Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial.

We evaluated the effectiveness of an interdisciplinary, primary care-based model of care for chronic obstructive pulmonary disease (COPD).A cluster randomised controlled trial was conducted in 43 general practices in Australia. Adults with a history of smoking and/or COPD, aged ≥40 years with two or more clinic visits in the previous year were enrolled following spirometric confirmation of COPD. The model of care comprised smoking cessation support, home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase). Main outcomes included changes in St George's Respiratory Questionnaire (SGRQ) score, COPD Assessment Test (CAT), dyspnoea, smoking abstinence and lung function at 6 and 12 months.We identified 272 participants with COPD (157 intervention, 115 usual care); 49 (31%) out of 157 completed both HMR and HomeBase. Intention-to-treat analysis showed no statistically significant difference in change in SGRQ at 6 months (adjusted between-group difference 2.45 favouring intervention, 95% CI -0.89-5.79). Per protocol analyses showed clinically and statistically significant improvements in SGRQ in those receiving the full intervention compared to usual care (difference 5.22, 95% CI 0.19-10.25). No statistically significant differences were observed in change in CAT, dyspnoea, smoking abstinence or lung function.No significant evidence was found for the effectiveness of this interdisciplinary model of care for COPD in primary care over usual care. Low uptake was a limitation.

Diagnosing COPD and supporting smoking cessation in general practice: evidence-practice gaps.

OBJECTIVES: To review the accuracy of diagnoses of chronic obstructive pulmonary disease (COPD) in primary care in Australia, and to describe smokers' experiences with and preferences for smoking cessation. DESIGN, SETTING AND PARTICIPANTS: Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months, reported being current or ex-smokers with a smoking history of at least 10 pack-years, or were being managed for COPD. Interviews based on a structured questionnaire and case finding (FEV1/FEV6 measurement) were followed, when appropriate, by spirometry testing and assessment of health-related quality of life, dyspnoea and symptoms. RESULTS: 1050 patients attended baseline interviews (February 2015 - April 2017) at 41 practices. Of 245 participants managed for COPD, 130 (53.1%) met the spirometry-based definition (post-bronchodilator FEV1/FVC < 0.7) or had a clinical correlation; in 37% of cases COPD was not confirmed, and no definitive result was obtained for 9.8% of patients. Case finding and subsequent spirometry testing identified 142 new COPD cases (17.6% of participants without prior diagnosis; 95% CI, 15.1-20.5%). 690 participants (65.7%) were current smokers, of whom 360 had attempted quitting during the previous 12 months; 286 (81.0% of those attempting to quit) reported difficulties during previous quit attempts. Nicotine replacement therapy (205, 57.4%) and varenicline (110, 30.8%) were the most frequently employed pharmacological treatments; side effects were common. Hypnotherapy was the most popular non-pharmacological option (62 smokers, 17%); e-cigarettes were tried by 38 (11%). 187 current smokers (27.6%) would consider using e-cigarettes in future attempts to quit. CONCLUSIONS: COPD was both misdiagnosed and missed. Case finding and effective use of spirometry testing could improve diagnosis. Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common. Health professionals should emphasise evidence-based treatments, and closely monitor quitting difficulties and side effects of cessation aids. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Clinical Characteristics Of Patients With Asthma COPD Overlap (ACO) In Australian Primary Care.

Purpose: Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices. Patients and methods: Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George's Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone. Results: Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p<0.001), but no difference was found in post-bronchodilator spirometry. Demographic and clinical characteristics, dyspnoea, quality of life, comorbidities and treatment prescribed did not differ significantly between groups. Conclusion: This is the first study describing the clinical characteristics of ACO patients in Australian general practices. Our finding of lower pre-bronchodilator lung function in the ACO group compared to those with COPD reinforces the importance of spirometry in primary care to inform management. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Interdisciplinary model of care (RADICALS) for early detection and management of chronic obstructive pulmonary disease (COPD) in Australian primary care: study protocol for a cluster randomised controlled trial.

INTRODUCTION: Up to half of all smokers develop clinically significant chronic obstructive pulmonary disease (COPD). Gaps exist in the implementation and uptake of evidence-based guidelines for managing COPD in primary care. We describe the methodology of a cluster randomised controlled trial (cRCT) evaluating the efficacy and cost-effectiveness of an interdisciplinary model of care aimed at reducing the burden of smoking and COPD in Australian primary care settings. METHODS AND ANALYSIS: A cRCT is being undertaken to evaluate an interdisciplinary model of care (RADICALS - Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers). General practice clinics across Melbourne, Australia, are identified and randomised to the intervention group (RADICALS) or usual care. Patients who are current or ex-smokers, of at least 10 pack years, including those with an existing diagnosis of COPD, are being recruited to identify 280 participants with a spirometry-confirmed diagnosis of COPD. Handheld lung function devices are being used to facilitate case-finding. RADICALS includes individualised smoking cessation support, home-based pulmonary rehabilitation and home medicines review. Patients at control group sites receive usual care and Quitline referral, as appropriate. Follow-ups occur at 6 and 12 months from baseline to assess changes in quality of life, abstinence rates, health resource utilisation, symptom severity and lung function. The primary outcome is change in St George's Respiratory Questionnaire score of patients with COPD at 6 months from baseline. ETHICS AND DISSEMINATION: This project has been approved by the Monash University Human Research Ethics Committee and La Trobe University Human Ethics Committee (CF14/1018 - 2014000433). Results of the study will be disseminated in peer-reviewed journals and research conferences. If the intervention is successful, the RADICALS programme could potentially be integrated into general practices across Australia and sustained over time. TRIAL REGISTRATION NUMBER: ACTRN12614001155684; Pre-results.

