Improving depression outcomes among Australian primary care patients: protocol for a cluster randomised controlled trial.

INTRODUCTION: Depression is a common and debilitating condition. In Australia, general practitioners (GPs) are the key providers of depression care. However, available evidence suggests that case finding for depression in primary care is poor. This study will examine whether a systematic approach to screening for depression and assessing patient preferences for depression care improves depression outcomes among primary care patients. METHODS AND ANALYSIS: A cluster randomised controlled design will be used with general practice clinics randomly assigned to either the intervention (n=12) or usual care group (n=12). Patients who are aged 18 and older, presenting for general practice care, will be eligible to participate. Eighty-three participants will be recruited at each clinic. Participants will be asked to complete a baseline survey administered on a touch screen computer at their GP clinic, and then a follow-up survey at 3, 6 and 12 months. Those attending usual care practices will receive standard care. GPs at intervention practices will complete an online Clinical e-Audit, and will be provided with provider and patient-directed resources for depression care. Patients recruited at intervention practices who score 10 or above on the Patient Health Questionnaire-9 will have feedback regarding their depression screening results and preferences for care provided to their GP. The primary analysis will compare the number of cases of depression between the intervention and control groups. ETHICS AND DISSEMINATION: The study has been approved by the University of Newcastle Human Research Ethics Committee, and registered with Human Research Ethics Committees of the University of Wollongong, Monash University and University of New South Wales. Results will be disseminated through peer-reviewed journal publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12618001139268; Pre-results.

The male reproductive system - An overview of common problems.

BACKGROUND: Many male reproductive system problems could be perceived as being embarrassing, which may be one of the reasons that they are often not identified in general practice. OBJECTIVE: This article provides an overview of some common problems affecting the male reproductive system, and outlines current treatment options. DISCUSSION: Erectile dysfunction, premature ejaculation, loss of libido, testicular cancer and prostate disease may cause embarrassment to the patient and, occasionally, the general practitioner. We describe how patients affected by these conditions may present to general practice, and discuss the reasons why they may not present. We also discuss how GPs can overcome difficulties in identifying and dealing with their male patients suffering from male reproductive system issues.

Transgenerational learning: maximising resources, minimising teaching gaps and fostering progressive learning.

The need to rationalise teaching resources underpinned a project at Monash University that used a Delphi technique to re-examine the teaching curriculum of two key topic areas in the medical curriculum - ophthalmology and dermatology - from an undergraduate, graduate and vocational perspective. Using Bloom's taxonomy the learning objectives from these topic areas were collated and analysed. This process allowed the revising and redistributing of learning objectives of the curricula to reduce the likelihood of duplication of teaching or more importantly gaps in teaching occurring. This process highlighted the potential utility of using a transgenerational approach to curriculum planning but the outcomes are limited due to the small number of participating educators and the lack of formal evaluation of the method.

Simplifying screening for osteoporosis in Australian primary care: the Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests (PROSPECT) study.

OBJECTIVE: Although bone density by dual-energy x-ray absorptiometry (DXA) is the standard measure for the diagnosis of osteoporosis, as a screening tool, it has significant cost and availability of DXA is not universal. Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests (PROSPECT) was a national study undertaken to establish an effective prescreening protocol to be used in primary care facilitating targeted radiological investigation for osteoporosis in older women. METHODS: Two hundred sixty-seven primary care physicians recruited 2,466 women 70 years and older who had no previous diagnosis of osteoporosis in a community-based cross-sectional study. The main outcome measures used were lumbar spine and femoral neck T-scores on DXA and presence of a vertebral fracture on thoracolumbar x-ray. Participant characteristics, gap-on-wall occiput test, and rib-to-pelvis distance measurements were provided by each primary care physician. RESULTS: Of the study population, 21.8% (95% CI, 19.9%-23.8%) had osteoporosis of the femoral neck and/or lumbar spine based on DXA, and 24.7% (95% CI, 22.5%-26.9%) had at least one vertebral fracture. Only 7.3% (95% CI, 6.2%-8.3%) had both osteoporosis and radiological vertebral fracture. Univariate and multivariate regression modeling of the demographic and clinical data collected resulted in a three-factor predictive tool for the diagnosis of osteoporosis and/or vertebral fracture that included the following variables: rib-pelvis distance greater than 2 fingerbreadths (yes/no), ever use of estrogen for more than 6 months (yes/no), and body mass index (<25, 25-30, >30 kg/m²). Only screening women classified as moderate to high risk by the tool DXA plus plain x-ray would then result in 14% of women 70 years or older who were not being screened, with 93% of cases being detected. CONCLUSIONS: The Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests tool will contribute to the diagnosis and management of osteoporosis by facilitating targeted screening and hence reducing the need for unnecessary radiology tests at the primary care level.

