Effectiveness of patient reminders on influenza vaccination coverage among adults with chronic conditions: A feasibility study in Australian general practices.

BACKGROUND: Influenza vaccination is recommended for Australians 18+ years old with medical risk factors, but coverage is suboptimal. We aimed to examine whether automatic, opportunistic patient reminders (SMS and/or printed) before appointments with a general practitioner increased influenza vaccination uptake. METHODS: This clustered non-randomised feasibility study in Australian general practice included patients aged 18-64 years with at least one medical risk factor attending participating practices between May and September 2021. Software installed at intervention practices identified unvaccinated eligible patients when they booked an appointment, sent vaccination reminders (SMS on booking and 1 h before appointments), and printed automatic reminders on arrival. Control practices provided usual care. Clustered analyses adjusted for sociodemographic differences among practices were performed using logistic regression. RESULTS: A total of 12,786 at-risk adults attended 16 intervention practices (received reminders = 4066; 'internal control' receiving usual care = 8720), and 5082 individuals attended eight control practices. Baseline influenza vaccination uptake (2020) was similar in intervention and control practices (∼34%). After the intervention, uptake was similar in all groups (control practices = 29.3%; internal control = 30.0%; intervention = 31.6% (p-value = 0.203). However, SMS 1 h before appointments increased vaccination coverage (39.3%, adjusted OR = 1.65; 95%CI 1.20;2.27; number necessary to treat = 13), especially when combined with other reminder forms. That effect was more evident among adults with chronic respiratory, rheumatologic, or inflammatory bowel disease. CONCLUSION: These findings indicate that automated SMS reminders delivered at proximate times to appointments are a low-cost strategy to increase influenza vaccination among adults at higher risk of severe disease attending Australian general practices.

Measuring the impact of steroid therapy on health-related quality of life in patients with rheumatic diseases: international development of a glucocorticoid treatment-specific patient-reported outcome measure.

OBJECTIVES: Glucocorticoids (GCs) ('steroids') are used to treat rheumatic diseases but adverse effects are common. We aimed to explore the impact of GC therapy on health-related quality of life (HRQoL), to inform the development of a treatment-specific patient-reported outcome measure (PROM) for use in clinical trials and practice. METHODS: Semi-structured qualitative interviews were conducted with patients from the UK, USA and Australia, treated for a rheumatic condition with GCs in the last 2 years. Purposive sampling was used to select participants with a range of demographic and disease features. An initial conceptual framework informed interview prompts and cues. Interviews elicited GC-related physical and psychological symptoms and salient aspects of HRQoL in relation to GC therapy. Interview data were analysed inductively to develop initial individual themes and domains. Candidate questionnaire items were developed and refined. RESULTS: Sixty semi-structured qualitative interviews were conducted (UK n = 34, USA n = 10, Australia n = 16). The mean age was 58 years; 39/60 were female; and 18 rheumatic diseases were represented. Some 126 individual themes were identified and organized into six domains: physical symptoms; psychological symptoms; psychological impact of steroids; impact of steroids on participation; impact of steroids on relationships; and benefits of steroids. Candidate questionnaire items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews and linguistic translatability assessment, informing a draft questionnaire. CONCLUSION: We describe an international qualitative study to develop candidate items for a treatment-specific PROM for patients with rheumatic diseases. A future survey will enable the validation of a final version of the PROM.

Establishing a clinical ethics support service: lessons from the first 18 months of a new Australian service - a case study.

BACKGROUND: Although the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established service, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting. METHODS: HOW THE STUDY WAS PERFORMED AND STATISTICAL TESTS USED: A qualitative case study approach was utilised. The study gathered and analysed data using observations of service committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies. RESULTS: THE MAIN FINDINGS: An overarching theme identified in the data was a strong commitment to supporting clinicians facing difficult patient care decisions and navigating difficult discussions with patients and families. Another key theme was the role of the new clinical ethics support service in providing clinicians with a pathway to raise system-wide issues with the organisation Executive. While there was strong clinical engagement, consumer and community participation remained a challenge, as did unresolved governance issues and a need for clearer policy relationship between the service and the organisation. Considering these themes in relation to the national capacity building resources, the study identifies three areas likely to require ongoing development and negotiation. These are: the role of the clinical ethics support service as a link between the workforce and the Executive; the incorporation of consumers and patients; and ethical reasoning. To improve the effectiveness of the service, it is necessary to increase clarity on the service's role at the governance and policy level, as well as develop strategies for engaging consumers, patients and families. Finally, the capacity of the service to reflect on complex cases may be enhanced through explicit discussions of various different ethical frameworks and ways of deliberating.

