Falls prevention in rural general practice: what stands the test of time and where to from here?

Objective: General practitioner recall of the 1992–96 'Stay on Your Feet' (SOYF) program and its influence on practice were surveyed five years post-intervention to gauge sustainability of the SOYF General Practice (GP) component.

Methods: A survey assessed which SOYF components were still in existence, current practice related to falls prevention, and interest in professional development. All general practitioners (GPs) situated within the boundaries of a rural Area Health Service were mailed a survey in late 2001.

Results: Response rate was 66.5% (139/209). Of 117 GPs in practice at the time of SOYF, 80.2% reported having heard of SOYF and 74.4% of those felt it had influenced practice. Half (50.9%) still had a copy of the SOYF GP resource and of those, 58.6% used it at least 'occasionally'. Three-quarters of GPs surveyed (75.2%) checked medications 'most/almost all' of the time with patients over 60 years; 46.7% assessed falls risk factors; 41.3% gave advice; and 22.6% referred to allied health practitioners. GPs indicated a strong interest in falls prevention-related professional development. There was no significant association between use of the SOYF resource package and any of the current falls prevention practices (all χ² >0.05).

Conclusions and implications: There was high recall of SOYF and a general belief that it influenced practice. There was little indication that use of the resource had any lasting influence on GPs' practices. In future, careful thought needs to go into designing a program that has potential to affect long-term change in GPs' falls prevention practice.

Nutrition care for adult cardiac patients : Australian general practitioners' perceptions of their role

Background. Australia has implemented systematic managed care for patients with chronic disease. Little is known about how GPs perceive their nutrition care role in this system.
Objective. To examine GPs’ perceptions of their roles in the nutrition care of cardiac patients and to identify factors that influence their role.
Methods. Multi-methods research design. Semi-structured interviews were conducted with a sample (n = 30) GPs Victoria, Australia. The resulting narratives were used to develop a quantitative questionnaire to survey a random sample of GPs. Principal components analysis was conducted to reduce the role items to a small number of underlying dimensions. The association between roles and demographic variables were examined using stepwise multiple regressions.
Results. In all, 248 GPs (30% response) participated. Three main roles were established: Influencing, Coordinating and Nutrition Educator role. Together, the roles explained 54% of the total variance. Demographic variables were not associated with these roles. The majority (mean = 88%) endorsed the items which loaded on to the Influencing and Coordinating (mean = 49%) roles. Short consultation time, use of prescribed medications and perception of patient attendance at cardiac rehabilitation reduced the priority for nutrition education.
Conclusions. This study highlights the importance of developing more effective team care arrangements for patients with chronic disease and working with the medical education colleges to develop education resources for doctors that include an explanation of the non-pharmaceutical as well as the pharmaceutical treatment for each chronic disease condition.

Contribution of Australian cardiologists, general practitioners and dietitians to adult cardiac patients’ dietary behavioural change

Aim:  To investigate the use of behavioural change techniques by cardiologists, general practitioners and dietitians in adult cardiac patients within 12 months of their cardiac event.
Method:  Quantitative cross-sectional surveys. Frequency analyses were conducted on the respondents' answers to questionnaire items. Chi-squared test of independence compared responses of the three professional groups on the questionnaire items. Analyses of variance were conducted to explore the impact of the independent variables: age, sex and time worked on the behavioural change techniques used by the respondents.
Results:  The respondents included 248 general practitioners (30% response), 189 cardiologists (47% response) and 180 dietitians (60% response). General practitioners and cardiologists acted mainly as advocates for dietary change in the dietary management process. Dietitians provided nutrition knowledge and a range of techniques to assist dietary behavioural change. Cardiologists and dietitians shared little nutrition information with general practitioners (cardiologists with general practitioners = 8%, dietitians with general practitioners = 49%).
Conclusion:  The present study shows that cardiac patients may have insufficient access to knowledge of nutrition and techniques to assist them with dietary behavioural change.

