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.

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.

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.

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).

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.

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.

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.

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.

A self-management support program for older Australians with multiple chronic conditions: a randomised controlled trial.

OBJECTIVE: To determine whether a clinician-led chronic disease self-management support (CDSMS) program improves the overall self-rated health level of older Australians with multiple chronic health conditions. DESIGN: Randomised controlled trial: participants were allocated to a clinician-led CDSMS group (including client-centred goal setting and the development of individualised care plans) or to a control group in which they received positive attention only. SETTING AND PARTICIPANTS: Patients aged 60 years or more with at least two chronic conditions, recruited between September 2009 and June 2010 from five general practices in Adelaide. MAIN OUTCOME MEASURES: The primary outcome was self-rated health. Secondary outcome measures related to health status (fatigue, pain, health distress, energy, depression, illness intrusiveness), health behaviour (exercise, medication adherence), and health service utilisation. RESULTS: 254 participants were randomised to the CDSMS and control groups, of whom 231 (117 control and 114 CDSMS participants) completed the 6-month programs and provided complete outcomes data (91%). An intention-to-treat analysis found that CDSMS participants were more likely than control participants to report improved self-rated health at 6 months (odds ratio, 2.50; 95% confidence interval, 1.13-5.50; P = 0.023). Between-group differences for secondary outcomes were not statistically significant. CONCLUSION: CDSMS may benefit some older people with multiple chronic conditions to a greater extent than positive attention and health education. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000726257.

Pathways to research impact in primary healthcare: What do Australian primary healthcare researchers believe works best to facilitate the use of their research findings?

BACKGROUND: Primary healthcare researchers are under increasing pressure to demonstrate measurable and lasting improvement in clinical practice and healthcare policy as a result of their work. It is therefore important to understand the effectiveness of the research dissemination strategies used. The aim of this paper is to describe the pathways for research impact that have been achieved across several government-funded primary healthcare projects, and the effectiveness of these methods as perceived by their Chief Investigators. METHODS: The project used an online survey to collect information about government-funded primary healthcare research projects. Chief Investigators were asked how they disseminated their findings and how this achieved impact in policy and practice. They were also asked to express their beliefs regarding the most effective means of achieving research impact and describe how this occurred. RESULTS: Chief Investigators of 17 projects indicated that a number of dissemination strategies were used but that professional networks were the most effective means of promoting uptake of their research findings. Utilisation of research findings for clinical practice was most likely to occur in organisations or among individual practitioners who were most closely associated with the research team, or when research findings were included in educational programmes involving clinical practice. Uptake of both policy- and practice-related research was deemed most successful if intermediary organisations such as formal professional networks were engaged in the research. Successful primary healthcare researchers had developed critical relationships with intermediary organisations within primary healthcare before the initiation of the research and had also involved them in the design. The scale of research impact was influenced by the current policy environment, the type and significance of the results, and the endorsement (or lack thereof) of professional bodies. CONCLUSIONS: Chief Investigators believed that networks were the most effective means of research dissemination. Researchers who were embedded in professional, clinical or policy-focussed intermediary organisations, or had developed partnerships with clinical services, which had a vested interest in the research findings, were more able to describe a direct impact of their research. This suggests that development of these relationships and engagement of these stakeholders by primary healthcare researchers is a vital step for optimal research utilisation in the primary healthcare setting.

The Australian Defence Force Post­discharge GP Health Assessment.

BACKGROUND: All former serving members of the Australian Defence Force (ADF) can receive a comprehensive health assessment from their general practitioners (GPs). OBJECTIVE: The aim of this article is to describe the ADF Post-discharge GP Health Assessment and introduce a tool that assists GPs in performing the assessment. DISCUSSION: The ADF Post-discharge GP Health Assessment is intended to promote the early detection and intervention of potential mental or physical health concerns in the veteran population and facilitate the establishment of ongoing care with a GP.

Medicare Local-Local Health Network partnerships in South Australia: lessons for Primary Health Networks.

