National Health and Medical Research Council statement on electronic cigarettes: 2022 update.

INTRODUCTION: Electronic cigarette (e-cigarette) use in Australia has rapidly increased since the 2017 National Health and Medical Research Council (NHMRC) Chief Executive Officer (CEO) statement on e-cigarettes. The type of products available and the demographic characteristics of people using these products have changed. New evidence has been published and there is growing concern among public health professionals about the increased use, particularly among young people who do not currently smoke combustible cigarettes. The combination of these issues led NHMRC to review the current evidence and provide an updated statement on e-cigarettes. In this article, we describe the comprehensive process used to review the evidence and develop the 2022 NHMRC CEO statement on electronic cigarettes. MAIN RECOMMENDATIONS: E-cigarettes can be harmful; all e-cigarette users are exposed to chemicals and toxins that have the potential to cause adverse health effects. There are no health benefits of using e-cigarettes if you do not currently smoke tobacco cigarettes. Adolescents are more likely to try e-cigarettes if they are exposed to e-cigarettes on social media. Short term e-cigarette use may help some smokers to quit who have been previously unsuccessful with other smoking cessation aids. There are other proven safe and effective options available to help smokers to quit. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: The evidence base for the harms of e-cigarette use has strengthened since the previous NHMRC statement. Significant gaps in the evidence base remain, especially about the longer term health harms of using e-cigarettes and the toxicity of many chemicals in e-cigarettes inhaled as an aerosol.

COPD-X Australian guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2022 update.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a treatable and preventable disease characterised by persistent respiratory symptoms and chronic airflow limitation on spirometry. COPD is highly prevalent and is associated with exacerbations and comorbid conditions. "COPD-X" provides quarterly updates in COPD care and is published by the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. MAIN RECOMMENDATIONS: The COPD-X guidelines (version 2.65) encompass 26 recommendations addressing: case finding and confirming diagnosis; optimising function; preventing deterioration; developing a plan of care; and managing an exacerbation. CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES: Both non-pharmacological and pharmacological strategies are included within these recommendations, reflecting the importance of a holistic approach to clinical care for people living with COPD to delay disease progression, optimise quality of life and ensure best practice care in the community and hospital settings when managing exacerbations. Several of the new recommendations, if put into practice in the appropriate circumstances, and notwithstanding known variations in the social determinants of health, could improve quality of life and reduce exacerbations, hospitalisations and mortality for people living with COPD.

Effect of Cytisine vs Varenicline on Smoking Cessation: A Randomized Clinical Trial.

Importance: Cytisine is more effective than placebo and nicotine replacement therapy for smoking cessation. However, cytisine has not been tested against the most effective smoking cessation medication, varenicline, which is associated with adverse events known to lead to discontinuation of therapy. Objective: To examine whether standard cytisine treatment (25 days) was at least as effective as standard varenicline treatment (84 days) for smoking cessation. Design, Setting, and Participants: This noninferiority, open-label randomized clinical trial with allocation concealment and blinded outcome assessment was undertaken in Australia from November 2017 through May 2019; follow-up was completed in January 2020. A total of 1452 Australian adult daily smokers willing to make a quit attempt were included. Data collection was conducted primarily by computer-assisted telephone interview, but there was an in-person visit to validate the primary outcome. Interventions: Treatments were provided in accordance with the manufacturers' recommended dosage: cytisine (n = 725), 1.5-mg capsules taken 6 times daily initially then gradually reduced over the 25-day course; varenicline (n = 727), 0.5-mg tablets titrated to 1 mg twice daily for 84 days (12 weeks). All participants were offered referral to standard telephone behavioral support. Main Outcomes and Measures: The primary outcome was 6-month continuous abstinence verified using a carbon monoxide breath test at 7-month follow-up. The noninferiority margin was set at 5% and the 1-sided significance threshold was set at .025. Results: Among 1452 participants who were randomized (mean [SD] age, 42.9 [12.7] years; 742 [51.1%] women), 1108 (76.3%) completed the trial. Verified 6-month continuous abstinence rates were 11.7% for the cytisine group and 13.3% for the varenicline group (risk difference, -1.62% [1-sided 97.5% CI, -5.02% to ∞]; P = .03 for noninferiority). Self-reported adverse events occurred less frequently in the cytisine group (997 events among 482 participants) compared with the varenicline group (1206 events among 510 participants) and the incident rate ratio was 0.88 (95% CI, 0.81 to 0.95; P = .002). Conclusions and Relevance: Among daily smokers willing to quit, cytisine treatment for 25 days, compared with varenicline treatment for 84 days, failed to demonstrate noninferiority regarding smoking cessation. Trial Registration: anzctr.org.au Identifier: ACTRN12616001654448.

Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial.

BACKGROUND: Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. METHODS: We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. RESULTS: One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86-1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). CONCLUSIONS: Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. TRIAL REGISTRATION: ANZCTRN12611000076976 Retrospectively registered.

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.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018.

INTRODUCTION: Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations: These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: screening, prevention and diagnostic work-up; acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies; stroke prevention and optimal use of anticoagulants; and integrated multidisciplinary care. Changes in management as a result of the guideline: Opportunistic screening in the clinic or community is recommended for patients over 65 years of age. The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. ß-Blockers or non-dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation. The sexless CHA2DS2-VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of ≥ 2. If anticoagulation is indicated, non-vitamin K oral anticoagulants are recommended in preference to warfarin. An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.

Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

BACKGROUND: To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. METHODS: We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged ≥45 years and have experienced knee pain ≥4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving care by intervention group GPs will receive tailored OA educational materials, a leg muscle strengthening program, and access to a weight-loss program as appropriate and agreed. GPs in the control group will receive no additional training and their patients will receive usual care. DISCUSSION: This project aims to address a major evidence-to-practice gap in primary care management of OA by evaluating a new service delivery model implemented with an intervention targeting GP practice behaviours to improve the health of people with knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12617001595303 , date of registration 1/12/2017.

Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative.

OBJECTIVES: To describe the management of cardiovascular disease (CVD) risk in Australian patients with diabetes; to compare the effectiveness of a quality improvement initiative for people with and without diabetes. RESEARCH DESIGN AND METHODS: Subgroup analyses of patients with and without diabetes participating in a cluster randomised trial. SETTING AND PARTICIPANTS: Indigenous people (≥ 35 years old) and non-Indigenous people (≥ 45 years old) who had attended one of 60 Australian primary health care services at least three times during the preceding 24 months and at least once during the past 6 months. INTERVENTION: Quality improvement initiative comprising point-of-care electronic decision support with audit and feedback tools. MAIN OUTCOME MEASURES: Adherence to CVD risk screening and prescribing guidelines. RESULTS: Baseline rates of guideline-recommended screening were higher for 8829 patients with diabetes than for 44 335 without diabetes (62.0% v 39.5%; P < 0.001). Baseline rates of guideline-recommended prescribing were greater for patients with diabetes than for other patients at high risk of CVD (55.5% v 39.6%; P < 0.001). The proportions of patients with diabetes not attaining recommended treatment targets for blood pressure, low-density lipoprotein-cholesterol or HbA1c levels who were not prescribed the corresponding therapy at baseline were 28%, 44% and 24% respectively. The intervention was associated with improved screening rates, but the effect was smaller for patients with diabetes than for those without diabetes (rate ratio [RR], 1.14 v 1.28; P = 0.01). It was associated with improved guideline-recommended prescribing only for undertreated individuals at high risk; the effect size was similar for those with and without diabetes (RR, 1.63 v 1.53; P = 0.28). CONCLUSIONS: Adherence to CVD risk management guidelines was better for people with diabetes, but there is room for improvement. The intervention was modestly effective in people with diabetes, but further strategies are needed to close evidence-practice gaps.Australian and New Zealand Clinical Trials Registry number: ACTRN12611000478910.

COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities. Advances in the management of COPD are updated quarterly in the national COPD guidelines, the COPD-X plan, published by Lung Foundation Australia in conjunction with the Thoracic Society of Australia and New Zealand and available at http://copdx.org.au. Main recommendations: Spirometry detects persistent airflow limitation (post-bronchodilator FEV1/FVC < 0.7) and must be used to confirm the diagnosis.Non-pharmacological and pharmacological therapies should be considered as they optimise function (ie, improve symptoms and quality of life) and prevent deterioration (ie, prevent exacerbations and reduce decline).Pulmonary rehabilitation and regular exercise are highly beneficial and should be provided to all symptomatic COPD patients.Short- and long-acting inhaled bronchodilators and, in more severe disease, anti-inflammatory agents (inhaled corticosteroids) should be considered in a stepwise approach.Given the wide range of inhaler devices available, inhaler technique and adherence should be checked regularly.Smoking cessation is essential, and influenza and pneumococcal vaccinations reduce the risk of exacerbations.A plan of care should be developed with the multidisciplinary team. COPD action plans reduce hospitalisations and are recommended as part of COPD self-management.Exacerbations should be managed promptly with bronchodilators, corticosteroids and antibiotics as appropriate to prevent hospital admission and delay COPD progression.Comorbidities of COPD require identification and appropriate management.Supportive, palliative and end-of-life care are beneficial for patients with advanced disease.Education of patients, carers and clinicians, and a strong partnership between primary and tertiary care, facilitate evidence-based management of COPD. Changes in management as result of the guideline: Spirometry remains the gold standard for diagnosing airflow obstruction and COPD. Non-pharmacological and pharmacological treatment should be used in a stepwise fashion to control symptoms and reduce exacerbation risk.

Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis.

It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97-0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92-0.99; RR after 12 months follow-up 0.98, 95% CI 0.96-1.00).Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.

Guideline for the diagnosis and management of hypertension in adults - 2016.

The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010). Main recommendations For patients at low absolute cardiovascular disease risk with persistent blood pressure (BP) ≥ 160/100 mmHg, start antihypertensive therapy. The decision to treat at lower BP levels should consider absolute cardiovascular disease risk and/or evidence of end-organ damage, together with accurate BP assessment. For patients at moderate absolute cardiovascular disease risk with persistent systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, start antihypertensive therapy. Treat patients with uncomplicated hypertension to a target BP of < 140/90 mmHg or lower if tolerated. Changes in management as a result of the guideline Ambulatory and/or home BP monitoring should be offered if clinic BP is ≥ 140/90 mmHg, as out-of-clinic BP is a stronger predictor of outcome. In selected high cardiovascular risk populations, aiming for a target of < 120 mmHg systolic can improve cardiovascular outcomes. If targeting < 120 mmHg, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury. Why the changes have been made A 2015 meta-analysis of patients with uncomplicated mild hypertension (systolic BP range, 140-169 mmHg) demonstrated that BP-lowering therapy is beneficial (reduced stroke, cardiovascular death and all-cause mortality). A 2015 trial comparing lower with higher blood pressure targets in selected high cardiovascular risk populations found improved cardiovascular outcomes and reduced mortality, with an increase in some treatment-related adverse events.

Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: a cluster randomized trial.

