Prevalence and associations of provision of nursing home visits and home visits by early-career specialist general practitioners.

OBJECTIVE: To establish prevalence and associations of provision of nursing home visits (NHV) and home visits (HV) by early-career specialist GPs. Of particular interest were associations of rurality with performing NHVs and HVs. METHODS: A cross-sectional study. DESIGN: A questionnaire-based study. SETTING: Australian general practice. PARTICIPANTS: Early-career specialist GPs, practising in Australia, who attained Fellowship between January 2016 and July 2018, inclusive, having completed GP training in NSW, the ACT, Eastern Victoria or Tasmania. MAIN OUTCOME MEASURES: Current provision of NHV and HV. RESULTS: NHV were provided by 34% of participants (59% in rural areas) and HV by 41% of participants (60% in rural areas). Remote, rural or regional practice location, as compared to major-city practice, was strongly associated with performing NHV as an early-career specialist GP; multivariable OR 5.87 (95% CI: 2.73, 12.6), p < 0.001, and with the provision of HV; multivariable OR 3.64 (95% CI: 1.63, 8.11), p = 0.002. Rurality of GP training (prior to attaining Fellowship) was significantly univariably associated with providing NHV and with providing HV as an early-career specialist GP. On multivariable analyses, these were no longer statistically significant. CONCLUSION: Early-career specialist GPs located in regional/remote areas are more likely than their urban colleagues to provide NHV and HV.

Perceptions of the effectiveness of using patient encounter data as an education and reflection tool in general practice training.

Introduction Patient encounter tools provide feedback and potentially reflection on general practitioner (GP) registrars' in-practice learning and may contribute to the formative assessment of clinical competencies. However, little is known about the perceived utility of such tools. Aim To investigate the perceived utility of a patient encounter tool by GP registrars, their supervisors, and medical educators (MEs). Methods General practice registrars, supervisors and MEs from two Australian regional training organisations completed a cross-sectional questionnaire. Registrars rated how Registrar Clinical Encounters in Training (ReCEnT), a patient encounter tool, influenced their reflection on, and change in, clinical practice, learning and training. Supervisors' and MEs' perceptions provided contextual information about understanding their registrars' clinical practice, learning and training needs. Results Questionnaires were completed by 48% of registrars (n = 90), 22% of supervisors (n = 182), and 61% of MEs (n = 62). Most registrars agreed that ReCEnT helped them reflect on their clinical practice (79%), learning needs (69%) and training needs (72%). Many registrars reported changing their clinical practice (54%) and learning approaches (51%). Fewer (37%) agreed that ReCEnT influenced them to change their training plans. Most supervisors (68%) and MEs (82%) agreed ReCEnT reports helped them better understand their registrars' clinical practice. Similarly, most supervisors (63%) and MEs (68%) agreed ReCEnT reports helped them better understand their registrars' learning and training needs. Discussion ReCEnT can prompt self-reflection among registrars, leading to changes in clinical practice, learning approaches and training plans. Reaching its potential as an assessment for learning (as opposed to an assessment of learning) requires effective engagement between registrars, their supervisors and MEs.

Utilisation of in-consultation supervisor assistance in general practice training and personal cost to trainees: a cross-sectional study.

Aim The aim of the study was to establish whether two previously described barriers to effective in-consultation assistance-seeking by general practice (GP) vocational specialist trainees (ie concern about patient impressions of their competence, and discomfort presenting to supervisors in front of patients) influenced the frequency of trainee in-consultation assistance-seeking from their supervisor. Methods This was a cross-sectional study nested in the Registrar Clinical Encounters in Clinical Training ongoing cohort study of Australian GP trainees. Trainee participants completed contemporaneous records of 60 consecutive patient consultations, including whether supervisory assistance was sought. Trainees also completed a cross-sectional survey including items eliciting their beliefs about patient impressions and their own discomfort in seeking in-consultation supervisory assistance. These were factors of interest in multivariable logistic regression analyses; the outcome factor in both regression models was the seeking of in-consultation supervisory assistance. Results In 2018, 778 trainees (778/876, response rate 89%) completed the cross-sectional survey. No association was found between the odds of in-consultation help-seeking and perceived decrease in patient impressions of trainee competence (OR = 1.09; 95% CI: 0.91, 1.31; P = 0.36) or higher comfort presenting outside patients' hearing (OR = 0.9; 95% CI: 0.77, 1.05; P = 0.19). Discussion Contrary to expected utility models of help-seeking, trainees may not consider personal discomfort or impression management to be important enough, compared to patient safety and other considerations, to influence decisions regarding in-consultation help-seeking. Clinical supervisors should, nevertheless, consider the potential personal costs to trainees and maintain trainee self-esteem and confidence by providing in-consultation assistance in front of patients as comfortably and effectively as possible.

