Predicting patient use of general practice services in Australia: models developed using national cross-sectional survey data.

BACKGROUND: The ageing population and increasing prevalence of multimorbidity place greater resource demands on the health systems internationally. Accurate prediction of general practice (GP) services is important for health workforce planning. The aim of this research was to develop a parsimonious model that predicts patient visit rates to general practice. METHODS: Between 2012 and 2016, 1449 randomly selected Australian GPs recorded GP-patient encounter details for 43,501 patients in sub-studies of the Bettering the Evaluation and Care of Health (BEACH) program. Details included patient characteristics, all diagnosed chronic conditions per patient and the number of GP visits for each patient in previous 12 months. BEACH has a single stage cluster design. Survey procedures in SAS version 9.3 (SAS Inc., Cary, NC, USA) were used to account for the effect of this clustering. Models predicting patient GP visit rates were tested. R-square value was used to measure how well each model predicts GP attendance. An adjusted R-square was calculated for all models with more than one explanatory variable. Statistically insignificant variables were removed through backwards elimination. Due to the large sample size, p < 0.01 rather than p < 0.05 was used as level of significance. RESULTS: Number of diagnosed chronic conditions alone accounted for 25.48% of variance (R-square) in number of visits in previous year. The final parsimonious model accounted for 27.58% of variance and estimated that each year: female patients had 0.52 more visits; Commonwealth Concessional Health Care Card holders had 1.06 more visits; for each chronic condition patients made 1.06 more visits; and visit rate initially decreased with age before increasing exponentially. CONCLUSIONS: Number of diagnosed chronic conditions was the best individual predictor of the number of GP visits. Adding patient age, sex and concession card status explained significantly more variance. This model will assist health care planning by providing an accurate prediction of patient use of GP services.

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.

Lifestyle risk factors and corresponding levels of clinical advice and counselling in general practice.

BACKGROUND: The objective of this study was to examine prevalence rates of lifestyle risk factors in the Western Victorian Primary Health Network (WV PHN) general practice patient population and the corresponding levels of clinical advice and counselling. METHODS: Analysed data from the Bettering the Evaluation and Care of Health (BEACH) program from April 2011 to March 2015 were examined, providing a comparison of three geographical areas of general practice patients: WV PHN, Victoria and Australia. RESULTS: Rates of clinical advice and counselling for diet and exercise provided by general practitioners (GPs) in the WV PHN network were significantly lower than Victorian and Australian rates, despite the region's higher obesity rates. Smoking rates were higher in the WV PHN compared with Australia, but there was no difference in the levels of smoking cessation advice disseminated. Across all regions, one in four patients drank alcohol at hazardous levels. DISCUSSION: GPs in rural practice require further support, encouragement and resources to provide diet and exercise advice to their patients more frequently.

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.

General practice antibiotic prescribing for management of otitis media in children.

Otitis media (OM) is one of the most common infections in children. The cause can be viral, but is most often bacterial. It remains one of the most common reasons for antibiotic prescribing for children. Many episodes of acute OM are self-limiting and resolve without treatment, but antibiotics are often prescribed because these infections can develop into serious, sometimes life-threatening complications.

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.

General practitioners' prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians, 2001-2013.

OBJECTIVE: To examine the prescribing of lipid-lowering medications during general practitioner encounters with Indigenous and non-Indigenous Australians from 2001 to 2013. DESIGN, SETTING AND PARTICIPANTS: Observational time trend study, using data from the Bettering the Evaluation and Care of Health (BEACH) survey, of 9594 primary care encounters with Indigenous patients and 750 079 encounters with non-Indigenous patients aged 30 years or over. MAIN OUTCOME MEASURE: Prescription of at least one lipid-lowering medication. RESULTS: The age-sex standardised proportion of encounters that resulted in at least one lipid-lowering medication being prescribed was 5.5% (95% CI, 4.7%-6.3%) for Indigenous patients and 4.6% (95% CI, 4.5%-4.7%) for non-Indigenous patients. The proportion of encounters with Indigenous patients at which a lipid-lowering medication was prescribed increased significantly from 4.1% during 2001-2005 to 6.4% during 2009-2013 (P = 0.013 for trend). For encounters with non-Indigenous patients, the proportion increased significantly from 3.8% during 2001-2005 to 5.2% during 2009-2013 (P < 0.01). For encounters during which GPs managed diabetes, hypertension or ischaemic heart disease, the proportion of Indigenous encounters during which lipid-lowering medication was prescribed was similar to that for non-Indigenous patients. For encounters in which GPs managed a lipid disorder, however, the age-sex standardised proportion was significantly greater for Indigenous (78.4%; 95% CI, 72.6%-84.2%) than for non-Indigenous patients (65.2%; 95% CI, 64.5%-65.8%). CONCLUSION: We detected substantial increases in the prescribing of lipid-lowering medications from 2001 to 2013 for both Indigenous and non-Indigenous patients seen in Australian general practice. Providers were more likely to prescribe lipid-lowering medications for Indigenous than for non-Indigenous patients, suggesting some measure of success in expanding access to medications and reducing cardiovascular risk among Indigenous people.