Isolation, marginalisation and disempowerment - understanding how interactions with health providers can influence smoking cessation in pregnancy.

BACKGROUND: Maternal smoking during pregnancy can lead to serious adverse health outcomes for both women and their infants. While smoking in pregnancy has declined over time, it remains consistently higher in women with lower socioeconomic circumstances. Furthermore, fewer women in this group will successfully quit during pregnancy. AIM: This study explores the barriers to smoking cessation experienced by socially disadvantaged pregnant women and investigates how interactions with health providers can influence their smoking cessation journey. METHODS: Women (either pregnant or birthed in the previous 10 years, who smoked or quit smoking in pregnancy) were recruited from a metropolitan public hospital antenatal clinic in South Australia and community organisations in surrounding suburbs. Seventeen women participated in qualitative semi-structured small focus groups or interviews. The focus groups and interviews were recorded, transcribed and thematically analysed. FINDINGS: Four interconnected themes were identified: 1) smoking embedded in women's challenging lives and pregnancies, 2) cyclic isolation and marginalisation, 3) feeling disempowered, and 4) autonomy and self-determination. Themes 3 and 4 are characterised as being two sides of a single coin in that they coexist simultaneously and are inseparable. A key finding is a strong unanimous desire for smoking cessation in pregnancy but women felt they did not have the necessary support from health providers or confidence and self-efficacy to be successful. CONCLUSION: Women would like improvements to antenatal care that increase health practitioners' understanding of the social and contextual healthcare barriers faced by women who smoke in pregnancy. They seek improved interventions from health providers to make informed choices about smoking cessation and would like women-centred care. Women feel that with greater support, more options for cessation strategies and consistency and encouragement from health providers they could be more successful at antenatal smoking cessation. If such changes were made, then South Australian practice could align more with best practice international guidelines for addressing smoking cessation in pregnancy, and potentially improve outcomes for women and their children.

Patient perceptions of health-related quality of life in giant cell arteritis: international development of a disease-specific patient-reported outcome measure.

OBJECTIVES: GCA is a large vessel vasculitis (LVV) presenting with headache, jaw claudication, musculoskeletal and visual involvement. Current treatment is glucocorticoids and anti-IL-6 tocilizumab in refractory disease. The objective of this study was to explore the impact of GCA and its treatment on people's health-related quality of life (HRQoL), to inform the development of a disease-specific patient-reported outcome measure (PROM) for use in clinical trials and practice. METHODS: Participants from the UK and Australia, with biopsy- or imaging-confirmed GCA, were interviewed to identify salient aspects of HRQoL in relation to GCA and its treatment. Purposive sampling included a range of demographic and disease features (cranial, LVV-GCA and visual involvement). Inductive analysis identified individual themes of importance, then domains. Candidate questionnaire items were developed from the individual themes, refined by piloting, cognitive interviews and a linguistic translatability assessment. RESULTS: Thirty-six interviews were conducted to saturation with participants with GCA from the UK (25) and Australia (11). Mean age was 74 years, 23 (63.9%) were female, 13 (36.1%) had visual loss and 5 (13.9%) had LVV-GCA. Thirty-nine individual themes within five domains were identified: physical symptoms; activity of daily living and function; participation; psychological impact; and impact on sense of self and perception of health. Sixty-nine candidate items were developed from individual themes; piloting and refinement resulted in a 40-item draft questionnaire. CONCLUSION: This international qualitative study underpins the development of candidate items for a disease-specific PROM for GCA. The draft questionnaire is now ready for psychometric testing.

Patient satisfaction and acceptability with telehealth at specialist medical outpatient clinics during the COVID-19 pandemic in Australia.

