Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis.

BACKGROUND: Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing. OBJECTIVE: To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years. MAIN MEASURES: The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015). KEY RESULTS: Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]). CONCLUSIONS: Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.

Reducing early career general practitioners' antibiotic prescribing for respiratory tract infections: a pragmatic prospective non-randomised controlled trial.

Background: Inappropriate antibiotic prescription and consequent antibacterial resistance is a major threat to healthcare. Objectives: To evaluate the efficacy of a multifaceted intervention in reducing early career general practitioners' (GPs') antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis/bronchiolitis. Methods: A pragmatic non-randomized trial employing a non-equivalent control group design nested within an existing cohort study of GP registrars' (trainees') clinical practice. The intervention included access to online modules (covering the rationale of current clinical guidelines recommending non-prescription of antibiotics for URTI and bronchitis/bronchiolitis, and communication skills in management of acute bronchitis) followed by a face-to-face educational session. The intervention was delivered to registrars (and their supervisors) in two of Australia's seventeen regional GP training providers (RTPs). Three other RTPs were the control group. Outcomes were proportion of registrars' URTI consultations and bronchitis/bronchiolitis consultations prescribed antibiotics. Intention-to-treat analyses employed logistic regression within a Generalised Estimating Equation framework, adjusted for relevant independent variables. The predictors of interest were time; treatment group; and an interaction term for time-by-treatment group. The P value associated with an interaction term determined statistically significant differences in antibiotic prescribing. Results: Analyses include data of 217 intervention RTPs' and 311 control RTPs' registrars. There was no significant reduction in antibiotic prescribing for URTIs. For bronchitis/bronchiolitis, a significant reduction (interaction P value = 0.024) remained true for analysis adjusted for independent variables (P value = 0.040). The adjusted absolute reduction in prescribing was 15.8% (95% CI: 4.2%-27.5%). Conclusions: A multifaceted intervention reduced antibiotic prescribing for bronchitis/bronchiolitis but not URTIs.

General practice registrars' clinical exposure to dermatological procedures during general practice training: a cross-sectional analysis.

Australian general practitioners (GPs) commonly manage dermatological conditions requiring procedures. GP registrars have limited pre-vocational training exposure to dermatology and find skin problems challenging. We aimed to establish the prevalence, nature and associations of GP registrars' performance of skin procedures. We conducted a cross-sectional analysis from the Registrar Clinical Encounters in Training cohort study. Multivariable logistic regression was used to establish associations of our outcome (skin procedures, both including and excluding cryotherapy). Independent variables included patient and doctor demographics, diagnoses/problems managed and registrars' recourse to in-consultation assistance/information. A total of 1161 registrars provided data on 166,988 consultations, recording 2927 skin procedures (16.7% of all procedures; performed in 1.7% of consultations). Cryotherapy, excision, punch biopsy and shave biopsy were most common. More complex procedures were performed infrequently. Significant associations of performing procedures included rural/remote location (compared to major city), male patients, patient age 65+ (compared to age 15-34) and registrars seeking in-consultation information/assistance. Skin procedures were less likely for Aboriginal patients or those from non-English-speaking backgrounds. For non-cryotherapy procedures, rurality was not significantly associated, but significant differences were found between training regions. In summary, GP registrars perform fewer dermatological procedures compared to established GPs. Findings will inform GP vocational training in skin procedures.

Changes in pathology test ordering by early career general practitioners: a longitudinal study.

OBJECTIVE: To assess the number of pathology tests ordered by general practice registrars during their first 18-24 months of clinical general practice. DESIGN: Longitudinal analysis of ten rounds of data collection (2010-2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%. MAIN OUTCOME MEASURE: Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms. RESULTS: 876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8-15%; P < 0.001) per training term. CONCLUSIONS: Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns.

Protecting Pain Patients. The Evaluation of a Chronic Pain Educational Intervention.