Exploring how a patient encounter tracking and learning tool is used within general practice training: a qualitative study.

Introduction In Australian general practitioner (GP) training, feedback and reflection on in-practice experience is central to developing GP registrars' (trainees') clinical competencies. Patient encounter tracking and learning tools (PETALs) that encompass an audit of consecutive patient consultations, feedback, and reflection are used to determine registrars' in-practice exposure and have been suggested as a tool for learning within a programmatic assessment framework. However, there is limited qualitative literature on the utility of PETALs in GP training. Aim To provide greater understanding of how PETALs are used in GP training, using Registrars' Clinical Encounters in Training (ReCEnT) as a case study. Methods Medical educators, supervisors, and registrars from two Australian regional GP training organisations participated in focus groups and interviews, designed to explore participants' perceptions of ReCEnT's utility. Data were analysed using reflexive thematic analysis. Results Eight themes were identified that enhance our understanding of: how ReCEnT reports are used (reassuring registrars, facilitating self-reflection, identifying learning needs), what enables ReCEnT to reach its full potential (a culture of reflection, meaningful discussions with supervisors and medical educators, valuing objective data), and differences in understanding about ReCEnT's role in a programmatic assessment framework (as a tool for learning, as 'one piece of the puzzle'). Discussion The findings were used to develop a Structure-Process-Outcomes model to demonstrate how ReCEnT is currently used and explores how it can be used for learning, rather than of learning, in a programmatic assessment framework for GP training. ReCEnT's longitudinal format has potential for enhancing learning throughout training.

Prediction of general practice licensure/certification examination performance by a measure of 'questionable' activities in clinical practice: a retrospective cohort study.

PURPOSE: 'Low-value' clinical care and medical services are 'questionable' activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars' (trainees') performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP). METHODS: The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars' scores on the three Fellowship examinations ('AKT', 'KFP', and 'OSCE' examinations) and pass/fail rates during 2012-21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was 'QUIT-CAI score percentage'-the percentage of times a registrar performed a QUIT-CAI clinical activity when 'at risk' (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option). RESULTS: A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P = .001), poorer Key Features Problem scores (P = .003), and poorer Objective Structured Clinical Exam scores (P = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P = .043]. CONCLUSION: Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination).

Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review.

BACKGROUND: Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance. OBJECTIVES: To determine antibiotic prescribing patterns by early-career GPs for common acute infections. METHODS: A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing. RESULTS: Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context. CONCLUSIONS: Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.

Health risk factors in Australian Stroke Survivors: A latent class analysis.

ISSUES ADDRESSED: To (i) determine the prevalence of health risk factors (physical activity, diet, alcohol, smoking, blood pressure medication use and mental health) in community-dwelling stroke survivors; and (ii) examine how these health risk factors cluster, and identify associations with physical functioning, independent living, or sociodemographic factors. METHODS: A secondary analysis of data obtained during a national randomised controlled trial. Participants had experienced stroke and completed a baseline telephone survey on demographic and stroke characteristics, health risk factors, physical functioning and independence in activities of daily living. A latent class analysis was performed to determine health risk profiles. Univariate logistic regressions were performed to identify if participant characteristics were associated with resulting classes. RESULTS: Data analysed from 399 participants. Two classes of health risk factors were identified: Low Mood, Food & Moves Risk (16% of participants) and Alcohol Use Risk (84% of participants). The Low Mood, Food & Moves Risk group had poorer diet quality, lower physical activity levels and higher levels of depression and anxiety. Lower levels of independence and physical functioning were predictor variables for this group. In contrast, the Alcohol Use Risk group had better physical activity and diet scores, significantly lower probability of depression and anxiety, but a higher probability of risky drinking. CONCLUSIONS: We identified two distinct health risk factor groups in our population. SO WHAT?: Future interventions may benefit from targeting the specific needs and requirements of people who have experienced stroke based on their distinct risk group. Alcohol consumption in poststroke populations requires further attention.

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.

Video versus telephone for telehealth delivery: a cross-sectional study of Australian general practice trainees.

