Two-year follow-up of a clustered randomised controlled trial of a multicomponent general practice intervention for people at risk of poor health outcomes.

BACKGROUND: This study was a two-year follow-up evaluation of health service use and the cost-effectiveness of a multicomponent general practice intervention targeted at people at high risk of poor health outcomes. METHODS: A two-year follow-up study of a clustered randomised controlled trial was conducted in South Australia during 2018-19, recruiting 1044 patients from three cohorts: children; adults (aged 18-64 years with two or more chronic diseases); and older adults (aged ≥ 65 years). Intervention group practices (n = 10) provided a multicomponent general practice intervention for 12 months. The intervention comprised patient enrolment to a preferred general practitioner (GP), access to longer GP appointments and timely general practice follow-up after episodes of hospital care. Health service outcomes included hospital use, specialist services and pharmaceuticals. The economic evaluation was based on quality-adjusted life years (QALYs) calculated from EuroQoL 5 dimensions, 5 level utility scores and used an A$50,000 per QALY gained threshold for determining cost-effectiveness. RESULTS: Over the two years, there were no statistically significant intervention effects for health service use. In the total sample, the mean total cost per patient was greater for the intervention than control group, but the number of QALYs gained in the intervention group was higher. The estimated incremental cost-effectiveness ratio (ICER) was A$18,211 per QALY gained, which is lower than the A$50,000 per QALY gained threshold used in Australia. However, the intervention's cost-effectiveness was shown to differ by cohort. For the adult cohort, the intervention was associated with higher costs and lower QALYs gained (vs the total cohort) and was not cost-effective. For the older adults cohort, the intervention was associated with lower costs (A$540 per patient), due primarily to lower hospital costs, and was more effective than usual care. CONCLUSIONS: The positive cost-effectiveness results from the 24-month follow-up warrant replication in a study appropriately powered for outcomes such as hospital use, with an intervention period of at least two years, and targeted to older people at high risk of poor health outcomes.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study).

BACKGROUND: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

General practice staff and patient experiences of a multicomponent intervention for people at high risk of poor health outcomes: a qualitative study.

BACKGROUND: This study reports the experiences of general practice staff and patients at high risk of poor health outcomes who took part in a clustered randomised controlled trial of a multicomponent general practice intervention. The intervention comprised patient enrolment to a preferred General Practitioner (GP) to promote continuity of care, access to longer GP appointments, and timely general practice follow-up after hospital care episodes. The aims of the study were to better understand participant's (practice staff and patients) perspectives of the intervention, their views on whether the intervention had improved general practice services, reduced hospital admissions and finally whether they believed the intervention would be sustainable after the trial had completed. METHODS: A qualitative study design with semi-structured interviews was employed. The practice staff sample was drawn from both the control and intervention groups. The patient sample was drawn from those who had expressed an interest in taking part in an interview during the trial and who had also experienced a recent hospital care episode. RESULTS: Interviews were conducted with 41 practice staff and 45 patients. Practice staff and patients expressed support for the value of appointments with a regular GP and having sufficient time in appointments for the provision of comprehensive care. There were mixed views with respect to the extent to which the intervention had improved services. The positive changes reported were related to services being provided in a more proactive, thorough, and systematic manner with a greater emphasis on team based care involving the Practice Nurse. Patients nominated after hours care and financial considerations as the key reasons for seeking hospital care. Practice staff noted that the intervention would be difficult to sustain financially in the absence of additional funding. CONCLUSIONS: The multicomponent intervention was supported by practice staff and patients and some patients perceived that it had led to improvements in care.

Capacity building for mental health services: methodology and lessons learned from the Partners in Recovery initiative.

BACKGROUND: The Partners in Recovery (PIR) program was implemented by the Australian Government Department of Health. Its overriding aim was to improve the coordination of services for people with severe and persistent mental illness, and who have complex needs that are not being met. The PIR capacity-building project (CBP) was funded to provide capacity building activities to the nationwide network of consortia that were set up in 2013 to deliver PIR over a 3-year period. The purpose of this paper is to describe the design and findings from an evaluation of the PIR CBP. METHODS: The evaluation involved collecting feedback from consenting PIR staff via an online survey and follow-up semi-structured interviews. CBP activities included: state and national meetings; a web portal; teleconferences; webinars; a support facilitator mentor program; and tailored support from the CBP team. RESULTS: The CBP made a positive contribution to the implementation and delivery of PIR. Staff highly valued activities that employed face-to-face interaction or provided informative knowledge exchange, and were appreciative of CBP staff being responsive and adaptable to their needs. CONCLUSIONS: From this evaluation, we recommend the following: identify relevant functions (e.g. prioritise networking), select the right mode of delivery (e.g. establish an online presence) and abide by key principles (e.g. be responsive to staff needs). This information is informing the mental health workforce capacity building activities that our team is currently undertaking.