BACKGROUND: Outpatient clinics were shifted rapidly to telehealth in Australia during the Coronavirus disease 19 (COVID-19) pandemic, drastically altering patient care and experience. AIMS: To investigate patient satisfaction and acceptability of telehealth consultations during the COVID-19 pandemic. METHODS: Prospective observation study conducted in two hospital rheumatology outpatient departments (OPD) undertaking telehealth consultations during COVID-19. A modified version of a validated telehealth evaluation survey was posted to all patients attending the telehealth OPD rheumatology clinics, including balanced 5-point Likert scales and free-text responses. Cluster analysis was applied to the Likert-scale questions, alongside thematic analysis of free-text responses. RESULTS: There were 128 respondents (29% response rate), of which 69.5% were women and the majority (87.5%) was aged 50 years or older. All telehealth consultations were conducted by telephone. Nearly one-fifth of patients indicated consistent dissatisfaction with telehealth across the range of questions. These patients were older, reported lower educational qualifications and lower health literacy scores and lacked access to the Internet. While many patients found this mode of consultation to be convenient, patients expressed concerns regarding absence of physical examination. A recurrent theme was a desire for a mixed-model clinic in the future, with flexibility of having both telehealth and face-to-face consultations. CONCLUSIONS: This study offers unique insights into patients' experiences with telehealth, which until the current global pandemic, has been an uncommon mode of consultation delivery in urban areas. This study suggests when defining the place of telehealth in future healthcare delivery, patient perspective and careful patient selection will be key. Disease progression, language and cognitive ability, health literacy, technology access and patient and clinician preference are important considerations when deciding how effectively to embed and integrate telehealth into consultations.

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

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

Primary care management of chronic insomnia: a qualitative analysis of the attitudes and experiences of Australian general practitioners.

BACKGROUND: Chronic insomnia is a highly prevalent disorder, with ten to thirty percent of Australian adults reporting chronic difficulties falling asleep and/or staying asleep such that it causes significant daytime impairment. Current Australian general practice guidelines recommend cognitive behavioural therapy for insomnia (CBTi) as first line treatment for insomnia, however research suggests that most general practice consultations for insomnia result in a prescription for hypnotic or sedative medicines. Although the first point of contact for patients experiencing symptoms of insomnia is often general practice, little is known about the current role, experiences and capacity of Australian general practitioners to manage insomnia. This study aimed to address that gap by exploring the attitudes and opinions of general practitioners regarding insomnia management, to inform the development and implementation of new models of best practice insomnia care within general practice. METHODS: A descriptive, pragmatic qualitative study. Purposive sampling was used to recruit practising Australian general practitioners, varying in age, years of experience and geographic location. Semi-structured interviews were conducted, and data analysed using thematic analysis.  RESULTS: Twenty-eight general practitioners participated in the study. Three major themes were identified: 1) Responsibility for insomnia care; 2) Complexities in managing insomnia; and 3) Navigating treatment pathways. Whilst general practitioners readily accepted responsibility for the management of insomnia, provision of care was often demanding and difficult within the funding and time constraints of general practice. Patients presenting with comorbid mental health conditions and insomnia, and decision-making regarding long-term use of benzodiazepines presented challenges for general practitioners. Whilst general practitioners confidently provided sleep hygiene education to patients, their knowledge and experience of CBTi, and access and understanding of specialised referral pathways for insomnia was limited.  CONCLUSIONS: General practitioners report that whilst assessing and managing insomnia can be demanding, it is an integral part of general practice. Insomnia presents complexities for general practitioners. Greater clarity about funding options, targeted education about effective insomnia treatments, and referral pathways to specialist services, such as benzodiazepine withdrawal support and psychologists, would benefit insomnia management within general practice.

Multimorbidity, health-related quality of life and health service use among individuals with mental health problems: Urban-rural differences in South Australia.

OBJECTIVE: To investigate urban-rural differences in the relationship between the coexistence of multiple physical health conditions, health-related quality of life and health service use among individuals with mental health problems. DESIGN: Cross-sectional. SETTING: Population-based. PARTICIPANTS: Random sample of 2977 South Australians aged 15+ years. Analyses restricted to 535 individuals self-reporting a "current" mental health problem (anxiety, depression, another mental condition). EXPOSURE: Number of physical health conditions (none, 1-2, 3+ conditions) based on a list of 16 self-reported chronic diseases. MAIN OUTCOME MEASURES: Physical and mental health-related quality of life, frequently visited a GP (3+ times), visited a mental health specialist, visited an emergency department, was hospitalised in the last 3 months. RESULTS: The mean age of the participants was 57.3 ± 13.9 years (51.9% females) with 10.6% of them living in inner regional and 14.9% in outer/remote locations. Mental health problems had similar prevalence in major cities (15.4%; 95% confidence intervals [CI]: 13.5-17.4), inner regional (19.3%; 95% CI: 14.8-24.7) and outer/remote areas (16.8%; 95% CI: 14.4-17.7). The remoteness of residence did not affect the relationship between the number of physical health conditions with health-related quality of life or visits to the emergency department/hospitalisations. Individuals without a physical health condition living in major cities were five times more likely to have frequently visited a GP than their counterparts in outer/remote South Australia (35% and 7%, respectively), but these differences were less marked among those with multiple co-morbidities. CONCLUSION: The coexistence of multiple physical health conditions among patients with a mental health problem is associated with less urban-rural disparities in terms of visiting a GP.

