Global impacts of COVID-19 pandemic on sexual and reproductive health services: An international comparative study on primary care from the INTRePID Consortium.

OBJECTIVE: To understand how the COVID-19 pandemic has impacted sexual and reproductive health (SRH) visits. DESIGN: An ecological study comparing SRH services volume in different countries before and after the onset of the COVID-19 pandemic. SETTING: Seven countries from the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID) across four continents. POPULATION: Over 3.8 million SRH visits to primary care physicians in Australia, China, Canada, Norway, Singapore, Sweden and the USA. METHODS: Difference in average SRH monthly visits before and during the pandemic, with negative binomial regression modelling to compare predicted and observed number of visits during the pandemic for SRH visits. MAIN OUTCOME MEASURES: Monthly number of visits to primary care physicians from 2018 to 2021. RESULTS: During the pandemic, the average volume of monthly SRH visits increased in Canada (15.6%, 99% CI 8.1-23.0%) where virtual care was pronounced. China, Singapore, Sweden and the USA experienced a decline (-56.5%, 99% CI -74.5 to -38.5%; -22.7%, 99% CI -38.8 to -6.5%; -19.4%, 99% CI -28.3 to -10.6%; and -22.7%, 99% CI -38.8 to -6.5%, respectively); while Australia and Norway showed insignificant changes (6.5%, 99% CI -0.7 to -13.8% and 1.7%, 99% CI -6.4 to -9.8%). The countries that maintained (Australia, Norway) or surpassed (Canada) pre-pandemic visit rates had the greatest use of virtual care. CONCLUSIONS: In-person SRH visits to primary care decreased during the pandemic. Virtual care seemed to counterbalance that decline. Although cervical cancer screening appeared insensitive to virtual care, strategies such as incorporating self-collected samples for HPV testing may provide a solution in a future pandemic.

Adoption, acceptance, and use of a decision support tool to promote timely investigations for cancer in primary care.

BACKGROUND: The complexities of diagnosing cancer in general practice has driven the development of quality improvement (QI) interventions, including clinical decision support (CDS) and auditing tools. Future Health Today (FHT) is a novel QI tool, consisting of CDS at the point-of-care, practice population-level auditing, recall, and the monitoring of QI activities. OBJECTIVES: Explore the acceptability and usability of the FHT cancer module, which flags patients with abnormal test results that may be indicative of undiagnosed cancer. METHODS: Interviews were conducted with general practitioners (GPs) and general practice nurses (GPNs), from practices participating in a randomized trial evaluating the appropriate follow-up of patients. Clinical Performance Feedback Intervention Theory (CP-FIT) was used to analyse and interpret the data. RESULTS: The majority of practices reported not using the auditing and QI components of the tool, only the CDS which was delivered at the point-of-care. The tool was used primarily by GPs; GPNs did not perceive the clinical recommendations to be within their role. For the CDS, facilitators for use included a good workflow fit, ease of use, low time cost, importance, and perceived knowledge gain. Barriers for use of the CDS included accuracy, competing priorities, and the patient population. CONCLUSIONS: The CDS aligned with the clinical workflow of GPs, was considered non-disruptive to the consultation and easy to implement into usual care. By applying the CP-FIT theory, we were able to demonstrate the key drivers for GPs using the tool, and what limited the use by GPNs.

Development and acceptability of a digital tool for promoting syphilis testing in Australian general practice: qualitative study using the Theoretical Framework of Acceptability.

Background In Australia, syphilis notifications increased 2.5-fold during 2013-2022 and 83 congenital syphilis cases were reported. Timely diagnosis and management are crucial. We developed a tool to promote syphilis testing into our existing 'Future Health Today' (FHT) software and explored its acceptability in general practice. Methods Our tool (FHT-syphilis) scans electronic medical record data to identify and prompt testing for pregnant women, and, people recently tested for sexually transmissible infection (STI) or HIV, but not syphilis. It links to relevant guidelines and patient resources. We implemented FHT-syphilis in 52 general practices using FHT for other conditions and interviewed practice clinicians (n =9) to explore it's acceptability. Data were analysed deductively guided by the Theoretical Framework of Acceptability. Results Interviewees considered syphilis an important infection to focus on and broadly viewed FHT-syphilis as acceptable for identifying patients and giving clinicians authority to discuss syphilis testing. Time constraints and unrelated reasons for a patient's visit were barriers to initiating syphilis testing discussions. Australian STI guidelines were considered appropriate to link to. Some interviewees considered prompts should be based on sexual behaviour, however this is not well captured in the electonic medical record. Two interviewees were alerted to updated Australian STI guidelines via their interaction with FHT-syphilis and expanded their syphilis testing practices. Expertise to initiate discussions about syphilis and risk was deemed important. Conclusions A digital tool for prompting syphilis testing was acceptable to clinicians already using FHT. Linkage to STI guidelines alerted some end-users to updated guidelines, informing STI testing practices.

