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(2008)Journal ArticlePurpose: Despite considerable work in developing and validating cardiovascular absolute risk (CVAR) algorithms, there has been less work on models for their implementation in assessment and management. The aim of our study was to develop a model for a joint approach to its implementation based on an exploration of views of patients, general practitioners (GPs) and key informants (KIs). Methods: We conducted six focus group (three with GPs and three with patients) and nine KI interviews in Sydney. Thematic analysis was used with comparison to highlight the similarities and differences in perspectives of participants. Results: Conducting CVAR was seen as more acceptable for regular patients rather than new patients for whom GPs had to attract their interest and build rapport before doing so at the next visit. GPs' interest and patients' positive attitude in managing risk were important in implementing CVAR. Long consultations, good communication skills and having a trusting relationship helped overcome the barriers during the process. All the participants supported engaging patients to self-assess their risk before the consultation and sharing decision making with GPs during consultation. Involving practice staff to help with the patient self-assessment, follow-up and referral would be helpful in implementing CVAR assessment and management, but GPs, patients and practices may need more support for this to occur. Conclusions: Multiple strategies are required to promote the better use of CVAR in the extremely busy working environment of Australian general practice. An implementation model has been developed based on our findings and the Chronic Care Model. Further research needs to investigate the effectiveness of the proposed model.
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(2008)Journal ArticleBackground and Purpose: Anticoagulation reduces the risk of stroke in nonvalvular atrial fibrillation yet remains underused. We explored barriers to the use of anticoagulants among Australian family physicians. Methods: The authors conducted a representative, national survey. Results: Of the 596 (64.4%) eligible family physicians who participated, 15.8% reported having a patient with nonvalvular atrial fibrillation experience an intracranial hemorrhage with anticoagulation and 45.8% had a patient with known nonvalvular atrial fibrillation experience a stroke without anticoagulation. When presented with a patient at `very high risk` of stroke, only 45.6% of family physicians selected warfarin in the presence of a minor falls risk and 17.1% would anticoagulate if the patient had a treated peptic ulcer. Family physicians with less decisional conflict and longer-standing practices were more likely to endorse anticoagulation. Conclusion: Strategies to optimize the management of nonvalvular atrial fibrillation should address psychological barriers to using anticoagulation.
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(2008)Journal ArticleBackground: Prevalence of tobacco smoking in the Australian community has fallen. However, tobacco smoking remains a major cause of illness and death. General practitioners play an important role in assisting their patients to quit smoking. Objective: This article describes evidence based approaches to smoking cessation that can be applied in general practice. Discussion: Evidence based approaches to smoking cessation include brief counselling, pharmacotherapy, referral to a specialised Service such as Quitline, and follow up. The five As approach - Ask, Assess, Advise, Assist and Arrange follow up - provides a structure for intervention. Smoking cessation pharmacotherapies (nicotine replacement therapy and bupropion) have been shown to double quit rates. A new pharmacotherapy (varenicline) has recently become available which evidence to date suggests is more effective. Clinical suitability, the context of the quit attempt, and patient preference are important considerations in choosing a pharmacotherapy. Active follow up helps to reduce the rate of relapse which is otherwise high in what is commonly a chronic relapsing condition.
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(2008)Journal ArticleAustralian general practitioners have a pivotal role in helping their patients with problems of alcohol and tobacco dependence, but have been less likely than their peers in the United Kingdom to be involved in the management of opioid dependence. This is despite the fact that most GPs are seeing opioid dependent patients whether they know it or not, and that GPs are ideally placed to manage this problem given the other advantages of the general practice context – continuity, accessibility, and whole patient care, including the ability to address other health issues.
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(2008)Journal ArticleObjective: In 2002, New South Wales (NSW) Health introduced an updated policy for occupational screening and vaccination against infectious diseases. This study describes healthcare worker (HCW) immunity to hepatitis B, measles, mumps, rubella (MMR) and varicella based on serological screening, following introduction of this policy. Methods: HCW screening serology performed at two healthcare facilities in south western Sydney (Bankstown and Fairfield) was extracted for the period September 2003 to September 2005. Immunity to hepatitis B, MMR and varicella was quantitated and cross-tabulated against age, sex and staff risk category. Results: A total of 1,320 HCWs were screened. Almost two thirds were immune to hepatitis B while immunity to MMR and varicella ranged from 88% to 94%. Age stratification showed lower levels of measles immunity in those born after 1965. Conclusions: Despite availability of vaccination for over two decades, a significant proportion of HCWs at these two facilities were non-immune to hepatitis B. This is of concern for those non-immune staff involved in direct clinical care, who are at risk of blood and body fluid exposures. The small group of HCWs non-immune to MMR and varicella pose a risk to themselves and others in the event of an outbreak. Implications: There is a need for improved implementation of the occupational screening and vaccination policy, including better education of HCWs about the risks of non-immunity to vaccine preventable diseases. The revised 2007 NSW Health policy may assist this process and will need evaluation to determine whether HCW immunity improves in the coming years.