INTRODUCTION: Advocacy and commercially funded education successfully reduced barriers to the provision of long-term opioid analgesia. The subsequent escalation of opioid prescribing for chronic noncancer pain has seen increasing harms without improved pain outcomes. METHODS: This was a one-group pretest-posttest design study. A multidisciplinary team developed a chronic pain educational package for general practitioner trainees emphasizing limitations, risk-mitigation, and deprescribing of opioids with transition to active self-care. This educational intervention incorporated prereadings, a resource kit, and a 90-minute interactional video case-based workshop incorporated into an education day. Evaluation was via pre- and postintervention (two months) questionnaires. Differences in management of two clinical vignettes were tested using McNemar's test. RESULTS: Of 58 eligible trainees, 47 (response rate = 81.0%) completed both questionnaires (36 of whom attended the workshop). In a primary analysis including these 47 trainees, therapeutic intentions of tapering opioid maintenance for pain (in a paper-based clinical vignette) increased from 37 (80.4%) pre-intervention to 44 (95.7%) postintervention (P = 0.039). In a sensitivity analysis including only trainees attending the workshop, 80.0% pre-intervention and 97.1% postintervention tapered opioids (P = 0.070). Anticipated initiation of any opioids for a chronic osteoarthritic knee pain clinical vignette reduced from 35 (74.5%) to 24 (51.1%; P = 0.012) in the primary analysis and from 80.0% to 41.7% in the sensitivity analysis (P = 0.001). CONCLUSIONS: Necessary improvements in pain management and opioid harm avoidance are predicated on primary care education being of demonstrable efficacy. This brief educational intervention improved hypothetical management approaches two months subsequently. Further research measuring objective changes in physician behavior, especially opioid prescribing, is indicated.

Home visits and nursing home visits by early-career GPs: a cross-sectional study.

BACKGROUND: Home visits (HVs) and nursing home visits (NHVs) are accepted as core elements of general practice. There is concern regarding declining rates of HVs and an increasing demand for NHVs together with a perceived decreased willingness of younger GPs to provide these services. OBJECTIVES: To establish the prevalence and associations of recently vocationally qualified GPs ('graduates') performing HVs and NHVs. METHODS: A cross-sectional questionnaire-based study of recent (within 5 years) graduates of 3 of Australia's 17 regional general practice training programs. Outcome factors were performing, as part of current practice, HVs and NHVs. Factors associated with each outcome were assessed by logistic regression with graduate and current practice characteristics and vocational training experiences as independent variables. RESULTS: Of 230 responding graduates, 48.1% performed HVs and 40.6% performed NHVs in their current clinical GP role. Factors associated with both HVs and NHVs were participating in in-practice clinical teaching/supervision [odds ratios (ORs) 2.65 and 2.66], conducting HVs/NHVs during training (ORs 5.05 and 10.8) and working full-time (ORs for part-time work 0.20 and 0.29). Further associations with performing HVs were older GP age (compared to <36 years: ORs 3.65 for 36-40 and 2.53 for 41+), smaller practice size (OR 0.53 for larger practices), Australian undergraduate education (OR 0.31 for non-Australian) and greater number of years in their current practice as a qualified GP (OR 1.25 per year). CONCLUSIONS: Our findings of graduates' modest engagement with HVs and NHVs reinforce concerns regarding Australian general practice's capacity to accommodate the needs of an aging population.

General practitioner trainees' in-consultation generation of clinical questions for later answering: prevalence and associations.

