitals, were randomised to receive either 12-weeks of varenicline tartrate (titrated from 0.5mg daily to 1mg twice-daily) plus Quitline-counselling, (n = 196) or Quitline-counselling alone, (n = 196), with continuous abstinence from smoking assessed at 104 weeks.ResultsA total of 1959 potential participants were screened for eligibility between August 2008 and December 2011. The proportion of participants who remained continuously abstinent (intention-to-treat) at 104 weeks were significantly greater in the varenicline tartrate plus counselling arm (29.2% n = 56) compared to counselling alone (18.8% n = 36; p = 0.02; odds ratio 1.78; 95%CI 1.10 to 2.86, p = 0.02). Twenty-two deaths occurred during the 104 week study (n = 10 for varenicline tartrate plus counselling and n = 12 for Quitline-counselling alone). All of these participants had known or developed underlying co-morbidities.ConclusionsThis is the first study to examine the efficacy and safety of varenicline tartrate over 104 weeks within any setting. Varenicline tartrate plus Quitline-counselling was found to be an effective opportunistic treatment when initiated for inpatient smokers who had been admitted with tobacco-related disease.

Background A perennial challenge of primary care quality improvement is to establish why interventions work in some circumstances, but not others. This study aimed to identify factors explaining variations in the impact on clinical practice of a facilitation led vascular health intervention in Australian family practice. Methods Our mixed methods study was embedded within a cluster randomised controlled trial of a facilitation intervention designed to increase the uptake of evidence-based prevention of vascular disease in family practices. The study was set in four Australian states using eight of the study’s 16 intervention practices. Facilitators worked with intervention practices to develop and implement improvements in preventive care informed by a vascular risk factor audit. We constructed case studies of each practice’s “intervention narrative” from semi-structured interviews with clinicians, facilitators and other staff, practice observation, and document analysis of facilitator diaries. The intervention narratives were combined with pre- and post-intervention audit data to generate typologies of practice responses to the intervention. Results We found substantial variability between practices in the changes made to vascular risk recording. Context (i.e. practice size), adaptive reserve (i.e. interpersonal relationships, manager and nurse involvement), and occasional data idiosyncrasies interacted to influence this variability. Conclusion The findings emphasise the importance of tailoring facilitation interventions to practice size, clinician engagement and, critically, the organisation of, and relationships between, the members of the practice team. Trial registration The trial was registered with the 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. Electronic supplementary material The online version of this article (10.1186/s12875-019-0995-7) contains supplementary material, which is available to authorized users.

Australia has a universal infant pneumococcal conjugate vaccination program and until recently a universal pneumococcal polysaccharide vaccine program for non-Indigenous adults aged ≥65 years and Indigenous adults aged ≥50 years. We documented the impacts of infant and adult vaccination programs on the epidemiology of invasive pneumococcal disease (IPD) in Indigenous and non-Indigenous adults. IPD notifications from the National Notifiable Disease Surveillance System were analysed from 2002 to 2017, grouped by age, vaccine serotype group and Indigenous status. Since the universal funding of infant and elderly pneumococcal vaccination programs in January 2005, total IPD decreased by 19% in non-Indigenous adults aged ≥65 years but doubled in Indigenous adults aged ≥50 years. Vaccine uptake was suboptimal in both groups but lower in Indigenous adults. IPD due to the serotypes contained in the pneumococcal conjugate vaccines (PCV) except for serotype 3 declined markedly over the study period but were replaced by non-PCV serotypes. Serotype 3 is currently the most common in older adults. In the populations eligible for the adult 23-valent pneumococcal polysaccharide vaccine (23vPPV) program, IPD rates due to its exclusive serotypes increased to a lower extent than non-vaccine types. In 2017, non-vaccine serotypes accounted for most IPD in the older population eligible for the 23vPPV program, while it's eleven exclusive serotypes accounted for the majority of IPD in younger adults. Infant and adult pneumococcal vaccination programs in Australia have shaped the serotype-specific epidemiology of IPD in older adults. IPD remains a significant health burden for the Indigenous population. Herd immunity impact is clear for PCV serotypes excluding serotype 3 and serotype replacement is evident for non-PCV serotypes. The adult 23vPPV immunisation program appears to have partially curbed replacement with IPD due to its eleven exclusive serotypes, highlighting a potential benefit of increasing adult 23vPPV coverage in Australia.

