General practitioners knowledge and management of whiplash associated disorders and post-traumatic stress disorder: implications for patient care.

BACKGROUND: In Australia, general practitioners (GPs) see around two-thirds of people injured in road traffic crashes. Road traffic crash injuries are commonly associated with diverse physical and psychological symptoms that may be difficult to diagnose and manage. Clinical guidelines have been developed to assist in delivering quality, consistent care, however the extent to which GPs knowledge and practice in diagnosing and managing road traffic crash injuries concords with the guidelines is unknown. This study aimed to explore Australian GPs knowledge, attitudes and practices regarding the diagnosis and management of road traffic crash injuries, specifically whiplash associated disorders (WAD) and post-traumatic stress disorder (PTSD). METHOD: A cross-sectional survey of 423 GPs across Australia conducted between July and December 2014. We developed a questionnaire to assess their knowledge of WAD and PTSD, confidence in diagnosing and managing WAD and PTSD, frequency of referral to health providers, barriers to referral, and attitudes towards further education and training. Factor analysis, Spearman's correlation, and multiple ordered logistic regressions were performed. RESULTS: Overall, GPs have good level knowledge of WAD and PTSD; only 9.6 % (95 % CI: 7.1 %, 12.8 %) and 23.9 % (95 % CI: 20.8 %, 28.2 %) of them were deemed to have lower level knowledge of WAD and PTSD respectively. Key knowledge gaps included imaging indicators for WAD and indicators for psychological referral for PTSD. GPs who were male, with more years of experience, working in the urban area and with higher knowledge level of WAD were more confident in diagnosing and managing WAD. Only GPs PTSD knowledge level predicted confidence in diagnosing and managing PTSD. GPs most commonly referred to physiotherapists and least commonly to vocational rehabilitation providers. Barriers to referral included out-of-pocket costs incurred by patients and long waiting times. Most GPs felt positive towards further education on road traffic crash injury management. CONCLUSION: This study has enhanced understanding of the knowledge skills and attitudes of GPs towards road traffic crash injury care in Australia, and has identified areas for further education and training. If delivered, this training has the potential to reduce unnecessary imaging for WAD and optimise the early referral of patients at risk of delayed recovery following a road traffic crash.

How general practitioners manage mental illness in culturally and linguistically diverse patients: an exploratory study.

BACKGROUND: General practitioners (GPs) see a range of mental illnesses and a diversity of patients, including patients from culturally and linguistically diverse (CALD) backgrounds. The aim of this study was to understand the barriers and facilitators GPs encounter when managing mental illness in CALD patients. METHODS: Semi-structured interviews with 10 Melbourne GPs were undertaken between May and July 2013. Data were analysed thematically. RESULTS: GP barriers included difficulties in recognising initial symptoms, communicating the diagnosis and using interpreter services. Facilitators included cultural concordance between the GP and patient, practice-based initiatives targeting CALD patients, and areas of further education for GPs and CALD patients. DISCUSSION: Cultural concordance between GPs and CALD patients is likely to be effective in facilitating management of mental illness. Further research is needed on interpreter use and scaling up practice-based initiatives to improve service delivery. At a population level, GPs thought it necessary to improve mental health literacy in CALD communities.

Online continuing medical education (CME) for GPs: does it work? A systematic review.

BACKGROUND: Numerous studies have assessed the effectiveness of online continuing medical education (CME) designed to improve healthcare professionals' care of patients. The effects of online educational interventions targeted at general practitioners (GP), however, have not been systematically reviewed. METHODS: A computer search was conducted through seven databases for studies assessing changes in GPs' knowledge and practice, or patient outcomes following an online educational intervention. RESULTS: Eleven studies met the eligibility criteria. Most studies (8/11, 72.7%) found a significant improvement in at least one of the following outcomes: satisfaction, knowledge or practice change. There was little evidence for the impact of online CME on patient outcomes. Variability in study design, characteristics of online and outcome measures limited conclusions on the effects of online CME. DISCUSSION: Online CME could improve GP satisfaction, knowledge and practices but there are very few well-designed studies that focus on this delivery method of GP education.

Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews.

