Dissonant views - GPs' and parents' perspectives on antibiotic prescribing for young children with respiratory tract infections.

BACKGROUND: Antibiotics are not recommended for treating uncomplicated respiratory tract infections (RTIs), despite this, antibiotic prescribing for this is widespread. General practitioners (GPs) report parental pressure and fear of losing patients if they do not prescribe antibiotics, however, parental views on antibiotics for RTIs are unclear. Therefore, this study examined GPs' and parents' perceptions regarding antibiotic prescribing for RTIs in young children. METHODS: We conducted semi-structured interviews with 20 GPs, and a survey and focus groups with 50 parents and carers of children under the age of five between June 2014 and July 2015 in Melbourne, Australia. Qualitative data were thematically analysed using NVivo and quantitative data were analysed using SPSS. RESULTS: GPs believed that parents expect antibiotics for RTIs and were more likely to prescribe them if parents were insistent. They believed parents would go elsewhere if they did not prescribe antibiotics. GPs suggested that there would be less conflict if parents were better educated on appropriate antibiotics use. In contrast, parents demonstrated good knowledge of RTIs and appropriate antibiotic use. Their main expectation from GPs was to obtain a diagnosis, discuss management, and receive reassurance that the illness was not serious. Parental satisfaction with GPs was not dependent on receiving antibiotics (r = 0.658, p < 0.001), and they would not seek another GP if antibiotics were not prescribed (r = 0.655, p < 0.001). CONCLUSION: GPs and parents have dissonant views on antibiotic prescribing for RTI in young children. GPs perceived parents wanting a diagnosis and reassurance that their child is not severely ill as pressure to prescribe antibiotic. To overcome these barriers, targeted training for both GPs and parents to improve communication and reassurance that satisfaction is not related to receiving antibiotics may reduce unnecessary antibiotic prescribing for RTI in young children.

Preventive healthcare for young children: A systematic review of interventions in primary care.

High rates of preventable health problems amongst children in economically developed countries have prompted governments to seek pathways for early intervention. We systematically reviewed the literature to discover what primary care-targeted interventions increased preventive healthcare (e.g. review child development, growth, vision screening, social-emotional health) for preschool children, excluding vaccinations. MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched for published intervention studies, between years 2000 and 2014, which reflected preventive health activities for preschool children, delivered by health practitioners. Analysis included an assessment of study quality and the primary outcome measures employed. Of the 743 titles retrieved, 29 individual studies were selected, all originating from the United States. Twenty-four studies employed complex, multifaceted interventions and only two were rated high quality. Twelve studies addressed childhood overweight and 11 targeted general health and development. Most interventions reported outcomes that increased rates of screening, recording and recognition of health risks. Only six studies followed up children post-intervention, noting low referral rates by health practitioners and poor follow-through by parents and no study demonstrated clear health benefits for children. Preliminary evidence suggests that multi-component interventions, that combine training of health practitioners and office staff with modification of the physical environment and/or practice support, may be more effective than single component interventions. Quality Improvement interventions have been extensively replicated but their success may have relied on factors beyond the confines of individual or practice-led behaviour. This research reinforces the need for high quality studies of pediatric health assessments with the inclusion of clinical end-points.

Perceptions of general practitioners towards managing dental presentations in Australia: a qualitative study.

Background Patients presenting with dental pain are common in general practice, despite dental infections being most appropriately managed with dental treatment to address the cause of the infection. Although antibiotics are not appropriate for the management of localised toothache without signs of systemic spread, general practitioners (GPs) often prescribe antibiotics and analgesics for the management of dental pain. The aim of this study was to explore GPs' perceptions and management of dental presentations in Australia. Methods Twelve semi-structured interviews were conducted with GPs across Victoria, Australia, between October 2022 and January 2023. Data were thematically analysed. Results The study found that dental pain was the most common presenting complaint for patients attending general practice with a dental problem. Five major themes were identified in this study: knowledge, beliefs about capabilities, emotion, environmental context and resources, and social influences/social professional role and identity. In terms of knowledge and capabilities, GPs would advise patients to seek dental care, as they are aware that antibiotics would not resolve the underlying issue. Challenges for GPs included limited training in oral and dental treatment, as well as emotions, such as patient anxiety and phobia resulting in patients seeking dental care through a GP rather than a dentist. Barriers due to the context, such as access to dental care, long waiting lists within the public dental system and cost, were some of the reasons patients present to general practice rather than a seeing a dentist. Furthermore, issues that influenced GPs' antibiotic prescribing included patients' expectations for antibiotics to treat their dental pain, as well as dentists advising their patients to attend their GP for antibiotics prior to dental treatment. Conclusions This study identified factors that influenced GPs' management of patients with dental conditions. To address these issues, it is imperative to develop interventions addressing patients' knowledge around oral health, as well as providing improved access to dental care for these patients.