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(2008)Journal ArticleBackground: This article examines the prevalence of smoking among general practice patients and assesses their stage of readiness to quit. Method: Descriptive study involving eight general practice registrars working in teaching practices in metropolitan Sydney (New South Wales) who surveyed 1069 consecutive patients over 16 years of age to determine their smoking status; and for smokers, their stage of readiness to stop smoking. Results: Of these patients 375 (35%) were current smokers, with smoking more common among men (40%) than women (33%). Proportions of smokers in each stage of change were: 137 in precontemplation (36.5%), 158 in contemplation (42%) and 79 in preparation (21%). The majority of patients in preparation (67%) and contemplation (53%) were assessed as willing to further discuss their smoking, whereas only 16% of those in the contemplation stage were willing. Discussion: Smoking rates among general practice patients were higher than in community samples. Most of the smokers were either contemplating or preparing to quit, and the majority of smokers in these groups were willing to receive advice about smoking cessation.
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(2007)Journal Article
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(2006)Conference PaperBackground: Warfarin reduces stroke risk associated with non-valvular atrial fibrillation (NVAF) yet is underutilised. Wider use of warfarin is advocated to reduce the risk of mortality and disability. Aims: We have funding to: 1) develop an innovative intervention (Stop-Stroke) to optimise General Practitioners' (GPs) management of NVAF; 2) evaluate Stop-Stroke using a rigorous, clustered RCT; 3) determine the incremental cost per life year saved due to Stop-Stroke. Methods: Random allocation of 110 GPs from across Australia to control or the Stop-Stroke intervention. Stop-Stroke will comprise patient identification and recall, management plans, peer coaching, specialist support and decision tools. Data will be collected from over 2500 patients. Primary Outcome: The proportion of patients with NVAF over 65 who are on 'appropriate' antithrombotic treatment (judged against standardised criteria) will be compared. 'Appropriate treatment' will be determined using standardised medical record audits and blinded expert review. Results and Analysis: Outcomes will be compared, adjusting for clustered randomisation. Analysis will be by intention to treat. Implications: There is no proven implementation strategy for enhancing the prevention of stroke in patients with NVAF. If effective, Stop-Stroke will bridge evidence-practice gaps in managing NVAF and reduce the risk of stroke and disability in the Australian community.
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(2007)Conference PaperBackground: Optimising the management of NVAF is proving difficult and the potential to reduce stroke risk is yet to be fully realised. Barriers to using anticoagulants need to be addressed. Aims: To describe GP management of NVAF and barriers to the use of warfarin. Methods: Representative survey of Australian GPs. b: Of the 593 GP participants (response = 64.3%), 46.2% reported the experience of an ischaemic stroke in their NVAF patients without anticoagulation. When asked to select treatment for a hypothetical NVAF patient at 'high' risk of stroke, 71.0% appropriately selected warfarin. In the presence of a minor falls risk, 45.4% of GPs selected warfarin. Only 28.8% would anticoagulate the patient at high risk of stroke with a history of recurrent nosebleeds and 16.9% would anti-coagulate such a patient with a treated peptic ulcer bleed. 37.9% agreed that 'it is hard to decide whether the benefits of warfarin outweigh the risks', while only 54.3% agreed they fully understood their patients' views on both the benefits and risks of warfarin. Conclusion: Any strategy to improve the evidence based management of NVAF must address the excessive concerns clinicians have about anticoagulation. We need to reduce anxiety about 'acts of commission' in the management of NVAF.
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(2007)Journal ArticleChronic disease self-management (CDSM) programs have been found effective in improving clinical, behavioural, and self-efficacy outcomes associated with a range of chronic illnesses, and evidence suggests that CDSM is effective in reducing health care costs and health service utilisation. As the setting where most chronic disease is managed, primary health care is an ideal setting for supporting CDSM. This study aimed to explore the uptake and sustainability of CDSM within routine activities of primary health care clinicians involved in the implementation of a demonstration project within an Area Health Service in Sydney NSW. Interviews and focus groups were conducted with managers and clinicians involved in the project. Findings included (1) widespread support from participants for CDSM (2) participating clinicians thought that CDSM was valuable to themselves, their clients and the health system (3) the program required clients to be able to speak and understand English and so presented many barriers for implementation in CALD communities, and (4) the program was not effective in engaging some key members of the primary care team; in particular, general practitioners. The study highlights system design issues including communication and continuity of care between service providers, workforce supply and demands of acute care delivery in the community that will need to be addressed for sustainable and effective CDSM to be achieved.