Nurse-patient encounters in general practice: patterns in general practitioner involvement and use of nurse-specific Medicare items.

A significant gap exists in knowledge about general practice nurses' (GPNs) patient care activities, despite their now strong presence in Australian general practice. The aim of this paper is to explore the extent of direct general practitioner (GP) involvement in nurse-patient consultations, and to compare consultations where nurse-specific Medicare items were claimable with consultations where they were not. Data from the Practice Nurse Work Survey, a national cross-sectional survey conducted between May 2007 and May 2008, were analysed. Of the total 5253 nurse-patient encounters, 29% did not involve any contact between the patient and a GP, either directly before, during or directly after the nurse consultation. Encounters without GP involvement were more likely to be indirect (e.g. by telephone) and off-site (e.g. home visits), and had higher rates of administrative actions such as documentation and arranging visits. Nurse-specific Medicare item numbers applied in less than half (42%) of nurse-patient encounters. Encounters where no such item applied were more likely to involve medical examinations, blood tests, electrical tracings, physical function tests, removal of sutures, test results, assisting at operations and preparing for procedures. These results confirm that existing data collections do not capture the extent and nature of GPNs' clinical work.

The impact of a GP clinical audit on the provision of smoking cessation advice.

AIM: To investigate whether participation in a clinical audit and education session would improve GP management of patients who smoke. METHODS: GPs who participated in an associated smoking cessation research program were invited to complete a three-stage clinical audit. This process included a retrospective self-audit of smoking cessation management practices over the 6 months prior to commencing the study, attending a 2.5 hour education session about GP management of smoking cessation, and completion of a second retrospective self-audit 6 months later. Twenty-eight GPs completed the full audit and education process, providing information about their smoking cessation management with 1114 patients. The main outcome measure was changes in GP management of smoking cessation with patients across the audit period, as measured by the clinical audit tool. RESULTS: The majority of GPs (57%) indicated that as a result of the audit process they had altered their approach to the management of patients who smoke. Quantitative analyses confirmed significant increases in various forms of evidence-based smoking cessation management practices to assist patients to quit, or maintain quitting across the audit period. However comparative analyses of patient data challenged these findings, suggesting that the clinical audit process had less impact on GP practice than suggested in GP's self-reported audit data. CONCLUSION: This study provides some support for the combined use of self-auditing, feedback and education to improve GP management of smoking cessation. However further research is warranted to examine GP- and patient-based reports of outcomes from clinical audit and other educational interventions.

Quality and consistency of clinical practice guidelines for diagnosis and management of osteoarthritis of the hip and knee: a descriptive overview of published guidelines.

OBJECTIVE: To present a descriptive overview of the quality and recommendations of clinical practice guidelines (CPGs) on diagnosis or management of osteoarthritis (OA) of the hip and/or knee. DATA SOURCES: CPGs were identified from several research databases (MEDLINE, EMBASE and The Cochrane Library) and guideline-specific databases from 1966 to August 2005. GUIDELINE RETRIEVAL: Thirty-four relevant CPGs were identified. DATA EXTRACTION: Recommendations were extracted from CPGs and categorised into: assessment and diagnosis, pharmacological management, nonpharmacological management, complementary/alternative therapy, or surgery. The quality of the CPGs were assessed by two appraisers using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. DATA SYNTHESIS: Most recommendations for aspects of diagnosis and treatment of OA of the hip and/or knee were consistent among the CPGs included in this study. However, quality varied considerably, with few CPGs being "strongly recommended" according to the AGREE quality appraisal instrument. CONCLUSIONS: Given the number of CPGs available relevant to OA, and the consistency of recommendations within them, and considering the time and resources required for CPG development, future efforts to guide management of OA of the hip and/or knee may be better directed towards adapting existing CPGs to the local context, implementing practices known to be effective, and facilitating research to answer important questions where there is little evidence.

GPs as medical educators--an Australian train-the-trainer program.

BACKGROUND: General practitioners undertake ongoing education in many areas. A train-the-trainer (TTT) approach may be an option for facilitation of continuing professional development (CPD) activities. METHODS: With the aim of training GPs to facilitate peer CPD activities, Monash University's Department of General Practice undertook a national TTT program on men's sexual and reproductive health. Over a 3 year period, 40 'GP trainers' were trained to facilitate education sessions on the topics of androgen deficiency, erectile dysfunction, prostate cancer and male infertility for 568 GPs from 33 Australian divisions of general practice. RESULTS: Evaluation of this program showed that GP trainers were a valuable resource for conducting training programs for GPs, being experienced role models who could provide relevant and practical training to their colleagues. DISCUSSION: While resource intensive, the TTT model provided an effective means of improving GP knowledge and clinical practice on men's sexual and reproductive health.

