Worsening trends in analgesics recommended for spinal pain in primary care.

PURPOSE: Limited evidence exists on secular trends of analgesics for spinal pain. We investigated general practitioner's (GP) recommendations of analgesic medicines for spinal pain and investigated characteristics associated with their recommendation. METHODS: We accessed data on spinal pain consultations from the Bettering the Evaluation and Care of Health (BEACH) database, a nationally representative database on GP activity in Australia. Data extracted included consultation details and management provided. Medicines recommended were grouped as simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics or neuropathic pain medicines. Multivariate logistic regression determined if patient characteristics and GP characteristics were associated with medication recommendations. RESULTS: We analysed BEACH data for 9100 GPs who managed 39,303 patients with spinal pain between 2004 and 2014. Over the decade, analgesic recommendations increased. After accounting for patient and GP characteristics, there was a significant increase in the rate single-ingredient opioid analgesics [annual relative increase of 6% (RR 1.06 (95% CI 1.05-1.07), P < 0.001)] and neuropathic pain medicines [annual relative increase of 19% (RR 1.19 (95% CI 1.16-1.22), P < 0.001)] were recommended; and a significant decrease in the rate NSAIDs were recommended [annual relative decrease of 4% (RR 0.96 (95% CI 0.95-0.97), P < 0.001)]. Logistic regression identified several patient and GP characteristics associated with medicine recommendations, e.g. stronger opioids were less likely recommended for Indigenous patients [odds ratio 0.15 (95% CI 0.04-0.56)]. CONCLUSIONS: GP's analgesic recommendations for spinal pain have become increasingly divergent from guideline recommendations over time.

Assessment and management of asthma and chronic obstructive pulmonary disease in Australian general practice.

BACKGROUND: Dispensing data suggest potential issues with the quality use of medicines for airways disease. OBJECTIVE: The objective of this article was to describe the management of asthma and chronic obstructive pulmonary disease (COPD) in general practice, and investigate the appropriateness of prescribing. METHODS: The method used for this study consisted of a national cross­sectional survey of 91 Australian general practitioners (GPs) participating in the Bettering the Evaluation and Care of Health (BEACH) program. RESULTS: Data were available for 2589 patients (288 asthma; 135 COPD). For the patients with asthma, GPs classified asthma as well controlled in 76.4%; 54.3% were prescribed inhaled corticosteroids (ICS), mostly (84.9%) as combination therapy, and mostly at moderate-high dose; only 26.3% had a written action plan. GPs classified COPD as mild for 42.9%. Most patients with COPD (60.9%) were prescribed combination ICS therapy and 36.7% were prescribed triple therapy. DISCUSSION: There were substantial differences between guideline-based and GP- recorded assessment and prescription for asthma and COPD. Further research is needed to improve care and optimise patient outcomes with scarce health resources.

Estimating non-billable time in Australian general practice.

OBJECTIVES: To quantify the time that general practitioners spend on patient care that is not claimable from Medicare (non-billable) and the monetary value of this work were it claimable, and to identify variables independently associated with non-billable time. DESIGN: Prospective, cross-sectional survey, April 2012 - March 2014. SETTING: Australian general practice; a substudy of the national Bettering the Evaluation and Care of Health (BEACH) program. PARTICIPANTS: 1935 randomly sampled GPs (77.4% participation rate) from across Australia provided filled questionnaires on 66 458 patient encounters. MAIN OUTCOME MEASURES: Non-billable time spent on patient care since patient's previous consultation; duration of and reasons for non-billable time; estimate of its monetary value were it claimable from Medicare; variables associated with non-billable time. RESULTS: 69.5% of GPs reported non-billable care outside patient visits; 8019 patient encounters (12.1%) were associated with an occasion of non-billable time. Mean time spent per occasion was 10.1 min (range, 1-240 min). Reasons for non-billable time included arranging tests and referrals, consulting specialists or allied health professionals, medication renewals, and advice and education, and encompassed all International Classification of Primary Care Version 2 chapters. The notional average annual value per GP of this work was $10 525.95 (level A rebate) to $23 008.05 (level B). Non-billable time was independently associated with female GPs, younger GPs (under 55 years), female patients, patients aged 65 years or more, and one or more chronic problems being managed at the recorded encounter. CONCLUSION: Most GPs spend a significant amount of unpaid time on patient care between consultations, an inherent problem of the fee-for-service system. This work should inform discussions of future funding models.

General practice antibiotic prescribing for management of otitis media in children.

Otitis media (OM) is one of the most common infections in children. The cause can be viral, but is most often bacterial. It remains one of the most common reasons for antibiotic prescribing for children. Many episodes of acute OM are self-limiting and resolve without treatment, but antibiotics are often prescribed because these infections can develop into serious, sometimes life-threatening complications.

Management of chronic heart failure in general practice in Australia.