BACKGROUND: Remunerated telehealth consultations were introduced in Australia in 2020 in response to the COVID-19 pandemic. Videoconferencing has advantages over telephone-consulting, including improved diagnostic and decision-making accuracy. However, videoconferencing uptake in Australia has been low. This study aimed to establish prevalence and associations of video versus telephone consultations in Australian general practice (GP) registrars' practice. METHODS: A cross-sectional analysis of data from 2020 to 2021 (three 6-monthly data-collection rounds) from the Registrars Clinical Encounters in Training (ReCEnT) study. GP registrars record details of 60 consecutive consultations every 6-month term, for a total of 3 terms. Univariable and multivariable logistic regression were performed within the Generalized Estimating Equations framework with the outcome video versus telephone. RESULTS: 102,286 consultations were recorded by 1,168 registrars, with 21.4% of consultations performed via telehealth. Of these, telephone accounted for 96.6% (95% CI: 96.3-96.8%) and videoconferencing for 3.4% (95% CI: 3.2-3.7%). Statistically significant associations of using videoconferencing, compared to telephone, included longer consultation duration (OR 1.02, 95% CI: 1.01-1.03 per minute; and mean 14.9 versus 12.8 min), patients aged 0-14 years old (OR 1.29, 95% CI: 1.03-1.62, compared to age 15-34), patients new to the registrar (OR 1.19, 95% CI: 1.04-1.35), part-time registrars (OR 1.84, 95% CI: 1.08-3.15), and areas of less socioeconomic disadvantage (OR 1.27, 95% CI: 1.00-1.62 per decile). CONCLUSIONS: Registrars' telehealth consultations were mostly performed via telephone. Telephone use being associated with socioeconomic disadvantage has health equity implications. Future research should explore barriers to videoconferencing use and strategies to increase its uptake.

A novel, multidomain, primary care nurse-led and mHealth-assisted intervention for dementia risk reduction in middle-aged adults (HAPPI MIND): study protocol for a cluster randomised controlled trial.

INTRODUCTION: Middle-aged multidomain risk reduction interventions targeting modifiable risk factors for dementia may delay or prevent a third of dementia cases in later life. We describe the protocol of a cluster randomised controlled trial (cRCT), HAPPI MIND (Holistic Approach in Primary care for PreventIng Memory Impairment aNd Dementia). HAPPI MIND will evaluate the efficacy of a multidomain, nurse-led, mHealth supported intervention for assessing dementia risk and reducing associated risk factors in middle-aged adults in the Australian primary care setting. METHODS AND ANALYSIS: General practice clinics (n≥26) across Victoria and New South Wales, Australia, will be recruited and randomised. Practice nurses will be trained to implement the HAPPI MIND intervention or a brief intervention. Patients of participating practices aged 45-65 years with ≥2 potential dementia risk factors will be identified and recruited (approximately 15 patients/clinic). Brief intervention participants receive a personalised report outlining their risk factors for dementia based on Australian National University Alzheimer's Disease Risk Index (ANU-ADRI) scores, education booklet and referral to their general practitioner as appropriate. HAPPI MIND participants receive the brief intervention as well as six individualised dementia risk reduction sessions with a nurse trained in motivational interviewing and principles of behaviour change, a personalised risk reduction action plan and access to the purpose-built HAPPI MIND smartphone app for risk factor self-management. Follow-up data collection will occur at 12, 24 and 36 months. Primary outcome is ANU-ADRI score change at 12 months from baseline. Secondary outcomes include change in cognition, quality of life and individual risk factors of dementia. ETHICS AND DISSEMINATION: Project approved by Monash University Human Research Ethics Committee (ID: 28273). Results will be disseminated in peer-reviewed journals and at healthcare conferences. If effective in reducing dementia risk, the HAPPI MIND intervention could be integrated into primary care, scaled up nationally and sustained over time. TRIAL REGISTRATION NUMBER: ACTRN12621001168842.

Exam prediction and the general Practice Registrar Competency Assessment Grid (GPR-CAG).

