POLAR Diversion: Using General Practice Data to Calculate Risk of Emergency Department Presentation at the Time of Consultation.

OBJECTIVE: This project examined and produced a general practice (GP) based decision support tool (DST), namely POLAR Diversion, to predict a patient's risk of emergency department (ED) presentation. The tool was built using both GP/family practice and ED data, but is designed to operate on GP data alone. METHODS: GP data from 50 practices during a defined time frame were linked with three local EDs. Linked data and data mapping were used to develop a machine learning DST to determine a range of variables that, in combination, led to predictive patient ED presentation risk scores. Thirteen percent of the GP data was kept as a control group and used to validate the tool. RESULTS: The algorithm performed best in predicting the risk of attending ED within the 30-day time category, and also in the no ED attendance tests, suggesting few false positives. At 0 to 30 days the positive predictive value (PPV) was 74%, with a sensitivity/recall of 68%. Non-ED attendance had a PPV of 82% and sensitivity/recall of 96%. CONCLUSION: Findings indicate that the POLAR Diversion algorithm performed better than previously developed tools, particularly in the 0 to 30 day time category. Its utility increases because of it being based on the data within the GP system alone, with the ability to create real-time "in consultation" warnings. The tool will be deployed across GPs in Australia, allowing us to assess the clinical utility, and data quality needs in further iterations.

Compliance with pathology testing guidelines in Australian general practice: protocol for a secondary analysis of electronic health record data.

INTRODUCTION: In Australia, general practitioners usually are the first point of contact for patients with non-urgent medical conditions. Appropriate and efficient utilisation of pathology tests by general practitioners forms a key part of diagnosis and monitoring. However overutilisationand underutilisation of pathology tests have been reported across several tests and conditions, despite evidence-based guidelines outlining best practice in pathology testing. There are a limited number of studies evaluating the impact of these guidelines on pathology testing in general practice. The aim of our quantitative observational study is to define how pathology tests are used in general practice and investigate how test ordering practices align with evidence-based pathology guidelines. METHODS AND ANALYSIS: Access to non-identifiable patient data will be obtained through electronic health records from general practices across three primary health networks in Victoria, Australia. Numbers and characteristics of patients, general practices, encounters, pathology tests and problems managed over time will be described. Overall rates of encounters and tests, alongside more detailed investigation between subcategories (encounter year, patient's age, gender, and location and general practice size), will also be undertaken. To evaluate how general practitioner test ordering coincides with evidence-based guidelines, five key candidate indicators will be investigated: full blood counts for patients on clozapine medication; international normalised ratio measurements for patients on warfarin medication; glycated haemoglobin testing for monitoring patients with diabetes; vitamin D testing; and thyroid function testing. ETHICS AND DISSEMINATION: Ethics clearance to collect data from general practice facilities has been obtained by the data provider from the RACGP National Research and Evaluation Ethics Committee (NREEC 17-008). Approval for the research group to use these data has been obtained from Macquarie University (5201700872). This study is funded by the Australian Government Department of Health Quality Use of Pathology Program (Agreement ID: 4-2QFVW4M). Findings will be reported to the Department of Health and disseminated in peer-reviewed academic journals and presentations (national and international conferences, industry forums).

General practitioners' knowledge and management of dry mouth - A qualitative study.

BACKGROUND: Dry mouth (xerostomia) is common and can have significant consequences for a patient's general and oral health. Multiple medications may compromise the flow and quality of saliva. OBJECTIVE: This study explored general practitioners' (GPs') perceptions, knowledge and management of dry mouth, and whether consideration of oral health influences prescribing patterns. METHODS: Semi-structured interviews with 20 GPs in Melbourne, Victoria, were audiotaped, transcribed and analysed. RESULTS: GPs who participated in the study were aware of dry mouth, but diagnosed it infrequently. They had limited knowledge about the oral health implications and management of dry mouth, with some offering potentially harmful advice. Some participants reported that dry mouth would influence their prescribing, but few referred patients to dentists for management. DISCUSSION: Dry mouth is not on GPs' radar, and patients are rarely questioned about this during routine medical examinations. GPs in this study would welcome additional information to enhance patients' oral health and patient resources on dry mouth.

