Nurse and midwife involvement in task-sharing and telehealth service delivery models in primary care: A scoping review.

AIM: To synthesise and map current evidence on nurse and midwife involvement in task-sharing service delivery, including both face-to-face and telehealth models, in primary care. DESIGN: This scoping review was informed by the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews. DATA SOURCE/REVIEW METHODS: Five databases (Ovid MEDLINE, Embase, PubMed, CINAHL and Cochrane Library) were searched from inception to 16 January 2024, and articles were screened for inclusion in Covidence by three authors. Findings were mapped according to the research questions and review outcomes such as characteristics of models, health and economic outcomes, and the feasibility and acceptability of nurse-led models. RESULTS: One hundred peer-reviewed articles (as 99 studies) were deemed eligible for inclusion. Task-sharing models existed for a range of conditions, particularly diabetes and hypertension. Nurse-led models allowed nurses to work to the extent of their practice scope, were acceptable to patients and providers, and improved health outcomes. Models can be cost-effective, and increase system efficiencies with supportive training, clinical set-up and regulatory systems. Some limitations to telehealth models are described, including technological issues, time burden and concerns around accessibility for patients with lower technological literacy. CONCLUSION: Nurse-led models can improve health, economic and service delivery outcomes in primary care and are acceptable to patients and providers. Appropriate training, funding and regulatory systems are essential for task-sharing models with nurses to be feasible and effective. IMPACT: Nurse-led models are one strategy to improve health equity and access; however, there is a scarcity of literature on what these models look like and how they work in the primary care setting. Evidence suggests these models can also improve health outcomes, are perceived to be feasible and acceptable, and can be cost-effective. Increased utilisation of nurse-led models should be considered to address health system challenges and improve access to essential primary healthcare services globally. REPORTING METHOD: This review is reported against the PRISMA-ScR criteria. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. PROTOCOL REGISTRATION: The study protocol is published in BJGP Open (Moulton et al., 2022).

Expanding community pharmacists' scope of practice in relation to contraceptive counselling and referral: a protocol for a pragmatic, stepped-wedge, cluster randomised trial (ALLIANCE).

INTRODUCTION: Improving access to effective contraception has the potential to reduce unintended pregnancy and abortion rates. Community pharmacists could play an expanded role in contraceptive counselling and referral to contraceptive prescribers particularly when women are already attending community pharmacy to obtain emergency contraceptive pills (ECPs) or to have medical abortion (MA) medicines dispensed. The ALLIANCE trial aims to compare the subsequent uptake of effective contraception (hormonal or intrauterine) in women seeking ECP or MA medicines, who receive the ALLIANCE community pharmacy-based intervention with those who do not receive the intervention. METHODS AND ANALYSIS: ALLIANCE is a stepped-wedge pragmatic cluster randomised trial in Australian community pharmacies. The ALLIANCE intervention involves community pharmacists delivering structured, patient-centred, effectiveness-based contraceptive counselling (and a referral to a contraceptive prescriber where appropriate) to women seeking either ECPs or to have MA medicines dispensed. Women participants will be recruited by participating pharmacists. A total of 37 pharmacies and 1554 participants will be recruited. Pharmacies commence in the control phase and are randomised to transition to the intervention phase at different time points (steps). The primary outcome is the self-reported use of effective contraception at 4 months; secondary outcomes include use of effective contraception and the rate of pregnancies or induced abortions at 12 months. A process and economic evaluation of the trial will also be undertaken. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Monash University Human Research Ethics Committee (#34563). An explanatory statement will be provided and written consent will be obtained from all participants (pharmacy owner, pharmacist and women) before their commencement in the trial. Dissemination will occur through a knowledge exchange workshop, peer-reviewed journal publications, presentations, social media and conferences. TRIAL REGISTRATION NUMBER: ACTRN12622001024730.

Improving rural and regional access to long-acting reversible contraception and medical abortion through nurse-led models of care, task-sharing and telehealth (ORIENT): a protocol for a stepped-wedge pragmatic cluster-randomised controlled trial in Australian general practice.