Epidemiology of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis among 1.5 million patients in Australian general practice: NPS MedicineWise MedicineInsight dataset.

BACKGROUND: Previous estimates for the prevalence of musculoskeletal conditions (MSK) and chronic pain in Australia have been based on self-report. We aimed to determine the prevalence and distribution of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis and current consultations for chronic pain among adults attending Australian general practice, and describe their distribution according to sociodemographic characteristics and presence of co-morbidities. METHODS: We investigated 1,501,267 active adult patients (57.6% females; 22.5% ≥65y) evaluated between 2013 and 2016 and included in the MedicineInsight database (a National Prescribing Service MedicineWise program), a large general practice data program that extracts longitudinal de-identified electronic medical record data from 'active' patients in over 550 practices. Three main groups of outcomes were investigated: 1) "prevalence" of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies, and/or rheumatoid arthritis between 2000 and 2016; 2) "current" diagnosis/encounter for the same conditions occurring between 2013 and 2016, and; 3) "current" consultations for chronic pain of any type occurring between 2013 and 2016. RESULTS: The combined "prevalence" of the investigated MSK (diagnosis between 2000 and 2016) among adults attending Australian general practice was 16.8% (95%CI 15.9;17.7) with 21.3% (95%CI 20.2;22.4) of the sample consulting for chronic pain between 2013 and 2016. The investigated MSK with the highest "prevalence" were arthritis (9.5%) and chronic back pain (6.7%). Patients with some of these MSK attended general practices more frequently than those without these conditions (median 2.0 and 1.0 contacts/year, respectively). The "prevalence" of the investigated MSK and "current" consultations for chronic pain increased with age, especially in women, but chronic pain remained stable at 22% for males aged > 40 years. The investigated MSK and chronic pain were more frequent among those in lower socioeconomic groups, veterans, Aboriginal and Torrent Strait Islanders, current and ex-smokers, and patients with chronic obstructive pulmonary disease or heart failure. CONCLUSIONS: The investigated MSK are more frequent among lower socioeconomic groups and the elderly. Based on information collected from adults attending Australian general practices, MedicineInsight provided similar estimates to those obtained from population-based studies, with the advantage of being based on medical diagnosis and including a national sample.

A population analysis of self-management and health-related quality of life for chronic musculoskeletal conditions.

BACKGROUND: There is growing policy emphasis on self-management as an essential component of musculoskeletal chronic care models. Underpinning this drive is the assumption that with correct 'informational' framing people will better manage their condition's progression and thereby maintain quality of life. OBJECTIVE: To assess associations between self-management behaviours and health-related quality of life for people with chronic musculoskeletal conditions. DESIGN: Using survey data from health census and follow-up structured telephone interviews, linear regression (cumulatively adjusted for potential confounders) and logistic regression examined associations between use of specific self-management behaviours and quality of life. SETTING AND PARTICIPANTS: A total of 885 respondents (2012) who indicated still having a musculoskeletal condition reported in a 2010 health census (Port Lincoln, South Australia). VARIABLES: Specific self-management activities, age, sex, education, marital status, smoking, comorbidities and pain. OUTCOME MEASURE: EQ-5D-5L. RESULTS: Exercise (63%) and diet (19%) were the most commonly reported self-management activities used to manage musculoskeletal conditions. About 24% reported not using any specific self-management activities. Involvement in self-management showed no association with quality of life, with and without adjustment for confounders. Diet had a negative association with quality of life as did use of formal support (self-management course or community group support). DISCUSSION: Taking a real-world perspective, these findings raise important questions about how people currently engage with self-management activities and the kinds of outcomes that can be expected from undertaking these activities. The timing of people's uptake of self-management within the musculoskeletal disease continuum is an issue requiring further attention in both research and practice.

Unconnected and out-of-sight: identifying health care non-users with unmet needs.