BACKGROUND: In GP training, identifying early predictors of poor summative examination performance can be challenging. We aimed to establish whether external clinical teaching visit (ECTV) performance, measured using a validated instrument (GP Registrar Competency Assessment Grid, GPR-CAG) is predictive of Royal Australian College of General Practitioners (RACGP) Fellowship examination performance. METHODS: A retrospective cohort study including GP registrars in New South Wales/Australian Capital Territory with ECTV data recorded during their first training term (GPT1), between 2014 and 2018, who attempted at least one Fellowship examination. Independent variables of interest included the four GPR-CAG factors assessed in GPT1 ('patient-centredness/caring', 'formulating hypotheses/management plans', 'professional responsibilities', 'physical examination skills'). Outcomes of interest included individual scores of the three summative examinations (Applied Knowledge Test (AKT); Key Feature Problem (KFP); and the Objective Structured Clinical Examination (OSCE)) and overall Pass/Fail status. Univariable and multivariable regression analyses were performed. RESULTS: Univariably, there were statistically significant associations (p < 0.01) between all four GPR-CAG factors and all four summative examination outcomes, except for 'formulating hypotheses/management plans' and OSCE score (p = 0.07). On multivariable analysis, each factor was significantly associated (p < 0.05) with at least one exam outcome, and 'physical examination skills' was significantly associated (p < 0.05) with all four exam outcomes. DISCUSSION: ECTV performance, via GPR-CAG scores, is predictive of RACGP Fellowship exam performance. The univariable findings highlight the pragmatic utility of ECTVs in flagging registrars who are at-risk of poor exam performance, facilitating early intervention. The multivariable associations of GPR-CAG scores and examination performance suggest that these scores provide predictive ability beyond that of other known predictors.

'Low-value' clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs' practice.

Nonevidence-based and 'low-value' clinical care and medical services are 'questionable' clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with their cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key nonevidence-based or low-value 'questionable' clinical practices. The study was nested in the Registrar Clinical Encounters in Training study-an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on Registrar Clinical Encounters in Training data from 2010 to 2020, was the score on the QUestionable In-Training Clinical Activities Index (QUIT-CAI), which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. A total of 3206 individual registrars (response rate 89.9%) recorded 406 812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15 560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training terms: incidence rate ratios (IRRs) of 0.91 [95% confidence interval (CI) 0.87, 0.95] and 0.85 (95% CI 0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12, 1.45), the patient being of non-English-speaking background (IRR 1.24; 95% CI 1.04, 1.47), the practice being in a higher socioeconomic area decile (IRR 1.01; 95% CI 1.00, 1.02), small practice size (IRR 1.05; 95% CI 1.00, 1.10), shorter consultation duration (IRR 0.99 per minute; 95% CI 0.99, 1.00), and fewer problems addressed in the consultation (IRR 0.84; 95% CI 0.79, 0.89) for each additional problem]. Senior registrars' clinical practice entailed less 'questionable' clinical actions than junior registrars' practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests that continuity should be supported and facilitated during GP training (and in established GPs' practice).

General practice registrars training part-time: a cross-sectional analysis of prevalence and associations.

While GPs are working fewer clinical hours and many GP trainees (registrars) do not foresee themselves working full-time in clinical practice, little is known of the epidemiology of registrars training part-time. We aimed to establish the prevalence of general practice part-time training (PTT), and part-time registrars' characteristics and practice patterns. A cross-sectional analysis was conducted of data from the Registrar Clinical Encounters in Training project, an ongoing cohort study of Australian GP registrars' clinical experiences over 60 consecutive consultations in each of three training terms. Univariable and multivariable logistic regression analyses were conducted with the outcome 'training part-time'. 1790 registrars contributed data for 4,135 registrar-terms and 241,945 clinical encounters. Nine hundred and twenty-two registrar-terms (22%, 95%CI:21%-24%) and 52,339 clinical encounters (22%, 95%CI:21%-22%) involved PTT. Factors associated with PTT were registrar characteristics - female gender, older age, in a later training stage, performing other regular medical work; practice characteristics - working in a higher socioeconomic status area; and patient characteristics - seeing more patients new to the registrar and seeing more patients from a non-English-speaking background. No consultation or consultation action factors were significantly associated with PTT. Registrars, practices, and patient associations have GP training implications. The lack of registrar consultation or consultation action associations suggests there may be limited impact of PTT on patient care.

Absolute cardiovascular risk assessment by Australian early-career general practitioners: a cross-sectional study.

