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Abstract Background There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. Methods The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? Results A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. Conclusions We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process.

Abstract Background Evidence generated from reliable research is not frequently implemented into clinical practice. Evidence-based clinical practice guidelines are a potential vehicle to achieve this. A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines. Recommendations from this review, and other studies, have suggested the use of interventions that are theoretically based because these may be more effective than those that are not. An evidence-based clinical practice guideline for the management of acute low back pain was recently developed in Australia. This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common, has a high burden, and for which there is an evidence-practice gap in the primary care setting. Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria, Australia. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray, and improving mean level of disability for patients three months post-consultation. Methods/Design This study protocol describes the details of a cluster randomised controlled trial. Ninety-two general practices (clusters), which include at least one consenting general practitioner, will be randomised to an intervention or control arm using restricted randomisation. Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion. An average of twenty-five patients per general practice will be recruited, providing a total of 2,300 patient participants. General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy. Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory. Investigators (not involved in the delivery of the intervention), patients, outcome assessors and the study statistician will be blinded to group allocation. Trial registration Australian New Zealand Clinical Trials Registry ACTRN012606000098538 (date registered 14/03/2006).

Introduction: Retention of general practice registrars in their training practices is important for addressing the GP workforce deficit and maldistribution of GPs. Given that rural and remote general practices are disproportionately affected by low retention, identifying the factors that promote retention may be as important as developing recruitment strategies in these areas. Quantifying the impact of relevant factors on registrar retention will enable a better understanding of how to incentivise retention and attenuate the loss of the rural workforce to other areas. We sought to establish the prevalence and associations of retention of general practice registrars in their training practices. Methods: This analysis was a component of the New alumni Experience of Training and independent Unsupervised Practice (NEXT-UP) study: a cross-sectional questionnaire-based study of early-career GPs in conjunction with evaluation of data contemporaneously recorded as part of vocational training. Participants were former registrars of three regional training organisations delivering general practice training in New South Wales, Tasmania, the Australian Capital Territory and Eastern Victoria, who had attained Fellowship of the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine between January 2016 and July 2018. The outcome measured was whether the registrar had previously worked at their current practice during vocational training. Multivariable logistic regression was used to estimate the association between relevant explanatory variables and the outcome. Results: A total of 354 alumni responded (response rate 28%), of whom 322 provided data regarding previous training practice retention, with 190 (59%) having previously worked at their current practice as registrars. Among respondents who reported currently working in a regional--rural practice location (n=100), 69% reported having previously worked at their current practice during training. GPs were more likely to be retained by a practice they had trained at if it was of lower socioeconomic status (adjusted odds ratio (aOR) 0.82 (95% confidence interval (CI) 0.73-0.91), p<0.001 for each decile of socioeconomic status) and if the practice provided two or more of home visits, nursing home visits or afterhours services (aOR 4.29 (95%CI 2.10-8.75), p<0.001). They were less likely to be retained by the practice if training was completed in a regional-rural area (aOR 0.35 (95%CI 0.17-0.72), p=0.004). Conclusion: Regional--rural training location is associated with reduced odds of subsequent retention of general practice registrars. This is occurring despite significant government investment in expansion of general practice training in regional and rural areas. The practice factor most strongly associated with GP retention was the provision of out-of-practice and after-hours care. There may be altruistic, rather than monetary, reasons that explain this finding. Such training opportunities, if provided to all trainees, especially in regional and rural areas, would be a learning opportunity, a way of promoting holistic community-based care and an incentive for subsequent retention within the practice and community as an established GP. [ABSTRACT FROM AUTHOR]

Background Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship. Objectives To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis. Design A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019. Participants ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate. Main measures The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010–2019). Key results Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86–0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86–0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001). Conclusions Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010–2019. However, educational (and other) interventions to further reduce prescribing are warranted. [ABSTRACT FROM AUTHOR]