OBJECTIVES: To investigate whether General Practice Management Plans (GPMPs), Team Care Arrangements (TCAs) and reviews of these improve the management and outcomes of patients with diabetes when supported by cdmNet, a web-based chronic disease management system; and to investigate adherence to the annual cycle of care (ACOC), as recommended in diabetes guidelines. DESIGN, PARTICIPANTS AND SETTING: A before-and-after study to analyse prospectively collected data on 577 patients with type 1 or 2 diabetes mellitus who were managed with a GPMP created using cdmNet between June 2008 and November 2012. MAIN OUTCOME MEASURES: Completion of the clinical tests in the ACOC (process outcome) and values of six of these clinical measurements (clinical outcomes). RESULTS: Significant improvements were seen after creation of a GPMP in the proportion of ACOC clinical tests completed (57.9% v 74.8%, P < 0.001), total cholesterol level (P < 0.01), low-density lipoprotein (LDL) cholesterol level (P < 0.001) and body mass index (BMI) (P < 0.01). Patients using GPMPs and TCAs also improved their glycated haemoglobin (HbA1c) level (P < 0.05). Patients followed up with irregular reviews had significant improvements in the proportion of ACOC clinical tests completed (59.2% v 77.6%, P < 0.001), total cholesterol level (P < 0.05), and BMI (P < 0.01), but patients with regular reviews had greater improvements in the proportion of ACOC clinical tests completed (58.9% v 85.0%, P < 0.001), HbA(1c) level (57.7 v 53.0 mmol/mol, P < 0.05), total cholesterol level (4.8 v 4.5 mmol/L, P < 0.05), LDL cholesterol level (2.8 v 2.4 mmol/L, P < 0.01) and diastolic blood pressure (76.0 v 74.0 mmHg, P < 0.05). CONCLUSION: There were significant improvements in process and clinical outcomes for patients on a GPMP or a GPMP and TCA, particularly when these were followed up by regular reviews. Patients using cdmNet were four times more likely to have their GPMP or TCA followed up through regular reviews than the national average.

Care planning and adherence to diabetes process guidelines: medicare data analysis.

OBJECTIVE: To test the association, in patients with a diagnosis of diabetes I and II, between having or not having a care plan, (i.e. General Practice Management Plans (GPMPs),Team Care Arrangements (TCAs)), and having the recommended number of biochemical checks according to the diabetes Annual Cycle of Care guideline. The checks comprised HbA1c, HDL cholesterol and urinary microalbumin. METHODS: Chi-square analysis of retrospective group data obtained from the Medicare database (from 'billing' patterns only). RESULTS: The creation of GPMPs was associated with general practitioners (GPs) requesting checks for HbA1c (59.7%), HDL cholesterol (36.9%) and microalbumin (50.8%) for diabetes patients in accordance with guideline recommendations. Although the introduction of multidisciplinary care via a TCA was associated with an increase in the frequency of HbA1c checks (61.3%) in accordance with the guidelines, there was a reduction in the number of HDL cholesterol (23.7%) and microalbumin (36.8%) checks. The group with no care plans had the lowest association with HbA1c (47.8%), HDL cholesterol (19.7%) and microalbumin (29.3%) checks that met guideline requirements for diabetes. CONCLUSIONS: The use of GPMPs showed strong association with increased testing of process measures that met guideline requirements for diabetes. Further research is needed to understand the value and benefits of TCAs in promoting adherence to diabetes guidelines.

Fitness to drive - GP perspectives of assessing older and functionally impaired patients.

BACKGROUND: General practitioners have expressed concern about their ability to assess patients' driving fitness. This study explores GP perspectives regarding assessing fitness to drive in older and functionally impaired patients. METHODS: We held face-to-face interviews with seven metropolitan GPs and a focus group with nine rural GPs. Data were analysed using thematic analysis. RESULTS: General practitioners were unsure whether they or driving authorities should have responsibility for assessing patients' fitness to drive; recognised that driving is important for maintaining independence; described referral to an occupational therapist as useful, and expressed concern about the lack of access to alternative forms of transport and also about privacy issues. Opinion was divided about the merits of the VicRoads Medical Report Form and the usefulness of the Austroads guide. DISCUSSION: This qualitative study suggests that some GPs may find assessing fitness to drive to be challenging and problematic in general practice. Further resources and education could assist these GPs to increase their confidence and competence in assessing a patient's fitness to drive.