OBJECTIVE: To determine the prevalence and associations of general practice registrars' performing absolute cardio-vascular risk (ACVR) assessment (ACVRa). DESIGN: A cross-sectional study employing data (2017-2018) from the Registrar Clinical Encounters in Training project, an ongoing inception cohort study of Australian GP registrars. The outcome measure was whether an ACVRa was performed. Analyses employed univariable and multivariable regression. Analysis was conducted for all patient problems/diagnoses, then for an 'at-risk' population (specific problems/diagnoses for which ACVRa is indicated). SETTING: Three GP regional training organisations (RTOs) across three Australian states. PARTICIPANTS: GP registrars training within participating RTOs. RESULTS: 1003 registrars (response rate 96.8%) recorded details of 69 105 problems either with Aboriginal and/or Torres Strait patients aged 35 years and older or with non-Indigenous patients aged 45 years and older. Of these problems/diagnoses, 1721 (2.5% (95% CI 2.4% to 2.6%)) involved an ACVRa. An ACVRa was 'plausibly indicated' in 10 384 problems/diagnoses. Of these, 1228 (11.8% (95% CI 11.2% to 12.4%)) involved ACVRa. For 'all problems/diagnoses', on multivariable analysis female gender was associated with reduced odds of ACVRa (OR 0.61 (95% CI 0.54 to 0.68)). There was some evidence for Aboriginal and/or Torres Strait Islander people being more likely to receive ACVRa (OR 1.40 (95% CI 0.94 to 2.08), p=0.10). There were associations with variables related to continuity of care, with reduced odds of ACVRa: if the patient was new to the registrar (OR 0.65 (95% CI 0.57 to 0.75)), new to the practice (OR 0.24 (95% CI 0.15 to 0.38)) or the problem was new (OR 0.68 (95% CI 0.59 to 0.78)); and increased odds if personal follow-up was organised (OR 1.43 (95% CI 1.24 to 1.66)). For 'ACVRa indicated' problems/diagnoses, findings were similar to those for 'all problems/diagnoses'. Association with Aboriginal and/or Torres Strait Islander status, however, was significant at p<0.05 (OR 1.60 (95% CI 1.04 to 2.46)) and association with female gender was attenuated (OR 0.88 (95% CI 0.77 to 1.01)). CONCLUSION: Continuity of care is associated with registrars assessing ACVR, reinforcing the importance of care continuity in general practice. Registrars' assessment of an individual patient's ACVR is targeted to patients with individual risk factors, but this may entail ACVRa underutilisation in female patients and younger age groups.

The prevalence and associations of Australian early-career general practitioners' provision of after-hours care.

INTRODUCTION: Access to after-hours care (AHC) is an important aspect of general practice service provision. OBJECTIVE: To establish the prevalence and associations of early-career GPs' provision of AHC. DESIGN: An analysis of data from the New alumni Experiences of Training and independent Unsupervised Practice (NEXT-UP) cross-sectional questionnaire-based study. Participants were early-career GPs (6-month to 2-year post-Fellowship) following the completion of GP vocational training in NSW, the ACT, Victoria or Tasmania. The outcome factor was 'current provision of after-hours care'. Associations of the outcome were established using multivariable logistic regression. FINDINGS: Three hundred and fifty-four early-career GPs participated (response rate 28%). Of these, 322 had responses available for analysis of currently performing AHC. Of these observations, 128 (40%) reported current provision of AHC (55% of rural participants and 32% of urban participants). On multivariable analysis, participants who provided any AHC during training were more likely to be providing AHC (odds ratio (OR) 5.51, [95% confidence interval (CI) 2.80-10.80], p < 0.001). Current rural location and in-training rural experience were strongly associated with currently providing AHC in univariable but not multivariable analysis. DISCUSSION: Early-career GPs who provided AHC during training, compared with those who did not, were more than five times more likely to provide after-hours care in their first 2 years after gaining Fellowship, suggesting participation in AHC during training may have a role in preparing registrars to provide AHC as independent practitioners. CONCLUSION: These findings may inform future GP vocational training policy and practice concerning registrars' provision of AHC during training.

Influenza presentations and use of neuraminidase inhibitors by Australian general practice registrars: a cross-sectional analysis from the ReCEnT study.