IntroductionMotivating behavioural change during client consultations is of crucial importance across all health professions to address the growing burden of chronic conditions. Yet health professionals often lack the skills and confidence to use evidence-based counselling interventions to support clients’ behavioural change and mobilise clients’ resources and self-efficacy for change to address their long-term needs.AimsThis pre–post pilot study will develop a motivational interviewing (MI) virtual client training tool for health professionals and test the effectiveness of the educational content and usability of the virtual client interaction.Methods and analysisPostgraduate students across a range of health disciplines will be recruited. Data assessing attitudes towards preventive healthcare will be collected using a modified version of the Preventive Medicine Attitudes and Activities Questionnaire. Conversations with the virtual client will be analysed using the Motivational Interviewing Treatment Integrity code to assess changes in MI skills. The System Usability Scale will be used to assess the usability of the virtual client training tool.Ethics and disseminationThis protocol was approved by the Flinders University Social and Behavioural Research Ethics Committee in May 2019. The results of the pilot study will inform the development of an avatar-based mobile application consisting of MI teaching and interactions with a generic virtual client that can be easily adapted to multiple scenarios.

s Background Motivational interviewing (MI) is internationally recognised as an effective intervention to facilitate health-related behaviour change; although, how it is best implemented and maintained in everyday clinical practice is not so clear. The aim of this study is to understand how MI as an intervention can be embedded and sustained in the clinical practice and learning environments. Methods A concurrent iterative mixed methodology was utilised. Data collection occurred in two parts: a scoping review to identify reported barriers and enablers to embedding and sustaining MI in healthcare settings, and a survey of health professionals at an international clinical educator workshop on the topic. Results from both methods were integrated at the analysis phase (‘following a thread’) to understand how MI is embedded and the fidelity sustained in the clinical environments. Complexity theory as a conceptualising framework was utilised. Results Eleven studies were included, and 30 health professionals were surveyed. Sustainability of MI at micro-clinical levels can be fostered through use of enabling technology, focus on patient-centred care, personnel development and process improvement. At the meso-organisational level, developing shared vision, creating opportunities and an organisational culture supportive of continuous learning are relevant issues. At the macro levels, adopting systems thinking and a learning organisation approach is important for sustaining MI. Conclusions In addressing the recognised barriers to embedding and sustaining MI in health service provisions, clinical educators could potentially play a central role as change agents within and across the complex clinical system. Electronic supplementary material The online version of this article (10.1186/s12909-019-1606-y) contains supplementary material, which is available to authorized users.

The prevalence of people seeking care for Borderline Personality Disorder (BPD) in primary care is four to five times higher than in the general population. Therefore, general practitioners (GPs) are important sources of assessment, diagnosis, treatment, and care for these patients, as well as important providers of early intervention and long-term management for mental health and associated comorbidities. A thematic analysis of two focus groups with 12 GPs in South Australia (in discussion with 10 academic, clinical, and lived experience stakeholders) highlighted many challenges faced by GPs providing care to patients with BPD. Major themes were: (1) Challenges Surrounding Diagnosis of BPD, (2) Comorbidities and Clinical Complexity, (3) Difficulties with Patient Behaviour and the GP&ndash, Patient Relationship, and (4) Finding and Navigating Systems for Support. Health service pathways for this high-risk/high-need patient group are dependent on the quality of care that GPs provide, which is dependent on GPs&rsquo, capacity to identify and understand BPD. GPs also need to be supported sufficiently in order to develop the skills that are necessary to provide effective care for BPD patients. Systemic barriers and healthcare policy, to the extent that they dictate the organisation of primary care, are prominent structural factors obstructing GPs&rsquo, attempts to address multiple comorbidities for patients with BPD. Several strategies are suggested to support GPs supporting patients with BPD.

