Primary Care Visits in the USA and Australia 2000-2016.

BACKGROUND: There are major concerns about the sustainability of the US primary care (PC) system. OBJECTIVE: We use similar data from the USA and Australia on adult visits to primary care physicians to examine how primary care service delivery and content in the countries have changed since the year 2001. DESIGN/SETTING/PARTICIPANTS: Longitudinal analyses of nationally representative data collected in a similar manner on outpatient visits to PC in the USA (National Ambulatory Medical Care Survey, NAMCS) and Australia (Bettering the Evaluation and Care of Health, BEACH), 2001-2016. MAIN MEASURES: For each visit, we ascertained the problems/diagnoses managed; the length of the visit in minutes; what medications were recorded; whether counseling, advice, or education was provided; the rate of imaging and diagnostics tests; the laboratory tests ordered; and whether the visit resulted in a referral to another physician. KEY RESULTS: Between 2001 and 2016, there were 128,770 encounters with adult patients in NAMCS and 1,338,963 in BEACH. In the USA, the proportion of encounters with 3 or more problems managed increased from 28.7 to 54.8% whereas Australia started at a lower proportion (10.6%) and increased to just 14.1%. Visit times in the USA increased from 17.2 min in 2001 to 22.9 min in 2016 as compared to 14.4 min increasing to 15.2 in Australia. There were significantly more medications recorded over time in NAMCS than BEACH (2.02 in 2001 to 3.32 in 2016, USA, and 1.10 and 1.04, Australia), and US encounters resulted in imaging studies, lab tests, or referrals with relatively increasing frequency. CONCLUSION: Relative to Australia, PC visits in the USA increasingly entail more complexity with visits that have grown comparatively longer over time, with more problems addressed, and with more content.

Management of Whiplash Associated Disorders in Australian general practice.

BACKGROUND: Whiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments. METHODS: We analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters. Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines. RESULTS: Of 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8). CONCLUSIONS: GPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

Assessment and management of asthma and chronic obstructive pulmonary disease in Australian general practice.

BACKGROUND: Dispensing data suggest potential issues with the quality use of medicines for airways disease. OBJECTIVE: The objective of this article was to describe the management of asthma and chronic obstructive pulmonary disease (COPD) in general practice, and investigate the appropriateness of prescribing. METHODS: The method used for this study consisted of a national cross­sectional survey of 91 Australian general practitioners (GPs) participating in the Bettering the Evaluation and Care of Health (BEACH) program. RESULTS: Data were available for 2589 patients (288 asthma; 135 COPD). For the patients with asthma, GPs classified asthma as well controlled in 76.4%; 54.3% were prescribed inhaled corticosteroids (ICS), mostly (84.9%) as combination therapy, and mostly at moderate-high dose; only 26.3% had a written action plan. GPs classified COPD as mild for 42.9%. Most patients with COPD (60.9%) were prescribed combination ICS therapy and 36.7% were prescribed triple therapy. DISCUSSION: There were substantial differences between guideline-based and GP- recorded assessment and prescription for asthma and COPD. Further research is needed to improve care and optimise patient outcomes with scarce health resources.

Estimating non-billable time in Australian general practice.

OBJECTIVES: To quantify the time that general practitioners spend on patient care that is not claimable from Medicare (non-billable) and the monetary value of this work were it claimable, and to identify variables independently associated with non-billable time. DESIGN: Prospective, cross-sectional survey, April 2012 - March 2014. SETTING: Australian general practice; a substudy of the national Bettering the Evaluation and Care of Health (BEACH) program. PARTICIPANTS: 1935 randomly sampled GPs (77.4% participation rate) from across Australia provided filled questionnaires on 66 458 patient encounters. MAIN OUTCOME MEASURES: Non-billable time spent on patient care since patient's previous consultation; duration of and reasons for non-billable time; estimate of its monetary value were it claimable from Medicare; variables associated with non-billable time. RESULTS: 69.5% of GPs reported non-billable care outside patient visits; 8019 patient encounters (12.1%) were associated with an occasion of non-billable time. Mean time spent per occasion was 10.1 min (range, 1-240 min). Reasons for non-billable time included arranging tests and referrals, consulting specialists or allied health professionals, medication renewals, and advice and education, and encompassed all International Classification of Primary Care Version 2 chapters. The notional average annual value per GP of this work was $10 525.95 (level A rebate) to $23 008.05 (level B). Non-billable time was independently associated with female GPs, younger GPs (under 55 years), female patients, patients aged 65 years or more, and one or more chronic problems being managed at the recorded encounter. CONCLUSION: Most GPs spend a significant amount of unpaid time on patient care between consultations, an inherent problem of the fee-for-service system. This work should inform discussions of future funding models.