BACKGROUND: While current debates on how to deliver sustainable health care recognise socio-economic dimensions to health service use, attention has focussed on how to reduce demand for services. However, the measures of demand may not account for a subgroup of the population who to date have remained out of sight because they do not access health services. This study aimed to describe the characteristics of individuals who self-reported having fair or poor health but did not use health services. METHODS: Data from the 2010 LINKIN health census survey (n = 7895) and the 2013 HILDA National Panel Survey (n = 13,609) were analysed focussing on the population who self-reported their overall health status as fair or poor. Simple and multivariable logistic regression modelling examined characteristics associated with a lack of health services use. The outcome measure of interest was no health service use in the previous 12 months and co-variables included demographic and socioeconomic indicators, health-related quality of life, having no health condition and health risk factors. RESULTS: Overall 21% of LINKIN respondents reported their overall health as fair or poor compared to 18% in the HILDA dataset. In LINKIN, 4.4% of those reporting fair or poor health, reported not using any health service provider in the past 12 months. Similarly, 4.5% of HILDA respondents were non-users. When adjusted for multiple co-variables, unemployment (aOR 3.24, 95% CI 1.28-8.17), educational level at Year 10 or below (aOR 1.94, 95% CI 1.02-3.70) and smoking (aOR 2.67, 95% CI 1.38-5.17) were significantly associated with non-use for the LINKIN data, as did lack of health conditions (aOR 0.18, 95% CI 0.08-0.41). The HILDA regression analyses indicated the same directions of association between equivalent variables and lack of health service use, with the exception of educational level. CONCLUSIONS: In line with recent assertions on real denominators in health need, this study describes those people rarely included in the population at risk and the potential for systematic bias towards the overestimation of the effectiveness of interventions. This study informs current policy debates and planning, including how we connect with hard-to-reach populations and how this sub-group might be more appropriately included when measuring effectiveness of health policies and programs.

Take Charge of Pain: evaluating a community-targeted self-management education program for people with musculoskeletal pain.

Issue addressed Musculoskeletal conditions are highly prevalent, affecting 28% of the Australian population. Given the persistent nature of many musculoskeletal conditions self-management is recognised as an important aspect of effective disease management. However, participant recruitment and retention for formal self-management programs is a challenge. Methods Arthritis SA (Arthritis Foundation of South Australia, a non-profit community health organisation) redesigned a shorter, community-orientated self-management education program delivered by health professionals. The program utilises aspects of the Stanford model of chronic disease self-management and motivational interviewing as well as principles of adult learning to create an effective learning environment. The program aims to guide participants to learn and practise a range of pain management strategies that are known to be effective in improving quality of life. This study used a pre- and post-test (at 6 weeks) design to determine whether this program achieved benefits in self-reported health outcomes. Outcomes that were measured included pain, fatigue, health distress, self-efficacy and communication. Results A response rate of 47% (n=102) was achieved and small but statistically significant improvements in mean [s.d.] pain scores (6.1 [2.3] to 5.4 [2.4], P=0.001), health distress (2.3 [1.3] to 2.0 [1.3], P=0.002) and self-efficacy (6.2 [2.1] to 6.8 [2.2], P=0.002) were found. Conclusion Community-based participants of this shorter, focused program recorded small but significant improvements in self-reported pain, health distress and self-efficacy. For those who completed the current program, Arthritis SA is currently exploring the potential of developing a booster session to promote sustainable positive health outcomes. So what? Supporting self-management through education is recognised as important but also as a key challenge for effective management of musculoskeletal conditions. Using a pre-post evaluation design, this study demonstrated effectiveness (short-term improvements for self-reported pain, health distress and self-efficacy) for a redesigned and shortened community-targeted program focusing on musculoskeletal pain.

Is the Counterweight Program a feasible and acceptable option for structured weight management delivered by practice nurses in Australia? A mixed-methods study.

Nurse-led weight management programs, like the Counterweight Program in the United Kingdom, may offer a way for Australian general practices to provide weight management support to adults who are overweight or obese. During Counterweight, nurses provide patients with six fortnightly education sessions and three follow-up sessions to support weight maintenance. This study examined the feasibility, acceptability and perceived value of the Counterweight Program in the Australian primary care setting using a mixed-methods approach. Six practice nurses, from three general practices, were trained and subsidised to deliver the program. Of the 65 patients enrolled, 75% (n=49) completed the six education sessions. General practitioners and practice nurses reported that the training and resource materials were useful, the program fitted into general practices with minimal disruption and the additional workload was manageable. Patients reported that the program created a sense of accountability and provided a safe space to learn about weight management. Overall, Counterweight was perceived as feasible, acceptable and valuable by Australian practice staff and patients. The key challenge for future implementation will be identifying adequate and sustainable funding. An application to publically fund Counterweight under the Medicare Benefits Schedule would require stronger evidence of effectiveness and cost-effectiveness in Australia.