Enhancing the dietary management of general practice patients through collaborative care: perspectives of general practitioners and dietitians

Aim:  To describe how general practitioners and dietitians view their role in the dietary management of cardiac patients and to provide insights on how to facilitate collaborative care.
Methods:  Two studies were conducted in Victoria (Australia) 2005–2006. Study One: semi-structured interviews with general practitioners. Study Two: cross-sectional quantitative surveys of general practitioners and dietitians. Study One: texts were analysed using the grounded theory approach. Study Two: frequency analysis was conducted and chi-squared test for independence was used to explore the impact of age, sex and consultation time on the role and reporting scales.
Results:  Study One: Themes arising from the interviews with 30 general practitioners showed their involvement in dietary management fell into three broad roles: ‘Influencing’, ‘Coordinator’ of referrals and dietary ‘Educator’. They described dietetic education as a process that included dietary assessment, education, application of behavioural change techniques and reporting back to general practitioners. Study Two: Respondents were 248 general practitioners (30% response) and 180 dietitians (60% response). General practitioners' counselling consisted mostly of advocating for dietary change, coordinating dietetic referrals and reinforcing dietitians' recommendations. General practitioners considered dietary education as the role of dietitians. Dietitians reported a much broader role in the management of patients with some overlap with general practitioners' roles.
Conclusions:   The findings indicate the need: (i) for more structured reporting to ensure general practitioners receive appropriate information to enable them to reinforce dietetic counselling and recommendations; and (ii) to streamline the communication process in order to expedite dietitians' reports to general practitioners.

Opportunities for primary and secondary prevention of excess gestational weight gain : General Practitioners’ perspectives

Background

The impact of excess gestational weight gain (GWG) on maternal and child health outcomes is well documented. Understanding how health care providers view and manage GWG may assist with influencing healthy gestational weight outcomes. This study aimed to assess General Practitioner's (GPs) perspectives regarding the management and assessment of GWG and to understand how GPs can be best supported to provide healthy GWG advice to pregnant women.
Methods

Descriptive qualitative research methods utilising semi - structured interview questions to assess GPs perspectives and management of GWG. GPs participating in shared antenatal care in Geelong, Victoria and Sydney, New South Wales were invited to participate in semi - structured, individual interviews via telephone or in person. Interviews were digitally recorded and transcribed verbatim. Data was analysed utilising thematic analysis for common emerging themes.
Results

Twenty eight GPs participated, 14 from each state. Common themes emerged relating to awareness of the implications of excess GWG, advice regarding weight gain, regularity of gestational weighing by GPs, options for GPs to seek support to provide healthy lifestyle behaviour advice and barriers to engaging pregnant women about their weight. GPs perspectives concerning excess GWG were varied. They frequently acknowledged maternal and child health complications resulting from excess GWG yet weighing practices and GWG advice appeared to be inconsistent. The preferred support option to promote healthy weight was referral to allied health practitioners yet GPs noted that cost and limited access were barriers to achieving this.
Conclusions

GPs were aware of the importance of healthy GWG yet routine weighing was not standard practice for diverse reasons. Management of GWG and perspectives of the issue varied widely. Time efficient and cost effective interventions may assist GPs in ensuring women are supported in achieving healthy GWG to provide optimal maternal and infant health outcomes.

Computer reminders for chlamydia screening in general practice : a randomized controlled trial

Background: Chlamydia notifications are increasing in Australia, and the use of a computer alert prompting general practitioners to test young women is a potential way to increase opportunistic chlamydia testing. The aim of this trial was to determine the effectiveness of a computer alert in general practice on chlamydia testing in young women.

Methods: In 2006, clinics (n = 68) in Melbourne, Australia were cluster randomized into 2 groups: the intervention group received a computerized alert advising the general practitioner to discuss chlamydia testing with their patient which popped up when the medical record of a 16- to 24-year-old woman was opened; the control group received no alert. The outcome was whether or not that patient received a chlamydia test at the level of a single consultation with an eligible patient. A mixed effects logistic regression model adjusting for clustering was used to assess the impact of the alert on the proportion of women tested for chlamydia during the trial period.