Background: As well as generating patient-specific questions, patient consultations are a rich source of questions relating to clinicians' need to acquire or maintain wider clinical knowledge. This is especially so for GP trainees. Objectives: To establish the prevalence and associations of GP trainees' generation of 'learning goals' (LGs: questions generated during clinical consultations for intended post-consultation answering). Also, to characterize the type of learning goals generated. Methods: A cross-sectional analysis (2010-15) of an ongoing cohort study of Australian GP trainees' consultations. Once each 6-month training term, trainees record detailed data of 60 consecutive consultations. The primary outcome was generation of an LG. Analysis was at the level of individual problem/diagnosis managed. The secondary outcome was the problems/diagnoses to which the LGs related. Results: One thousand one hundred and twenty-four trainees contributed data for 154746 consultations including 222307 problems/diagnoses. LGs were generated for 16.6% [95% confidence intervals (CI) = 16.4-16.7] of problems/diagnoses, in 22.1% (95% CI = 21.9-22.3%) of consultations. Associations of LGs included patient factors: younger age and having seen the trainee previously; trainee factors: earlier training stage, being overseas-trained and the trainee's training organization; consultation factors: longer duration, addressing a chronic disease, referring the patient, organizing follow-up, organizing investigations and accessing in-consultation information. LGs were commonly generated for skin (12.9% of all learning goals), musculoskeletal (12.7%) and respiratory (8.7%) problems. LGs were generated for 31.8% of male genital, 27.0% of neurological and 23.3% of eye problems. Conclusion: Australian GP trainees frequently generate questions in-consultation to be pursued post-consultation. Prevalence, 'complexity' and familiarity of clinical topic area influenced LG generation.

Antibiotic prescribing for acute otitis media and acute sinusitis: a cross-sectional analysis of the ReCEnT study exploring the habits of early career doctors in family practice.

Background: Antibiotic resistance is a public health concern, and is linked to over-prescribing. In self-limiting infections such as acute otitis media (AOM) and acute sinusitis, prescribing remains high despite strong guideline recommendations against the routine use of antibiotics. Early career General Practitioners may find evidence-based prescribing challenging. Aim: To establish the prevalence and associations of antibiotic prescribing for AOM and acute sinusitis by Australian vocational trainees in General Practice. Method: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. This ongoing, multicentre prospective cohort study documents trainees' consultation-based clinical experiences. Univariate and logistic regression analyses were conducted on data recorded in consultations for AOM or acute sinusitis in nine collection periods during 2010-2014. Results: Data from 856 individual trainees (response rate 95.2%) were analysed. AOM was managed in 0.9% of encounters. Antibiotics were prescribed in 78.8% of cases. Prescribing was significantly associated with longer consultation time and first presentation for this problem. There was no significant association with patient age group. Acute sinusitis was managed in 0.9% of encounters. Antibiotics were prescribed in 71.2% of cases. Later-stage trainees and trainees who did not receive their primary medical qualification in Australia were more likely to prescribe an antibiotic for acute sinusitis. Conclusion: Early career GPs are not prescribing in an evidence-based manner. The complexity of guidelines for AOM and acute sinusitis may be confusing for prescribers, especially early career doctors struggling with inexperience and diagnostic uncertainty. Educational interventions are necessary to bring prescribing rates closer to quality benchmarks.

Responses to clinical uncertainty in Australian general practice trainees: a cross-sectional analysis.

CONTEXT: Tolerance for ambiguity is essential for optimal learning and professional competence. General practice trainees must be, or must learn to be, adept at managing clinical uncertainty. However, few studies have examined associations of intolerance of uncertainty in this group. OBJECTIVES: The aim of this study was to establish levels of tolerance of uncertainty in Australian general practice trainees and associations of uncertainty with demographic, educational and training practice factors. METHODS: A cross-sectional analysis was performed on the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing multi-site cohort study. Scores on three of the four independent subscales of the Physicians' Reaction to Uncertainty (PRU) instrument were analysed as outcome variables in linear regression models with trainee and practice factors as independent variables. RESULTS: A total of 594 trainees contributed data on a total of 1209 occasions. Trainees in earlier training terms had higher scores for 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose diagnosis/treatment uncertainty to patients'. Beyond this, findings suggest two distinct sets of associations regarding reaction to uncertainty. Firstly, affective aspects of uncertainty (the 'Anxiety' and 'Concern' subscales) were associated with female gender, less experience in hospital prior to commencing general practice training, and graduation overseas. Secondly, a maladaptive response to uncertainty (the 'Reluctance to disclose' subscale) was associated with urban practice, health qualifications prior to studying medicine, practice in an area of higher socio-economic status, and being Australian-trained. CONCLUSIONS: This study has established levels of three measures of trainees' responses to uncertainty and associations with these responses. The current findings suggest differing 'phenotypes' of trainees with high 'affective' responses to uncertainty and those reluctant to disclose uncertainty to patients. More research is needed to examine the relationship between clinical uncertainty and clinical outcomes, temporal changes in tolerance for uncertainty, and strategies that might assist physicians in developing adaptive responses to clinical uncertainty.

Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis.

AIMS: Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of "non-symptomatic" PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars). METHODS: A cross-sectional analysis from the ReCEnT cohort study of registrars' consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an "asymptomatic" PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors. RESULTS: A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69 years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test). CONCLUSION: GP registrars frequently order "asymptomatic" PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted.

General practice trainees' clinical experience of dermatology indicates a need for improved education: A cross-sectional analysis from the Registrar Clinical Encounters in Training Study.

BACKGROUND/OBJECTIVES: Skin conditions are commonly encountered in general practice but dermatology is underrepresented in undergraduate medical courses. Australian and international studies have shown that the dermatological diagnostic ability of general practitioners (GPs) is suboptimal, contributing to increased dermatology outpatient referrals. Dermatological experience in GP vocational training is thus of particular importance. We aimed to document the prevalence of skin disease presentations and the range of skin diseases encountered by GP trainees. We also sought to establish associations of GP trainee's skin disease experience, including their personal characteristics, consultation factors, and the actions arising from the consultation. METHODS: This study took place in the Registrars Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, prospective, multi-site cohort study of Australian GP trainees' consultations. A descriptive cross-sectional analysis was performed on trainees' consultation data. RESULTS: In total, 645 individual trainees contributed data from 84 615 consultations. Altogether, 11% of all problems managed were skin problems. Infections, dermatitis, injury and wounds were the most common presentations. Associations of consultations for skin problems (compared with all other problems) included seeking in-consultation advice, planning patient follow up and generating learning goals. CONCLUSIONS: These findings suggest GP trainees find skin problems challenging and may indicate a need for more and better targeted undergraduate and GP trainee education.

Procedural skills of Australian general practice registrars: A cross-sectional analysis.

BACKGROUND: Procedural skills are an essential component of general practice vocational training. The aim of this study was to investigate the type, frequency and rural or urban associations of procedures performed by general practice registrars, and to establish levels of concordance of procedures performed with a core list of recommended procedural skills in general practice training. METHODS: A cross-sectional analysis of a cohort study of registrars' consultations between 2010 and 2016 was undertaken. Registrars record 60 consecutive consultations during each six-month training term. The outcome was any procedure performed. RESULTS: In 182,782 consultations, 19,411 procedures were performed. Procedures (except Papanicolaou [Pap] tests) were performed more often in rural than urban areas. Registrars commonly sought help from supervisors for more complex procedures. The majority of procedures recommended as essential in registrar training were infrequently performed. DISCUSSION: Registrars have low exposure to many relevant clinical procedures. There may be a need for greater use of laboratory-based training and/or to review the expectations of the scope of procedural skills in general practice.

Antibiotic prescribing for sore throat: a cross-sectional analysis of the ReCEnT study exploring the habits of early-career doctors in family practice.

BACKGROUND: Acute sore throat is a common condition presenting to family practitioners. It is usually self-limiting, with antibiotic treatment recommended only for high-risk presentations. Overprescribing of antibiotics contributes to individual and community resistance. Learning to prescribe in the context of diagnostic uncertainty and patient pressures is a challenge for early-career doctors. Prescribing habits develop early and tend not to change with time. OBJECTIVE: To establish the prevalence and associations of antibiotic prescribing for acute sore throat by Australian vocational trainees in family practice. METHOD: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. This ongoing, multicentre prospective cohort study documents the nature of trainees' consultation-based clinical experiences. Univariate and logistic regression analyses were conducted on data recorded in consultations for sore throat in nine collection periods during 2010-14. RESULTS: Data from 856 individual trainees (response rate 95.2%) were analysed. Sore throat was managed in 2.3% encounters. Antibiotics were prescribed for 71.5% of sore throat diagnoses. The variables associated with prescribing were inner-regional location and higher socio-economic area. There was no significant association with younger age of patient or greater trainee experience. If an antibiotic was prescribed, the trainee was more likely to seek information from guidelines or a supervisor. CONCLUSIONS: The high frequency of antibiotic prescribing and the lack of attenuation in prescribing with increased experience suggest current educational interventions and the apprenticeship model of training is not fostering appropriate practice in this important clinical area. Targeted educational interventions, for supervisors as well as trainees, are indicated.

