Cohort profile: Using primary care data to understand Opioid Prescribing, Policy Impacts and Clinical Outcomes (OPPICO) in Victoria, Australia.

PURPOSE: The OPPICO cohort is a population-based cohort based on non-identifiable electronic health records routinely collected from 464 general practices in Victoria, Australia, created with the aim of understanding opioid prescribing, policy impacts and clinical outcomes. The aim of this paper is to provide a profile of the study cohort by summarising available demographic, clinical and prescribing characteristics. PARTICIPANTS: The cohort described in this paper comprises people who were aged at least 14 years at cohort entry, and who were prescribed an opioid analgesic at least once at participating practices for a total of 1 137 728 person-years from 1 January 2015 to 31 December 2020. The cohort was formed using the data collected from electronic health records through the Population Level Analysis and Reporting (POLAR) system. The POLAR data primarily consist of patient demographics, clinical measurements, Australian Medicare Benefits Scheme item numbers, diagnoses, pathology testing and prescribed medications. FINDING TO DATE: In total, the cohort consists of 676 970 participants with 4 389 185 opioid prescription records from 1 January 2015 to 31 December 2020. Approximately half (48.7%) received a single opioid prescription, and 0.9% received more than 100 opioid prescriptions. The mean number of opioid prescriptions per patient was 6.5 (SD=20.9); prescriptions for strong opioids accounted for 55.6% of all opioid prescriptions. FUTURE PLANS: The OPPICO cohort data will be used for various types of pharmacoepidemiological research, including examining the impact of policy changes on coprescription of opioids with benzodiazepines and gabapentin, and monitoring trends and patterns of other medication utilisation. Through data-linkage between our OPPICO cohort and hospital outcome data, we will examine whether policy changes for opioid prescribing lead to changes in prescription opioid-related harms, and other drug and mental health-related outcomes. TRIAL REGISTRATION NUMBER: EU PAS Register (EUPAS43218, prospectively registered).

Treatment with Multiple Therapeutic Classes of Medication Is Associated with Survival after Stroke.

INTRODUCTION: Treatment with several therapeutic classes of medication is recommended for secondary prevention of stroke. We analyzed the associations between the number of classes of prevention medications supplied within 90 days after discharge for ischemic stroke (IS)/transient ischemic attack (TIA) and survival. METHODS: This is a retrospective cohort study of adults with first-ever IS/TIA (2010-2014) from the Australian Stroke Clinical Registry individually linked with data from national pharmaceutical and Medicare claims. Exposure was the number of classes of recommended medications, i.e., blood pressure-lowering, antithrombotic, or lipid-lowering agents, supplied to patients within 90 days after discharge for IS/TIA. The longitudinal association between the number of classes of medications and survival was evaluated with Cox proportional hazards regression models using the landmark approach. A landmark date of 90 days after hospital discharge was used to separate exposure and outcome periods, and only patients who survived until this date were included. RESULTS: Of 8,429 patients (43% female, median age 74 years, 80% IS), 607 (7%) died in the year following 90 days after discharge. Overall, 56% of patients were supplied all 3 classes of medications, 28% 2 classes of medications, 11% 1 class of medications, and 5% no class of medications. Compared to patients supplied all 3 medication classes, adjusted hazard ratios for all-cause mortality ranged from 1.43 (95% confidence interval [CI]: 1.18-1.72) in those supplied 2 medication classes to 2.04 (95% CI: 1.44-2.88) in those supplied with no medication class. DISCUSSION/CONCLUSION: Treatment with all 3 classes of guideline-recommended medications within 90 days after discharge was associated with better survival. Ongoing efforts are required to ensure optimal pharmacological intervention for secondary prevention of stroke.

International Comparison of Six Basic eHealth Indicators Across 14 Countries: An eHealth Benchmarking Study.

BACKGROUND: Many countries adopt eHealth applications to support patient-centered care. Through information exchange, these eHealth applications may overcome institutional data silos and support holistic and ubiquitous (regional or national) information logistics. Available eHealth indicators mostly describe usage and acceptance of eHealth in a country. The eHealth indicators focusing on the cross-institutional availability of patient-related information for health care professionals, patients, and care givers are rare. OBJECTIVES: This study aims to present eHealth indicators on cross-institutional availability of relevant patient data for health care professionals, as well as for patients and their caregivers across 14 countries (Argentina, Australia, Austria, Finland, Germany, Hong Kong as a special administrative region of China, Israel, Japan, Jordan, Kenya, South Korea, Sweden, Turkey, and the United States) to compare our indicators and the resulting data for the examined countries with other eHealth benchmarks and to extend and explore changes to a comparable survey in 2017. We defined "availability of patient data" as the ability to access data in and to add data to the patient record in the respective country. METHODS: The invited experts from each of the 14 countries provided the indicator data for their country to reflect the situation on August 1, 2019, as date of reference. Overall, 60 items were aggregated to six eHealth indicators. RESULTS: Availability of patient-related information varies strongly by country. Health care professionals can access patients' most relevant cross-institutional health record data fully in only four countries. Patients and their caregivers can access their health record data fully in only two countries. Patients are able to fully add relevant data only in one country. Finland showed the best outcome of all eHealth indicators, followed by South Korea, Japan, and Sweden. CONCLUSION: Advancement in eHealth depends on contextual factors such as health care organization, national health politics, privacy laws, and health care financing. Improvements in eHealth indicators are thus often slow. However, our survey shows that some countries were able to improve on at least some indicators between 2017 and 2019. We anticipate further improvements in the future.

Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence.

OBJECTIVES: To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety. DATA SOURCES: 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance. STUDY SELECTION: 19 high-quality studies that assessed outcomes were included. DATA EXTRACTION: All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives. DATA SYNTHESIS: Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance. CONCLUSIONS: The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Enhancing care, improving quality: the six roles of the general practice nurse.

OBJECTIVE: To describe the evolving roles of practice nurses in Australia and the impact of nurses on general practice function. DESIGN, SETTING AND PARTICIPANTS: Multimethod research in two substudies: (a) a rapid appraisal based on observation, photographs of workspaces, and interviews with nurses, doctors and managers in 25 practices in Victoria and New South Wales, conducted between September 2005 and March 2006; and (b) naturalistic longitudinal case studies of introduced change in seven practices in Victoria, NSW, South Australia, Queensland and Western Australia, conducted between January 2007 and March 2008. RESULTS: We identified six roles of nurses in general practice: patient carer, organiser, quality controller, problem solver, educator and agent of connectivity. Although the first three roles are appreciated as nursing strengths by both nurses and doctors, doctors tended not to recognise nurses' educator and problem solver roles within the practice. Only 21% of the clinical activities undertaken by nurses were directly funded through Medicare. The role of the nurse as an agent of connectivity, uniting the different workers within the practice organisation, is particularly notable in small and medium-sized practices, and may be a key determinant of organisational resilience. CONCLUSION: Nursing roles may be enhanced through progressive broadening of the scope of the patient care role, fostering the nurse educator role, and addressing barriers to role enhancement, such as organisational inexperience with interprofessional work and lack of a career structure. In adjusting the funding structure for nurses, care should be taken not to create perverse incentives to limit nurses' clinical capacity or undermine the flexibility that gives practice nursing much of its value for nurses and practices.