Results: Testing increased from 8.3% (95% confidence interval (CI): 6.8, 9.8) to 12.2% (95% CI: 9.1, 15.3) (P < 0.01) in the intervention group, and from 8.8% (95% CI: 6.8, 10.7) to 10.6% (95% CI: 8.5, 12.7) (P < 0.01) in the control group. Overall, the intervention group had a 27% (OR = 1.3; 95% CI: 1.1, 1.4) greater increase in testing.

Conclusion: The results of this study suggest that alerts alone may not be sufficient to get chlamydia testing levels up sufficiently high enough to have an impact on the burden of chlamydia in the population but that they could be included as part of a more complex intervention.

Nutrition screening of older people in a community general practice, using the MNA-SF

Background: Objective The study aimed to determine the prevalence of malnutrition risk in a population of older people (aged 75 years and over) attending a community general practice and identify characteristics of those classified as malnourished or at risk of malnutrition.

Design Cross-sectional study of nutritional risk screen conducted over a six month period.

Participants and setting Patients attending a general practice clinic in Victoria, Australia, who attended for the “75 plus” health assessment check.

Measurements The Mini Nutritional Assessment Short Form (MNA®-SF) was included as part of the health assessment. Information was collected on living situation, co-morbidities, independence with meal preparation and eating, number of medications. Height and weight was measured and MNA®-SF score recorded.

Results Two hundred and twenty five patients attending a general practice for a health assessment with a mean age of 81.3(4.3)(SD) years, 52% female and 34% living alone. Only one patient was categorised by the MNA®-SF as malnourished, with an additional 16% classified as at risk of malnutrition. The mean Body Mass Index (BMI) of the at-risk group was significantly lower than the well-nourished group (23.6 ± 0.8 (SEM) vs 27.4 ± 0.3; p=0.0001). However, 34% of the at-risk group had a BMI of 25 or more with only 13% in the underweight category.

Conclusion In this population of older adults attending their general practitioner for an annual health assessment, one in six were identified as being at nutritional risk which is an additional risk factor for a severe health issue. Importantly, one third of the at-risk group had a BMI in the overweight or obese category, highlighting that older people can be at nutritional risk although they may be overweight or obese.

Managing panic disorder in general practice

BACKGROUND: Panic disorder (PD) is common in the community and contributes to significant distress and decreased quality of life for people who suffer from it. Most people with PD will present in the first instance to their general practitioner or hospital emergency department for assistance, often with a focus on somatic symptoms and concerns.

OBJECTIVE: This article aims to assist the GP to manage this group of patients by providing an outline of aetiology, approaches to assessment, and common management strategies.

DISCUSSION Although GPs have an important role to play in ruling out any causal organic basis for panic symptoms, the diagnosis of PD can usually be made as a positive diagnosis on the basis of careful history taking. Thorough and empathic education is a vital step in management. The prognosis for PD can be improved by lifestyle changes, specific psychological techniques, and the judicious use of pharmacotherapy.

Managing panic disorder in general medical practice

Panic disorder (PD) is common in the community and contributes to significant distress and decreased quality of life for people who suffer from it. Most people with PD will present in the first instance to their general practitioner or hospital emergency department for assistance, often with a focus on somatic symptoms and concerns. This article aims to assist the GP to manage this group of patients by providing an outline of aetiology, approaches to assessment, and common management strategies. Although GPs have an important role to play in ruling out any causal organic basis for panic symptoms, the diagnosis of PD can usually be made as a positive diagnosis on the basis of careful history taking. Thorough and empathic education is a vital step in management. The prognosis for PD can be improved by lifestyle changes, specific psychological techniques, and the judicious use of pharmacotherapy.

Improving chlamydia knowledge should lead to increased chlamydia testing among Australian general practitioners: a cross-sectional study of chlamydia testing uptake in general practice

Female general practitioners (GPs) have higher chlamydia testing rates than male GPs, yet it is unclear whether this is due to lack of knowledge among male GPs or because female GPs consult and test more female patients.