Fragmentation of care between intensive and primary care settings and opportunities for improvement.

PURPOSE: To explore the gaps in care provided across the transitions from the intensive care unit (ICU) to primary care, in order to improve post-ICU care. METHODS: Semistructured interviews with three participant groups: intensivists, general practitioners (GPs) and patients and carers with framework analysis of textual data were used to investigate experiences of transitions of care post-ICU. Participants were purposively sampled for diversity. Eligible patients were adults, mechanically ventilated for >24 hours, with access to a video-enabled device. Exclusion criteria were non-English speaking and any cognitive/neurological limitation precluding interview participation. RESULTS: A total of 46 interviews (15 patients, 8 caregivers, 15 intensivists and 8 GPs) were completed. Eight themes were identified, and categorised into three healthcare tiers. Tier 1, health system factors: (1) fragmentation of care; (2) communication gaps; (3) limited awareness and recognition of issues beyond the ICU; (4) lack of a specialised ICU follow-up pathway; Tier 2, clinician factors: (5) relationships among ICU, hospitals, GPs and patients and carers; (6) need for clinician role definition and clarity in ICU follow-up; Tier 3, patient and carer factors: (7) patient autonomy and self-actualisation and (8) the evolving caregiver role. A conceptual model was developed, highlighting bidirectional feedback loops between hospital and primary care. CONCLUSION: This study identified gaps in care between ICU discharge and reintegration with primary care from the lived experience of patients, caregivers, intensivists and GPs. These data provide foci for future interventional research to improve the integration of care for this vulnerable and underserved cohort.

Exploring the appropriateness of antibiotic prescribing for dental presentations in Australian general practice-A pilot study.

AIMS: Dental pain is a common presentation in general medical practice for which patients are often prescribed antibiotics. The aim of this pilot study was to assess prescriptions by general medical practitioners (GPs) for dental presentations in Australia. METHODS: Anonymised electronic medical data relating to antibiotic prescribing across 2 periods (3 August-30 November 2019 and 3 August-30 November 2020) were extracted from 8 general practices in Victoria that contributed data to the University of Melbourne's Data for Decisions programme. Extracted de-identified data included antibiotics prescribed for dental presentations, practice site number, visit date, patient age, sex, reason for prescription, reason for visit and the regimen of the antibiotic. Appropriateness of the prescribed antibiotic was assessed against the Australian national dental guidelines Therapeutic Guidelines Oral and Dental. RESULTS: From 13 641 recorded prescriptions, 178 were recorded for dental presentations, representing 1.3% of all antibiotic prescriptions. When assessed against the guidelines, 23.6% (n = 42) were considered appropriate. The top 3 most commonly prescribed antibiotics were amoxicillin (n = 84, 47.2%), amoxicillin/clavulanic acid (n = 52, 29.2%) and metronidazole (n = 15, 8.4%). The reasons for inappropriate prescribing were as follows: third-line treatment being chosen, inappropriate spectrum, incorrect regimen or prescribing an antibiotic not recommended in the guidelines. CONCLUSION: These results indicate a need to better understand the potential patient drivers for antibiotic prescription for GPs and patients, and resources GPs need to manage dental presentations. These results will inform the codesign of targeted interventions to address any educational gaps and barriers to accessing dental treatment and thus improving antibiotic prescribing.

Informing the design of a digital intervention to support sexually transmissible infection care in general practice: a qualitative study exploring the views of clinicians.