Unsafe care in residential settings for older adults: a content analysis of accreditation reports.

Residents of aged care services can experience safety incidents resulting in preventable serious harm. Accreditation is a commonly used strategy to improve the quality of care; however, narrative information within accreditation reports is not generally analysed as a source of safety information to inform learning. In Australia, the Aged Care Quality and Safety Commission (ACQSC), the sector regulator, undertakes over 500 accreditation assessments of residential aged care services against eight national standards every year. From these assessments, the Aged Care Quality and Safety Commission generates detailed Site Audit Reports. In over one-third (37%) of Site Audit Reports, standards relating to Personal and Clinical Care (Standard 3) are not being met. The aim of this study was to identify the types of resident Safety Risks that relate to Personal and Clinical Care Standards not being met during accreditation or re-accreditation. These data could inform priority setting at policy, regulatory, and service levels. An analytical framework was developed based on the World Health Organization's International Classification for Patient Safety and other fields including Clinical Issue (the issue related to the incident impacting the resident, e.g. wound/skin or pain). Information relating to safety incidents in the Site Audit Reports was extracted, and a content analysis undertaken using the analytical framework. Clinical Issue and the International Classification for Patient Safety-based classification were combined to describe a clinically intuitive category ('Safety Risks') to describe ways in which residents could experience unsafe care, e.g. diagnosis/assessment of pain. The resulting data were descriptively analysed. The analysis included 65 Site Audit Reports that were undertaken between September 2020 and March 2021. There were 2267 incidents identified and classified into 274 types of resident Safety Risks. The 12 most frequently occurring Safety Risks account for only 32.3% of all incidents. Relatively frequently occurring Safety Risks were organisation management of infection control; diagnosis/assessment of pain, restraint, resident behaviours, and falls; and multiple stages of wounds/skin management, e.g. diagnosis/assessment, documentation, treatment, and deterioration. The analysis has shown that accreditation reports contain valuable data that may inform prioritization of resident Safety Risks in the Australian residential aged care sector. A large number of low-frequency resident Safety Risks were detected in the accreditation reports. To address these, organizations may use implementation science approaches to facilitate evidence-based strategies to improve the quality of care delivered to residents. Improving the aged care workforces' clinical skills base may address some of the Safety Risks associated with diagnosis/assessment and wound management.

National disability insurance scheme access: What evidence do you need to provide for psychosocial disability?

OBJECTIVES: The National Disability Insurance Scheme (NDIS) was introduced in 2013 and offered a new way of providing support to people with permanent and significant disabilities. Despite pilot testing, implementation of the scheme has been challenging, particularly for people with a disability arising from a mental health condition. In 2019, to address the challenge of accessing the NDIS, researchers from Flinders University worked with the National Disability Insurance Agency (NDIA) to develop a streamlined access process for psychosocial disability. The aim of this paper is to provide guidance on the evidence required to demonstrate that a person has a significant and persistent psychosocial disability to access the NDIS. CONCLUSION: Providing evidence for a psychosocial disability requires knowledge of how to address the disability requirements. The Evidence of Psychosocial Disability (EPD) form has been designed to address these requirements and offers guidance on the evidence that should be provided. A range of resources to accompany the EPD form are freely available online. These resources address a significant knowledge gap that currently exists with the implementation of the NDIS.

Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study.

BACKGROUND: People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. OBJECTIVE: In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care. METHODS: Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care. RESULTS: From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n = 41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep. CONCLUSIONS: The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.

A general practice intervention for people at risk of poor health outcomes: the Flinders QUEST cluster randomised controlled trial and economic evaluation.