Promoting clinical reasoning in general practice trainees: role of the clinical teacher

BACKGROUND: Clinical reasoning requires knowledge, cognition and metacognition, and is contextually bound. Clinical teachers can and should play a key role in explicitly promoting clinical reasoning.

CONTEXT: The aim of this article is to relate the clinical reasoning literature to the general practice or family medicine context, and to provide clinical teachers with strategies to promote clinical reasoning.

INNOVATION: It is important that the clinical teacher teaches trainees the specific skills sets of the expert general practitioner (e.g. synthesising skills, recognising prototypes, focusing on cues and clues, using community resources and dealing with uncertainty) in order to promote clinical reasoning in the context of general practice or family medicine. Clinical teachers need to understand their own reasoning processes as well as be able to convey that knowledge to their trainees. They also need to understand the developmental stages of clinical reasoning and be able to nurture each trainee's own expertise. Strategies for facilitating effective clinical reasoning in trainees include adequate exposure to patients, offering the trainees opportunity for reflection and feedback, and coaching on the techniques of reasoning in the general practice context.

IMPLICATIONS: The journey to expertise in clinical reasoning is unique to each clinician, with different skills developing at different rates, depending on content, context and past experience. Doctors enter into general practice training with the building blocks of biomedical and clinical knowledge and a desire to learn how to be a general practitioner. Clinical teachers are integral in the process of helping trainees learn how to 'think like a general practitioner'.

You kind of want to fix it don’t you? Exploring general practice trainees’ experiences of managing patients with medically unexplained symptoms

Background
Much of a General Practitioner’s (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees’ clinical and educational experiences of managing people presenting with MUS.
Method
A mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach.


Results

Eighty questionnaires out of 120 (67 %) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient.
Conclusion
Managing MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.

Obesity impacts on general practice appointments

Objective: To quantify the impact of obesity on the number of visits to both primary and secondary care teams.

Research Methods and Procedures: The adult populations of 80 general practices throughout the United Kingdom were classified according to their BMI. We undertook a cross-sectional survey of computer-generated and handwritten records of 6150 obese people (BMI ≥ 30 kg/m2) and 1150 normal weight (BMI = 18.5 to 24.9 kg/m2) control subjects over an 18-month retrospective period.

Results: Obese patients made significantly more visits to the general practitioner (GP), practice nurse (PN), and hospital outpatient units than normal weight patients (all p < 0.001), and they were admitted to the hospital more often (p = 0.034). For both GP and PN visits, the relationship remained after adjusting for age, sex, social deprivation category, country, and number of comorbidities. Among obese patients, there was an increasing relationship between frequent GP visits (at least four appointments) and greater BMI, which remained significant after adjustment had been made for age, sex, deprivation, country, and number of comorbidities.

Discussion: The human resource burden to general practice is significantly higher in the obese population than in the normal weight population, even when adjusted for confounding factors. The increase in prevalence of obesity will continue to put pressure on GP and PN time unless appropriate action is taken.

Perceptions of ad hoc supervision encounters in general practice training: a qualitative interview-based study

BACKGROUND: Ad hoc supervision encounters occur between general practitioner (GP) supervisors and general practice registrars outside scheduled teaching sessions. Anecdotally reported as important learning opportunities, these encounters are rarely explored in the literature. OBJECTIVE: This study examined supervisors', registrars' and practice managers' perceptions of ad hoc supervisory encounters. METHODS: Semi-structured interviews were conducted with purposively sampled supervisors, registrars and practice managers from regional general practice settings. Data were analysed using template analysis. RESULTS: Fifteen respondents participated in the interviews. Their perceptions of ad hoc encounters were reported under the categories of immediacy, safety, education, professional identity and supervisor stress. DISCUSSION: Ad hoc encounters in general practice registrar training are highly valued for supporting patient safety and registrar education. The encounters serve a range of practical purposes for supervisors, registrars and practices, and warrant further exploration on how to optimise their benefits within general practice.

A cluster randomised controlled trial of vascular risk factor management in general practice

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.