BACKGROUND: Strengthening sexually transmissible infection (STI) management in general practice is prioritised in Australian STI strategy. Digital interventions incorporating clinical decision support offer a mechanism to assist general practitioners (GPs) in STI care. This study explored clinicians' views towards a proposed digital intervention for supporting STI care in Australian general practice as a first step in the tool's design. METHODS: Semi-structured one-to-one interviews were conducted during 2021 with sexual health physicians (n =2) and GPs (n =7) practicing in the state of Victoria, Australia. Interviews explored views on a proposed STI digital intervention for general practice. We applied the Theoretical Domains Framework (TDF), a behaviour change framework to our analysis. This involved: (1) directed content analysis of transcripts into TDF domains; and (2) thematic analysis to identify sub-themes within relevant TDF domains. Subthemes were subsequently categorised into enablers and barriers to the use and implementation of a STI computerised clinical decision support system (CDSS). RESULTS: All interviewees viewed a digital intervention for STI care favourably, expressing confidence in its potential to improve care and support management. Within the relevant TDF domains (e.g. environmental context and resources), subthemes emerged as barriers (e.g. lack of sensitivity to patient context) or enablers (e.g. clear communication and guidance) to the use and implementation of a STI CDSS in primary care. Multiple subthemes (e.g. time constraints) have the potential to be a barrier or an enabler, and is largely dependent on end-user needs being met and clinical context being appropriately addressed. CONCLUSIONS: A digital intervention incorporating clinical decision support was viewed favourably, indicating a possible role for such a tool in Australian general practice. Co-design with end-users and prototype evaluation with health consumers is recommended to ensure relevance and usefulness.

Cost-effectiveness of professional-mode flash glucose monitoring in general practice among adults with type 2 diabetes: Evidence from the GP-OSMOTIC trial.

AIM: To assess the cost-effectiveness of professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice compared with usual clinical care. METHODS: An economic evaluation was conducted as a component of the GP-OSMOTIC trial, a pragmatic multicentre 12-month randomised controlled trial enrolling 299 adults with type 2 diabetes in Victoria, Australia. The economic evaluation was conducted from an Australian healthcare sector perspective with a lifetime horizon. Health-related quality of life (EQ-5D) and total healthcare costs were compared between the intervention and the usual care group within the trial period. The 'UKPDS Outcomes Model 2' was used to simulate post-trial lifetime costs, life expectancy and quality-adjusted life years (QALYs). RESULTS: No significant difference in health-related quality of life and costs was found between the two groups within the trial period. Professional-mode flash glucose monitoring yielded greater QALYs (0.03 [95% CI: 0.02, 0.04]) and a higher cost (A$3807 [95% CI: 3604, 4007]) compared with usual clinical care using a lifetime horizon under the trial-based monitoring frequency, considered not cost-effective (incremental cost-effectiveness ratio = A$120,228). The intervention becomes cost-effective if sensor price is reduced to lower than 50%, or monitoring frequency is decreased to once per year while maintaining the same treatment effect on HbA1c . CONCLUSIONS: Including professional-mode flash glucose monitoring every 3 months as part of a management plan for people with type 2 diabetes in general practice is not cost-effective, but could be if the sensor price or monitoring frequency can be reduced.

'For me, it didn't seem as drastic a step as being controlled by insulin': A qualitative investigation of expectations and experiences of non-insulin injectable therapy among adults with type 2 diabetes.

AIMS: This qualitative study aims to explore beliefs, attitudes and experiences of injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs) use and discontinuation, as well as attitudes to further injectable treatment intensification, among adults with type 2 diabetes (T2D). METHODS: Nineteen in-depth semi-structured interviews lasting (mean ± standard deviation) 45 ± 18 min were conducted, face-to-face (n = 14) or via telephone (n = 5). Transcripts were analysed using inductive template analyses. Eligible participants were English-speaking adults with T2D who had recently initiated (≤3 years) GLP-1RA treatment. RESULTS: Participants were aged 28-72 years, who predominantly lived in metropolitan areas (n = 15), and had an experience of daily (n = 11) and/or once-weekly (n = 13) GLP-1RA formulations. Six participants had discontinued treatment and seven had trialled two or more formulations. Expectations and experiences of GLP-1RA were related to the perceived: (1) symbolism and stigma of injectable diabetes treatment; (2) ease of injectable administration and device preferences; (3) treatment convenience and social impact; (4) treatment efficacy and benefits, and; (5) negative treatment side effects. Some participants reported increased receptiveness to insulin therapy following their GLP-1RA experience, others emphasised unique concerns about insulin beyond injectable administration. CONCLUSIONS: This study provides a novel understanding of expectations and experience of non-insulin injectables among Australian adults with T2D. Our data suggest expectations may be informed by attitudes to insulin therapy, while perceived treatment benefits (e.g. weight-related benefits, administration frequency) may motivate uptake and ongoing use despite concerns. Experience of GLP-1RA injections may impact receptiveness to future insulin use.

People with type 2 diabetes experiences and needs of emotional support in Australian general practice: A qualitative study.