Changes in early-career family physicians' antibiotic prescribing for upper respiratory tract infection and acute bronchitis: a multicentre longitudinal study.

BACKGROUND: Inappropriate antibiotic prescription and subsequent antibacterial resistance are major threats to health worldwide. OBJECTIVES: We aimed to establish whether early-career 'apprenticeship-model' experience in family practice influences antibiotic prescribing for respiratory tract infections and to also establish other associations of antibiotic prescribing changes during this early-career experience. METHODS: A longitudinal analysis (2010-2014) of a cohort study of Australian GP registrars' (vocational trainees') consultations. Registrars from five regional training programs recorded data from 60 consecutive consultations, once each 6-month training Term, including the diagnoses managed and medications prescribed. The outcomes were whether an antibiotic was prescribed for the diagnoses 'upper respiratory tract infection (URTI)' and 'acute bronchitis/bronchiolitis'. Generalized linear mixed modelling was used to account for repeated measures on registrars and to include the time component: 'Term'. RESULTS: A total of 856 registrars recorded 108759 consultations, including 8715 'URTI' diagnoses (5.15% of diagnoses) and 2110 'acute bronchitis/bronchiolitis' diagnoses (1.25%). Antibiotics were prescribed in 16.3% [95% confidence interval (CI) 14.9-17.8] of URTI and 72.2% (95% CI 69.6-74.6) of acute bronchitis/bronchiolitis diagnoses. Moving from an earlier to later term did not significantly influence registrars' antibiotic prescribing for URTI [adjusted odds ratio (OR) 0.95; 95% CI 0.87, 1.04, P = 0.27] or acute bronchitis/bronchiolitis [OR 1.01 (95% CI 0.90-1.14), P = 0.86]. Significant associations of antibiotic prescribing for URTIs were the registrar being non-Australian educated, greater patient age, practices not privately billing patients, pathology being ordered, longer consultation duration and the registrar seeking in-consultation information or advice (including from their supervisor). CONCLUSIONS: Early-career experience/training failed to produce rational antibiotic prescribing for URTI and acute bronchitis/bronchiolitis. Our findings suggest that prescribing interventions could target the registrar-supervisor dyad.

Changing the Antibiotic Prescribing of general practice registrars: the ChAP study protocol for a prospective controlled study of a multimodal educational intervention.

BACKGROUND: Australian General Practitioners (GPs) are generous prescribers of antibiotics, prompting concerns including increasing antimicrobial resistance in the community. Recent data show that GPs in vocational training have prescribing patterns comparable with the high prescribing rate of their established GP supervisors. Evidence-based guidelines consistently advise that antibiotics are not indicated for uncomplicated upper respiratory tract infections (URTI) and are rarely indicated for acute bronchitis. A number of interventions have been trialled to promote rational antibiotic prescribing by established GPs (with variable effectiveness), but the impact of such interventions in a training setting is unclear. We hypothesise that intervening while early-career GPs are still developing their practice patterns and prescribing habits will result in better adherence to evidence-based guidelines as manifested by lower antibiotic prescribing rates for URTIs and acute bronchitis. METHODS/DESIGN: The intervention consists of two online modules, a face-to-face workshop for GP trainees, a face-to-face workshop for their supervisors and encouragement for the trainee-supervisor dyad to include a case-based discussion of evidence-based antibiotic prescribing in their weekly one-on-one teaching meetings. We will use a non-randomised, non-equivalent control group design to assess the impact on antibiotic prescribing for acute upper respiratory infections and acute bronchitis by GP trainees in vocational training. DISCUSSION: Early-career GPs who are still developing their clinical practice and prescribing habits are an underutilized target-group for interventions to curb the growth of antimicrobial resistance in the community. Interventions that are embedded into existing training programs or are linked to continuing professional development have potential to increase the impact of existing interventions at limited additional cost. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12614001209684 (registered 17/11/2014).