Functionality and substrate specificity of human box H/ACA guide RNAs.

A large number of box H/ACA RNAs have been identified in human cells, and have been predicted to account for nearly all pseudouridylation sites in human rRNAs. However, the function of these mammalian H/ACA RNAs in directing pseudouridylation has been verified experimentally in only two cases. In this study, we used three in vitro reconstitution systems, including yeast and mammalian systems, to test the function of seven H/ACA RNAs guiding16 pseudouridylation sites. Our results verified 12 of these sites; four predictions were incorrect. Further analyses indicated that three components, including the stability of the hairpin structure harboring the pseudouridylation pocket, the stability of guide sequence-target RNA base-pairing interaction, and the distance between the target uridine and the box H or ACA, were critical for the guide function, as changes in these components were sufficient to alter the functionality and specificity of the pseudouridylation pocket. The dynamic functional changes in response to changes in these three important components were further tested in vivo, and the results were completely consistent with the in vitro results. Finally, we compared our results with predictions made by two computer programs, as well as predictions made by human experts using visual inspection. We found that the predictions of one program (snoGPS) agreed with our experimental results with 100% sensitivity (12/12) and 75% specificity (3/4).

Web based diabetes care planning - sociotechnical barriers to implementation in general practice.

BACKGROUND: This research explored the sociotechnical barriers in the implementation of web based diabetes care plans in general practice from the perspective of implementing stakeholders. METHODS: A qualitative case study design was use to explore the sociotechnical barriers. Twenty-one stakeholders were purposely recruited and interviewed. RESULTS: Technological barriers included rudimentary IT applications in general practice; standardisation and interoperability issues; and 'bugs' in the system. The role of practice managers as gatekeepers influenced the uptake of the technology. General practitioners were noted to be time poor, while practice nurses preferred to stick with paper based ways of doing care plans. The relationship between allied health professionals and GPs also influenced the adoption process. DISCUSSION: Implementers had significant insight into the sociotechnical barriers to diabetes web based care planning in general practice. Future research should examine the roles of the stakeholders involved in determining standards and the interoperability of systems.

Electronic care plans and medicolegal liability.

BACKGROUND: Government policy encourages the use of care plans in general practice, and developments in information technology have the potential to facilitate their use via a shared electronic care plan. Sharing a comprehensive set of patient data raises privacy issues and questions about the nature and extent of potential liability. METHODS: A round table discussion was held with participants purposively selected for expertise in their fields. RESULTS: Consensus stressed the privacy dangers inherent in the creation of a shared electronic care plan accessible by multiple treating professionals and a private sector intermediary information technology provider, and the difficulties in ensuring appropriate informed consent is provided by patients. DISCUSSION: As the use of shared electronic care plans increases in Australia, new legal and ethical issues may emerge which need to be understood and addressed if general practitioners and other healthcare team members are to be able to participate with confidence.

Data extraction and feedback - does this lead to change in patient care?

BACKGROUND Computers enable general practitioners to collate clinical data within their practices. The improvements that this can make to clinical care remain the subject of enquiry. OBJECTIVE Does the analysis of clinical data for the purpose of instigating quality improvement strategies in general practice, with support from a local division of general practice, lead to positive changes in measures of care after 12 months? DISCUSSION This study demonstrated that, in this setting, the collection and analysis of clinical data, with support from a division of general practice, led to modest increases in the recording of information rather than improvements in clinical outcomes.

Identification of features of electronic prescribing systems to support quality and safety in primary care using a modified Delphi process.