Context: Diabetes distress is the negative emotional response to the burden of living with and managing diabetes. It is associated with sub-optimal glycemia and diabetes self-management, with up to 40% of people with type 2 diabetes experiencing diabetes distress. Australian guidelines specifically recommend using Patient Reported Outcome Measures such as Problem Areas In Diabetes (PAID) scale to assess diabetes distress and discuss sources of distress with people with diabetes. However, use of the PAID scale in Australian general practice is low. Objective: Explore the experiences of people with type 2 diabetes, their needs and expectations of emotional support in general practice, and barriers and facilitators to completing the PAID scale. Study Design: Qualitative study with semi-structured interviews conducted via Zoom or telephone. Guided by Richie's framework thematic analysis, following familiarisation with the data, an initial thematic framework was developed using inductive and deductive approach. Data were coded using the thematic framework. Setting: General practices in Victoria, Australia. Participants: Adults >18 years with type 2 diabetes who primarily attend general practice for diabetes care. Outcomes to be reported: Themes and subthemes related to experiences, needs and expectations of emotional support of people with type 2 diabetes attending general practice are reported. Results: Twelve adults with type 2 diabetes participated. Seven women and five men participated; age range from 27-79 years. Participants considered the pre-existing general practitioner (GP)-patient relationship important when exploring emotional health during diabetes care. Key themes identified that influenced experiences of care were: (1) biomedical focus of diabetes care; (2) the GP-patient relationship; (3) importance of communication. No participants recalled completing the PAID scale with their GP to assess emotional health. They believed that the PAID scale could promote an understanding from the GP about issues impacting their life beyond the biomedical aspects of diabetes. Conclusions: Our findings indicate people with type 2 diabetes have no experience of using the PAID scale during diabetes care but perceive the use of the PAID scale could improve communication with their GP due to pre-identification of emotional issues. The findings will be used to develop a tool to implement the PAID scale in general practices in Victoria, Australia.

Process mining-driven analysis of COVID-19's impact on vaccination patterns.

Process mining is a discipline sitting between data mining and process science, whose goal is to provide theoretical methods and software tools to analyse process execution data, known as event logs. Although process mining was originally conceived to facilitate business process management activities, research studies have shown the benefit of leveraging process mining in healthcare contexts. However, applying process mining tools to analyse healthcare process execution data is not straightforward. In this paper, we show a methodology to: i) prepare general practice healthcare process data for conducting a process mining analysis; ii) select and apply suitable process mining solutions for successfully executing the analysis; and iii) extract valuable insights from the obtained results, alongside leads for traditional data mining analysis. By doing so, we identified two major challenges when using process mining solutions for analysing healthcare process data, and highlighted benefits and limitations of the state-of-the-art process mining techniques when dealing with highly variable processes and large data-sets. While we provide solutions to the identified challenges, the overarching goal of this study was to detect differences between the patients' health services utilization pattern observed in 2020-during the COVID-19 pandemic and mandatory lock-downs -and the one observed in the prior four years, 2016 to 2019. By using a combination of process mining techniques and traditional data mining, we were able to demonstrate that vaccinations in Victoria did not drop drastically-as other interactions did. On the contrary, we observed a surge of influenza and pneumococcus vaccinations in 2020, as opposed to other research findings of similar studies conducted in different geographical areas.

Identifying primary care datasets and perspectives on their secondary use: a survey of Australian data users and custodians.

BACKGROUND: Most people receive most of their health care in in Australia in primary care, yet researchers and policymakers have limited access to resulting clinical data. Widening access to primary care data and linking it with hospital or other data can contribute to research informing policy and provision of services and care; however, limitations of primary care data and barriers to access curtail its use. The Australian Health Research Alliance (AHRA) is seeking to build capacity in data-driven healthcare improvement; this study formed part of its workplan. METHODS: The study aimed to build capacity for data driven healthcare improvement through identifying primary care datasets in Australia available for secondary use and understand data quality frameworks being applied to them, and factors affecting national capacity for secondary use of primary care data from the perspectives of data custodians and users. Purposive and snowball sampling were used to disseminate a questionnaire and respondents were invited to contribute additional information via semi-structured interviews. RESULTS: Sixty-two respondents collectively named 106 datasets from eclectic sources, indicating a broad conceptualisation of what a primary care dataset available for secondary use is. The datasets were generated from multiple clinical software systems, using different data extraction tools, resulting in non-standardised data structures. Use of non-standard data quality frameworks were described by two-thirds of data custodians. Building trust between citizens, clinicians, third party data custodians and data end-users was considered by many to be a key enabler to improve primary care data quality and efficiencies related to secondary use. Trust building qualities included meaningful stakeholder engagement, transparency, strong leadership, shared vision, robust data security and data privacy protection. Resources to improve capacity for primary care data access and use were sought for data collection tool improvements, workforce upskilling and education, incentivising data collection and making data access more affordable. CONCLUSIONS: The large number of identified Australian primary care related datasets suggests duplication of labour related to data collection, preparation and utilisation. Benefits of secondary use of primary care data were many, and strong national leadership is required to reach consensus on how to address limitations and barriers, for example accreditation of EMR clinical software systems and the adoption of agreed data and quality standards at all stages of the clinical and research data-use lifecycle. The study informed the workplan of AHRA's Transformational Data Collaboration to improve partner engagement and use of clinical data for research.