OBJECTIVE: To determine whether a multicomponent general practice intervention cost-effectively improves health outcomes and reduces health service use for patients at high risk of poor health outcomes. DESIGN, SETTING: Clustered randomised controlled trial in general practices in metropolitan Adelaide. PARTICIPANTS: Three age-based groups of patients identified by their general practitioners as being at high risk of poor health outcomes: children and young people (under 18 years), adults (18-64 years) with two or more chronic diseases, and older people (65 years or more). INTERVENTION: Enrolment of patients with a preferred GP, longer general practice appointments, and general practice follow-up within seven days of emergency department and hospital care episodes. Intervention practices received payment of $1000 per enrolled participant. MAIN OUTCOME MEASURES: Primary outcome: change in self-rated health between baseline and 12-month follow-up for control (usual care) and intervention groups. SECONDARY OUTCOMES: numbers of emergency department presentations and hospital admissions, Medicare specialist claims and Pharmaceutical Benefits Scheme (PBS) items supplied, Health Literacy Questionnaire scores, and cost-effectiveness of the intervention (based on the number of quality-adjusted life-years [QALYs] gained over 12 months, derived from EQ-5D-5L utility scores for the two adult groups). RESULTS: Twenty practices with a total of 92 GPs were recruited, and 1044 eligible patients participated. The intervention did not improve self-rated health (coefficient, -0.29; 95% CI, -2.32 to 1.73), nor did it have significant effects on the numbers of emergency department presentations (incidence rate ratio [IRR], 0.90; 95% CI, 0.69-1.17), hospital admissions (IRR, 0.90; 95% CI, 0.66-1.22), Medicare specialist claims (IRR, 1.00; 95% CI, 0.91-1.09), or PBS items supplied (IRR, 0.99; 95% CI, 0.96-1.03), nor on Health Literacy Questionnaire scores. The intervention was effective in terms of QALYs gained (v usual care: difference, 0.032 QALYs; 95% CI, 0.001-0.063), but the incremental cost-effectiveness ratio was $69 585 (95% CI, $22 968-$116 201) per QALY gained, beyond the willingness-to-pay threshold. CONCLUSIONS: Our multicomponent intervention did not improve self-rated health, health service use, or health literacy. It achieved greater improvement in quality of life than usual care, but not cost-effectively. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617001589370 (prospective).

Assessment, referral and management of obstructive sleep apnea by Australian general practitioners: a qualitative analysis.

BACKGROUND: The high and increasing demand for obstructive sleep apnea (OSA) care has exceeded the capacity of specialist sleep services prompting consideration of whether general practitioners could have an enhanced role in service delivery. However, little is known about the current involvement, experiences and attitudes of Australian general practitioners towards OSA. The purpose of this study was to provide an in-depth analysis of Australian general practitioners' experiences and opinions regarding their care of patients with OSA to inform the design and implementation of new general practice models of care. METHODS: Purposive sampling was used to recruit participants with maximum variation in age, experience and location. Semi-structured interviews were conducted and were analysed using Thematic Analysis. RESULTS: Three major themes were identified: (1) General practitioners are important in recognising symptoms of OSA and facilitating a diagnosis by others; (2) Inequities in access to the assessment and management of OSA; and (3) General practitioners currently have a limited role in the management of OSA. CONCLUSIONS: When consulting with patients with symptoms of OSA, general practitioners see their primary responsibility as providing a referral for diagnosis by others. General practitioners working with patients in areas of greater need, such as rural/remote areas and those of socio-economic disadvantage, demonstrated interest in being more involved in OSA management. Inequities in access to assessment and management are potential drivers for change in future models of care for OSA in general practice.

Co-occurring depression and insomnia in Australian primary care: recent scientific evidence.

Depression and insomnia commonly co-occur, resulting in greater morbidity for patients, and difficult diagnostic and treatment decisions for clinicians. When patients report symptoms of both depression and insomnia, it is common for medical practitioners to conceptualise the insomnia as a secondary symptom of depression. This implies that there is little purpose in treating insomnia directly, and that management of depression will improve both the depression and insomnia symptoms. In this review, we present an overview of research investigating the comorbidity and treatment approaches for patients presenting with depression and insomnia in primary care. Evidence shows that clinicians should avoid routinely conceptualising insomnia as a secondary symptom of depression. This is because insomnia symptoms: (i) often occur before mood decline and are independently associated with increased risk of future depression; (ii) commonly remain unchanged following depression treatment; and (iii) predict relapse of depression after treatment for depression only. Furthermore, compared with control, cognitive behaviour therapy for insomnia improves symptoms of both depression and insomnia. It is critical that primary care clinicians dedicate specific diagnostic and treatment attention to the management of both depression (eg, psychotherapy, antidepressants) and insomnia (eg, cognitive behaviour therapy for insomnia administered by trained therapists or psychologists through a mental health treatment plan referral, by online programs, or by a general practitioner or nurse) when they co-occur. These treatments may be offered concurrently or sequentially (eg, insomnia treatment followed by depression treatment, or vice versa), depending on presenting symptoms, history, lifestyle factors and other comorbidities.