BEACH program update.

BACKGROUND: The Bettering the Evaluation and Care of Health (BEACH) program, a continuous national study of general practice clinical activity, is now in its 18th year. In March 2015 the database included details of almost 1.7 million encounters from 16,639 participants, representing about 10,300 individual general practitioners (GPs). OBJECTIVES: This paper summarises the BEACH methods, the uses to which the data supplied by participating GPs are put and the many publications resulting from the program, with an indication of how these can be accessed by readers. DISCUSSION: BEACH is the only continuous nationally representative study of general practice in the world that provides direct linkage of GP management actions to the problem being managed. This paper provides the reference point for the coming series of more specific articles associated with the theme of each edition of Australian Family Physician.

Ordering chest X-rays in Australian general practice.

Data from the BEACH program between 2012­14 were used to examine general practice encounters where chest X-rays were ordered. This included the most common problems associated with chest X-ray ordering and patient characteristics. Changes in ordering between 2004­05 and 2013­14 were also investigated. The rate of chest X-ray ordering between 2004­05 and 2013­14 decreased significantly. In 2012­14, chest X-rays were most often ordered in the management of acute bronchitis/bronchiolitis, cough and pneumonia. Pleurisy/pleural effusion had the highest likelihood of resulting in a chest X-ray order, followed by shortness of breath/dyspnoea and pneumonia.

Gastro-oesophageal reflux disease (GORD) in Australian general practice patients.

Gastro-oesophageal reflux disease (GORD) imposes a high level of societal and financial burden on the community. Recently, concern has been expressed regarding the number of prescriptions for proton pump inhibitors (PPIs), mostly for GORD, in Australia. This study investigated changes in the management of GORD since 2006­08. This was a secondary analysis of data from the Bettering the Evaluation and Care of Health (BEACH) program. There was an increase of about 15% in the management rate of GORD between 2006­08 and 2012­14. Medication rates were high, with 95 prescriptions per 100 GORD problems managed, of which 83% were for PPIs. Most patients with GORD are on long-term PPI therapy, usually at full dosage. Trials of cessation or dosage reduction may be appropriate in many patients.

The management of unresolved gastrointestinal symptoms in Australian general practice.

BEACH data collected in 2012-14 were used to investigate the management of unresolved gastrointestinal (GI) symptoms in Australian general practice. This included the characteristics of patients who had unresolved GI symptoms managed, and a comparison with the management of new GI symptoms. Nearly half of the GI symptoms managed in 2012-14 were unresolved (had been managed previously). The findings suggest that general practitioners order pathology and imaging tests more often during first presentations of GI symptoms, and often refer patients when GI symptoms are unresolved.

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.

Genetic testing.

There have been rapid advances in genetics in recent years. DNA tests available on the Medicare Benefits Schedule (MBS) include HFE (haemochromatosis), Fragile X syndrome and Factor V Leiden.

Cardiomyopathy.

Cardiomyopathy is a disease that causes the heart muscle to become weak and ineffective, reducing the heart's ability to pump blood through the body and possibly leading to heart failure. The rate at which cardiomyopathy was recorded by general practitioner (GP) participants in the BEACH program has not changed significantly since 2000. On average, it was managed at 0.9 per 1000 encounters between April 2000 and March 2013, a total of 1175 times over that period. In 9 out of 10 cases, GPs used the general term cardiomyopathy, whereas in the other 10% this was specified as hypertrophic, congestive, secondary or restrictive.

Stroke.

In 2012, about 50,000 Australians had a stroke (cerebrovascular accident (CVA)). The risk of stroke is associated with increased age, previous stroke or transient ischaemic attack, hypertension, smoking, diabetes mellitus (DM), hypercholesterolaemia and atrial fibrillation/flutter (AF). Australian general practice data from the national BEACH program between April 2000 and March 2013 inclusive (1,276,200 GP-patient encounters) were analysed to determine the patient characteristics, associated conditions and management options at those encounters where a CVA was recorded, and detect changes in the annual management rates of CVA, AF, lipid disorders (LD), DM and hypertension.

Testing for gluten sensitivity.

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

Technology in practice ­ GP computer use by age.

Since 2005, more than 95% of general practitioners (GPs) have had access to computers in their clinical work. We have analysed the most recent 2 years of BEACH data (April 2012-March 2014) to determine whether GP age affects clinical computer use.