Translating a health service intervention into a rural setting: lessons learned.

BACKGROUND: Limited research exists on the process of applying knowledge translation (KT) methodology to a rural-based population health intervention. METHODS: This study reports on the implementation and translational stages of a previously described Co-creating KT (Co-KT) framework in the rural town of Port Lincoln, South Australia (population: 14,000). The Co-KT framework involves five steps: (i) collecting local data; (ii) building stakeholder relationships; (iii) designing an evidence-based intervention incorporating local knowledge; (iv) implementation and evaluation of the intervention; and (v) translating the research into policy and practice. Barriers and enablers to the overall Co-KT implementation process were identified. Our intervention focused on musculoskeletal (MSK) conditions. RESULTS: Although the Co-KT framework was valuable in engaging with the community, translating the final intervention into daily clinical practice was prevented by a lack of an accessible policy or financial framework to anchor the appropriate intervention, a lack of continued engagement with stakeholders, access problems to general practitioners (GPs) and Allied Health Professionals; and the paucity of referrals from GPs to Allied Health Professionals. Consequently, while many aspects of the intervention were successful, including the improvement of both function and pain in study participants, the full implementation of the Co-KT framework was not possible. DISCUSSION: This study implemented and evaluated a Co-KT framework for a population with MSK conditions, linking locally generated health care system knowledge with academic input. Further policy, health system changes, and on-the-ground support are needed to overcome the identified implementation challenges in order to create sustainable and effective system change.

Management of physical and psychological trauma resulting from motor vehicle crashes in Australian general practice: a mixed-methods approach.

BACKGROUND: In Australia, motor vehicle crashes (MVC)-related health data are available from insurance claims and hospitals but not from primary care settings. This study aimed to identify the frequency of MVC-related consultations in Australian general practices, explore the pharmacological management of health conditions related to those crashes, and investigate general practitioners' (GPs) perceived barriers and enablers in managing these patients. METHODS: Mixed-methods study. The quantitative component explored annual MVC-related consultation rates over seven years, the frequency of chronic pain, depression, anxiety or sleep issues after MVC, and management with opioids, antidepressants, anxiolytics or sedatives in a sample of 1,438,864 patients aged 16 + years attending 402 Australian general practices (MedicineInsight). Subsequently, we used content analysis of 81 GPs' qualitative responses to an online survey that included some of our quantitative findings to explore their experiences and attitudes to managing patients after MVC. RESULTS: MVC-related consultation rates remained stable between 2012 and 2018 at around 9.0 per 10,000 consultations. In 2017/2018 compared to their peers, those experiencing a MVC had a higher frequency of chronic pain (48% vs. 26%), depression/anxiety (20% vs. 13%) and sleep issues (7% vs. 4%). In general, medications were prescribed more after MVC. Opioid prescribing was much higher among patients after MVC than their peers, whether they consulted for chronic pain (23.8% 95%CI 21.6;26.0 vs. 15.2%, 95%CI 14.5;15.8 in 2017/2018, respectively) or not (15.8%, 95%CI 13.9;17.6 vs. 6.7%, 95% CI 6.4;7.0 in 2017/2018). Qualitative analyses identified a lack of guidelines, local referral pathways and decision frameworks as critical barriers for GPs to manage patients after MVC. GPs also expressed interest in having better access to management tools for specific MVC-related consequences (e.g., whiplash/seatbelt injuries, acute/chronic pain management, mental health issues). CONCLUSION: Chronic pain, mental health issues and the prescription of opioids were more frequent among patients experiencing MVC. This reinforces the relevance of appropriate management to limit the physical and psychological impact of MVC. GPs identified a lack of available resources (e.g. education, checklists and management support tools) for managing MVC-related consequences, and the need for local referral pathways and specific guidelines to escalate treatments.

Profiling bone and joint problems and health service use in an Australian regional population: the Port Lincoln Health Study.