BACKGROUND: Electronic prescribing is increasingly being used in primary care and in hospitals. Studies on the effects of e-prescribing systems have found evidence for both benefit and harm. The aim of this study was to identify features of e-prescribing software systems that support patient safety and quality of care and that are useful to the clinician and the patient, with a focus on improving the quality use of medicines. METHODS: Software features were identified by a literature review, key informants and an expert group. A modified Delphi process was used with a 12-member multidisciplinary expert group to reach consensus on the expected impact of the features in four domains: patient safety, quality of care, usefulness to the clinician and usefulness to the patient. The setting was electronic prescribing in general practice in Australia. RESULTS: A list of 114 software features was developed. Most of the features relate to the recording and use of patient data, the medication selection process, prescribing decision support, monitoring drug therapy and clinical reports. The expert group rated 78 of the features (68%) as likely to have a high positive impact in at least one domain, 36 features (32%) as medium impact, and none as low or negative impact. Twenty seven features were rated as high positive impact across 3 or 4 domains including patient safety and quality of care. Ten features were considered "aspirational" because of a lack of agreed standards and/or suitable knowledge bases. CONCLUSIONS: This study defines features of e-prescribing software systems that are expected to support safety and quality, especially in relation to prescribing and use of medicines in general practice. The features could be used to develop software standards, and could be adapted if necessary for use in other settings and countries.

Genomics made easier: an introductory tutorial to genome datamining.

Integrated genome databases--such as the UCSC, Ensembl and NCBI MapViewer databases--and their associated data querying and visualization interfaces (e.g. the genome browsers) have transformed the way that molecular biologists, geneticists and bioinformaticists analyze genomic data. Nevertheless, because of the complexity of these tools, many researchers take advantage of only a fraction of their capabilities. In this tutorial, using examples from medical genetics and alternative splicing, I describe some of the biological questions that can be addressed with these techniques. I also show why doing so typically is more effective than using alternative methods and indicate some of the resources available for learning more about the advanced capabilities of these powerful tools.

Clinical data extraction and feedback in general practice: a case study from Australian primary care.

BACKGROUND: Quality improvement in general practice has increasingly focused on the analysis of its clinical databases to guide its improvement strategies. However, general practitioners (GPs) need to be motivated to extract and review their clinical data, and they need skills to do so. This study examines the initial experience of 15 practices in undertaking clinical data extraction and management and the support they were given by their local division of general practice. OBJECTIVES: To explore the uptake of data extraction tools in general practice and understand how divisions of general practice can assist with their uptake. METHOD: This study was conducted within a single division of general practice within the south-eastern suburbs of metropolitan Melbourne, Australia. Self-selected practices were offered a data extraction program ('tool') free of charge, with ongoing division support. Practice representatives, either GPs, practice nurses or other practice staff members, were given instructions on how to extract data using the data extraction tool. This was followed by discussion with division staff regarding which clinical areas might be focused on. Division staff systematically recorded information about the experience of the practices and collated their clinical data. RESULTS: Fifteen practices, representing 69 GPs, participated. The practices chose from the following areas to work on as quality improvement activities: improving data entry; inactivating patient files for those who no longer attended the practice; correcting demographic information; diabetes and coronary heart disease management. The recording of data, according to the extraction tool, was found to be incomplete. For example, one-third of the patients who had HbA1cs recorded were on target, i.e. <7%, but nearly half the patients with diabetes did not have HbA1cs recorded at all. About half the patients with coronary heart disease were not reported as taking aspirin and one-third were not on a statin. Nearly half the patients who had attended their practice in the previous 30 months did not have smoking status recorded. CONCLUSION: While data extraction programs provide GPs with useful tools for examining their clinical databases and identifying clinical practice issues which could be improved, external support, such as that provided by divisions, is helpful. Technical barriers, such as the failure of extraction tools to recognise some data and the failure to comprehensively enter data, are impediments, but in spite of these considerable interest exists in the use of clinical data to improve practice.

A bibliometric analysis of Australian general practice publications from 1980 to 2007 using PubMed.

