Medicine & Health

Publication Search Results

Now showing 1 - 10 of 78
  • (2008) Wan, Qing; Harris, Mark; Zwar, N; Vagholkar, Sanjyot
    Journal Article
    Purpose: 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.

  • (2008) Gattellari, Melina; Worthington, John; Zwar, N; Middleton, Susan
    Journal Article
    Background 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.

  • (2008) Zwar, N
    Journal Article
    Background: 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.

  • (2008) Bunker, Jeremy; Winstock, Adam; Zwar, N
    Journal Article
    Australian 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.

  • (2008) Vagholkar, Sanjyot; Ng, Judy; Chan, Raymond; Bunker, Jeremy; Zwar, N
    Journal Article
    Objective: 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.

  • (2008) Zwar, N; Richmond, Robyn; Harris, Michael
    Journal Article
    Background: 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.

  • (2007) Comino, Elizabeth; Zwar, N; Hermiz, Oshana
    Journal Article

  • (2007) Williams, Anna; Harris, Mark; Daffurn, K; Powell Davies, G; Pascoe, Shane; Zwar, N
    Journal Article
    Chronic 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.

  • (2007) Vagholkar, Sanjyot; Zwar, N; Hermiz, Oshana; Shortus, Timothy; Comino, Elizabeth; Harris, Mark
    Journal Article
    BACKGROUND: The Enhanced Primary Care package, introduced in 1999, included an item number for multidisciplinary care plans. There has been little research into what is contained in care plans. This study investigated what general practitioners documented in care plans for their diabetic patients. METHODS: A retrospective audit of care plans was conducted as part of a larger audit that evaluated the impact of multidisciplinary care plans on the care of patients with type 2 diabetes. The subjects were GPs and their diabetic patients with care plans. RESULTS: The care plans of 230 patients, identified by 26 GPs, were audited. Most GPs used a template to document care plans and the nature of the template influenced the content. There was limited information documented in care plans. DISCUSSION: Simplification and consistency of care plan templates would assist the care planning process and encourage better documentation. Appropriate GP education is required to support this.

  • (2007) Zwar, N; Hermiz, Oshana; Comino, Elizabeth; Shortus, Tim; Burns, Joan; Harris, Mark
    Journal Article
    BACKGROUND: Since the introduction of the Enhanced Primary Care package, care plans have become part of Australian general practice. Previous research has focused on barriers to the uptake of care plans. This study examined the effect of multidisciplinary care plans on provision and outcome of care for patients with type 2 diabetes. METHODS: A retrospective before/after medical record audit design was chosen. Subjects of the study were general practitioners practising in Southwest Sydney (New South Wales) and their diabetic patients who had written care plans. Outcome measures were frequency and results of glycosylated haemoglobin, blood pressure, foot, serum lipids, weight, and microalbumin checks. RESULTS: The medical records of 230 patients were audited. Following the care plan, adherence to diabetes guidelines increased. Metabolic control and cardiovascular risk factors improved for patients who had multidisciplinary care implemented. DISCUSSION: Whether the improved diabetes care shown here is attributed to improved teamwork and/or coordination of care needs further research.