Objective: To establish prevalence and associations of provision of nursing home visits (NHV) and home visits (HV) by early‐career specialist GPs. Of particular interest were associations of rurality with performing NHVs and HVs. Methods: A cross‐sectional study. Design: A questionnaire‐based study. Setting: Australian general practice. Participants: Early‐career specialist GPs, practising in Australia, who attained Fellowship between January 2016 and July 2018, inclusive, having completed GP training in NSW, the ACT, Eastern Victoria or Tasmania. Main Outcome Measures: Current provision of NHV and HV. Results: NHV were provided by 34% of participants (59% in rural areas) and HV by 41% of participants (60% in rural areas). Remote, rural or regional practice location, as compared to major‐city practice, was strongly associated with performing NHV as an early‐career specialist GP; multivariable OR 5.87 (95% CI: 2.73, 12.6), p < 0.001, and with the provision of HV; multivariable OR 3.64 (95% CI: 1.63, 8.11), p = 0.002. Rurality of GP training (prior to attaining Fellowship) was significantly univariably associated with providing NHV and with providing HV as an early‐career specialist GP. On multivariable analyses, these were no longer statistically significant. Conclusion: Early‐career specialist GPs located in regional/remote areas are more likely than their urban colleagues to provide NHV and HV. [ABSTRACT FROM AUTHOR]

Background Remunerated telehealth consultations were introduced in Australia in 2020 in response to the COVID-19 pandemic. Videoconferencing has advantages over telephone-consulting, including improved diagnostic and decision-making accuracy. However, videoconferencing uptake in Australia has been low. This study aimed to establish prevalence and associations of video versus telephone consultations in Australian general practice (GP) registrars' practice. Methods A cross-sectional analysis of data from 2020 to 2021 (three 6-monthly data-collection rounds) from the Registrars Clinical Encounters in Training (ReCEnT) study. GP registrars record details of 60 consecutive consultations every 6-month term, for a total of 3 terms. Univariable and multivariable logistic regression were performed within the Generalized Estimating Equations framework with the outcome video versus telephone. Results 102,286 consultations were recorded by 1,168 registrars, with 21.4% of consultations performed via telehealth. Of these, telephone accounted for 96.6% (95% CI: 96.3–96.8%) and videoconferencing for 3.4% (95% CI: 3.2–3.7%). Statistically significant associations of using videoconferencing, compared to telephone, included longer consultation duration (OR 1.02, 95% CI: 1.01–1.03 per minute; and mean 14.9 versus 12.8 min), patients aged 0–14 years old (OR 1.29, 95% CI: 1.03–1.62, compared to age 15–34), patients new to the registrar (OR 1.19, 95% CI: 1.04–1.35), part-time registrars (OR 1.84, 95% CI: 1.08–3.15), and areas of less socioeconomic disadvantage (OR 1.27, 95% CI: 1.00–1.62 per decile). Conclusions Registrars' telehealth consultations were mostly performed via telephone. Telephone use being associated with socioeconomic disadvantage has health equity implications. Future research should explore barriers to videoconferencing use and strategies to increase its uptake. [ABSTRACT FROM AUTHOR]

Aim. The aim of the study was to establish whether two previously described barriers to effective in-consultation assistance-seeking by general practice (GP) vocational specialist trainees (ie concern about patient impressions of their competence, and discomfort presenting to supervisors in front of patients) influenced the frequency of trainee in-consultation assistanceseeking from their supervisor. Methods. This was a cross-sectional study nested in the Registrar Clinical Encounters in Clinical Training ongoing cohort study of Australian GP trainees. Trainee participants completed contemporaneous records of 60 consecutive patient consultations, including whether supervisory assistance was sought. Trainees also completed a cross-sectional survey including items eliciting their beliefs about patient impressions and their own discomfort in seeking in-consultation supervisory assistance. These were factors of interest in multivariable logistic regression analyses; the outcome factor in both regression models was the seeking of inconsultation supervisory assistance. Results. In 2018, 778 trainees (778/876, response rate 89%) completed the cross-sectional survey. No association was found between the odds of inconsultation help-seeking and perceived decrease in patient impressions of trainee competence (OR = 1.09; 95% CI: 0.91, 1.31; P = 0.36) or higher comfort presenting outside patients' hearing (OR = 0.9; 95% CI: 0.77, 1.05; P = 0.19). Discussion. Contrary to expected utility models of helpseeking, trainees may not consider personal discomfort or impression management to be important enough, compared to patient safety and other considerations, to influence decisions regarding in-consultation help-seeking. Clinical supervisors should, nevertheless, consider the potential personal costs to trainees and maintain trainee self-esteem and confidence by providing in-consultation assistance in front of patients as comfortably and effectively as possible. [ABSTRACT FROM AUTHOR]