Consultations conducted in languages other than English in Australian general practice.

This study sought to determine the need for, and use of, professional interpreters in general practice. This is a sub-study of the Bettering the Evaluation and Care of Health (BEACH) program - a continuous, national, cross-sectional survey of Australian general practitioner (GP) activity. Data were provided by 206 randomly sampled GPs between December 2013 and March 2014. Of 6074 patients sampled, there were 986 (16.2%; 95% confidence interval [CI]: 13.2-19.3) who reported speaking a language other than English (LOTE) at home. Five per cent of all GP consultations involved communicating in a LOTE. Of these, 1% involved professional interpreters, 82.3% were conducted by multilingual GPs who spoke the patient's language, and 17.7% involved a family member or friend. GPs thought a professional interpreter would/may have improved the quality of 27.8% of these consultations. Our study suggests that GPs see the opportunity to improve the quality of LOTE consultations by using professional interpreters to replace family member/friend interpreters.

Management of chronic heart failure in general practice in Australia.

BACKGROUND: Chronic heart failure is a common clinical syndrome associated with high healthcare system use. OBJECTIVE: The aim of this study was to explore the management of chronic heart failure in Australian general practice. METHODS: Data from the Bettering the Evaluation and Care of Health program were used to determine the prevalence of chronic heart failure, use of natriuretic peptide testing, prescribing patterns, hospitalisation rates and referrals to community-based heart failure management programs in three study periods between 2010 and 2015. RESULTS: Data on 8989 patients from 308 general practitioners were analysed. Of these patients, 324 had chronic heart failure (prevalence 3.6%; 95% confidence interval [CI]: 3.1-4.2), 44% (95% CI: 34.5-53.6) of whom had been hospitalised for the condition. The mean number of prescribed heart failure medication agents was 2.26 (95% CI: 2.13-2.39) per patient. Discharge under community heart failure programs was not routine. DISCUSSION: Chronic heart failure is a significant burden in general practice. Strategies to optimise management and avoid hospitalisation, where possible, are needed.

The cost of freezing general practice.

OBJECTIVES: We aimed to assess the effect on general practitioners' income, and the amount of any copayment required for GPs to recoup lost income, of two policies (individually and combined) proposed by the Australian Government: a continued indexation freeze of Medicare schedule fees; and a $5 rebate reduction (now retracted). DESIGN, SETTING AND PARTICIPANTS: Analysis of data from the Bettering the Evaluation and Care of Health (BEACH) program, a continuous cross-sectional, national study of GP activity in Australia. We used data for April 2013 to March 2014 on direct encounters between patients and GPs for which at least one Medicare Benefits Schedule or Department of Veterans' Affairs general practice consultation item was claimable. MAIN OUTCOME MEASURES: The reduction in GP rebate income due to the policies and the size of any copayment needed to address this loss. RESULTS: The $5 rebate reduction would have reduced GPs' income by $219.53 per 100 consultations. This would have required a $4.81 copayment at all non-concessional patient consultations to recoup lost income. The freeze would cost GPs $384.32 in 2017-18 dollars per 100 consultations, requiring an $8.43 copayment per non-concessional patient consultation. Total estimated loss in rebate income to GPs would have been $603.85 in 2017-18 per 100 encounters, a reduction of 11.2%. The non-concessional consultation copayment required to cover lost income from both policies would have been $7-$8 in 2015-16, and $12-$15 by 2017-18. CONCLUSION: If both policies had gone ahead, GPs would have needed to charge substantially more than the suggested $5 copayment for consultations with non-concessional patients in order to maintain 2014-15 relative gross income. Even though the rebate reduction has been retracted, the freeze will have greater impact with time - nearly double the amount of the rebate reduction by 2017-18. For economic reasons, the freeze may still force GPs who currently bulk bill to charge copayments.

'The kids are alright' - Changes in GP consultations with children 2000-15.