Diagnosis and management of acute infections during telehealth consultations in Australian general practice: a qualitative study.

BACKGROUND: The use of telehealth has increased dramatically since the beginning of the COVID-19 pandemic. Little is known about how GPs manage acute infections during telehealth, and the potential impact on antimicrobial stewardship. AIM: To explore the experiences and perceptions of GP trainees' and supervisors' use of telehealth, and how it influences their management of acute infections. DESIGN & SETTING: Australian GP registrars (trainees) and supervisors were recruited via email through their training organisations. Semi-structured interviews with 18 participants were conducted between July and August 2022. METHOD: Interviews were transcribed verbatim and analysed using a reflexive thematic approach. RESULTS: We identified six overall themes. 1. Participants experienced impaired diagnostic capacity during telehealth consultations. 2. Attempts to improve diagnostic acuity included various methods, such as having patients self-examine. 3. The management of clinical uncertainty frequently entailed referring patients for in-person assessment, overinvestigating, or overtreating. 4. Antibiotic prescribing decisions during telehealth were informed by less information than were in-person consults, with varying impact. 5. Participants believed that other GPs improperly prescribed antibiotics during telehealth. 6. Supervisors believed that registrars hadn't developed the knowledge or skills to determine when conditions could be managed appropriately via telehealth. CONCLUSION: Telehealth has potential for reducing transmission of acute infections and increasing access to healthcare. However, the implications of GPs, especially less experienced GPs, making diagnoses with less certainty, and consequently compromising antimicrobial stewardship, are a concern. Patient self-assessment tools may improve outcomes of telehealth consultations for acute infections.

Managing same day appointments--a qualitative study in Australian general practice.

BACKGROUND: General practices are required to have flexible systems to accommodate urgent appointments. Not all patients requesting a same day appointment receive one. There is scant research detailing how requests for same day appointments are managed. Our study examined this issue from the perspective of practice staff. METHODS: Twenty practice staff (receptionists, practice managers, general practitioners, practice nurse) from 10 general practices participated in semistructured interviews, which were audiorecorded, transcribed and analysed thematically. RESULTS: All but three practices set aside appointments for patients requesting a same day appointment. Themes included contradictions between policy and practice and the role of experience in determining urgency. Five types of urgent needs for same day appointments were identified: medical, administrative, therapeutic, logistic and emotional. DISCUSSION: Practice policies must make clear roles and responsibilities for all staff managing patient appointments. Aspects of clinic policies and practices could be reviewed to reduce medicolegal risk and additional workload caused by non-medically urgent needs.

Addressing Antimicrobial Stewardship in Primary Care-Developing Patient Information Sheets Using Co-Design Methodology.

Antibiotic resistance is a threat to global health, and inappropriate antibiotic use can be associated with adverse effects. Developing tools to encourage better communication between patients and general practitioners may reduce inappropriate use of antibiotics. The aim of the study was to develop shared decision support tools on common infections using a co-design methodology to address antimicrobial stewardship (AMS) in primary care. Three co-design/interview sessions were conducted with primary care providers and consumers between October 2019-April 2020 in Melbourne, Australia. Participants critiqued existing AMS tools, identified key elements required and optimised resulting prototypes. Primary care providers and consumers prioritised information to include in the AMS tools, such as when to see a doctor, management options, disease symptoms and cause of infection differently. However, both agreed content should be communicated in a plain, concise and logical manner, using inclusive and simple language accompanied by illustrations. Information sheets should be single-sided and A4-sized, appropriate for use before, during or after consultations. Co-design provided a collaborative forum to systematically design and develop products that meet the needs of both primary care providers and consumers. This resulted in the development of seven patient information sheets on common infections that encourage discussion of these infections, conservative management options and appropriate antibiotic use in primary care.

The development of Future Health Today: piloting a new platform for identification and management of chronic disease in general practice.