BACKGROUND: Early detection and intervention for chronic obstructive pulmonary disease (COPD) could potentially slow disease progress and minimize harm. OBJECTIVES: To assess the effectiveness of early intervention by a practice nurse-GP team on quality of life (QoL) and process of care in patients with newly diagnosed COPD, compared with usual care. Nurses and GPs in intervention practices were educated to develop and implement disease management plans for COPD. METHODS: A 12-month, multicentre, pragmatic randomized controlled trial with blinded outcome assessment was conducted. Participants were current and former smokers aged 40 to 85 years newly identified as having COPD on post-bronchodilator spirometry. The primary outcome was health-related QoL, assessed with the St George's Respiratory Questionnaire (SGRQ). Secondary outcome measures were other QoL measures, lung function, disease knowledge, smoking and immunization status, inhaler technique and health service use. RESULTS: Of the 10 234 patients from 36 practices in Sydney invited to a case-finding appointment, 1641 (16%) attended and 287 (18%) were diagnosed with COPD. Nineteen practices (144 patients) were randomized to the intervention group and 17 practices (110 patients) to the control group. Only 15.3% (n = 22) patients in the intervention group saw the nurse for COPD care following case finding. There was no between-group difference in SGRQ score at follow-up (mean difference -0.21; P = 0.86). Influenza vaccination was higher in the intervention group (OR 2.31: P = 0.035), but there were no other significant between-group differences in outcomes. CONCLUSION: Intervention uptake was low and had no additional beneficial effect, over usual care, on participants' health-related QoL.

Quit in general practice: a cluster randomized trial of enhanced in-practice support for smoking cessation.

OBJECTIVES: To evaluate the uptake and effectiveness of tailored smoking cessation support, provided primarily by the practice nurse (PN), and compare this to other forms of cessation support. METHODS: Three arm cluster randomized controlled trial conducted in 101 general practices in Sydney and Melbourne involving 2390 smokers. The Quit with PN intervention was compared to Quitline referral and a usual care control group. Smoking cessation pharmacotherapy was recommended to all groups. Outcomes were assessed by self-report at 3- and 12-month follow-up. Uptake of the interventions is also reported. RESULTS: The three groups were similar at baseline. Follow-up at 12 months was 82%. The sustained and point prevalence abstinence rates, respectively, at 3 months by group were: PN intervention 13.1% and 16.3%; Quitline referral 10.8% and 14.2%; Usual GP care 11.4% and 15.0%. At 12 months, the rates were: PN intervention 5.4% and 17.1%; Quitline referral 4.4% and 18.8%; Usual GP care 2.9% and 16.4%. Only 43% of patients in the PN intervention group attended to see the nurse. Multilevel regression analysis showed no effect of the intervention overall, but patients who received partial or complete PN support were more likely to report sustained abstinence [partial support odds ratio (OR) 2.27; complete support OR 5.34]. CONCLUSION: The results show no difference by group on intention to treat analysis. Those patients who received more intensive PN intervention were more likely to quit. This may have been related to patient motivation or an effect of PN led cessation support.

Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: views of general practitioners and practice nurses.

BACKGROUND: Support in primary care can assist smokers to quit successfully, but there are barriers to general practitioners (GPs) providing this support routinely. Practice nurses (PNs) may be able to effectively take on this role. OBJECTIVES: The aim of this study was to perform a process evaluation of a PN-led smoking cessation intervention being tested in a randomized controlled trial in Australian general practice. METHODS: Process evaluation was conducted by means of semi-structured telephone interviews with GPs and PNs allocated in the intervention arm (Quit with PN) of the Quit in General Practice trial. Interviews focussed on nurse training, content and implementation of the intervention. RESULTS: Twenty-two PNs and 15 GPs participated in the interviews. The Quit with PN intervention was viewed positively. Most PNs were satisfied with the training and the materials provided. Some challenges in managing patient data and follow-up were identified. CONCLUSION: The Quit with PN intervention was acceptable to participating PNs and GPs. Issues to be addressed in the planning and wider implementation of future trials of nurse-led intervention in general practice include providing ongoing mentoring support, integration into practice management systems and strategies to promote greater collaboration in GPs and PN teams in general practice. The ongoing feasibility of the intervention was impacted by the funding model supporting PN employment and the competing demands on the PNs time.

Challenges to establishing successful partnerships in community health promotion programs: local experiences from the national implementation of healthy eating activity and lifestyle (HEAL™) program.