BACKGROUND: We analysed Australian general practice (GP) publications in PubMed from 1980 to 2007 to determine journals, authors, publication types, national health priority areas (NHPA) and compared the results with those from three specialties (public health, cardiology and medical informatics) and two countries (the UK and New Zealand). METHOD: Australian GP publications were downloaded in MEDLINE format using PubMed queries and were written to a Microsoft Access database using a software application. Search Query Language and online PubMed queries were used for further analysis. RESULTS: There were 4777 publications from 1980 to 2007. Australian Family Physician (38.1%) and the Medical Journal of Australia (17.6%) contributed 55.7% of publications. Reviews (12.7%), letters (6.6%), clinical trials (6.5%) and systematic reviews (5%) were the main PubMed publication types. Thirty five percent of publications addressed National Health Priority Areas with material on mental health (13.7%), neoplasms (6.5%) and cardiovascular conditions (5.9%). The comparable numbers of publications for the three specialties were: public health - 80 911, cardiology - 15 130 and medical informatics - 3338; total country GP comparisons were: UK - 14 658 and New Zealand - 1111. DISCUSSION: Australian GP publications have shown an impressive growth from 1980 to 2007 with a 15-fold increase. This increase may be due in part to the actions of the Australian government over the past decade to financially support research in primary care, as well as the maturing of academic general practice. This analysis can assist governments, researchers, policy makers and others to target resources so that further developments can be encouraged, supported and monitored.

Does patient satisfaction of general practice change over a decade?

BACKGROUND: The Patient Participation Program (PPP) was a patient satisfaction survey endorsed by the Royal Australian College of General Practitioners and designed to assist general practitioners in continuous quality improvement (CQI). The survey was been undertaken by 3500 practices and over a million patients between 1994 and 2003. This study aimed to use pooled patient questionnaire data to investigate changes in satisfaction with primary care over time. METHODS: The results of 10 years of the PPP surveys were analyzed with respect to 10 variables including the year of completion, patient age, gender, practice size, attendance at other doctors, and whether the practice had previously undertaken the survey. Comparisons were made using Logistic Generalized Estimating Equations (LGEE). RESULTS: There was a very high level of satisfaction with general practice in Australia (99% of respondents). An independent indicator of satisfaction was created by pooling the results of 12 questions. This new indicator had a greater variance than the single overall satisfaction question. Participants were shown to have higher levels of satisfaction if they were male, older, did not attend other practitioners or the practice was small in size. A minimal improvement in satisfaction was detected in this pooled indicator for the second or third survey undertaken by a practice. There was however no statistically significant change in pooled satisfaction with the year of survey. CONCLUSION: The very high level of satisfaction made it difficult to demonstrate change. It is likely that this and the presentation of results made it difficult for GPs to use the survey to improve their practices. A more useful survey would be more sensitive to detect negative patient opinions and provide integrated feedback to GPs. At present, there are concerns about the usefulness of the PPP in continuous quality improvement in general practice.

GP and nurses' perceptions of how after hours care for people receiving palliative care at home could be improved: a mixed methods study.

BACKGROUND: Primary health care providers play a dominant role in the provision of palliative care (PC) in Australia but many gaps in after hours service remain. In some rural areas only 19% of people receiving palliative care achieve their goal of dying at home. This study, which builds on an earlier qualitative phase of the project, investigates the gaps in care from the perspective of general practitioners (GPs) and PC nurses. METHODS: Questionnaires, developed from the outcomes of the earlier phase, and containing both structured and open ended questions, were distributed through Divisions of General Practice (1 urban, 1 rural, 1 mixed) to GPs (n = 524) and through a special interest group to palliative care nurses (n = 122) in both rural and urban areas. RESULTS: Questionnaires were returned by 114 GPs (22%) and 52 nurses (43%). The majority of GPs were associated with a practice which provided some after hours services but PC was not a strong focus for most. This was reflected in low levels of PC training, limited awareness of the existence of after hours triage services in their area, and of the availability of Enhanced Primary Care (EPC) Medicare items for care planning for palliative patients. However, more than half of both nurses and GPs were aware of accessible PC resources.Factors such as poor communication and limited availability of after hours services were identified the as most likely to impact negatively on service provision. Strategies considered most likely to improve after hours services were individual patient protocols, palliative care trained respite carers and regular multidisciplinary meetings that included the GP. CONCLUSION: While some of the identified gaps can only be met by long term funding and policy change, educational tools for use in training programs in PC for health professionals, which focus on the utilisation of EPC Medicare items in palliative care planning, the development of advance care plans and good communication between members of multidisciplinary teams, which include the GP, may enhance after hours service provision for patients receiving palliative care at home. The role of locums in after PC is an area for further research.