Experiences of patients with chronic diseases of access to multidisciplinary care during COVID-19 in South Australia.

ObjectiveThis study investigated the experience of patients with chronic diseases regarding access to and utilisation of multidisciplinary care during COVID-19 in South Australia.MethodsTelephone interviews were conducted with 30 patients with chronic conditions attending nine general practices in metropolitan Adelaide. Supplementary data were obtained from the Medicare Benefit Schedule (MBS) to compare health services activity data provided by different health professionals before and after COVID-19 (from January 2019 to June 2020).ResultsThere was variation in access to different health services by patients with chronic conditions during COVID-19. The introduction of telehealth facilitated continuity of general practitioner (GP) services, with a high level of satisfaction among patients. Changes in medicines regulation, including the home delivery of medications, enabled timely access to medications for patients. The use of telehealth was less common for specialist and particularly allied health services. Dental check-ups that are important for the management of some chronic conditions were disrupted the most during COVID-19.ConclusionThe findings of this study suggest that the policy measures introduced in Australia provided an opportunity to maintain multidisciplinary care for patients with chronic diseases during COVID-19. GPs, as core members of the primary healthcare team, as well as pharmacy and pathology services, were highly accessible. Telehealth was less accessed for chronic care services provided by specialists and allied health professionals.What is known about the topic?Access to multidisciplinary care is critical to ensure continuity and quality of care for patients with chronic health conditions. Evidence suggests disruptions in health services can occur during pandemics. To continue access to routine care, the Australian Government introduced several policy initiatives during COVID-19 to enhance access to multidisciplinary care.What does this paper add?Telehealth policy was particularly effective in facilitating patients' access to general practice services during COVID-19 particularly those services that did not need physical examinations. This policy complemented changes in medicines regulations that enabled timely and convenient access to medications for patients with chronic conditions. Allied health services, as important elements of multidisciplinary care, were more likely to be disrupted during COVID-19.What are the implications for practitioners?Continuation of telehealth services is likely to enhance access to general practice services. The acceptability and use of telehealth for allied health services may require more flexibility, and training for both practitioners and patients.

Predicting Australian Adults at High Risk of Cardiovascular Disease Mortality Using Standard Risk Factors and Machine Learning.

Effective cardiovascular disease (CVD) prevention relies on timely identification and intervention for individuals at risk. Conventional formula-based techniques have been demonstrated to over- or under-predict the risk of CVD in the Australian population. This study assessed the ability of machine learning models to predict CVD mortality risk in the Australian population and compare performance with the well-established Framingham model. Data is drawn from three Australian cohort studies: the North West Adelaide Health Study (NWAHS), the Australian Diabetes, Obesity, and Lifestyle study, and the Melbourne Collaborative Cohort Study (MCCS). Four machine learning models for predicting 15-year CVD mortality risk were developed and compared to the 2008 Framingham model. Machine learning models performed significantly better compared to the Framingham model when applied to the three Australian cohorts. Machine learning based models improved prediction by 2.7% to 5.2% across three Australian cohorts. In an aggregated cohort, machine learning models improved prediction by up to 5.1% (area-under-curve (AUC) 0.852, 95% CI 0.837-0.867). Net reclassification improvement (NRI) was up to 26% with machine learning models. Machine learning based models also showed improved performance when stratified by sex and diabetes status. Results suggest a potential for improving CVD risk prediction in the Australian population using machine learning models.