As a principal requirement of lifestyle medicine is change, the ability to help motivate individuals to change is of paramount importance. Skills to help do this include motivational interviewing and knowledge of how “ready, willing, and able” an individual is, and the barriers and triggers to change for that individual. Procedures are discussed to help facilitate these changes. These provide tactics to help the client move from requiring “extrinsic” to more “intrinsic,” and self-rewarding, motivation.

Self-management is a core concept of Lifestyle Medicine. This is designed to ensure optimal outcomes from the interaction of a health team and patient over the extended time (maybe a lifetime) needed to manage chronic diseases and conditions. Prompts to self-management discussed here include: (1) being client centered, (2) being motivation focused, and (3) being health literacy oriented. Each of these has implications for counseling, the health care practice, and desired outcomes—the long-term goal being greater involvement of the patient or client in his or her own care.

Smoking: Hazardous alcohol consumption is associated with considerable morbidity and mortality ( Rehm et al., 2015b ; National Health and Medical Research Council, 2009 ). The leading causes of death are liver disease followed by road crash injury, cancer, and suicide. More people (particularly those amongst 15- to 19-year-olds) die from the acute effects of alcohol, while more of those 45 years and over died from chronic effects. Alcohol: One in five Australians drinks at levels that puts them at risk from lifetime harm ( AIHW, 2014a , AIHW, 2014b ). Alcohol is a major contributor to the global burden of disease. Up to 10% of cancers, 20% of intentional injuries, and 7% of all deaths and 3.9% of disability-adjusted life years can be attributed to excessive alcohol use. Heavy drinking also increases the risk of high blood pressure, stroke, unintentional injuries, and cancer. It is implicated in a significant number of hospital admissions and imposes a significant cost burden on society. Heavier consumption has been consistently associated with poorer quality of life and increased mortality ( Rehm et al., 2015b ; National Health and Medical Research Council, 2009 ). The effects of high-risk drinking on the body are shown in Fig. 23.1 . Lifetime risky drinkers (1 in 5 in the population) are defined as people who consume more than two standard drinks per day (on average over a 12-month period). Single-occasion risky drinkers (1 in 4 in the population) are defined as people consuming five or more standard drinks on a single drinking occasion ( AIHW, 2014a , AIHW, 2014b ).

Background Lifestyle has been shown to affect fertility in both males and females, with compelling evidence that smoking and being under or overweight impairs natural and assisted fertility, and other factors such as stress and caffeine have also been implicated. The objective of this study was to determine whether providing infertile couples with individualized lifestyle assessments and ongoing support facilitates positive lifestyle changes enhancing healthy fertility. Methods We conducted a prospective cohort pilot study of 23 infertile couples attending an Adelaide-based fertility clinic for advice and treatment relating to infertility. The intervention was a comprehensive assessment interview with the couple, focused on health and lifestyle. Motivational interviewing techniques were used and ongoing support provided. The assessment was repeated after 4 months and included an exit questionnaire. The main outcome measure(s) was self-reported lifestyle changes, including increased exercise, modified diet, reduced caffeine and alcohol consumption, ceased or reduced smoking and decreased psychological stress. Results Following the initial lifestyle assessment interview, all participants reported adverse lifestyle behaviour. Conclusions The results suggest that the FAST (Fertility ASsessment and advice Targeting lifestyle choices and behaviours) approach of an individualized assessment of current lifestyle practice followed by ongoing one to two weekly telephone support is effective in promoting healthy lifestyle change. Larger studies using this methodology are now required.