The ageing of Australia's population has led to a focus on the health resources required for older patients, and there has been concern that this might be at the expense of children's healthcare. Over the past few decades the number of children in Australia has increased, but has steadily declined as a proportion of the population. This has paralleled an increase in the absolute number of general practitioner (GP) encounters with children aged <15 years, but a decline in the percentage of GP workload from 14.3% in 2000-01 to 11.2% in 2013-14. There are disparities in the use of general practice services by age, with children making up a greater proportion of the population (19.3%) than of GP visits (13.0%), while people aged 65 years and older accounted for 13.0% of the population and 26.5% of visits in 2006. It is unclear whether the decline in the proportion of GP workload accounted for by children reflects a change in the way children use these general practice services, or a redistribution based on the ageing of the patient population. Over time, there have been marked changes in the types of problems managed in children. From the 1990s to 2001, Australia's children became well vaccinated and decreasingly likely to have 'traditional' childhood illnesses (notably infections). More recently, there has been significant growth in the management of child mental health problems in general practice, although mental health problems account for a small proportion of childhood problems managed. We examined children's use of general practice services and the problems managed in 2000-03 and 2012-15 to determine whether their service use has been influenced by the demands associated with the management of older Australians, and whether trends in problems managed identified in early studies have continued.

Travel advice and vaccination.

Over the decade to June 2014, the number of annual short-term resident departures from Australia more than doubled, from 3.9 million to 8.9 million per year. A large number of these journeys involved destinations with known risk of exposure to vector-borne and enteric diseases. Many of these disease risks are preventable if travellers seek advice about the areas they choose to visit, and are vaccinated in the appropriate time frame before their departure. Vaccination is an essential component of national control of travel-associated infectious diseases. General practitioners (GPs) are well-placed to inform patients about potential disease risks in their intended travel regions and to vaccinate patients before their departure.

Management of childhood asthma in general practice.

BACKGROUND: Inhaled corticosteroids (ICS) are recommended for children with moderate or severe persistent asthma. The aims of this paper were to determine changes in childhood asthma management rates between 2004-14, and to examine current medication use and level of control in children attending general practice. METHODS: National BEACH data were used to investigate childhood (<15 years) asthma management rate. Prevalence, medication use and asthma control (Global Initiative for Asthma guidelines) were recorded for a subset of children. RESULTS: The management rate did not change over time. Prevalence was 13.7%. ICS were taken by 42.8% of children. Asthma was well controlled for 51.8%, partly controlled for 30.4% and uncontrolled for 17.9% of children. This study highlights the need to monitor appropriate medication use, particularly ICS/long-acting ß-agonist use, for asthma control in children.

Testing for gluten sensitivity.

There has been both medical and lay interest in the association of gluten with gastrointestinal conditions.

Prevalence, causes, severity, impact, and management of chronic pain in Australian general practice patients.

OBJECTIVE: To determine the prevalence of chronic pain, its causes, severity, management, impact on sleep, mood and activity levels, and general practitioner (GP) and patient satisfaction with pain management. DESIGN: A subset of 197 GPs and 5,793 patients from the BEACH program, a continuous, national cross-sectional survey of Australian general practice. RESULTS: The prevalence of chronic pain was 19.2% (95% confidence interval: 17.4-21.0) (N = 1,113). The most commonly reported causal conditions were osteoarthritis (48.1%) and back problems (29.4%). For pain severity (using Von Korff's pain grades), 25.2% were at Grade I (lowest); 37.1% were at Grade II; 28.3% at Grade III; and 9.4% at Grade IV (highest). Medication was used for pain management by 86.1% of patients, and one third also used nonpharmacological managements. One third of patients were taking opioids, most commonly those at the highest pain severity grades. On "Live Better with Pain Log" scale, the impact of pain was similar across activity (mean = 4.0), sleep (mean = 4.8), and mood (mean = 4.8). On a scale of 1 (highest) to 5 (lowest), GPs' satisfaction (mean = 2.5) was highly correlated (r = 0.7) with patients' satisfaction (mean = 2.6) with pain management. CONCLUSIONS: Chronic pain impairs patient quality of life, and is a public health burden. This study provides a national overview of the prevalence, causes, severity, management and impact of chronic pain in Australian general practice patients, and the parity between GP and patient satisfaction with pain management.

Suicide-related contacts--experience in general practice.