INTRODUCTION: Women living in rural and regional Australia often experience difficulties in accessing long-acting reversible contraception (LARC) and medical abortion services. Nurse-led models of care can improve access to these services but have not been evaluated in Australian general practice. The primary aim of the ORIENT trial (ImprOving Rural and regIonal accEss to long acting reversible contraceptioN and medical abortion through nurse-led models of care, Tasksharing and telehealth) is to assess the effectiveness of a nurse-led model of care in general practice at increasing uptake of LARC and improving access to medical abortion in rural and regional areas. METHODS AND ANALYSIS: ORIENT is a stepped-wedge pragmatic cluster-randomised controlled trial. We will enrol 32 general practices (clusters) in rural or regional Australia, that have at least two general practitioners, one practice nurse and one practice manager. The nurse-led model of care (the intervention) will be codesigned with key women's health stakeholders. Clusters will be randomised to implement the model sequentially, with the comparator being usual care. Clusters will receive implementation support through clinical upskilling, educational outreach and engagement in an online community of practice. The primary outcome is the change in the rate of LARC prescribing comparing control and intervention phases; secondary outcomes include change in the rate of medical abortion prescribing and provision of related telehealth services. A within-trial economic analysis will determine the relative costs and benefits of the model on the prescribing rates of LARC and medical abortion compared with usual care. A realist evaluation will provide contextual information regarding model implementation informing considerations for scale-up. Supporting nurses to work to their full scope of practice has the potential to increase LARC and medical abortion access in rural and regional Australia. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID: 29476). Findings will be disseminated via multiple avenues including a knowledge exchange workshop, policy briefs, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000086763).

Utilising HealthPathways to understand the availability of public abortion in Australia.

BACKGROUND: Access to publiclyfunded abortion in Australia is limited, with a considerable proportion carried out by private providers. There are no nationally reported data on public abortion services, and referral pathways are poorly coordinated between hospital and primary care sectors. HealthPathways is an online system for use in primary care that provides information on referral pathways to local services. The aim of this study was to describe abortion referral pathways for each HealthPathways portal in Australia. METHODS: A review of Australian HealthPathways content on abortion was undertaken between January and June 2022. For each HealthPathways portal, data were extracted on referral options to abortion services. RESULTS: Overall, 17 out of 34 Australian HealthPathways consented to be included. Nearly half (47%) had no public services listed for surgical abortion, and 35% had no public services for medical abortion. The majority (64% for surgical abortion, 67% for medical abortion) emphasised that public services should be considered only as a last resort. There was variation in information regarding gestation-specific options, the time-critical nature of referrals, and the importance of women's own preference when deciding between medical or surgical abortion. CONCLUSION: Despite few remaining legal restrictions to abortion, many regions across Australia either do not have public abortion services or do not provide information about them. There is an urgent need for transparency around public abortion service availability, clear guidelines to support referral pathways, and commitment from State and Federal governments to expand the availability of accessible, no-cost abortion in Australia.

Opportunities for Increasing Access to Effective Contraception in Australia.

Effective contraception can prevent unintended pregnancies, however there is an unmet need for effective contraception in Australia. Despite their being a range of contraceptive methods available, access to these remains equitable and uptake of the most effective methods is low. There is an opportunity to reduce the rate of unintended pregnancies in Australia by improving the uptake of effective contraception for those who desire this. Improving access will require increasing consumer health literacy about contraception, as well as the option of telehealth as a mode of service delivery, and stronger investment in contraceptive services through appropriate reimbursement for providers. There is also a need to test new models of care to increase access to and use of effective contraception in Australia, including nurse and midwifery-led models of contraceptive care and pharmacy involvement in contraceptive counseling.

Building a practice-based research network for healthcare integration: a protocol paper for a mixed-method project.

INTRODUCTION: Practice-based research networks (PBRNs) are sustained collaborations between healthcare professionals, researchers and members of the community that develop, conduct and report on research relevant to local needs. While PBRNs have traditionally been focused towards primary care practices and their patients, there has been increasing interest in how they may help facilitate healthcare integration. Yet, little is known on the ways in which PBRNs can best integrate with the broader healthcare system, in particular Advanced Health Research and Translation Centres. The overall project aim is to build a sustainable collaboration between a PBRN and an Advanced Health Research and Translation Centre to generate a research platform suitable for planning, undertaking and translating research to improve care across the healthcare continuum. METHODS AND ANALYSIS: We will use a developmental evaluation design. Our iterative approach will be informed by a programme logic model and consists of: preparation work (pre-implementation assessment, literature review, community and stakeholder engagement), adaptation and building for a sustainable collaboration (strategy for recruitment and sustainment of members) and planning for network action (designing and implementing priority initiatives, monitoring and follow-up). ETHICS AND DISSEMINATION: This project was approved by the Monash Health ethics committee (ERM Reference Number: 76281; Monash Health Ref: RES-21-0000-392L) and the Monash University Human Research ethics committee (Reference Number: 29786). Dissemination will take place via various channels, including relevant national and international committees and conferences, peer-reviewed journals and social media. Continuous dissemination to and communication with all participants in this project as well as other relevant stakeholders will help strengthen and sustain the network.