A behavior change workshop was conducted during the regional meeting of Wonca in Kuala Lumpur, Malaysia, in April 2002. It highlighted that general practitioners and primary care workers are key agents in facilitating smoking cessation. Participants from a variety of Asia Pacific countries shared their experiences regarding the problems associated with smoking cessation. Barriers to smoking cessation can be divided into 'Patient', 'Doctor' and 'System'. Practice-based strategies for smoking cessation are effective and will assist the general practitioner/family physician in helping patients quit smoking. Effective implementation requires a supportive infrastructure. © 2003 Blackwell Publishing Asia and Wonca

Reports on the results of a national survey conducted in Australia, in 2000. The objectives were to determine national estimates of influenza vaccination coverage for each state and territory of Australia, to obtain information related to attitudes towards and influences on immunisation decisions and explain the factors involved with failure to immunise.The survey was conducted using the Computer Assisted Telephone Interview (CATI) system. The overall participation rate for the survey was 88.6% and the final number of completed interviews across Australia was n = 10,505.Two target groups, those aged 65 years and over and those "at risk" of influenza aged between 40 and 64 years were defined. The overall immunisation rates in these two groups were 74% and 32% resp. The rate of immunisation among females generally exceeded that of males. A multivariate model provided the best joint set of explanatory variables for not getting immunised. These include sex, income, general practitioner recommendation, and general perceptions regarding the influenza injection.This study identified important issues in the decisions of people to immunise. It also highlighted the need to target the findings in effective immunisation policies and strategies to improve health outcomes for those at risk of adverse influenza events.

Introduction: Inpatient medical settings offer an opportunistic environment for initiating smoking cessation interventions to patients reflecting on their health. Current evidence has shown the superior efficacy of varenicline tartrate (VT) for smoking cessation compared with other tobacco cessation therapies; however, recent evidence also has highlighted concerns about the safety and tolerability of VT. Given these apprehensions, we aimed to evaluate the safety and effectiveness of VT plus quitlinecounseling compared to quitline-counseling alone in the inpatient medical setting. Methods: Adult patients (n = 392, 20–75 years) admitted with a smoking-related illnesses to 3 hospitals were randomized to receive either 12 weeks of varenicline tartrate (titrated from 0.5 mg daily to 1 mg twice daily) plus quitline-counseling (VT+C), (n = 196) or quitline-counseling alone (n = 196). Results: VT was well tolerated in the inpatient setting among subjects admitted with acute smoking-related illnesses (mean age 52.8 ± 2.89 and 53.7 ± 2.77 years in the VT+C and counseling alone groups, respectively). The most common self-reported adverse event during the 12-week treatment phase was nausea (16.3% in the VT+C group compared with 1.5% in the counseling alone group). Thirteen deaths occurred during the study period (n = 6 were in the VT+C arm compared with n = 7 in the counseling alone arm). All of these subjects had known comorbidities or developed underlying comorbidities. Conclusions: VT appears to be a safe and well-tolerated opportunistic treatment for inpatient smokers who have related chronic disease. Based on the proven efficacy of varenicline from outpatient studies and our recent inpatient evidence, we suggest it be considered as part of standard care in the hospital setting. Refereed/Peer-reviewed

Working relationships between practice nurses and general practitioners in Australia: a critical analysis This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.

Summary Tobacco smoking is the main preventable cause of morbidity and mortality in Australia. Recently published evidence-based guidelines for general practitioners recommend the 5As framework which is consistent with other international guidelines. Active follow-up of smokers by Quitline and the use of nurses to provide smoking cessation activities are two interventions that are likely to expand the reach of smoking cessation services and increase their effectiveness. Combination pharmacotherapies for nicotine dependence should be considered in smokers who have had difficulty quitting despite the concurrent use of brief behavioural counselling and pharmacotherapy.

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.

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.This article presents findings from a literature review that identified effective strategies for implementing guidelines.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.