Are general practice networks 'ready' for clinical data management?

BACKGROUND: Australian general practice networks (GPN) are required to report on national performance indicators under the Australian Government Department of Health and Ageing's National Quality Performance System (NQPS). OBJECTIVE: To investigate the extent to which Victorian GPN are 'ready' to manage clinical data from general practice for reporting under the NQPS. METHODS: A qualitative study using semistructured interviews from a purposive sample of chief executive officers from urban and rural Victorian GPN included those either participating or not participating in the Australian Primary Care Collaboratives Program. RESULTS: Australian Primary Care Collaborative experienced DGP have developed the range of skills and knowledge to undertake clinical data management for quality improvement and NQPS reporting. Trust by local general practices for the provision of clinical data has been developed through the demonstration of benefits to practices and improved patient health. General practice networks without Australian Primary Care Collaborative experience have a range of concerns about clinical data management for NQPS reporting, such as gaining cooperation from their practices, handling privacy issues and finding appropriately skilled staff. CONCLUSION: Victorian GPN involved in the Australian Primary Care Collaborative appear more 'ready' than GPN without this experience to undertake clinical data management for reporting purposes on the national performance indicators under the NQPS.

Glycaemic control of Type 2 diabetes in older patients visiting general practitioners: An examination of electronic medical records to identify risk factors for poor control.

OBJECTIVE: To investigate factors associated with glycaemic control of diabetes in older patients in the general practice setting in metropolitan Melbourne, Australia. METHOD: This retrospective study used the data from 10,257 patients aged ≥ 65 years with Type 2 diabetes from the Melbourne East Monash General Practice Database (MAGNET), 2009-2014. Poor glycaemic control was defined as HbA1c ≥ 9.0%. Univariate and multivariate analyses were conducted to assess the association between risk factors and glycaemic control. RESULTS: Of the total 10,257 patients, 6819 (66.5%) had their HbA1c recorded within a period of 2 years prior to their last GP visit. Between 4% and 6% had HbA1c level ≥ 9.0%. Robust predictors of poor glycaemic control were found to be decreasing age group (OR = 0.77, 95% CI: 0.65-0.90) and prescribed insulin (OR = 2.83, 95% CI: 2.41-3.32). CONCLUSION: One third of older patients with Type 2 diabetes did not have HbA1c recorded in the previous 2 years, despite clinical guidelines recommending at least annual testing. Many older patients had good glycaemic control, however the findings indicate that those aged 65-74 and those prescribed insulin may require special care and management to achieve this.

Non-coding RNAs: hope or hype?

The past four years have seen an explosion in the number of detected RNA transcripts with no apparent protein-coding potential. This has led to speculation that non-protein-coding RNAs (ncRNAs) might be as important as proteins in the regulation of vital cellular functions. However, there has been significantly less progress in actually demonstrating the functions of these transcripts. In this article, we review the results of recent experiments that show that transcription of non-protein-coding RNA is far more widespread than was previously anticipated. Although some ncRNAs act as molecular switches that regulate gene expression, the function of many ncRNAs is unknown. New experimental and computational approaches are emerging that will help determine whether these newly identified transcription products are evidence of important new biochemical pathways or are merely 'junk' RNA generated by the cell as a by-product of its functional activities.

eConsulting.

eConsulting, in all its contexts, can promote and improve the amount and quality of services and knowledge transferred to and among the community of health care providers and consumers. It can also improve the efficiency and effectiveness of the specialist and generalist workforce and accessibility to the services provided. This chapter defines eConsulting, provides the context, and introduces a conceptual framework to describe its current practice and future possibilities. A clinical scenario of a patient with a breast lump is used to ground the molecular, clinical, organizational, and social, legal, and ethical issues in real world practice. The approach/method used is based on the clinical process, evidence-based practice, and appraising the quality, validity, relevance, and usefulness of the information. The practicalities and utility of current eConsulting tools are discussed with a view to future ubiquitous use. Working through this chapter should assist readers to understand and describe (1) how eConsultations can link and translate scientific research into clinical practice, (2) the current implications of eConsultations, (3) the future potential of eConsultations.