Cost-effectiveness of a complex intervention in general practice to increase uptake of long-acting reversible contraceptives in Australia.

Objective The aim of this study was to evaluate the cost-effectiveness of the Australian Contraceptive ChOice pRoject (ACCORd) intervention. Methods An economic evaluation compared the costs and outcomes of the ACCORd intervention with usual care (UC). Data from the ACCORd trial were used to estimate costs and efficacy in terms of contraceptive uptake and quality of life. Rates of contraceptive failure and pregnancy were sourced from the literature. Using a Markov model, within-trial results were extrapolated over 10 years and subjected to univariate sensitivity analyses. Model outputs were expressed as the cost per quality-adjusted life years (QALY) gained and cost per unintended pregnancy resulting in birth (UPB) avoided. Results Over 10 years, compared with UC, initiating contraception through the ACCORd intervention resulted in 0.02 fewer UPB and higher total costs (A$2505 vs A$1179) per woman. The incremental cost-effectiveness of the ACCORd intervention versus UC was A$1172 per QALY gained and A$7385 per UPB averted. If the start-up cost of the ACCORd intervention was removed, the incremental cost-effectiveness ratio was A$81 per QALY gained and A$511 per UPB averted. The results were most sensitive to the probability of contraceptive failure, the probability of pregnancy-related healthcare service utilisation or the inclusion of the costs of implementing the ACCORd intervention. Conclusions From a health system perspective, if implemented appropriately in terms of uptake and reach, and assuming an implicit willingness to pay threshold of A$50 000 the ACCORd intervention is cost-effective. What is known about the topic? The uptake of long-active reversible contraceptives (LARC) in Australia is low. The ACCORd trial assessed the efficacy of providing structured training to general practitioners (GPs) on LARC counselling, together with access to rapid referral to insertion clinics. What does this paper add? This study is the first to assess the cost-effectiveness of a complex intervention in the general practice setting aimed at increasing the uptake of LARC in Australia. What are the implications for practitioners? The results show that implementing a complex intervention in general practice involving GP education and the availability of rapid referral to LARC insertion clinics is a cost-effective approach to increase LARC use and its attending efficacy. If the majority of Australian GPs were able to deliver effectiveness-based contraceptive counselling and either insert LARC or use a rapid referral process to a LARC insertion clinic, the additional cost associated with the purchase of LARC products and their insertion would be offset by reductions to health system costs as a result of fewer UPB and abortions. Moreover, the benefits to women's physical and psychological health of avoiding such events is substantial.

Implementing work-related Mental health guidelines in general PRacticE (IMPRovE): a protocol for a hybrid III parallel cluster randomised controlled trial.

BACKGROUND: The Clinical Guideline for the Diagnosis and Management of Work-related Mental Health Conditions in General Practice (the Guideline) was published in 2019. The objective of this trial is to implement the Guideline in general practice. TRIAL DESIGN: Implementing work-related Mental health conditions in general PRacticE is a hybrid III, parallel cluster randomised controlled trial undertaken in Australia. Its primary aim is to assess the effectiveness of a complex intervention on the implementation of the Guideline in general practice. Secondary aims are to assess patient health and work outcomes, to evaluate the cost-effectiveness of the trial, and to develop a plan for sustainability. METHODS: A total of 86 GP clusters will be randomly allocated either to the intervention arm, where they will receive a complex intervention comprising academic detailing, enrolment in a community of practice and resources, or to the control arm, where they will not receive the intervention. GP guideline concordance will be assessed at baseline and 9 months using virtual simulated patient scenarios. Patients who meet the eligibility criteria (>18years, employed, and receiving care from a participating GP for a suspected or confirmed work-related mental health condition) will be invited to complete surveys about their health and work participation and provide access to their health service use data. Data on health service use and work participation compensation claim data will be combined with measures of guideline concordance and patient outcomes to inform an economic evaluation. A realist evaluation will be conducted to inform the development of a plan for sustainability. RESULTS: We anticipate that GPs who receive the intervention will have higher guideline concordance than GPs in the control group. We also anticipate that higher concordance will translate to better health and return-to-work outcomes for patients, as well as cost-savings to society. CONCLUSIONS: The trial builds on a body of work defining the role of GPs in compensable injury, exploring their concerns, and developing evidence-based guidelines to address them. Implementation of these guidelines has the potential to deliver improvements in GP care, patient health, and return-to-work outcomes. TRIAL REGISTRATION: ACTRN12620001163998 , November 2020.