OBJECTIVE: This study aims to establish prevalence and associations of (1) influenza and influenza-like illness (IILI) presentations to Australian general practice (GP) registrars (trainees) and (2) the use of neuraminidase inhibitors (NAIs) by GP registrars for new presentations of IILI, for the 10 years leading up to the COVID-19 pandemic in Australia (2010-2019). DESIGN: This was a cross-sectional analysis of the Registrar Clinical Encounters in Training ongoing inception cohort study of the in-consultation experience and clinical behaviours of GP registrars. Data are collected by individual registrars three times (from 60 consecutive consultations each time) at 6 monthly intervals. Data include diagnoses/problems managed and medicines prescribed, along with multiple other variables. Univariate and multivariable logistic regression was used to establish associations of registrars seeing patients with IILI and of prescribing NAIs for IILI. SETTING: Teaching practices within the Australian general practitioner specialist vocational training programme. Practices were located in five of the six Australian states (plus one territory). PARTICIPANTS: GP registrars in each of their three compulsory 6-month GP training terms. RESULTS: From 2010 to 2019, 0.2% of diagnoses/problems seen by registrars were IILI. 15.4% of new IILI presentations were prescribed an NAI. IILI diagnoses were less likely in younger (0-14) and older (65+) age groups, and more likely in an area of higher socioeconomic advantage. There was considerable variation in NAI prescribing between regions. There was no significant association of prescribing NAIs with age or Aboriginal and/or Torres Strait Islander patients. CONCLUSIONS: IILI presentations were more likely among working-age adults and not among those groups at higher risk. Similarly, high-risk patient groups who would benefit most were not more likely to receive NAIs. The epidemiology and management of IILI has been distorted by the COVID-19 pandemic, but the burden of influenza in vulnerable populations must not be overlooked. Appropriately targeted antiviral therapy with NAIs influences outcomes for vulnerable patients. General practitioners manage the majority of IILI in Australia, and understanding GP IILI presentation and NAI prescribing patterns is a key first step to enabling sound and rational prescribing decisions for better patient outcomes.

Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study.

INTRODUCTION: Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing. OBJECTIVE: The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation. METHODS: This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥ 75 years admitted to the acute aged care service for ≥ 48 h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications. RESULTS: Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) -3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0-24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04). CONCLUSION: Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients.

Prevalence and associated skills of Australian general practice registrars seeing children with functional bowel and bladder problems.

AIM: Functional bowel (constipation and faecal incontinence) and bladder (urinary incontinence and enuresis) problems in children are often treated by paediatricians yet should mostly be managed by general practitioners (GPs). To understand whether the necessary skills and knowledge are being built in general practice, this study aimed to establish the prevalence and associated skills of Australian general practice registrars managing children with functional bowel and bladder problems. Together as paediatricians and GPs, we use these data to determine how best to ensure high quality, equitable care for children. METHODS: We drew on 16 rounds of data collection from the Registrar Clinical Encounters in Training (ReCEnT) multi-site cohort study (2010-2017) of general practice registrars' in-consultation experience. It included a measure of paediatric consultations in which a functional bowel or bladder problem was managed, as well as demographic information. RESULTS: Out of 62 721 problems/diagnoses for paediatric patients (0-17 years), 844 (1.4%) were coded as functional bowel (n = 709; 1.13% (95% confidence interval, CI: 1.05-1.22)) and/or bladder (n = 135; 0.22% (95% CI: 0.18-0.25)) presentations. Registrars were more likely to prescribe medication for bowel problems (odds ratio (OR) = 2.22 (95% CI: 1.86-2.64)) than for all other problems, but less likely to prescribe medication (OR = 0.31 (95% CI: 0.18-0.52)) for night-time wetting and more likely to make a specialist referral (OR = 1.99 (95% CI: 1.22-3.25)) compared to all other problems. CONCLUSIONS: Only a small proportion of children with functional bowel and bladder problems were seen by registrars despite high prevalence in the community and amenability to management in the general practice setting (i.e. generally low morbidity and low complexity) versus need for specialists. Registrars appeared to be managing functional bowel and bladder problems according to evidence-based guidelines, but with relatively high levels of referral. Given the inequitable access to specialist care, paediatricians should support local general practice management of these problems. This might include (i) engaging with training programs to ensure appropriate education and (ii) liaising with individual registrars/practices to provide management advice for individual or example cases.

Temporal patterns of antibiotic prescribing for sore throat, otitis media, and sinusitis: a longitudinal study of general practitioner registrars.

BACKGROUND: Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship. OBJECTIVES: To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis. DESIGN: A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019. PARTICIPANTS: ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate. MAIN MEASURES: The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010-2019). KEY RESULTS: Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86-0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86-0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001). CONCLUSIONS: Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010-2019. However, educational (and other) interventions to further reduce prescribing are warranted.