BACKGROUND: Chronic heart failure is a common clinical syndrome associated with high healthcare system use. OBJECTIVE: The aim of this study was to explore the management of chronic heart failure in Australian general practice. METHODS: Data from the Bettering the Evaluation and Care of Health program were used to determine the prevalence of chronic heart failure, use of natriuretic peptide testing, prescribing patterns, hospitalisation rates and referrals to community-based heart failure management programs in three study periods between 2010 and 2015. RESULTS: Data on 8989 patients from 308 general practitioners were analysed. Of these patients, 324 had chronic heart failure (prevalence 3.6%; 95% confidence interval [CI]: 3.1-4.2), 44% (95% CI: 34.5-53.6) of whom had been hospitalised for the condition. The mean number of prescribed heart failure medication agents was 2.26 (95% CI: 2.13-2.39) per patient. Discharge under community heart failure programs was not routine. DISCUSSION: Chronic heart failure is a significant burden in general practice. Strategies to optimise management and avoid hospitalisation, where possible, are needed.

The management of unresolved gastrointestinal symptoms in Australian general practice.

BEACH data collected in 2012-14 were used to investigate the management of unresolved gastrointestinal (GI) symptoms in Australian general practice. This included the characteristics of patients who had unresolved GI symptoms managed, and a comparison with the management of new GI symptoms. Nearly half of the GI symptoms managed in 2012-14 were unresolved (had been managed previously). The findings suggest that general practitioners order pathology and imaging tests more often during first presentations of GI symptoms, and often refer patients when GI symptoms are unresolved.

General practice encounters with Aboriginal and Torres Strait Islander people.

In the BEACH program between April 2008 and March 2013, general practitioners (GPs) recorded details of 7380 patient encounters with people who identified themselves as Aboriginal and Torres Strait Islander, which accounted for 1.5% of all BEACH encounters. The rates at which type 2 diabetes and asthma were managed at encounters with patients who identified as Aboriginal and Torres Strait Islander people were compared with those of other patients.

Tobacco smoking.

Worldwide, 22% of adults aged ≥15 years currently smoke tobacco. Up to half of current smokers will eventually die of a tobacco-related disease, and smoking is the leading cause of ill health, drug-related death and hospital separations in Australia.

Sevenfold rise in likelihood of pertussis test requests in a stable set of Australian general practice encounters, 2000-2011.

OBJECTIVE: To better understand the role that diagnostic test-ordering behaviour of general practitioners has on current pertussis epidemiology in Australia. DESIGN AND SETTING: Analysis of Australian general practice encounter data (from the Bettering the Evaluation and Care of Health [BEACH] program) on 13 "pertussis-related problem" (PRP) codes that were most likely to result in a pertussis laboratory test request and Australian pertussis notifications data (from the National Notifiable Diseases Surveillance System [NNDSS]) for the period April 2000 to March 2011. MAIN OUTCOME MEASURES: The change in the proportion of PRP general practice encounters with a pertussis test request between 2000 and 2011, and the change in national pertussis notifications over the same period. RESULTS: The proportion of PRP encounters resulting in a pertussis test request increased from 0.25% between April 2000 and March 2004 to 1.71% between April 2010 and March 2011 (odds ratio, 7.0; 95% CI, 5.5-8.8). The BEACH data on pertussis testing and NNDSS data on pertussis notifications were highly correlated (r = 0.99), and the notification data mirrored the likelihood of a pertussis test request in general practice. The proportion of NNDSS pertussis notifications with a polymerase chain reaction (PCR)-confirmed diagnosis increased from 16.3% between April 2000 and March 2004 to 65.3% between April 2010 and March 2011. CONCLUSION: An increase in pertussis testing following recognition of early epidemic cases may have led to identification of previously undetected infections, resulting in a further increase in notified disease and awareness among GPs. The changing likelihood of being tested may also be due to expanding availability and use of PCR testing in Australia.

Changes in longer consultations for children in general practice.

AIM: To determine if the duration of general practitioner (GP) consultations, or the proportional distribution of item numbers associated with longer consultations, with children has changed in association with the demographic changes in Australia. METHOD: Secondary data analysis of Medicare claims from 1996 to 2010, which were stratified by patient age and visit type as designated by billing item number, and of the Bettering the Evaluation of Care and Health (BEACH) database was conducted. The Medicare data that were analysed were changes in overall proportion and absolute numbers of longer consultations for children from 1996 to 2010, while the BEACH data that were analysed were changes in the average duration of visits for children and the proportion of visits by children for chronic conditions. RESULTS: Despite the increase in the population of children, and the increasing numbers of children with chronic illness, the absolute number of longer consultations for children has decreased over the time period studied. Further, the proportion of all longer consultations that are being provided to children has diminished. For those consultations that do occur, the GPs are not spending any more time with children in 2010 than they did in consultations in 2000. CONCLUSIONS: There have been significant changes in the patterns of longer consultations provided to children by GPs. Efforts to ensure that children receive primary care for chronic conditions and preventive care must now take on a greater urgency for the health-care system.

Gallbladder disease.