Chronic disease identification and management is a significant issue in Australia, with general practice being the primary contact point for those at risk of, or living with, chronic disease. However, there is a well-described gap between guideline recommendations for chronic disease management and translation in the general practice setting. In 2018, a group of researchers, clinicians and software developers collaborated to develop a tool to support the identification and management of chronic disease in general practice, with the aim to create a platform that met the needs of general practice. The co-design process drew together core principles and expectations for the establishment of a technological platform, called Future Health Today (FHT), which would sit alongside the electronic medical record (EMR) management system within general practice. FHT used algorithms applied to EMR data to identify patients with, or at risk of, chronic disease and requiring review. Using chronic kidney disease as a clinical focus, the FHT prototype was piloted in a large, metropolitan general practice, and a large regional general practice. Based on user feedback, the prototype was further developed and improved. This paper provides a report on the key features and functionalities that participants identified and implemented in practice.

Antibiotic stewardship: A review of successful, evidence-based primary care strategies.

BACKGROUND: Antibiotic resistance is a rising global threat with only two options for mitigation: 1) invent new antibiotics and/or 2) use current antibiotics more wisely. In Australia, the majority of antibiotic usage is in the community, hence primary care has a key role.  OBJECTIVE: With no single 'magic bullet', a range of approaches is needed. The aim of this article is to describe the options and evidence in three broad categories: 1) regulatory changes such as repeats and pack sizes, 2) policy initiatives such as public campaigns, academic detailing and education and 3) clinical strategies including delayed prescribing, clinical decision support tools, practice-based audit and feedback, and patient information sheets. DISCUSSION: Australia has good antibiotic regulation and guidelines but must invest in sustained primary care stewardship programs, which should include surveillance, information for consumers, support for general practitioners and general practice training, and an ongoing evaluation and research program.

Clinical insights into appropriate choice of antimicrobials for acute respiratory tract infections.

BACKGROUND AND OBJECTIVES: Australia has relatively high rates of antibiotic prescribing in the community. The aim of this study was to identify clinical insights regarding antibiotic prescribing choices for the management of common upper respiratory tract infections through analysis of anonymised primary care electronic medical records (EMRs). METHOD: EMR data relating to 1926 antimicrobial prescriptions for tonsillitis, pharyngitis and acute rhinosinusitis in adults and acute otitis media (AOM) in children were extracted from 11 general practices in Victoria and analysed for consistency with Australian Therapeutic Guidelines recommendations. RESULTS: The analysis suggests that underdosing of amoxicillin for AOM in children, prescription of phenoxymethylpenicillin at doses not consistent with Therapeutic Guidelines recommendations for tonsillitis and pharyngitis in adults, and potential overprescription of antibiotics for patients with acute rhinosinusitis are not infrequent in general practice. DISCUSSION: Anonymised EMR data provide an opportunity to analyse antibiotic prescribing practices at scale and provide insights relevant to clinical practice.

Costing of an Australian general practice COVID-19 drive-through testing and respiratory clinic.

BACKGROUND: Responding to the COVID-19 pandemic requires safe and efficient testing on a large scale over a prolonged period. Outpatient testing facilities can clinically assess and test symptomatic individuals and test asymptomatic contacts. This study identified the resources required to establish and maintain an Australian general practitioner (GP) led testing facility that combined a respiratory clinic for clinical assessment and testing with a drive-through testing facility. METHODS: Data were taken from clinic administrative records to identify the number of patients tested over the period April-June 2020. An independent auditor's report identified the resources used in establishing, running, and staffing both clinics for the same period. Analyses were performed using the minimum and maximum daily throughput to understand the effect of demand on price per sample collected. RESULTS: The respiratory clinic tested an average of 19 patients per day, at an estimated cost of $340.04 AUD. This varied to $687.99 AUD during the lowest demand scenario, and $281.04 AUD during the high demand scenario. The drive-through clinic tested an average of 47 patients per day, at an estimated cost of $153.57 AUD. This varied to $279.51 AUD during the lowest demand scenario, and $99.92 AUD during the high demand scenario. CONCLUSION: This study provides insight into the cost of testing at a drive through and respiratory clinic in Australia. The evidence highlights importance of considering variation in demand and the impact on efficiency, particularly where resource use is fixed in the short term.

Evaluating the Implementation of a Pilot Quality Improvement Program to Support Appropriate Antimicrobial Prescribing in General Practice.