HARMONY: a pragmatic cluster randomised controlled trial of a culturally competent systems intervention to prevent and reduce domestic violence among migrant and refugee families in general practice: study protocol.

INTRODUCTION: Domestic violence and abuse (DVA) is prevalent, harmful and more dangerous among diaspora communities because of the difficulty accessing DVA services, language and migration issues. Consequently, migrant/refugee women are common among primary care populations, but evidence for culturally competent DVA primary care practice is negligible. This pragmatic cluster randomised controlled trial aims to increase DVA identification and referral (primary outcomes) threefold and safety planning (secondary outcome) among diverse women attending intervention vs comparison primary care clinics. Additionally, the study plans to improve recording of DVA, ethnicity, and conduct process and economic evaluations. METHODS AND ANALYSIS: Recruitment of ≤28 primary care clinics in Melbourne, Australia with high migrant/refugee communities. Eligible clinics need ≥1 South Asian general practitioner (GP) and one of two common software programmes to enable aggregated routine data extraction by GrHanite. Intervention staff undertake three DVA training sessions from a GP educator and bilingual DVA advocate/educator. Following training, clinic staff and DVA affected women 18+ will be supported for 12 months by the advocate/educator. Comparison clinics are trained in ethnicity and DVA data entry and offer routine DVA care. Data extraction of DV identification, safety planning and referral from routine GP data in both arms. Adjusted regression analysis by intention-to-treat by staff blinded to arm. Economic evaluation will estimate cost-effectiveness and cost-utility. Process evaluation interviews and analysis with primary care staff and women will be framed by Normalisation Process Theory to maximise understanding of sustainability. Harmony will be the first primary care trial to test a culturally competent model for the care of diverse women experiencing DVA. ETHICS AND DISSEMINATION: Ethical approval from La Trobe University Human Ethics Committee (HEC18413) and dissemination by policy briefs, journal articles and conference and community presentations. TRIAL REGISTRATION NUMBER: ANZCTR- ACTRN12618001845224; Pre-results.

Pharmacy-based initiatives to reduce unintended pregnancies: A scoping review.

BACKGROUND: Community pharmacy contraception services are thought to improve access, with the potential to reduce the persistent sexual and reproductive health inequities observed globally. OBJECTIVES: We aimed to identify the range of pharmacy-based initiatives addressing unintended pregnancy in the primary literature and examine their feasibility, acceptability and effectiveness. METHOD: Using the Joanna Briggs Institute Methodology for Scoping Reviews, we searched seven bibliographic databases using combinations of keywords and subject headings for related to contraception and community pharmacy. Studies of any design undertaken in high income countries for reproductive-aged women were eligible provided they evaluated intervention or legislation after the implementation of these initiatives. Included articles were critically appraised and findings summarised narratively. RESULTS: We identified 49 articles, 80% of which involved pharmacist supply of emergency contraception (EC), 14% of regular contraception methods, and 6% involved adjuncts of EC dispensing: counselling (2%) and bridging initiatives to link clients with regular contraception (4%). EC initiatives were perceived as feasible and were facilitated by interdisciplinary partnerships but there are persistent barriers to the provision of initiatives congruous with the retail pharmacy setting. Furthermore, consumers may be reluctant to receive contraceptive counselling from pharmacists but often value the convenience and anonymity pharmacy services offer. Overall, interventions improved access to contraceptive products but did not consistently reduce inequities, and the health benefits of pharmacy initiatives are either small (EC) or lacking description in the literature (other contraceptive methods and contraceptive counselling). CONCLUSIONS: Pharmacy initiatives may not negate all barriers to access or reduce unintended pregnancy rates, however they are valued by pharmacists and consumers. Evidence gaps including the lack of description of health outcomes of regular contraception provision, contraceptive counselling and the perceived barriers and facilitators of access and provision from end-user perspectives, should be pursued in future research, to establish initiatives' utility and effectiveness.