The experience of Australian general practice patients at high risk of poor health outcomes with telehealth during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The emergence of the COVID-19 pandemic has raised concerns about the potential decrease in access and utilisation of general practice services and its impact on patient care. In March 2020, the Australian Government introduced telehealth services to ensure that people more vulnerable to COVID-19 do not delay routine care from their general practitioners. Evidence about patients' experience of telehealth and its impact on patient care is scarce. This study aimed to investigate the experience with telehealth by Australian general practice patients at high risk of poor health outcomes during the COVID-19 pandemic. METHODS: Semi-structured telephone interviews were conducted with 30 patients from nine general practices in metropolitan Adelaide (May-June 2020). Participants were identified by their regular doctor as being at high risk of poor health outcomes. Interviews sought participants' perspectives and experiences about telehealth services in the general practice setting during COVID-19, and the value of offering continued telehealth services post pandemic. Interviews were recorded and transcribed verbatim. Data were analysed using a coding structure developed based on deductive codes derived from the research questions and any additional concepts that emerged inductively from interviews. RESULTS: Participants expressed satisfaction with telehealth including convenient and timely access to general practice services. Yet, participants identified challenges including difficulties in expressing themselves and accessing physical exams. Prescription renewal, discussing test results and simple follow-ups were the most common reasons that telehealth was used. Telehealth was mainly via phone that better suited those with low digital literacy. Participants indicated that an existing doctor-patient relationship was important for telehealth services to be effective. Subjects believed that telehealth services should be continued but needed to be combined with opportunities for face-to-face consultations after the COVID-19 pandemic was over. CONCLUSIONS: The expansion of telehealth supported access to general practice including chronic disease management during the COVID-19 pandemic. In the future, telehealth in Australia is likely to have a stronger place in primary healthcare policy and practice and an increased acceptance amongst patients.

Reducing preventable harm to residents in aged care: A systems approach.

Residents in Australian aged care facilities can suffer serious preventable harm from incidents ('adverse events' (AEs)). An inadequate response to AEs by aged care facilities can compound distress to residents and their families/carers. Facilities have an obligation to respond to and investigate AEs involving residents, learn from them, and take action to reduce the chance of them reoccurring . Residential aged care facilities have a duty to create a culture where staff, residents and families/carers feel comfortable reporting AEs or complaints; there is adequate time and resources to manage AEs and complaints; and feedback is provided to staff, residents and their families/carers on the results of investigations into AEs/complaints. The Aged Care Quality and Safety Commission's role should encompass additional governance functions such as sharing results and lessons learnt from AEs, complaints and investigations across Australia, assuring the quality of investigations conducted by facilities, and undertaking national system-wide investigations.

Implementation of a standardized oral screening tool by paediatric cardiologists.

BACKGROUND: An examination of invasive procedure cancellations found that the lack of pre-procedural oral screening was a preventable cause, for children with congenital heart disease. The purpose of this study was to implement an oral screening tool within the paediatric cardiology clinic, with referral to paediatric dental providers for positive screens. The target population were children aged ≥6 months to <18 years old, being referred for cardiac procedures. METHODS: The quality implementation framework method was used for this study design. The multi-modal intervention included education, audit and feedback, screening guidelines, environmental support, and interdisciplinary collaboration. Baseline rates for oral screenings were determined by retrospective chart audit from January 2018 to January 2019 (n = 211). Provider adherence to the oral screening tool was the outcome measure. Positive oral screens, resulting in referral to the paediatric dental clinic, were measured as a secondary outcome. Provider adherence rates were used as a process measure. RESULTS: Data collected over 14 weeks showed a 29% increase in documentation of oral screenings prior to referral, as compared to the retrospective chart audit. During the study period, 13% of completed screenings were positive (n = 5). Provider compliance for the period was averaged at 70% adherence. CONCLUSION: A substantial increase in pre-procedural oral screenings by paediatric cardiologists was achieved using the quality implementation framework and targeted interventions.

Engagement of General Practice in an Australian Organised Bowel Cancer Screening Program: A Cross-Sectional Survey of Knowledge and Practice.

BACKGROUND: Understanding factors causing variation in family physicians/general practitioners (GPs) screening knowledge, understanding and support of organised population-based colorectal cancer (CRC) programs can direct interventions that maximise the influence of a CRC screening recommendation from a GP. This study aims to assess contextual factors that influence knowledge and quality improvement (QI) practice directed to CRC screening in Australian general practice. METHODS: A convenience sample of anonymous general practice staff from all Australian states and territories completed a web-based survey. Multivariate analyses assessed the association between CRC screening knowledge and QI-CRC practice scores and patient, organisational and environmental-level contextual factors.  Results: Of 1,013 survey starts, 918 respondents (90.6%) completed the survey. Respondents less likely to recommend FOBT screening had lower knowledge and QI practice scores directed to CRC screening. Controlling for individual and practice characteristics, respondents' rating of the Australian National Bowel Cancer Screening Program (NBCSP) support for preventive care, attending external education, and sufficient practice resources to implement QI practice (generally) were the strongest factors associated with QI practice directed towards CRC screening. Knowledge scores were less amenable to the influence of contextual factors explored. CONCLUSION: More active engagement of family medicine/general practice to improve screening promotion could be achieved through better QI resourcing without changing the fundamental design of population-based CRC screening programs.