OBJECTIVES: To examine the partnerships in population health planning between Medicare Locals (MLs) and Local Health Networks (LHNs) in South Australia, and the factors that facilitated or constrained collaborations, to offer lessons for LHNs and Primary Health Networks. DESIGN, PARTICIPANTS AND SETTING: We conducted a qualitative study using individual interviews with key informants (executive or program leader staff) from the five South Australian MLs and the five South Australian LHNs. A total of 34 interviews were conducted between March and July 2014. RESULTS: Significant work was undertaken by MLs in the process of population health planning and needs assessment. Participants from both MLs and LHNs described examples of collaborative work, including data sharing and synthesis, program implementation and community consultation. The focus of LHNs on acute and intermediate care, the lack of system-level strategies to support collaboration, and constant policy and structural changes leading to uncertainty in the primary health care landscape were perceived as key barriers to collaboration. CONCLUSIONS: The experience of MLs and their achievements in building relationships and trust with stakeholders in their regions, including LHNs, provide valuable lessons for the new Primary Health Networks in Australia.

Models of general practitioner services in residential aged care facilities.

BACKGROUND: Provision of timely and high-quality general practitioner (GP) services to patients in residential aged care facilities (RACFs) is essential for this group of patients as they have high medical needs. OBJECTIVE: The aim of this article is to describe different models for general practice care for patients in RACFs. DISCUSSION: Models for general practice services include the Continuity Model, where GPs follow long-term patients; the RACF Panel model, where GPs provide care to several patients in nearby RACFs; the GPs with Special Interest in Residential Aged Care (GPwSI RAC) model, where GPs provide regularly scheduled services to larger groups of patients; the Longitudinal General Practice Team (LGPT) model, where GPs provide team-based care; and RACF-based models of care, where GPs partner with RACFs. Hospital-based models of care have also been developed to provide in-reach services to patients in RACFs during episodes of acute illness. There is limited evidence for which of these models is most effective. Developing and testing different models of general practice care should be a priority.

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.

Recruitment for a clinical trial of chronic disease self-management for older adults with multimorbidity: a successful approach within general practice.

BACKGROUND: A robust research base is required in General Practice. The research output for General Practice is much less than those of other clinical disciplines. A major impediment to more research in this sector is difficulty with recruitment. Much of the research in this area focuses on barriers to effective recruitment and many projects have great difficulty with this process. This paper seeks to describe a systematic approach to recruitment for a randomized controlled trial that allowed the study team to recruit a substantial number of subjects from General Practice over a brief time period. METHODS: A systematic approach to recruitment in this setting based on prior literature and the experience of the investigator team was incorporated into the design and implementation of the study. Five strategies were used to facilitate this process. These included designing the study to minimize the impact of the research on the day-to-day operations of the clinics, engagement of general practitioners in the research, making the research attractive to subjects, minimizing attrition and ensuring recruitment was a major focus of the management of the study. Outcomes of the recruitment process were measured as the proportion of practices that agreed to participate, the proportion of potentially eligible subjects who consented to take part in the trial and the attrition rate of subjects. Qualitative interviews with a subset of successfully recruited participants were done to determine why they chose to participate in the study; data were analyzed using thematic analysis. RESULTS: Five out of the six general practices contacted agreed to take part in the study. Thirty-eight per cent of the 1663 subjects who received a letter of invitation contacted the university study personnel regarding their interest in the project. Recruitment of the required number of eligible participants (n = 256) was accomplished in seven months. Thematic analysis of interviews with 30 participants regarding key factors in their study participation identified a personalised letter of endorsement from their general practitioner, expectation of personal benefit and altruism as important factors in their decision to participate. CONCLUSION: Recruitment can be successfully achieved in General Practice through design of the research project to facilitate recruitment, minimize the impact on general practice operations and ensure special care in enrolling and maintaining subjects in the project.

Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial.

IMPORTANCE: Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment. OBJECTIVE: To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers. DESIGN, SETTING, AND PATIENTS: A randomized, controlled, noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practices (n=81) in metropolitan Adelaide, 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010. INTERVENTIONS: Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center; both plans included continuous positive airway pressure, mandibular advancement splints, or conservative measures only. MAIN OUTCOME AND MEASURES: The primary outcome was 6-month change in Epworth Sleepiness Scale (ESS) score, which ranges from 0 (no daytime sleepiness) to 24 points (high level of daytime sleepiness). The noninferiority margin was -2.0. Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using continuous positive airway pressure, patient satisfaction, and health care costs. RESULTS: There were significant improvements in ESS scores from baseline to 6 months in both groups. In the primary care group, the mean baseline score of 12.8 decreased to 7.0 at 6 months (P < .001), and in the specialist group, the score decreased from a mean of 12.5 to 7.0 (P < .001). Primary care management was noninferior to specialist management with a mean change in ESS score of 5.8 vs 5.4 (adjusted difference, -0.13; lower bound of 1-sided 95% CI, -1.5; P = .43). There were no differences in secondary outcome measures between groups. Seventeen patients (21%) withdrew from the study in the primary care group vs 6 patients (8%) in the specialist group. CONCLUSIONS AND RELEVANCE: Among patients with obstructive sleep apnea, treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12608000514303.

e-Mental health in South Australia: impact of age, gender and region of residence.