Inappropriate antimicrobial prescribing contributes to increasing antimicrobial resistance. An antimicrobial stewardship (AMS) program in the form of quality improvement activities that included audit and feedback, clinical decision support and education was developed to help optimise prescribing in general practice. The aim of this study was to evaluate the implementation of this program (Guidance GP) in three general practices in Melbourne, Australia, between November 2019 and August 2020. Thirty-one general practitioners (GPs) participated in the program, with 11 GPs and three practice managers participating in follow-up focus groups and interviews to explore the acceptability and feasibility of the program. Our findings showed that the quality improvement activities were acceptable to GPs, if they accurately fit GPs' decision-making process and workflow. It was also important that they provided clinically meaningful information in the form of audit and feedback to GPs. The time needed to coordinate the program, and costs to implement the program were some of the potential barriers identified. Facilitators of success were a "whole of practice" approach with enthusiastic GPs and practice staff, and an identified practice champion. The findings of this research will inform implementation strategies for both the Guidance GP program and AMS programs more broadly in Australian general practice, which will be critical for general practice participation and engagement.

Factors Influencing Australian Healthcare Workers' COVID-19 Vaccine Intentions across Settings: A Cross-Sectional Survey.

Healthcare workers' COVID-19 vaccination coverage is important for staff and patient safety, workforce capacity and patient uptake. We aimed to identify COVID-19 vaccine intentions, factors associated with uptake and information needs for healthcare workers in Victoria, Australia. We administered a cross-sectional online survey to healthcare workers in hospitals, primary care and aged or disability care settings (12 February-26 March 2021). The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework informed survey design and framing of results. Binary regression results adjusted for demographics provide risk differences between those intending and not intending to accept a COVID-19 vaccine. In total, 3074 healthcare workers completed the survey. Primary care healthcare workers reported the highest intention to accept a COVID-19 vaccine (84%, 755/898), followed by hospital-based (77%, 1396/1811) and aged care workers (67%, 243/365). A higher proportion of aged care workers were concerned about passing COVID-19 to their patients compared to those working in primary care or hospitals. Only 25% felt they had sufficient information across five vaccine topics, but those with sufficient information had higher vaccine intentions. Approximately half thought vaccines should be mandated. Despite current high vaccine rates, our results remain relevant for booster programs and future vaccination rollouts.

Towards optimising chronic kidney disease detection and management in primary care: Underlying theory and protocol for technology development using an Integrated Knowledge Translation approach.

Worldwide, Chronic Kidney Disease (CKD), directly or indirectly, causes more than 2.4 million deaths annually with symptoms generally presenting late in the disease course. Clinical guidelines support the early identification and treatment of CKD to delay progression and improve clinical outcomes. This paper reports the protocol for the codesign, implementation and evaluation of a technological platform called Future Health Today (FHT), a software program that aims to optimise early detection and management of CKD in general practice. FHT aims to optimise clinical decision making and reduce practice variation by translating evidence into practice in real time and as a part of quality improvement activities. This protocol describes the co-design and plans for implementation and evaluation of FHT in two general practices invited to test the prototype over 12 months. Service design thinking has informed the design phase and mixed methods will evaluate outcomes following implementation of FHT. Through systematic application of co-design with service users, clinicians and digital technologists, FHT attempts to avoid the pitfalls of past studies that have failed to accommodate the complex requirements and dynamics that can arise between researchers and service users and improve chronic disease management through use of health information technology.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development.

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Strengthening respiratory protection from SARS-CoV-2 in certain general practice contexts.

We recommend a precautionary approach to respiratory protection for healthcare workers potentially exposed to SARS-CoV-2 until the efficacy of surgical masks can be proven.

Future Health Today: codesign of an electronic chronic disease quality improvement tool for use in general practice using a service design approach.