Validity of algorithms for identifying five chronic conditions in MedicineInsight, an Australian national general practice database.

BACKGROUND: MedicineInsight is a database containing de-identified electronic health records (EHRs) from over 700 Australian general practices. It is one of the largest and most widely used primary health care EHR databases in Australia. This study examined the validity of algorithms that use information from various fields in the MedicineInsight data to indicate whether patients have specific health conditions. This study examined the validity of MedicineInsight algorithms for five common chronic conditions: anxiety, asthma, depression, osteoporosis and type 2 diabetes. METHODS: Patients' disease status according to MedicineInsight algorithms was benchmarked against the recording of diagnoses in the original EHRs. Fifty general practices contributing data to MedicineInsight met the eligibility criteria regarding patient load and location. Five were randomly selected and four agreed to participate. Within each practice, 250 patients aged ≥ 40 years were randomly selected from the MedicineInsight database. Trained staff reviewed the original EHR for as many of the selected patients as possible within the time available for data collection in each practice. RESULTS: A total of 475 patients were included in the analysis. All the evaluated MedicineInsight algorithms had excellent specificity, positive predictive value, and negative predictive value (above 0.9) when benchmarked against the recording of diagnoses in the original EHR. The asthma and osteoporosis algorithms also had excellent sensitivity, while the algorithms for anxiety, depression and type 2 diabetes yielded sensitivities of 0.85, 0.89 and 0.89 respectively. CONCLUSIONS: The MedicineInsight algorithms for asthma and osteoporosis have excellent accuracy and the algorithms for anxiety, depression and type 2 diabetes have good accuracy. This study provides support for the use of these algorithms when using MedicineInsight data for primary health care quality improvement activities, research and health system policymaking and planning.

Assessing the suitability of general practice electronic health records for clinical prediction model development: a data quality assessment.

BACKGROUND: The use of general practice electronic health records (EHRs) for research purposes is in its infancy in Australia. Given these data were collected for clinical purposes, questions remain around data quality and whether these data are suitable for use in prediction model development. In this study we assess the quality of data recorded in 201,462 patient EHRs from 483 Australian general practices to determine its usefulness in the development of a clinical prediction model for total knee replacement (TKR) surgery in patients with osteoarthritis (OA). METHODS: Variables to be used in model development were assessed for completeness and plausibility. Accuracy for the outcome and competing risk were assessed through record level linkage with two gold standard national registries, Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and National Death Index (NDI). The validity of the EHR data was tested using participant characteristics from the 2014-15 Australian National Health Survey (NHS). RESULTS: There were substantial missing data for body mass index and weight gain between early adulthood and middle age. TKR and death were recorded with good accuracy, however, year of TKR, year of death and side of TKR were poorly recorded. Patient characteristics recorded in the EHR were comparable to participant characteristics from the NHS, except for OA medication and metastatic solid tumour. CONCLUSIONS: In this study, data relating to the outcome, competing risk and two predictors were unfit for prediction model development. This study highlights the need for more accurate and complete recording of patient data within EHRs if these data are to be used to develop clinical prediction models. Data linkage with other gold standard data sets/registries may in the meantime help overcome some of the current data quality challenges in general practice EHRs when developing prediction models.

Multimorbidity, mortality, and HbA1c in type 2 diabetes: A cohort study with UK and Taiwanese cohorts.