Development of an antimicrobial stewardship implementation model involving collaboration between general practitioners and pharmacists: GPPAS study in Australian primary care.

BACKGROUND: Rising antimicrobial resistance (AMR) in primary care is a growing concern and a threat to community health. The rise of AMR can be slowed down if general practitioners (GPs) and community pharmacists (CPs) could work as a team to implement antimicrobial stewardship (AMS) programs for optimal use of antimicrobial(s). However, the evidence supporting a GP pharmacist collaborative AMS implementation model (GPPAS) in primary care remains limited. AIM: With an aim to design a GPPAS model in Australia, this paper outlines how this model will be developed. METHODS: This exploratory study undertakes a systematic review, a scoping review, nationwide surveys, and qualitative interviews to design the model. Medical Research Council (MRC) framework and Normalization Process Theory are utilized as guides. Reviews will identify the list of effective GPPAS interventions. Two AMS surveys and paired interviews of GPs and CPs across Australia will explore their convergent and divergent views about the GPPAS interventions, attitudes towards collaboration in AMS and the perceived challenges of implementing GPPAS interventions. Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model and factor analyses will guide the structure of GPPAS model through identifying the determinants of GPPAS uptake. The implementable GPPAS strategies will be selected based on empirical feasibility assessment by AMS stakeholders using the APEASE (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects and safety, Equity) criteria. DISCUSSION: The GPPAS model might have potential implications to inform how to better involve GPs and CPs in AMS, and, to improve collaborative services to optimize antimicrobial use and reduce AMR in primary care.

At-home telemedicine for medical abortion in Australia: a qualitative study of patient experiences and recommendations.

INTRODUCTION: This study aimed to explore patient experiences obtaining a medical abortion using an at-home telemedicine service operated by Marie Stopes Australia. METHODS: From July to October 2017, we conducted semistructured in-depth telephone interviews with a convenience sample of medical abortion patients from Marie Stopes Australia. We analysed interview data for themes relating to patient experiences prior to service initiation, during an at-home telemedicine medical abortion visit, and after completing the medical abortion. RESULTS: We interviewed 24 patients who obtained care via the at-home telemedicine medical abortion service. Patients selected at-home telemedicine due to convenience, ability to remain at home and manage personal responsibilities, and desires for privacy. A few telemedicine patients reported that a lack of general practitioner knowledge of abortion services impeded their access to care. Most telemedicine patients felt at-home telemedicine was of equal or superior privacy to in-person care and nearly all felt comfortable during the telemedicine visit. Most were satisfied with the home delivery of the abortion medications and would recommend the service. CONCLUSION: Patient reports suggest that an at-home telemedicine model for medical abortion is a convenient and acceptable mode of service delivery that may reduce patient travel and out-of-pocket costs. Additional provider education about this model may be necessary in order to improve continuity of patient care. Further study of the impacts of this model on patients is needed to inform patient care and determine whether such a model is appropriate for similar geographical and legal contexts.

Medical abortion.

BACKGROUND: Medical abortion (using mifepristone followed by misoprostol to end an early pregnancy) is a more accessible and less invasive option than surgical termination and can be provided in primary care settings. However, few general practitioners (GPs) currently provide this service, and there remains great inequity in access to abortion across Australia, particularly for young women and those living in rural and remote area. OBJECTIVE: The aim of this article is to help Australian GPs better understand the practical and legal considerations of providing medical abortion to patients. DISCUSSION: Provision of medical abortion is well within the scope of community general practice and improves the comprehensiveness of women's sexual and reproductive health services that GPs can deliver. This article will help GPs to better understand the process involved in providing medical abortion, including the practical considerations for patients; be better equipped to support patients who have decided that medical abortion is an appropriate choice for them; and make an informed decision as to whether to become a provider of medical abortion.

Improving assessment of child development: Results of a quality improvement intervention in general practice.