Neurobehavioral and Cardiovascular Effects of Potassium Cyanide Administered Orally to Mice.

The Food and Drug Administration Animal Rule requires evaluation of cardiovascular and central nervous system (CNS) effects of new therapeutics. To characterize an adult and juvenile mouse model, neurobehavioral and cardiovascular effects and pathology of a single sublethal but toxic, 8 mg/kg, oral dose of potassium cyanide (KCN) for up to 41 days postdosing were investigated. This study describes the short- and long-term sensory, motor, cognitive, and behavioral changes associated with oral dosing of a sublethal but toxic dose of KCN utilizing functional observation battery and Tier II CNS testing in adult and juvenile mice of both sexes. Selected tissues (histopathology) were evaluated for changes associated with KCN exposure with special attention to brain regions. Telemetry (adult mice only) was used to evaluate cardiovascular and temperature changes. Neurobehavioral capacity, sensorimotor responsivity or spontaneous locomotor activity, and rectal temperature were significantly reduced in adult and juvenile mice at 30 minutes post-8 mg/kg KCN dose. Immediate effects of cyanide included bradycardia, adverse electrocardiogram arrhythmic events, hypotension, and hypothermia with recovery by approximately 1 hour for blood pressure and heart rate effects and by 2 hours for body temperature. Lesions consistent with hypoxia, such as mild acute tubular necrosis in the kidneys corticomedullary junction, were the only histopathological findings and occurred at a very low incidence. The mouse KCN intoxication model indicates rapid and completely reversible effects in adult and juvenile mice following a single oral 8 mg/kg dose. Neurobehavioral and cardiovascular measurements can be used in this animal model as a trigger for treatment.

Identification of Aboriginal and Torres Strait Islander status by general practice registrars: Confidence and associations.

BACKGROUND: Identification of Aboriginal and Torres Strait Islander status in healthcare settings is essential for the delivery of culturally appropriate care. Under-identification is common and practitioner confidence is a known barrier. OBJECTIVE: The objective of this research was to document the self-reported confidence of general practice registrars in identifying the Aboriginal and Torres Strait Islander status of their patients, and associations of this confidence. METHODS: This research used cross-sectional analysis of survey and patient encounter data of general practice registrars training across five Australian states. RESULTS: Of the 698 registrars (97.5% response rate) who participated in the study, 74.5% had a high level of confidence in identifying a patient's Aboriginal and Torres Strait Islander status. Older and more senior registrars had significantly greater confidence. There was also a significant association with the registrars' training provider. DISCUSSION: More than a quarter of registrars reported low confidence for this basic consultation skill. Our findings will inform general prac-tice vocational training and continuing professional development, and reinforce the importance of a comprehensive, system-wide approach to the identification of patients' Aboriginal or Torres Strait Islander status.

Prevalence and associations of general practice nurses' involvement in consultations of general practitioner registrars: a cross-sectional analysis.

OBJECTIVE: To establish prevalence and associations of general practice nurses' (GPNs) involvement in general practitioner (GP) registrars' consultations. METHODS: A cross-sectional analysis from an ongoing cohort study of registrars' clinical consultations in five Australian states. Registrars recorded detailed data from 60 consecutive consultations per 6-month training term. Problems and diagnoses encountered, including chronic disease classification, were coded using the International Classification of Primary Care, second edition duplication system (ICPC-2plus) classification system. The outcome factor in our analysis was GPN involvement in management of individual problems and diagnoses. Independent variables were a range of patient, registrar, practice, consultation and educational factors. RESULTS: We analysed 108 759 consultations of 856 registrars including 169 307 problems or diagnoses. Of the problems/diagnoses, 5.1% (95% confidence interval (CI) 5.0-5.2) involved a GPN. Follow-up with a GPN was organised for 1.5% (95% CI 1.4-1.5) of all problems/diagnoses. Significant associations of GPN involvement included patient age, male sex, Aboriginal or Torres Strait Islander status, non-English-speaking background (NESB) and the patient being new to the practice. Larger practice size, the particular training organisation, and the problem/diagnosis being new and not a chronic disease were other associations. CONCLUSIONS: Associations with Aboriginal or Torres Strait Islander status and NESB status suggest GPNs are addressing healthcare needs of these under-serviced groups. But GPNs may be underutilised in chronic disease care.