ISSUE ADDRESSED: Community-based programs to address physical activity and diet are seen as a valuable strategy to reduce risk factors for chronic disease. Community partnerships are important for successful local implementation of these programs but little is published to describe the challenges of developing partnerships to implement health promotion programs. The aim of this study was to explore the experiences and opinions of key stakeholders on the development and maintenance of partnerships during their implementation of the HEAL™ program. METHOD: Semi-structured interviews with key stakeholders involved in implementation of HEAL™ in four local government areas. The interviews were transcribed verbatim and analysed thematically. RESULTS: Partnerships were vital to the success of the local implementation. Successful partnerships occurred where the program met the needs of the partnering organisation, or could be adapted to do so. Partnerships took time to develop and were often dependent on key people. Partnering with organisations that had a strong influence in the community could strengthen existing relationships and success. In remote areas partnerships took longer to develop because of fewer opportunities to meet face to face and workforce shortages and this has implications for program funding in these areas. CONCLUSION: Partnerships are important for the successful implementation of community preventive health programs. They take time to develop, are dependent on the needs of the stakeholders and are facilitated by stable leadership. SO WHAT?: An understanding of the role of partnerships in the implementation of community health programs is important to inform several aspects of program delivery, including flexibility in funding arrangements to allow effective and mutually beneficial partnerships to develop before the implementation phase of the program. It is important that policy makers have an understanding of the time it takes for partnerships to develop and to take this into consideration when programs are funded and implemented in the community.

Reflections on the history of general practice in Australia.

General practice has experienced change over the past century driven by a variety of influences, the most important of which have been changes in the health needs of the population, the organisation of the workforce, and medicine itself. Over this time, general practice has developed as a profession through education and, ultimately, recognition of its specialist qualifications. There has been increasing organisational sophistication at the practice, regional and national levels. Despite contested scope of practice and vision of its future, general practice's place in the health system as a whole has been increasingly recognised and affirmed.

Validation of the COPD Diagnostic Questionnaire in an Australian general practice cohort: a cross-sectional study.

BACKGROUND: The gold standard for the diagnosis of chronic obstructive pulmonary disease (COPD) is spirometry, but there are barriers to its use in primary care. AIMS: To externally validate the COPD Diagnostic Questionnaire (CDQ) as a diagnostic tool in patients at increased risk in Australian general practice and to compare its performance with other CDQ validation studies. METHODS: Patients were recruited from 36 general practices in Sydney, Australia. Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse. The CDQ was collected and pre- and postbronchodilator spirometry was performed. Cases for whom complete CDQ data were present and the spirometry met quality standards were analysed. RESULTS: Of 1,631 patients who attended case-finding recruitment, 1,054 (65%) could be analysed. Spirometry showed 13% had COPD. The ability of the CDQ to discriminate between patients with and without COPD was fair, represented by the area under the receiver operating characteristic curve of 0.713. With a CDQ cut-off point value of 16.5 the sensitivity was 80% and specificity 47% and, at a cut-off point value of 19.5, the sensitivity was 63% and specificity 70%. CONCLUSIONS: The CDQ did not discriminate between patients with and without COPD accurately enough to use as a diagnostic tool in patients at increased risk of COPD in Australian general practice. Further research is needed on the value of the CDQ as a tool for selecting patients for spirometry.

Tobacco smoking: options for helping smokers to quit.

BACKGROUND: Although great progress has been made on tobacco control, smoking remains one of the most important causes of preventable disease and death in the Australian population. The general practice team has much to offer in helping smokers to quit. OBJECTIVE: This article provides practical advice on structuring smoking cessation support in primary care using the 5As (Ask, Assess, Advise, Assist and Arrange follow-up) framework. Up-to-date information on pharmacotherapy and issues for special groups are also covered. DISCUSSION: The chances of successful quitting are maximised if the patient receives behavioural support combined with drug treatment, if nicotine-dependent. Special groups needing support include Aboriginal and Torres Strait Islander peoples, people with mental illness and pregnant women.