Crisis averted: How consumers experienced a police and clinical early response (PACER) unit responding to a mental health crisis.

When mental health crisis situations in the community are poorly handled, it can result in physical and emotional injuries. The purpose of this study was to ascertain the experiences and opinions of consumers about the way police and mental health services worked together, specifically via the Alfred Police and Clinical Early Response (A-PACER) model, to assist people experiencing a mental health crisis. Semi-structured in-depth interviews were conducted with 12 mental health consumers who had direct contact with the A-PACER team between June 2013 and March 2015. The study highlighted that people who encountered the A-PACER team generally valued and saw the benefit of a joint police-mental health clinician team response to a mental health crisis situation in the community. In understanding what worked well in how the A-PACER team operated, consumers perspectives can be summarized into five themes: communication and de-escalation, persistence of the A-PACER team, providing a quick response and working well under pressure, handover of information, and A-PACER helped consumers achieve a preferred outcome. All consumers acknowledged the complementary roles of the police officer and mental health clinician, and described the A-PACER team's supportive approach as critical in gaining their trust, engagement and in de-escalating the crises. Further education and training for police officers on how to respond to people with a mental illness, increased provision of follow-up support to promote rehabilitation and prevent future crises, and measures to reduce public scrutiny for the consumer when police responded, were proposed opportunities for improvement.

Implementing Anticipatory Care Plans in general practice: a practice approach to improving the health literacy of the community and reducing reliance on emergency services during after-hour periods.

The objective of this study was to trial a general practice approach to improve the health literacy of patients at risk of utilising medical, emergency or ambulatory services during after-hour periods in Australia. It did so by introducing an anticipatory after-hours care component in all new and revised care plans, known as an Anticipatory Care Plan (AntCaP).The pilot was conducted over a 6-month period in 2013-14. Thirteen general practices were recruited via expressions of interest and were paid a financial grant. Key practice staff were required to attend three workshops conducted by a Medicare Local and to be involved in the evaluation process. A pragmatic qualitative and quantitative evaluation process was conducted during the pilot, and ceased 6 months after the final workshop. The results indicate that the integration of AntCaPs into general practice was generally well received by practice staff and their patients, with early indications that AntCaPs can influence patient behaviour in the after-hours period.

'Your lack of organisation doesn't constitute our emergency' - repeat prescription management in general practice.

BACKGROUND: The importance of quality and safety in repeat prescribing is well documented, but few studies have examined how practices manage urgent requests for repeat prescriptions and why patients require them urgently. METHODS: Twenty practice staff (receptionists, practice managers, general practitioners, practice nurse) from 10 general practices participated in semi-structured interviews, which were audio-recorded, transcribed and analysed thematically. RESULTS: Requests for same-day appointments for patients needing repeat prescriptions emerged as problematic for most clinics in our study. Reasons included convenience, lost prescriptions and running out of medication. Clinics gave patients appointments, left prescriptions for collection at reception or ran prescription clinics. A need emerged for GPs to support individual clinic policy on repeat prescriptions. DISCUSSION: Many urgent requests for repeat prescriptions are avoidable. Improvements are needed in the way repeat prescriptions are managed, pointing to a closer examination of general practice systems, the role of practice staff, pharmacists and patients.

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.

Clinical, information and business process modeling to promote development of safe and flexible software.

Using a factorial vignette survey and modeling methodology, we developed clinical and information models - incorporating evidence base, key concepts, relevant terms, decision-making and workflow needed to practice safely and effectively - to guide the development of an integrated rule-based knowledge module to support prescribing decisions in asthma. We identified workflows, decision-making factors, factor use, and clinician information requirements. The Unified Modeling Language (UML) and public domain software and knowledge engineering tools (e.g. Protégé) were used, with the Australian GP Data Model as the starting point for expressing information needs. A Web Services service-oriented architecture approach was adopted within which to express functional needs, and clinical processes and workflows were expressed in the Business Process Execution Language (BPEL). This formal analysis and modeling methodology to define and capture the process and logic of prescribing best practice in a reference implementation is fundamental to tackling deficiencies in prescribing decision support software.