Respondents to the 2008 South Australian Health Omnibus survey (n=2996) indicated whether, in the previous 12 months, they had searched for information on the Internet relating to emotional issues such as depression, anxiety or relationship problems. Logistic regression was used to examine the penetration of e-mental health in rural and metropolitan areas (region of residence), and determine if other demographic variables (age group, gender) also impacted on the likelihood of an individual reporting that they had used the Internet to obtain such information. Overall, 9% of respondents reported that they had used the Internet for this purpose. The multivariate model was significant, F(11, 2985)=4.82, P<0.0001, with middle-aged rural females most likely to report doing so (18.1%), whereas older rural males were least likely to report doing so (2.2.%). These findings have important implications for the design of e-mental health promotional programs that provide information and interventions to improve mental health.

A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care.

BACKGROUND: To address the growing burden of disease and long waiting lists for sleep services, a simplified two-stage model was developed and validated for identifying obstructive sleep apnoea (OSA) in primary care using a screening questionnaire followed by home sleep monitoring. METHODS: 157 patients aged 25-70 years attending their primary care physician for any reason at six primary care clinics in rural and metropolitan regions of South Australia participated. The first 79 patients formed the development group and the next 78 patients the validation group. A screening questionnaire was developed from factors identified from sleep surveys, demographic and anthropometric data to be predictive of moderate to severe OSA. Receiver operating characteristic (ROC) curve analysis was used to validate the two-channel ApneaLink device against full polysomnography. The diagnostic accuracy of the overall two-stage model was then evaluated. RESULTS: Snoring, waist circumference, witnessed apnoeas and age were predictive of OSA and incorporated into a screening questionnaire (ROC area under curve (AUC) 0.84, 95% CI 0.75 to 0.94, p<0.001). ApneaLink oximetry with a 3% dip rate was highly predictive of OSA (AUC 0.96, 95% CI 0.91 to 1.0, p<0.001). The two-stage diagnostic model showed a sensitivity of 0.97 (95% CI 0.81 to 1.00) and specificity of 0.87 (95% CI 0.74 to 0.95) in the development group, and a sensitivity of 0.88 (95% CI 0.60 to 0.98) and specificity of 0.82 (95% CI 0.70 to 0.90) in the validation group. CONCLUSION: A two-stage model of screening questionnaire followed by home oximetry can accurately identify patients with OSA in primary care and has the potential to expedite care for patients with this common sleep disorder.

What research impacts do Australian primary health care researchers expect and achieve?

BACKGROUND: Funding for research is under pressure to be accountable in terms of benefits and translation of research findings into practice and policy. Primary health care research has considerable potential to improve health care in a wide range of settings, but little is known about the extent to which these impacts actually occur. This study examines the impact of individual primary health care research projects on policy and practice from the perspective of Chief Investigators (CIs). METHODS: The project used an online survey adapted from the Buxton and Hanney Payback Framework to collect information about the impacts that CIs expected and achieved from primary health care research projects funded by Australian national competitive grants. RESULTS AND DISCUSSION: Chief Investigators (CIs) provided information about seventeen completed projects. While no CI expected their project to have an impact in every domain of the framework used in the survey, 76% achieved at least half the impacts they expected. Sixteen projects had published and/or presented their work, 10 projects included 11 doctorate awards in their research capacity domain. All CIs expected their research to lead to further research opportunities with 11 achieving this. Ten CIs achieved their expectation of providing information for policy making but only four reported their research had influenced policy making. However 11 CIs achieved their expectation of providing information for organizational decision making and eight reported their research had influenced organizational decision making. CONCLUSION: CIs reported that nationally funded primary health care research projects made an impact on knowledge production, staff development and further research, areas within the realm of influence of the research team and within the scope of awareness of the CIs. Some also made an impact on policy and organizational decision-making, and on localized clinical practice and service delivery. CIs reported few broader economic benefits from their research. Routine use of an instrument of this type would facilitate primary health care research funders' determination of the payback for funding of research in this sector.