BACKGROUND: There is emerging interest in multimorbidity in type 2 diabetes (T2D), which can be either concordant (T2D related) or discordant (unrelated), as a way of understanding the burden of disease in T2D. Current diabetes guidelines acknowledge the complex nature of multimorbidity, the management of which should be based on the patient's individual clinical needs and comorbidities. However, although associations between multimorbidity, glycated haemoglobin (HbA1c), and mortality in people with T2D have been studied to some extent, significant gaps remain, particularly regarding different patterns of multimorbidity, including concordant and discordant conditions. This study explores associations between multimorbidity (total condition counts/concordant/discordant/different combinations of conditions), baseline HbA1c, and all-cause mortality in T2D. METHODS AND FINDINGS: We studied two longitudinal cohorts of people with T2D using the UK Biobank (n = 20,569) and the Taiwan National Diabetes Care Management Program (NDCMP) (n = 59,657). The number of conditions in addition to T2D was used to quantify total multimorbidity, concordant, and discordant counts, and the effects of different combinations of conditions were also studied. Outcomes of interest were baseline HbA1c and all-cause mortality. For the UK Biobank and Taiwan NDCMP, mean (SD) ages were 60.2 (6.8) years and 60.8 (11.3) years; 7,579 (36.8%) and 31,339 (52.5%) were female; body mass index (BMI) medians (IQR) were 30.8 (27.7, 34.8) kg/m2 and 25.6 (23.5, 28.7) kg/m2; and 2,197 (10.8%) and 9,423 (15.8) were current smokers, respectively. Increasing total and discordant multimorbidity counts were associated with lower HbA1c and increased mortality in both datasets. In Taiwan NDCMP, for those with four or more additional conditions compared with T2D only, the mean difference (95% CI) in HbA1c was -0.82% (-0.88, -0.76) p < 0.001. In UK Biobank, hazard ratios (HRs) (95% CI) for all-cause mortality in people with T2D and one, two, three, and four or more additional conditions compared with those without comorbidity were 1.20 (0.91-1.56) p < 0.001, 1.75 (1.35-2.27) p < 0.001, 2.17 (1.67-2.81) p < 0.001, and 3.14 (2.43-4.03) p < 0.001, respectively. Both concordant/discordant conditions were significantly associated with mortality; however, HRs were largest for concordant conditions. Those with four or more concordant conditions had >5 times the mortality (5.83 [4.28-7.93] p <0.001). HRs for NDCMP were similar to those from UK Biobank for all multimorbidity counts. For those with two conditions in addition to T2D, cardiovascular diseases featured in 18 of the top 20 combinations most highly associated with mortality in UK Biobank and 12 of the top combinations in the Taiwan NDCMP. In UK Biobank, a combination of coronary heart disease and heart failure in addition to T2D had the largest effect size on mortality, with a HR (95% CI) of 4.37 (3.59-5.32) p < 0.001, whereas in the Taiwan NDCMP, a combination of painful conditions and alcohol problems had the largest effect size on mortality, with an HR (95% CI) of 4.02 (3.08-5.23) p < 0.001. One limitation to note is that we were unable to model for changes in multimorbidity during our study period. CONCLUSIONS: Multimorbidity patterns associated with the highest mortality differed between UK Biobank (a population predominantly comprising people of European descent) and the Taiwan NDCMP, a predominantly ethnic Chinese population. Future research should explore the mechanisms underpinning the observed relationship between increasing multimorbidity count and reduced HbA1c alongside increased mortality in people with T2D and further examine the implications of different patterns of multimorbidity across different ethnic groups. Better understanding of these issues, especially effects of condition type, will enable more effective personalisation of care.

Utilising a Data Capture Tool to Populate a Cardiac Rehabilitation Registry: A Feasibility Study.

BACKGROUND: Clinical registries are effective for monitoring clinical practice, yet manual data collection can limit their implementation and sustainability. The objective of this study was to assess the feasibility of using a data capture tool to collect cardiac rehabilitation (CR) minimum variables from electronic hospital administration databases to populate a new CR registry in Australia. METHODS: Two CR facilities located in Melbourne, Australia participated, providing data on 42 variables including: patient socio-demographics, risk factors and co-morbidities, CR program information (e.g. number of CR sessions), process indicators (e.g. wait time) and patient outcomes (e.g. change in exercise capacity). A pre-programmed, automated data capture tool (GeneRic Health Network Information for the Enterprise [20]: https://www.grhanite.com/) (GRHANITE™) was installed at the sites to extract data available in an electronic format from hospital sites. Additionally, clinicians entered data on CR patients into a purpose-built web-based tool (Research Electronic Data Capture: https://www.project-redcap.org/) (REDCap). Formative evaluation including staff feedback was collected. RESULTS: The GRHANITE™ tool was successfully installed at the two CR sites and data from 176 patients (median age = 67 years, 76% male) were securely extracted between September-December 2017. Data pulled electronically from hospital databases was limited to seven of the 42 requested variables. This is due to CR sites only capturing basic patient information (e.g. socio-demographics, CR appointment bookings) in hospital administrative databases. The remaining clinical information required for the CR registry was collected in formats (e.g. paper-based, scanned or Excel spreadsheet) deemed unusable for electronic data capture. Manually entered data into the web-tool enabled data collection on all remaining variables. Compared to historical methods of data collection, CR staff reported that the REDCap tool reduced data entry time. CONCLUSIONS: The key benefits of a scalable, automated data capture tool like GRHANITE™ cannot be fully realised in settings with under-developed electronic health infrastructure. While this approach remains promising for creating and maintaining a registry that monitors the quality of CR provided to patients, further investment is required in the digital platforms underpinning this approach.