AIMS: Parents' Evaluation of Developmental Status (PEDS) is a validated tool used to assess child development that has not previously been tested in Australian general practice. We examined the effect of a Quality-Improvement intervention in a single general practice in Melbourne, Australia, that aimed to use this tool to improve the documented assessment of child developmental surveillance during vaccination visits. METHODS: Mixed methods incorporated audits of clinical records of children aged 1-5 years, before and after intervention, written questionnaires and a focus group (informed by the theoretical domains framework and Capability, Opportunity, Motivation-Behaviour (COM-B model)) with clinical and non-clinical staff. RESULTS: After 6 months, developmental surveillance more than doubled and was documented in more than one in three visits (34.1%). Almost one in five (18.6%) vaccination visits included the PEDS tool. Overall, the tool was positively received with staff expressing high levels of comfort asking parents to complete it (92.8%), increasing development of professional skills (71.4% staff) and confidence (55% clinicians) detecting developmental delays. Thematic analysis of the focus group transcript revealed underlying barriers arising from the practice environment, staff capabilities and motivation. CONCLUSIONS: In a whole of practice Quality-Improvement intervention that applied PEDS training and implementation, including the receptionist in the medical team more than doubled documented rates of child developmental surveillance during vaccination visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance.

Cost and Effectiveness of Using Facebook Advertising to Recruit Young Women for Research: PREFER (Contraceptive Preferences Study) Experience.

BACKGROUND: Social media is a popular and convenient method for communicating on the Web. The most commonly used social networking website, Facebook, is increasingly being used as a tool for recruiting research participants because of its large user base and its ability to target advertisements on the basis of Facebook users' information. OBJECTIVE: We evaluated the cost and effectiveness of using Facebook to recruit young women into a Web-based intervention study (PREFER). The PREFER study aimed to determine whether an educational video could increase preference for and uptake of long-acting reversible contraception (LARC). METHODS: We placed an advertisement on Facebook over a 19-day period from December 2017 to January 2018, inviting 16- to 25-year-old women from Australia to participate in a Web-based study about contraception. Those who clicked on the advertisement were directed to project information, and their eligibility was determined by using a screening survey. RESULTS: Our Facebook advertisement delivered 130,129 impressions, resulting in over 2000 clicks at an overall cost of Aus $918 (Aus $0.44 per click). Web-based project information was accessed by 493 women. Of these, 462 women completed the screening survey, and 437 (437/463, 95%) women were eligible. A total of 322 young women participated in Surveys 1 and 2 (74% response rate), and 284 women participated in Survey 3 (88% retention rate), with an advertising cost of Aus $2.85 per consenting participant. CONCLUSIONS: Facebook proved to be a quick, effective, and cost-efficient tool for recruiting young Australian women into a study that was investigating contraceptive preferences. However, Web-based recruitment may result in sociodemographic biases. Further research is required to evaluate whether Facebook is suitable for recruiting older study populations.

Effectiveness of quality incentive payments in general practice (EQuIP-GP): a study protocol for a cluster-randomised trial of an outcomes-based funding model in Australian general practice to improve patient care.

BACKGROUND: There is international interest in whether improved primary care, in particular for patients with chronic or complex conditions, can lead to decreased use of health resources and whether financial incentives help achieve this goal. This trial (EQuIP-GP) will investigate whether a funding model based upon targeted, continuous quality incentive payments for Australian general practices increases relational continuity of care, and lessens health-service utilisation, for high-risk patients and children. METHODS: We will use a mixed methods approach incorporating a two-arm pragmatic cluster randomised control trial with nested qualitative case studies. We aim to recruit 36 general practices from Practice-Based Research Networks (PBRN) covering urban and regional areas of Australia, randomised into intervention and control groups. Control practices will provide usual care while intervention practices will be supported to implement a new service model incorporating incentives for relational continuity and timely access to appointments. Patients will comprise three groups: older (over 65 years); 18-65 years with chronic and/or complex conditions; and those aged less than 16 years with increased risk of hospitalisation. The funding model includes financial incentives to general practitioners (GPs) for providing longer consultations, same day access and timely follow-up after hospitalisation to enrolled patients. The payments are proportional to expected health system savings associated with improved quality of GP care. An outreach facilitator will work with practices to help incorporate the incentive model into usual work. The main outcome measure is relational continuity of care (Primary Care Assessment Tool short-form survey), with secondary outcomes including health-related quality of life and health service use (hospitalisations, emergency presentations, GP and specialist services in the community, medicine prescriptions and targeted pathology and imaging ordering). Outcomes will be initially evaluated over a period of 12 months, with ongoing data collection for 5 years. DISCUSSION: The trial will provide robust evidence on a novel approach to providing continuous incentives for improving quality of general practice care, which can be compared to block payment incentives awarded at target quality levels of pay-for-performance, both within Australia and also internationally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000105246. Registered on 23 January 2018.