Using Patient Flow Information to Determine Risk of Hospital Presentation: Protocol for a Proof-of-Concept Study.

BACKGROUND: Every day, patients are admitted to the hospital with conditions that could have been effectively managed in the primary care sector. These admissions are expensive and in many cases are possible to avoid if early intervention occurs. General practitioners are in the best position to identify those at risk of imminent hospital presentation and admission; however, it is not always possible for all the factors to be considered. A lack of shared information contributes significantly to the challenge of understanding a patient's full medical history. Some health care systems around the world use algorithms to analyze patient data in order to predict events such as emergency presentation; however, those responsible for the design and use of such systems readily admit that the algorithms can only be used to assess the populations used to design the algorithm in the first place. The United Kingdom health care system has contributed data toward algorithm development, which is possible through the unified health care system in place there. The lack of unified patient records in Australia has made building an algorithm for local use a significant challenge. OBJECTIVE: Our objective is to use linked patient records to track patient flow through primary and secondary health care in order to develop a tool that can be applied in real time at the general practice level. This algorithm will allow the generation of reports for general practitioners that indicate the relative risk of patients presenting to an emergency department. METHODS: A previously designed tool was used to deidentify the general practice and hospital records of approximately 100,000 patients. Records were pooled for patients who had attended emergency departments within the Eastern Health Network of hospitals and general practices within the Eastern Health Network catchment. The next phase will involve development of a model using a predictive analytic machine learning algorithm. The model will be developed iteratively, testing the combination of variables that will provide the best predictive model. RESULTS: Records of approximately 97,000 patients who have attended both a general practice and an emergency department have been identified within the database. These records are currently being used to develop the predictive model. CONCLUSIONS: Records from general practice and emergency department visits have been identified and pooled for development of the algorithm. The next phase in the project will see validation and live testing of the algorithm in a practice setting. The algorithm will underpin a clinical decision support tool for general practitioners which will be tested for face validity in this initial study into its efficacy.

Developing professional attributes in critical care nurses using Team-Based Learning.

Australian nurses prepare for specialty practice by undertaking postgraduate theoretical and clinical education in partnership models between universities and hospitals. In our global healthcare system, nurses require advanced critical thinking and strong communication skills to provide safe, high quality patient care. Yet, few education programs focus on developing these skills. Team-Based Learning (TBL) is a specific educational strategy that encourages and rewards students to think critically and solve clinical problems individually and in teams. The aim of this study was to investigate critical care nursing students' perceptions and experiences of TBL after it was introduced into the second half of their postgraduate specialty course. Following Ethics Committee approval, thirty-two students were invited to participate in an extended response questionnaire on their perceptions of TBL as part of a larger study. Data were analyzed thematically. Postgraduate students perceived their professional growth was accelerated due to the skills and knowledge acquired through TBL. Four themes underpinned the development and accelerated acquisition of specialty nurse attributes due to TBL: Engagement, Learning Effectiveness, Critical Thinking, and Motivation to Participate. Team-Based Learning offered deep and satisfying learning experiences for students. The early acquisition of advanced critical thinking, teamwork and communication skills, and specialty practice knowledge empowered nurses to provide safe patient care with confidence.

Effectiveness of local support for the adoption of a national programme--a descriptive study.

BACKGROUND: Change management in health care is a complex and time-consuming endeavour, and no less so in implementing technological systems. In deploying a nationwide programme, the personally controlled electronic health record (PCEHR), the Australian Government employed a number of national and local change management programmes. OBJECTIVE: This article describes the processes undertaken and the experiences of introducing the PCEHR into 74 general practices across a specific area of metropolitan Melbourne. METHOD: An online survey was developed by an independent evaluator and offered to all participating practices. The response rate was 82%. RESULTS: The deployment and testing of the eHealth infrastructure and the roll-out of the PCEHR were deeply supported through face-to-face, locally contextualised support processes. The area Medicare Local (ML), an organisation that provides support services to general practice and allied health in the community, provided support and programme coordination. This support occurred in the environment of a number of other initiatives to improve adoption. CONCLUSION: The impact and value of this support in the registration and adoption process was explored in an online survey and found to be the key factor in practice engagement and success. ML support was seen as instrumental in improving adoption and was more effective than other activities. This article highlights the role of local support, in this case, MLs, in the effective implementation of eHealth programmes across a range of stakeholder groups, in particular, general practice, and the potential for the lessons learned from the engagement model of such an entity to be more generally applied.

Assessing psychometric properties of scales: a case study.

AIM: This paper is a report of a study to examine the construct validity of The Nursing Students' Attitudes and Awareness of Research and Development within Nursing Scale. BACKGROUND: The validity of instruments is critical in ensuring that data collected are sound and that the data measures what it purports to measure. When a new instrument is used in a different population or when it has been modified, it is useful to re-examine the construct validity of the instrument. METHOD: A survey design was used in September 2004 with a sample of 615 undergraduate nursing students to test the factor structure of The Nursing Students' Attitudes and Awareness of Research and Development within Nursing Scale and to estimate its similarity to the factor structure reported for the original scale developed and tested in a group of Registered Nurses. RESULTS: Using Maximum Likelihood Factor Analysis and then Principal Axis Factoring, we were unable to obtain a similar factor structure to that originally identified for the scale. Our data resulted in a two-factor structure. One factor consisted of 16 items that reflected a positive attitude to nursing research and the other consisted of 14 items that reflected a negative attitude to nursing research. CONCLUSION: The substantially different factor structure identified suggests that this scale requires further refinement and testing. This case study highlights the importance of a systematic and comprehensive approach to determining construct validity of scales, thus enabling researchers to determine their suitability as data collection instruments.