We examined the rate of suicide-related contacts (SRCs) in general practice between April 1998 and March 2013. We defined an SRC as a general practitioner (GP)-patient encounter where suicide ideation or attempt (International Classification of Primary Care 2nd edn, code P77) was recorded as either a problem under management or a patient's reason for encounter (RFE). Between 1998 and 2013, 14 793 GPs participated in BEACH (Bettering the Evaluation and Care of Health) and recorded details of 1 479 300 encounters with patients. There were 406 SRC encounters. Most of these were identified through the patient's RFE and not by the GP's label of a problem managed at the encounter. Depression was the most frequent problem managed at encounters where suicidal ideation or attempt was a patient's RFE. This suggests that suicide is often subsumed in the 'depression' label and that we are only identifying a subset of encounters with patients who are dealing with suicidal thoughts.

Gallbladder disease.

Gallbladder disease (GBD) is a common cause of upper abdominal pain. Prevalence of GBD increases with age, and is more common in women than men. United States population prevalence estimates indicate that 17% of women and 8% of men have GBD. Although common, it is often asymptomatic. We analysed data collected in the BEACH (Bettering the Evaluation and Care of Health) program from January 2010 to December 2012 to describe general practitioners' management of GBD when it is an 'active' clinical problem.

Premature ejaculation.

International studies suggest that premature ejaculation (PE) is the most common type of male sexual dysfunction, affecting 14-30% of males aged 18 years and over. The personal nature of PE, and the hesitancy of both patients and clinicians to raise the subject, means that only a small proportion of those affected seek or receive professional help.

Gestational diabetes.

Several studies have described an increasing prevalence of gestational diabetes mellitus (GDM), in line with the known increased prevalence of Type 2 diabetes. The risk of GDM is greater for pregnant women from selected ethnic groups (such as Indigenous, Asian and Indian) and for older pregnant women.

Self-monitoring blood glucose--non-insulin-treated type 2 diabetes in Australian general practice.

BACKGROUND: Benefits of self-monitoring blood glucose (SMBG) in non-insulin-treated type 2 diabetes (T2D) are questionable. We investigated proportions of general practitioner (GP) patients who self-monitor, and associations between SMBG, glycosylated haemoglobin (HbA1c) and body mass index (BMI). METHODS: Sub-studies of the Bettering the Evaluation and Care of Health (BEACH) program, involving 5 730 patients from 194 GPs. Outcomes Type 2 diabetes prevalence; HbA1c; BMI; blood glucose (BG) monitoring routine. RESULTS: Prevalence of non-insulin-treated T2D was 6.7%. Mean HbA1c level was 7.1%. Almost half (47.5%) of T2D patients were obese compared with 26.7% of patients at all BEACH encounters in 2011-2012. Of 344 non-insulin-treated T2D patients, 79.4% self-monitored fasting BG and 69.7% of 314 self-monitored post-prandial BG. For both groups, mean HbA1c was significantly higher for those who tested daily than for those who never tested. CONCLUSION: Patients with non-insulin-treated T2D who test BG daily may be those struggling for control. For others, benefits seem minimal for the proportion utilising self-monitoring.

Orders for thyroid function tests - changes over 10 years.

In the BEACH (Bettering the Evaluation and Care of Health) program, between 2001-02 and 2010-11, general practice orders for thyroid function tests increased by 51%.

Opioid prescribing in general practice: an Australian cross-sectional survey.

BACKGROUND: Prescribed opioid doses > 100 mg oral morphine equivalent (OME) and/or co-prescribing of sedating psychoactive medications increase the risk of unintentional fatal overdose. We describe general practice encounters where opioids are prescribed and examine high-risk opioid prescribing. METHODS: The 2006-2016 BEACH study data, a rolling national cross-sectional survey of randomly selected GPs, was analysed. RESULTS: Opioid prescribing increased 2006-2007 to 2015-2016, however, this plateaued across the latter half-decade. From 2012-2016 3,897 GPs recorded 389,700 encounters and at least one opioid was prescribed at 5.2%. Opioid encounters more likely involved males, those 45-64 years, concession card holders and the socioeconomically disadvantaged. GPs more likely to prescribe opioids were 55 years or older, male, Australian graduates, and in regional and remote areas. The most common problems managed with opioids involved chronic non-cancer pain. One-in-ten opioid prescribing episodes involved high-risk doses and 11% involved co-prescription of sedating psychoactive medications. Over one-third of GPs provided other (non-pharmacological) interventions at encounters with opioid prescriptions. CONCLUSIONS: Only 5% of GP encounters involved an opioid prescription. Of concern, were: prescribing for chronic non-cancer pain, potentially high-risk opioid encounters where > 100 OME daily dose was prescribed, and/or there was co-prescription of sedating psychoactive medication. However, approximately one-in-three opioid prescribing encounters involved non-pharmacological interventions.