Advancing integrated paediatric care in Australian general practices: Qualitative insights from the SC4C GP-paediatrician model of care.

The Strengthening Care for Children (SC4C) is a general practitioner (GP)-paediatrician integrated model of care that consists of co-consulting sessions and case discussions in the general practice setting, with email and telephone support provided by paediatricians to GPs during weekdays. This model was implemented in 21 general practices in Australia (11 Victoria and 10 New South Wales). Our study aimed to identify the factors moderating the implementation of SC4C from the perspectives of GPs, general practice personnel, paediatricians and families. We conducted a qualitative study as part of the mixed-methods implementation evaluation of the SC4C trial. We collected data through virtual and in-person focus groups at the general practices and phone, virtual and in-person interviews. Data was analysed using an iterative hybrid inductive-deductive thematic analysis. Twenty-one focus groups and thirty-seven interviews were conducted. Overall, participants found SC4C acceptable and suitable for general practices, with GPs willing to learn and expand their paediatric care role. GPs cited improved confidence and knowledge due to the model. Paediatricians reported an enhanced understanding of the general practice context and the strain under which GPs work. GPs and paediatricians reported that this model allowed them to build trust-based relationships with a common goal of improving care for children. Additionally, they felt some aspects, including the lack of remuneration and the work and effort required to deliver the model, need to be considered for the long-term success of the model. Families expressed their satisfaction with the shared knowledge and quality of care jointly delivered by GPs and paediatricians and highlighted that this model of care provides easy access to specialty services without out-of-pocket costs. Future research should focus on finding strategies to ensure the long-term Implementation of this model of care with a particular focus on the individual stressors in general practices.

Protocol for the implementation evaluation of an integrated paediatric and primary care model: Strengthening Care for Children (SC4C).

INTRODUCTION: Implementation evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines a detailed protocol of an implementation evaluation embedded in a stepped-wedge cluster randomised controlled trial of a model of care, Strengthening Care for Children (SC4C), that integrates paediatric care in general practice. The purpose of this manuscript is to describe the pragmatic methods that will be used to capture implementation evaluation process and outcome data within this trial. METHODS AND ANALYSIS: Our implementation evaluation will use a mixed methods design, with data collected in the intervention arm of the SC4C trial guided by a logic model developed using the Consolidated Framework for Implementation Research (CFIR) and Proctor and colleague's taxonomy of implementation outcomes. Data collection will be via questionnaires and semistructured interviews with general practitioners, paediatricians, general practice administrative staff and children and families. Each of the 21 general practices recruited into the study will be described in terms of staffing, patient throughput and location, in addition to the nuanced inner and outer contexts, use of the intervention and its acceptability. We will quantify implementation effectiveness in each general practice clinic using the CFIR validated scoring system. Importantly, we have embedded data collection post intervention to enable assessment of the sustainable adoption of the intervention. An inductive approach to the analysis of qualitative data will identify additional emerging themes that may not be covered by the formal frameworks underpinning our analysis. ETHICS AND DISSEMINATION: Ethical approval was granted by the Royal Children's Hospital Ethics Committee in August 2020 (HREC: 65955). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry 12620001299998 on 1 December 2020.

Strengthening Care for Children (SC4C): protocol for a stepped wedge cluster randomised controlled trial of an integrated general practitioner-paediatrician model of primary care.

INTRODUCTION: Australia's current healthcare system for children is neither sustainable nor equitable. As children (0-4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child's care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home. METHODS AND ANALYSIS: SC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children's (0-<18 years) GP appointments that result in a hospital referral, compared with the control period. Secondary outcomes include GP quality of care; GP experience and confidence in providing paediatric care; family trust in and preference for GP care; and the sustainability of the intervention. An implementation evaluation will assess the model to inform acceptability, adaptability, scalability and sustainability, while a health economic evaluation will measure the cost-effectiveness of the intervention. ETHICS AND DISSEMINATION: Human research ethics committee (HREC) approval was granted by The Royal Children's Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry 12620001299998.

Feasibility of single question mental health surveillance in chronic disease.

OBJECTIVE: To determine the (1) feasibility and acceptability of administering single question mental health surveillance to carers of children with chronic disease in the inpatient setting and (2) sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of this question to detect 'at risk' children compared with the Strengths and Difficulties Questionnaire (SDQ). DESIGN: Cross-sectional pilot SETTING: Day Medical Unit of a tertiary paediatric hospital, 1 April 2021-31 July 2021. PATIENTS: Carers of children aged 2-17 years with chronic medical conditions. INTERVENTIONS: Caregivers were asked to respond to 'Thinking about your child's mental health over the past 4 weeks, are they thriving/coping/struggling/always overwhelmed?' during the admission process. All carers and children 11-17 years were invited to complete the SDQ. MAIN OUTCOME MEASURES: Feasibility and acceptability were determined by nursing feedback. Sensitivity, specificity, PPV and NPV were determined by comparing question responses with clinical cut-points on the SDQ. RESULTS: 213 carers responded to the question. Nurses reported that the question was easy (12/14) or moderately easy (2/14) to use and was 'easily understood' (6/14) or 'understood after some explanation' (8/14) for most carers. The question demonstrated a high specificity (0.98)/PPV (0.87) but low sensitivity (0.2) when thriving/coping were considered together whereas when thriving was compared with all other responses the sensitivity increased to 0.7. CONCLUSIONS: Single question mental health surveillance appears acceptable to carers and nursing staff and has a high level of specificity for children who are 'struggling' or 'always overwhelmed' versus the SDQ screening measure.

The role of body image flexibility in the relationship between disordered eating cognitions and disordered eating symptoms among non-clinical college students.

OBJECTIVE: A growing body of evidence suggests that rigid and inflexible regulation and coping are at the core of psychopathology, including disordered eating (DE) problems. Employing two cross-sectional studies, the present paper investigated whether body image flexibility (BIF), a specific type of psychological flexibility, mediates the relations between DE cognitions and overall DE pathology. METHOD: Ethnically diverse non-clinical college undergraduates (Study 1 N=208; Study 2 N=178) completed an anonymous online survey. RESULTS: BIF was found to partially mediate the relationship between DE cognitions and overall DE pathology after controlling for gender and body mass index (BMI). DISCUSSION: Our findings suggest that the link between DE cognitions and overall DE pathology is established in part through an inflexible and avoidant coping style specific to negative body image. Clinical implications include targeting BIF as a mechanism of change and treating DE pathology with acceptance- and mindfulness-based behavioral interventions.