Clinical Decision Support Systems and Medico-Legal Liability in Recall and Treatment: A Fresh Examination.

Clinical decision support systems (CDSSs) provide a valuable tool for clinicians to aid in the care of patients with chronic disease. Various questions have emerged about their implications for the doctor's legal duty of care to their patients, in terms of recognition of risk, recall, testing and treatment. In this article, through an analysis of Australian legislation and international case law, we address these questions, considering the potential impact of CDSSs on doctors' liability in negligence. We conclude that the appropriate use of a well-designed CDSS should minimise, rather than heighten, doctor's potential liability. It should support optimal patient care without diminishing the capacity of the doctor to make individualised decisions about recall, testing and treatment for each patient. We foreshadow that in the future doctors in Australia may have a duty to use available well-established software systems in patient care.

Gathering data for decisions: best practice use of primary care electronic records for research.

In Australia, there is limited use of primary health care data for research and for data linkage between health care settings. This puts Australia behind many developed countries. In addition, without use of primary health care data for research, knowledge about patients' journeys through the health care system is limited. There is growing momentum to establish "big data" repositories of primary care clinical data to enable data linkage, primary care and population health research, and quality assurance activities. However, little research has been conducted on the general public's and practitioners' concerns about secondary use of electronic health records in Australia. International studies have identified barriers to use of general practice patient records for research. These include legal, technical, ethical, social and resource-related issues. Examples include concerns about privacy protection, data security, data custodians and the motives for collecting data, as well as a lack of incentives for general practitioners to share data. Addressing barriers may help define good practices for appropriate use of health data for research. Any model for general practice data sharing for research should be underpinned by transparency and a strong legal, ethical, governance and data security framework. Mechanisms to collect electronic medical records in ethical, secure and privacy-controlled ways are available. Before the potential benefits of health-related data research can be realised, Australians should be well informed of the risks and benefits so that the necessary social licence can be generated to support such endeavours.

Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study.

BACKGROUND: In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and TKA is overused. Empirical evidence and qualitative observations suggest that patients' willingness to accept nonsurgical interventions for knee OA is low. A qualitative investigation of why patients may feel that such interventions are of little value may be an important step toward increasing their use in the treatment of knee OA QUESTIONS/PURPOSES: This qualitative study was embedded in a larger study investigating patient-related factors (beliefs/attitudes toward knee OA and its treatment) and health-system related factors (access, referral pathways) known to influence patients' decisions to seek medical care. In this paper we focus on the patient-related factors with the aim of exploring why patients may feel that nonsurgical interventions are of little value in the treatment of knee OA. METHODS: A cross-sectional qualitative study was conducted in a single tertiary hospital in Australia. Patients with endstage knee OA on the waiting list for TKA were approached during their preadmission appointment and invited to participate in one-to-one interviews. As prescribed by the qualitative approach, data collection and data analysis were performed in parallel and recruitment continued until the authors agreed that the themes identified would not change through interviews with subsequent participants, at which point, recruitment stopped. Thirty-seven patients were approached and 27 participated. Participants were 48% female; mean age was 67 years. Participants' beliefs about knee OA and its treatment were identified in the interview transcripts. Beliefs were grouped into five belief dimensions: identity beliefs (what knee OA is), causal beliefs (what causes knee OA), consequence beliefs (what the consequences of knee OA are), timeline beliefs (how long knee OA lasts) and treatment beliefs (how knee OA can be controlled). RESULTS: All participants believed that their knee OA was "bone on bone" (identity beliefs) and most (> 14 participants) believed it was caused by "wear and tear" (causal beliefs). Most (> 14 participants) believed that loading the knee could further damage their "vulnerable" joint (consequence beliefs) and all believed that their pain would deteriorate over time (timeline beliefs). Many (>20 participants) believed that physiotherapy and exercise interventions would increase pain and could not replace lost knee cartilage. They preferred experimental and surgical treatments which they believed would replace lost cartilage and cure their knee pain (treatment beliefs). CONCLUSIONS: Common misconceptions about knee OA appear to influence patients' acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. Once the participants in this study had been "diagnosed" with "bone-on-bone" changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage. Future research involving larger, more representative samples are needed to understand how widespread these beliefs are and if/how they influence treatment decisions. In the meantime, clinicians seeking to encourage acceptance of nonsurgical interventions may consider exploring and targeting misconceptions that patients hold about the identity, causes, consequences, timeline, and treatment of knee OA. LEVEL OF EVIDENCE: Level II, prognostic study.