Gallbladder disease (GBD) is a common cause of upper abdominal pain. Prevalence of GBD increases with age, and is more common in women than men. United States population prevalence estimates indicate that 17% of women and 8% of men have GBD. Although common, it is often asymptomatic. We analysed data collected in the BEACH (Bettering the Evaluation and Care of Health) program from January 2010 to December 2012 to describe general practitioners' management of GBD when it is an 'active' clinical problem.

Common general practice presentations and publication frequency.

BACKGROUND: General practitioners see the widest range of conditions of any specialty. It is unclear if the most commonly managed problems in general practice are reflected in the volume of published general practice research, or in guidelines produced for general practice. METHODS: The 200 most commonly managed problems in general practice were sought from the BEACH database. For the 10 most often managed, we searched Australian Family Physician in MEDLINE (2005-10) for articles and the National Health and Medical Research Council Clinical Practice Guidelines Portal for guidelines, to determine publication frequency. RESULTS: The 10 most commonly managed problems were hypertension, immunisation, upper respiratory tract infection, depression, diabetes, lipid disorder, general check-up, osteoarthritis, back complaint, and prescription request. The top 30 problems accounted for approximately 48% of GP problems managed. To cover 75% of problems managed, GPs need to have knowledge of more than 100 problems. DISCUSSION: While GPs are required to have a working knowledge of numerous conditions, almost half of problems managed fall within the top 30 problem areas. Research published in Australian Family Physician and published clinical guidelines do not align with the problems most frequently encountered by GPs.

Self-monitoring blood glucose--non-insulin-treated type 2 diabetes in Australian general practice.

BACKGROUND: Benefits of self-monitoring blood glucose (SMBG) in non-insulin-treated type 2 diabetes (T2D) are questionable. We investigated proportions of general practitioner (GP) patients who self-monitor, and associations between SMBG, glycosylated haemoglobin (HbA1c) and body mass index (BMI). METHODS: Sub-studies of the Bettering the Evaluation and Care of Health (BEACH) program, involving 5 730 patients from 194 GPs. Outcomes Type 2 diabetes prevalence; HbA1c; BMI; blood glucose (BG) monitoring routine. RESULTS: Prevalence of non-insulin-treated T2D was 6.7%. Mean HbA1c level was 7.1%. Almost half (47.5%) of T2D patients were obese compared with 26.7% of patients at all BEACH encounters in 2011-2012. Of 344 non-insulin-treated T2D patients, 79.4% self-monitored fasting BG and 69.7% of 314 self-monitored post-prandial BG. For both groups, mean HbA1c was significantly higher for those who tested daily than for those who never tested. CONCLUSION: Patients with non-insulin-treated T2D who test BG daily may be those struggling for control. For others, benefits seem minimal for the proportion utilising self-monitoring.

Referrals to A&E--changes over 5 years.

In July 2008, using 2003 to 2007 data from BEACH (Bettering the Evaluation and Care of Health), we published an article in this journal about patients attending general practice who were referred to hospital accident and emergency departments (A&E).(1) The precise referral rate at that time was 1.85 per 1000 encounters (95% CI: 1.70-1.99). A new analysis using recent data shows that in 2008 to 2011 the general practice referral rate to A&E was significantly higher: 2.70 per 1000 encounters (95% CI: 2.48-2.92).

Orders for thyroid function tests - changes over 10 years.

In the BEACH (Bettering the Evaluation and Care of Health) program, between 2001-02 and 2010-11, general practice orders for thyroid function tests increased by 51%.

GPs in teaching practices.

From April 2010 to March 2011, 956 general practitioners took part in BEACH (Bettering the Evaluation and Care of Health). Five hundred and ninety-four (62%) worked in a teaching practice for undergraduates, junior doctors or general practice registrars.

Sprains and strains.

From April 2010 to March 2011 in BEACH (Bettering the Evaluation and Care of Health), sprains and strains were managed at a rate of 14 per 1000 encounters, suggesting an average 1.7 million sprain/strain patient-doctor encounters nationally per year.

Infants-- encounters and management in general practice.

At a BEACH (Bettering the Evaluation and Care of Health) consultation, up to three patient reasons for attending the encounter (RFE) and up to four diagnoses/problems managed can be recorded by the general practitioner. When there are multiple RFE and problems managed at an encounter, there is no direct link between the two. However, there is a direct association between the problem and its management. Medications can be recorded as prescribed, supplied or advised for over-the-counter purchase.

Management of nonmelanoma skin cancers.

From April 2010 to March 2011 in BEACH (Bettering the Evaluation and Care of Health), nonmelanoma skin cancers (NMSCs) were managed at one in 100 encounters, suggesting about 1.2 million NMSC patient-doctor encounters nationally in that year.

Osteoporosis.

From April 2010 to March 2011 in BEACH, osteoporosis was managed at a rate of 6 per 1000 general practice encounters, suggesting an average 708,000 osteoporosis patient-doctor encounters per year nationally.