Aim: Respiratory diseases are a public health issue throughout the world, with high prevalence and morbidity. This Research Needs Statement from the International Primary Care Respiratory Group (IPCRG) aims to highlight unanswered questions on the management of respiratory diseases that are of importance to practising primary care clinicians.Methods: An informal but inclusive consultation process was instigated in 2009. Draft statements in asthma, rhinitis, COPD, tobacco dependence, and respiratory infections were circulated widely to IPCRG members, other recognised experts, and representatives from a range of economic and healthcare backgrounds. An iterative process was used to generate, prioritise and refine research questions in each section.Results: Two overarching themes emerged. Firstly, there is a real need for research to be undertaken within primary care, which recruits patients representative of primary care populations, evaluates interventions realistically delivered within primary care, and draws conclusions that will be meaningful to professionals working within primary care. Secondly, international and national guidelines exist, but there is little evidence on the best strategies for implementing recommendations. Disease-specific research questions focus on effective and cost-effective ways to prevent disease, confirm the diagnosis, assess control, manage treatment, and empower self-management. Practical questions about how to deliver this comprehensive agenda in diverse primary care settings are highlighted.Conclusions: We hope that this Research Needs Statement will be used by clinicians and patients campaigning for answers to relevant questions, by researchers seeking funding to provide answers to these questions, and by funding bodies to enable them to prioritise research agendas. (c) 2010 Primary Care Respiratory Society UK. All rights reserved. H Pinnock et al. Prim Care Resp J 2010; 19(Suppl 1): S1-S21. doi:10.4104/perj.2010.00021

The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice (the 'red book') are now more than 20 years old. Therefore it is an important juncture to reflect on their appropriateness and implementation, and how they can be improved in future editions.This review analyses the guidelines and their development against criteria identified by the AGREE collaboration to ensure the quality and applicability for use in Australian general practice.The 'red book' is widely accepted as supporting the provision of preventive care and is now a key element of the quality system in Australian general practice. This independent guideline has rigor, relevance and applicability to general practice. However, its impact on practice could be improved by broader consultation and by using a wider range of means for dissemination and implementation. This needs to be informed by more rigorous evaluation of its implementation and impact on practice.

This study aimed to assess perceptions of continuity of care by patients from different socioeconomic areas using focus group interviews augmented by postal replies. Patients were randomly selected from two contrasting primary medical care locations: a middle class suburb and a less affluent suburb in Adelaide, South Australia. The Ethnograph was used to analyse the content of the interviews and postal responses. Analysis used the framework described by Curtis and Rogers in the USA and Freeman in the UK. The response rate was much lower from the lower socioeconomic group (5% focus group; 20% when postal replies included). They emphasized access factors and importance of records, and alleged situations where they were taken too casually and their problems were not dealt with. Those from the middle class area (response rate 25%) emphasized interpersonal ('art of care') factors and were more likely to use their presenting problem as a criterion to decide whether they needed to postpone the problem to a time when they could see their personal doctor. Focus groups can be useful evaluation tools in general practice, but oversampling of lower socioeconomic groups is needed. Continuity of care should be considered as an aid to consistent quality of care, rather than its essence. Well controlled intervention-outcome studies in different types of practice organization in differing socioeconomic situations will increase our understanding of continuity of care.

Dietary intervention to lower serum LDL-cholesterol (LDL-C) is effective, yet underutilised in general practice.This report summarises the findings of an expert roundtable convened to review the evidence relating to dietary interventions to lower serum LDL-C.Interventions that lower LDL-C lower the risk of cardiovascular disease. Comprehensive dietary intervention is indicated in all patients with an absolute 5 year risk for coronary disease of 10% or greater. Short term trials indicate that these interventions have the potential to lower LDL-C by approximately 20%. A year long trial has shown mean LDL-C lowering of 13%, with about one-third of subjects achieving a reduction greater than 20%, highlighting the importance of adherence to dietary advice. The most effective dietary strategies are replacing saturated and trans fatty acids with poly- and monounsaturated fats and increasing intake of plant sterols. Losing weight and increasing soluble fibre and soy protein intake can also lower serum cholesterol and may be considered when recommending a nutritionally balanced, cholesterol lowering diet. Motivational interviewing by general practitioners can improve the effectiveness of brief, behaviour orientated advice and dietary counselling to lower serum cholesterol.