Australian General Practitioners' and Compensable Patients: Factors Affecting Claim Management and Return to Work.

Purpose General Practitioners (GPs) play an important role in personal injury compensation systems yet system processes have been perceived as burdensome. Objectives were to (1) determine attitudes of Australian GPs on health benefits of return to work (RTW) after injury/illness and (2) identify associations between GP characteristics and agreement with issues surrounding treating compensable patients. Methods Cross-sectional postal survey of 423 Australian GPs to determine agreement with issues associated with compensable patients (including patient advocacy, conflicting opinions between GPs and compensation systems, fitness-for-work certification, and refusal to treat). Results The vast majority of GPs agreed there was a health benefit to early RTW. GPs with 16-20 years' experience had significantly higher odds of agreeing that the certificate of work capacity is the primary method of communication between RTW stakeholders (OR 2.36 [1.13-4.92]) than those with greater experience. 49% of GPs agreed they should be able to refuse to treat compensable patients. Female GPs had significantly lower odds (OR 0.60 [0.40-0.90]) of agreeing with right to refuse than male GPs, as did those from remote or regional practices (OR 0.43 [0.20-0.94]; OR 0.60 [0.39-0.92]) than GPs from urban practices. Conclusions Reducing administrative barriers identified by Australian GPs and improving communication with compensation systems will likely have a positive impact on their refusal to treat compensable patients.

Do Health Service Use and Return-to-Work Outcomes Differ with GPs' Injured-Worker Caseload?

Purpose To determine whether healthcare use and return-to-work (RTW) outcomes differ with GPs' injured-worker caseload. Methods Retrospective analyses of the Compensation Research Database, which captures approximately 85% of all injured worker claims in Victoria, Australia was conducted. Four injured-worker caseload groups were examined that represented the 25th, 50th, 75th, and 100th percentiles of claimants seen per GP over the 8-year study period (2003-2010): (i) 1-13 claimants; (ii) 14-26 claimants; (iii) 27-48 claimants; and (iv) 49+ claimants (total claims, n = 124,342; total GPs, n = 9748).The characteristics of claimants in each caseload group, as well as the influence of caseload on three outcomes relevant to RTW (weekly compensation paid, work incapacity days, medical-and-like costs), were examined. Results Distinct profiles for high versus low caseload groups emerged. High caseload GPs treated significantly more men in blue collar occupations and issued significantly more 'alternate duties' certificates. Conversely, low caseload GPs treated significantly more women in white collar occupations, predominantly for mental health injuries, and issued significantly more 'unfit-for-work' certificates. Few significant differences were found between the two intermediate GP caseload groups. High caseload was associated with significantly greater medical-and-like costs, however, no caseload group differences were detected for weekly compensation paid or duration of time-off-work. Conclusions Training GPs who have a low injured-worker caseload in workers' compensation processes, utilising high caseload GPs in initiatives involving peer-to-peer support, or system changes where employers are encouraged to provide preventive or rehabilitative support in the workplace may improve RTW outcomes for injured workers.

Agency, activation and compatriots: the influence of social networks on health-seeking behaviours among Sri Lankan migrants and Anglo-Australians with depression.

The nexus between social networks and illness behaviours is important in uptake of health care, however scant research has explored this relationship in South Asian migrants living with mental illness. We explored the interplay between culture, social networks and health seeking in Sri Lankan migrants and Anglo-Australians living with depression. Forty-eight in-depth interviews were conducted and data were analysed through the theoretical prism of the network episode model. Results showed that social networks were important in negotiating care. Decisions to initiate care occurred along a continuum of choice and agency; some took charge of their care, others were coerced into care, however some Sri Lankan migrants were led through various informal channels of care. Selective activation of compatriots - those perceived to understand mental illness-became increasingly important to participants through their illness careers. Compatriots were considered of greater benefit as participants progressed through depression than otherwise meaningful social networks based on ethnicity, culture and kinship. We argue that the role of social networks is pivotal in uptake of formal care, and engaging with communities to improve responses of social networks to mental illnesses may provide a bottom-up avenue for improving uptake of mental health services in migrant communities.