In-practice management versus quitline referral for enhancing smoking cessation in general practice: a cluster randomized trial.

BACKGROUND AND OBJECTIVE: GPs are an important source of smoking cessation advice. This research examined whether a model encouraging GP referral of patients who smoke to a specialist service would be acceptable and effective for increased smoking cessation when compared with a model of in-practice management. METHODS: The study design was cluster randomized controlled trial. Practices were randomized to one of two interventions, at a rate of 1:2: (i) standard in-practice GP management or (ii) referral to a quitline service. The main outcome measures were sustained abstinence of >or=1 month duration at 3-month follow-up and >or=10 months duration at 12 months, using intention to treat analysis. RESULTS: At 3-month follow-up, patients in the referral condition were twice as likely to report sustained abstinence than those in the in-practice condition [12.3% compared with 6.9%; odds ratio (OR) = 1.92 (95% confidence interval (CI) 1.17-3.13]. At 12-month follow-up, patients in the referral condition had nearly three times the odds of sustained abstinence [6.5% compared with 2.6%; OR = 2.86 (95% CI 0.94-8.71)]. The intervention effect was mediated by the amount of help received outside the practice. CONCLUSIONS: This research provided evidence that GPs referring smokers to an evidence-based quitline service results in increased cessation. The benefit is largely due to patients in the referral condition receiving more external help than patients in the in-practice condition, as they received equivalent practice-based help. Where suitable services exist, we recommend that referral become the normative strategy for management of smoking cessation in general practice to complement any practice-based help provided.

Identifying the health and mental health information needs of people with coronary heart disease, with and without depression.

OBJECTIVE: To identify the health and mental health information needs of people with coronary heart disease (CHD), with and without comorbid depression. DESIGN AND SETTING: A qualitative study conducted in Melbourne in 2006, using thematic analysis of semi-structured interviews on the types of health information that patients with CHD considered useful to assist with the management of their illness. Structured clinical interviews were used to assess current and prior depressive episodes in these patients. PARTICIPANTS: 14 general practice patients (eight with current or prior history of major depression) who had experienced myocardial infarction, coronary artery bypass graft surgery, angioplasty or angina (confirmed via testing). RESULTS: Four themes relating to information on how patients could manage their cardiovascular health and improve their psychosocial wellbeing emerged: psychosocial; physical activity; medical; and information for family. The most prominent information needs included identification and management of risk-related physical symptoms, and psychosocial information, most notably to enhance patients' social support. Patients considered this information important for alleviating health anxiety and negative affect. CONCLUSION: This small patient sample endorsed the need for health and mental health information on a range of psychosocial and physical health topics. Participants desired specific types of information to assist with the self-management of their health and to assuage their health concerns.

Chronic heart failure--optimising care in general practice.

BACKGROUND: Chronic heart failure (CHF) is a significant cause of mortality and morbidity in developed countries where it predominantly affects elderly persons with a range of other comorbid conditions requiring polypharmacy. In Australia, over 300 000 people are affected by CHF. Quality general practice forms the cornerstone for early diagnosis and evidence based integrated care. OBJECTIVE: This article examines the epidemiology of CHF, its clinical diagnosis, contemporary management and future treatment possibilities, as well as current barriers to optimal care. DISCUSSION: The global prevalence of CHF is rising. Optimal treatment requires a coordinated interdisciplinary approach using a biopsychosocial model of care in order to maximise compliance with therapy. Pharmacological treatment is essential and should include an angiotensin converting enzyme inhibitor and beta blocker where possible. Device based treatment and cardiac surgery may benefit selected cases.

Gastro-oesophageal reflux disease--current concepts in management.

BACKGROUND: Gastro-oesophageal reflux disease (GORD) is defined as recurring symptoms or mucosal damage resulting from exposure of the distal oesophagus to reflux of gastric contents. In the past, GORD has been managed with a 'step up' approach beginning with antacids and progressing to H2 antagonists or proton pump inhibitors (PPI) as required. OBJECTIVE: This article presents a systematic approach to the management of GORD. DISCUSSION: Diagnosis of GORD is made on the basis of symptoms and the decision to treat is based on the symptom pattern. Endoscopy is reserved for cases where there are alarm symptoms, diagnostic uncertainty, poor response to treatment or clinical suspicion of a complication such as Barrett's oesophagus or stricture. A 'step down' approach to treatment involves treating with a PPI for 4-8 weeks. Aggressive therapy is then reduced to maintenance doses, intermittent therapy or in some cases, withdrawn. However, relapse occurs in about 70% of all patients within 6 months. A step down approach ensures more rapid resolution of symptoms, improved quality of life, reduced risk of complications, and overall lower cost.