OBJECTIVE: To codesign an electronic chronic disease quality improvement tool for use in general practice. DESIGN: Service design employing codesign strategies. SETTING: General practice. PARTICIPANTS: Seventeen staff (general practitioners, nurses and practice managers) from general practice in metropolitan Melbourne and regional Victoria and five patients from metropolitan Melbourne. INTERVENTIONS: Codesign sessions with general practice staff, using a service design approach, were conducted to explore key design criteria and functionality of the audit and feedback and clinical decision support tools. Think aloud interviews were conducted in which participants articulated their thoughts of the resulting Future Health Today (FHT) prototype as they used it. One codesign session was held with patients. Using inductive and deductive coding, content and thematic analyses explored the development of a new technological platform and factors influencing implementation of the platform. RESULTS: Participants identified that the prototype needed to work within their existing workflow to facilitate automated patient recall and track patients with or at-risk of specific conditions. It needed to be simple, provide visual snapshots of information and easy access to relevant guidelines and facilitate quality improvement activities. Successful implementation may be supported by: accuracy of the algorithms in FHT and data held in the practice; the platform supporting planned and spontaneous interactions with patients; the ability to hide tools; links to Medicare Benefits Schedule; and prefilled management plans. Participating patients supported the use of the platform in general practice. They suggested that use of the platform demonstrates a high level of patient care and could increase patient confidence in health practitioners. CONCLUSION: Study participants worked together to design a platform that is clear, simple, accurate and useful and that sits within any given general practice setting. The resulting FHT platform is currently being piloted in general practices and will continue to be refined based on user feedback.

Management of respiratory tract infections in young children-A qualitative study of primary care providers' perspectives.

Respiratory tract infections in young children are the most common cause of general practice visits in Australia. Despite the availability of clinical practice guidelines, the treatment and management of respiratory tract infections in young children is inconsistent. The aim of the study was to explore the management of respiratory tract infections in young children from a multi-disciplinary perspective using across-sectional qualitative research design based on the theoretical domains framework and the Capability, Opportunity and Motivation-B model. In-depth interviews were conducted with 30 primary care providers to explore their knowledge, views and management of respiratory tract infections in young children. Interviews focused on symptomatic management, over-the-counter medications and antibiotic use, and data were thematically analysed. Our findings showed that factors such as primary care providers' time constraints, parental anxiety, general practitioners' perception of what parents want, perceived parental pressure, and fear of losing patients were some of the reasons why primary care providers did not always adhere to guideline recommendations. Primary care providers also provided conflicting advice to parents concerning over-the-counter medications and when children should resume normal activities. Overall, this study showed that complex interactions involving emotional and psychological factors influenced the decision making process of primary care providers' management of respiratory tract infections in young children. A team care approach with consistent advice, and improved communication between primary care providers and parents is vital to overcome some of these barriers and improve guideline adherence. The findings of this research will inform the development of interventions to better manage respiratory tract infections in young children. RESPIRATORY TRACT INFECTIONS: CLINICIANS SWAYED BY PARENTAL ANXIETY AND PRESSURE: The emotions and psychology of both parents and clinicians influence how respiratory tract infections (RTIs) are managed in young children. Researchers in Australia, led by Ruby Biezen from Monash University, interviewed 30 primary care clinicians about their views on how to care for children with RTIs, such as the common cold. The interviews focused on symptomatic management, over-the-counter medications and antibiotic use. Despite the availability of best-practice guidelines, clinicians did not always follow the recommendations owing to factors such as time constraints, parental anxiety, perceived parental pressure, and fear of losing patients. These are some of the reasons why clinicians sometimes advise or prescribe unnecessary medications. The authors suggest that a team approach involving multiple healthcare professionals who deliver consistent advice could improve guideline adherence.

Computer assisted chronic disease management: does it work? A pilot study using mixed methods.

Background. Key factors for the effective chronic disease management (CDM) include the availability of practical and effective computer tools and continuing professional development/education. This study tested the effectiveness of a computer assisted chronic disease management tool, a broadband-based service known as cdmNet in increasing the development of care plans for patients with chronic disease in general practice. Methodology. Mixed methods are the breakthrough series methodology (workshops and plan-do-study-act cycles) and semistructured interviews. Results. Throughout the intervention period a pattern emerged suggesting GPs use of cdmNet initially increased, then plateaued practice nurses' and practice managers' roles expanded as they became more involved in using cdmNet. Seven main messages emerged from the GP interviews. Discussion. The overall use of cdmNet by participating GPs varied from "no change" to "significant change and developing many the GPMPs (general practice management plans) using cdmNet." The variation may be due to several factors, not the least, allowing GPs adequate time to familiarise themselves with the software and recognising the benefit of the team approach. Conclusion. The breakthrough series methodology facilitated upskilling GPs' management of patients diagnosed with a chronic disease and learning how to use the broadband-based service cdmNet.