Author version made available in accordance with the publisher's policy, Objective This research aimed to identify the skills required by primary health care (PHC) professionals to provide effective chronic condition prevention and self -management (CCPSM) support, according to the perceptions of a sample of Australian consumers and carers. Methods Qualitative data was collected and integrated from a focus group, key informant interviews and National Stakeholder meetings and a National Workshop, supported by an extensive literature review. Results With the exception of health professionals specifically trained or currently working in this area, consumers and carers perceive there is a lack of understanding, competence and practice of CCPSM support among PHC professionals. Discussion The PHC workforce appears not to have the full set of skills needed to meet the growing burden of chronic conditions on the health system. Recommendations include education and training that focuses on improved communication skills, knowledge of community support resources, identification of consumers' strengths and current capacities, collaborative care with other health professionals, consumers and carers, and psychosocial skills to understand the impact of chronic conditions from the person’s perspective.

Influenza A virus has a range of subtypes characterised by the display of particular surface structures and is associated with significant symptoms and a tendency to cause epidemics and pandemics.This article presents a checklist to assist general practitioners in preparing for an influenza pandemic.The Australian Federal Government launched 'Exercise Cumpston' in October 2006 to assess Australian pandemic preparedness. The report of the outcomes recommends the integration of general practice into the planning process at a national and jurisdictional level. General practitioners are enthusiastic about receiving further information and training in pandemic preparedness but preparing a general practice to deal with an influenza pandemic is a complex task.

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

The burden of illness from herpes zoster (HZ) and postherpetic neuralgia (PHN) in the Australian community is high. The incidence and severity of HZ and PHN increase with age in association with a progressive decline in cell-mediated immunity to varicella-zoster virus (VZV). Antiviral medications (valaciclovir, famciclovir, aciclovir) have been shown to be effective in reducing much but not all of the morbidity associated with HZ and PHN, but are consistently underprescribed in Australia. Zoster-associated pain should be treated early and aggressively, as it is more difficult to treat once established. Clinicians should be proactive in their follow-up of individuals at high risk of developing PHN, and refer patients to a specialist pain clinic earlier, rather than later. A live, attenuated VZV vaccine (Oka/Merck strain, Zostavax [Merck Sharp & Dohme]) has proven to be efficacious in reducing the incidence of and morbidity associated with HZ and PHN in older adults. The vaccine's efficacy has been shown to persist for at least 4 years, but is likely to last a lot longer. Ongoing surveillance will determine the duration of protection and whether a booster dose is required. Clinicians should consider recommending the vaccine, which can be safely administered at the same time as the inactivated influenza vaccine, to all immunocompetent patients aged 60 years or older. Clinicians should refer to the Australian immunisation handbook for advice on the use of the live vaccine in immunosuppressed individuals.

General practice will play a key role in both prevention and management of an influenza pandemic. Australian pandemic plans acknowledge a role for general practice, but there are few published data addressing the issues that general practitioners and their practices will face in dealing with such a crisis. The outcome will revolve around preparation in three key areas: Definition of the role of general practice within a broad primary care pandemic response, and adequate preparation within general practices so they can play that role well. Planning exercises and forums must include GPs, and rehearsals must include practical experience for general practices and their staff. Local Divisions of General Practice and GP practices can advocate for this, can define their role, and can prepare by using pandemic preparedness checklists; Definition and enactment of communication strategies to facilitate transfer of useful clinical and administrative data from practices and rapid dissemination of information into the community via general practice; Resource provision, which should be centrally funded but locally distributed, with personal protective equipment, vaccines and antivirals readily available for distribution. Resources must include support for human resource management to ensure appropriate health care professionals reach areas of workforce demand. Administrative, clinical and financial resources must be available to train GPs and practices in pandemic awareness and response.

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.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.Every patient, GP, consultation and preventive opportunity characteristic studied was independently significantly associated with the performance of at least two of the preventive activities.These findings suggest ways of designing more effective reminders, particularly for patients least likely to receive prevention counselling.