OBJECTIVES: To describe the burden of bone and joint problems (BJP) in a defined regional population, and to identify characteristics and service-usage patterns. METHODS: In 2010, a health census of adults aged ≥15 years was conducted in Port Lincoln, South Australia. A follow-up computer-assisted telephone interview provided more specific information about those with BJP. RESULTS: Overall, 3350 people (42%) reported current BJP. General practitioners (GP) were the most commonly used provider (85%). People with BJP were also 85% more likely to visit chiropractors, twice as likely to visit physiotherapists and 34% more likely to visit Accident and Emergency or GP out of hours (compared with the rest of the population). Among the phenotypes, those with BJP with co-morbidities were more likely to visit GP, had a significantly higher mean pain score and higher levels of depression or anxiety compared with those with BJP only. Those with BJP only were more likely to visit physiotherapists. CONCLUSIONS: GP were significant providers for those with co-morbidities, the group who also reported higher levels of pain and mental distress. GP have a central role in effectively managing this phenotype within the BJP population including linking allied health professionals with general practice to manage BJP more efficiently.

Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role.

PROBLEM: The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas. BACKGROUND: Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation. AIM: We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care. METHODS: An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups. FINDINGS: Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care. DISCUSSION: A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care. CONCLUSION: Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

Trends and patterns of benzodiazepines and Z-drugs prescriptions in Australian general practice: A national study (2011-2018).

INTRODUCTION: We aimed to explore trends and sociodemographic patterns in benzodiazepine (BZD) (by half-life) and Z-drugs prescribing in Australian general practice. METHODS: This open cohort study used de-identified electronic health records of 1.4 million patients (50,812,413 consultations) from 402 Australian practices (MedicineInsight 2011-2018). Annual prescribing frequency and changes over time were estimated according to sex, age, socioeconomic position and rurality. RESULTS: Between 2011 and 2018, the prescribing of very short-acting BZD increased from 0.10 to 0.29 per 1000 consultations (average annual change +17.2% [95% CI 9.6; 25.3]), while it declined for short-intermediate (from 38.5 to 26.6 per 1000 consultations; annual change -5.1% [95% CI -5.6; -4.5]), long-acting BZD (from 24.1 to 21.6 per 1000 consultation; annual change -1.5% [95% CI -2.2; -0.8]) and Z-drugs (from 4.6 to 4.0 per 1000 consultations; annual change -1.9% [95% CI -3.0; -0.7]). Short-intermediate-acting BZD prescribing was three times more frequent among women aged 65+ years than younger women, and long-acting BZD three-to-four times more likely among younger than older men. Z-drugs prescribing was higher among women aged 45-64 years than younger or older females. Short-intermediate- and long-acting BZD were more likely prescribed for patients from more disadvantaged areas, and Z-drugs in more advantaged areas. There were no disparities by rurality. DISCUSSION AND CONCLUSIONS: Although most BZD and Z-drugs prescriptions declined over time, short-intermediate BZD prescriptions remained higher among older women and long-acting BZD more frequent among younger men, especially for those living in more disadvantaged areas. Targeted interventions could reduce the prescribing of BZD and Z-drugs in these groups.

Barriers and facilitators for the implementation of nurse-delivered chronic disease management within general practice: a mixed methods systematic review protocol.

OBJECTIVE: The objective of this review is to identify the barriers and facilitators for the implementation of nurse-delivered models of care for chronic diseases to inform the development and evaluation of nurse-delivered models of care for chronic sleep disorders. INTRODUCTION: Increasing prevalence of sleep disorders and subsequent demand for specialist-led sleep services has prompted investigation into the management of uncomplicated sleep disorders by general practitioners. Models of sleep health care with enhanced roles for general practice nurses have been investigated within the context of randomized controlled trials; however, it is unclear how best to implement these models into clinical practice. With limited research exploring the implementation of nurse-delivered models of sleep health care within general practice, this review will examine the barriers and facilitators for the implementation of nurse-delivered models of care for chronic disease. This will inform the integration of new nurse-delivered models of care for chronic sleep disorders into routine general practice. INCLUSION CRITERIA: Studies that report barriers and facilitators for the implementation of nurse-delivered models of care for chronic diseases for adults into a general practice setting will be included. METHODS: Six databases will be searched: MEDLINE, CINAHL, Embase, Scopus, Cochrane Library, and Emcare. The search will be limited to qualitative, quantitative, and mixed methods studies. Studies will be included if they contain data that report on barriers and facilitators for implementation of nurse-delivered models of care for chronic diseases. This review will be conducted in accordance with the JBI approach to mixed methods convergent integrated systematic reviews. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021273346.