Prescribing of diabetes medications to people with type 2 diabetes and chronic kidney disease: a national cross-sectional study.

BACKGROUND: Previous studies in general practice and hospital settings have identified that prescribing of non-insulin diabetes medications may be sub-optimal in people with type 2 diabetes (T2D) and renal impairment. Since these publications, a number of new medications have become available for the management of T2D. Study aims were to, in a cohort of Australians with T2D and renal impairment attending general practice, (1) investigate whether the prescribing of non-insulin diabetes medications is consistent with dosing adjustments recommended within current Australian Diabetes Society (ADS) guidelines; and (2) identify patient socio-demographic and clinical factors associated with at least one prescription of a non-insulin diabetes medication inconsistent with current ADS guidelines for medication doses. METHODS: Cross-sectional study using data from the MedicineInsight general practice database managed by NPS MedicineWise. Patients with T2D who were aged 18 years and over, with an average eGFR< 60 ml/min/1.73m2 and at least one prescription of a non-insulin diabetes medication between 1st January 2015 and 30th June 2017 were included. Descriptive statistics were used to summarise patient characteristics and medication use. Marginal logistic regression models were used to estimate associations between sociodemographic and clinical factors and prescribing of ≥1non-insulin diabetes medicine not consistent with ADS guidelines. RESULTS: The majority of the 3505 patients included (90.4%) had an average eGFR of 30-59 ml/min/1.73m2. In terms of absolute numbers, metformin was the medication most frequently prescribed at a dose not consistent with current ADS guidelines for dosing in renal impairment (n = 1601 patients), followed by DPP4 inhibitors (n = 611) and sulphonylureas (n = 278). The drug classes with the highest proportion of prescriptions with dosage not consistent with ADS guidelines were SGLT2 inhibitors (83%), followed by biguanides (58%) and DPP4 inhibitors (46%). Higher HbA1c, longer known diabetes duration and diagnosis of retinopathy were associated with receiving ≥1prescription with a dosage not consistent with guidelines. CONCLUSIONS: Prescribing of non-insulin diabetes medications at doses inconsistent with current ADS guideline recommendations for dosing adjustments for people with renal impairment was common. Further research is needed to understand how general practitioners access, interpret and apply the ADS guidelines and the impact this may have on patient outcomes.

Socioeconomic status and time in glucose target range in people with type 2 diabetes: a baseline analysis of the GP-OSMOTIC study.

BACKGROUND: Optimal glycaemia, reflected by glycated haemoglobin (HbA1c) levels, is key in reducing type 2 diabetes (T2D) complications. However, most people with T2D have suboptimal recall and understanding of HbA1c. Continuous glucose monitoring (CGM) measures glucose levels every 5 to 15-min over days and may be more readily understood. Given that T2D is more common in lower socioeconomic settings, we aim to study relationships between socioeconomic status (SES) and percentage time in glucose target range (TIR) which is a key metric calculated from CGM. METHODS: Analysis of baseline data from the General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC) randomised controlled trial (October 2016 - November 2017) of 300 people with T2D from 25 Victorian General Practices. FreeStyle Libre Pro® sensor patch was used for this study. SES was defined by the Index of Relative Socio-economic Disadvantage (IRSD) and educational attainment. Univariable and multivariable mixed-effects linear regression analyses controlling for age, BMI, diet, exercise and study arm were performed. RESULTS: One hundred and sixty-seven (60.1%) participants were male, the mean (SD) participant age was 61.0 (9.7) years, and the mean (SD) duration of CGM use was 12.3 (2.5) days. The 10th IRSD decile (least disadvantaged) was associated with a 15% higher TIR vs. the 1st decile (most disadvantaged) (95% CI 5, 25; p = 0.003) and a 0.6% lower HbA1c (95% CI 0.1, 1; p = 0.03). There was no evidence of an association between educational attainment and TIR/HbA1c. CONCLUSION: Higher SES measured at an area level is associated with better achievement of glycaemic target using complementary measures of HbA1c and TIR in the GP-OSMOTIC cohort. Given that TIR may be more easily used in patient education and self-management support compared to HbA1c values, the social gradient identified in TIR provides an opportunity for clinicians and policy makers to address health inequities in T2D. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry Trial ACTRN12616001372471 , prospective, Date registered 4/10/2016.