From participation to diagnostic assessment: a systematic scoping review of the role of the primary healthcare sector in the National Bowel Cancer Screening Program.

Primary health care (PHC) plays a vital support role in organised colorectal cancer (CRC) screening programs by encouraging patient participation and ensuring timely referral for diagnostic assessment follow up. A systematic scoping review of the current evidence was conducted to inform strategies that better engage the PHC sector in organised CRC screening programs. Articles published from 2005 to November 2019 were searched across five databases. Evidence was synthesised and interventions that specifically require PHC involvement were mapped to stages of the CRC screening pathway. Fifty-seven unique studies were identified in which patient, provider and system-level interventions align with defined stages of the CRC screening pathway: namely, identifying/reminding patients who have not responded to CRC screening (non-adherence) (n=46) and follow up of a positive screen referral (n=11). Self-management support initiatives (patient level) and improvement initiatives (system level) demonstrate consistent benefits along the CRC screening pathway. Interventions evaluated as part of a quality-improvement process tended to report effectiveness; however, the variation in reporting makes it difficult to determine which elements contributed to the overall study outcomes. To maximise the benefits of population-based screening programs, better integration into existing primary care services can be achieved through targeting preventive and quality care interventions along the entire screening pathway.

Patients' views on involving general practice in bowel cancer screening: a South Australian focus group study.

OBJECTIVES: To explore patients' experiences of bowel cancer screening and its promotion, and perspectives on possible input from general practice for improving screening rates. DESIGN: Qualitative focus group study underpinned by a phenomenological approach. SETTING: Three general practice clinics in metropolitan South Australia. PARTICIPANTS: Thirty active general practice patients, aged 50-74 years (60% female) who were eligible for the National Bowel Cancer Screening Program. FINDINGS: Factors affecting screening were described, with particular concerns regarding the nature of the test, screening process and culture. There were mixed views on the role for general practice in bowel cancer screening; some participants appreciated the current process and viewed screening as out of scope of primary care services, while others were in support of general practice involvement. Roles for general practice were proposed that comprised actions across the continuum from providing information through to reminders and the provision and collection of screening kits. With a view that multifaceted strategies are required to encourage participation, community-based solutions were suggested that centred on improving screening culture and education. CONCLUSIONS: There was a view among participants that general practice could play a useful role in supporting the uptake of the National Bowel Cancer Screening Program, however participants saw a need for multiple strategies at different levels and under different jurisdictions.

Patient perspectives on colorectal cancer screening and the role of general practice.

BACKGROUND: Colorectal cancer (CRC) is the second most frequent cause of cancer death in Australia. Early detection can reduce incidence and mortality. General practice-based initiatives have been proposed to improve CRC screening rates but to date have had modest impact. As there is limited research into the patient experience of CRC screening decision making, this study explored patient perspectives on CRC screening and the potential role for general practice. METHODS: Ten participants, aged between 50 and 74, from a general practice in South Australia were recruited by practice staff. Semi-structured interviews were conducted. Concurrent data collection and analysis were performed, guided by interpretative phenomenological analysis. RESULTS: Two key themes were evident: attitudes toward screening and potential roles for general practice. Participants structured the experience of screening in terms of being proactive, ambivalent or avoidant. Roles for general practice centred on tasks as educators, trusted advisors, monitors and screeners. Mixed views on whether general practice involvement was necessary prompted consideration of additional sources of health information and motivation around screening. CONCLUSIONS: Exploration of the patient experience provides insight into how participants make sense of screening and perceived roles for general practice (or other agents) in screening. There is satisfaction with current Government-driven processes but perceived value in general practice playing a complementary part in increasing screening rates. A multifaceted strategy, accounting for attitudes, is required to improve screening and population health outcomes.