The Pattern of Opioid Management by Australian General Practice Trainees.

OBJECTIVE: With escalating opioid prescribing come individual and public health harms. To inform quality improvement measures, understanding of opioid prescribing is essential. We aimed to establish consultation-level prevalence and associations of opioid prescribing. DESIGN: A cross-sectional secondary analysis from a longitudinal multisite cohort study of general practitioner (GP) vocational trainees: "Registrar Clinical Encounters in Training." SETTING: Four of Australia's seventeen GP Regional Training Providers, during 2010-13. SUBJECTS: GP trainees. METHODS: Practice and trainee demographic data were collected as well as patient, clinical and educational data of 60 consecutive consultations of each trainee, each training term. Outcome factors were any opioid analgesic prescription and initial opioid analgesic prescription for a specific problem for the first time. RESULTS: Overall, 645 trainees participated. Opioids comprised 4.3% prescriptions provided for 3.8% of patients. Most frequently prescribed were codeine (39.9%) and oxycodone (33.4%). Prescribing was for acute pain (29.3%), palliative care (2.6%) or other indications (68.1%). Most prescribing involved repeat prescriptions for pre-existing problems (62.7% of total). Other associations included older patients; prescriber and patient male gender; Aboriginal/Torres Strait Islander status; rural and disadvantaged locations; longer consultations; and generation of referrals, follow-up, and imaging requests. Opioid initiation was more likely for new patients with new problems, but otherwise associations were similar. Trainees rarely reported addiction risk-mitigation strategies. CONCLUSIONS: Most opioids were prescribed as maintenance therapy for non-cancer pain. Demographic associations with opioid analgesic prescribing resemble those presenting for opioid dependency treatment. Our findings should inform measures by regulators and medical educators supporting multimodal pain management.

Antibiotic prescribing for respiratory infections: a cross-sectional analysis of the ReCEnT study exploring the habits of early-career doctors in primary care.

BACKGROUND: Antibiotic resistance is among the most important current public health issues. Most antibiotics are prescribed in primary care. There is strong consensus that they are overprescribed, especially for conditions such as upper respiratory tract infections (URTI) and acute bronchitis, where they provide limited benefit. Interventions to alter prescribing patterns have shown limited effect. Trainees in family practice may be an appropriate target, as their prescribing habits are still developing. OBJECTIVE: To establish prevalence and associations of trainee prescribing of antibiotics for URTI and acute bronchitis/bronchiolitis. METHODS: A cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing cohort study of Australian General Practice (GP) trainees documenting the nature of their consultation-based clinical experiences. Trainees record details of 60 consecutive patient encounters every 6-month training term. Univariate and logistic regression analyses were conducted on data recorded in consultations related to URTI and acute bronchitis/bronchiolitis in six collection periods during 2010-12. RESULTS: Data from 401 trainees (94.7% response rate) were analysed. Antibiotics were prescribed in 21.6% of encounters for URTI and 73.1% of encounters for acute bronchitis/bronchiolitis. Trainees prescribing antibiotics were more likely to order tests, and to seek in-consultation advice. Logistic regression analysis demonstrated older patient age, Indigenous patient background, and practices in higher socioeconomic areas were significant predictors of antibiotic prescribing. CONCLUSION: GP trainee antibiotic prescribing is higher than justified by guidelines. Understanding factors contributing to this pattern will assist in developing educational interventions to improve evidence-based prescribing habits during the early stages of these doctors' careers.