Key stakeholder experiences of an integrated healthcare pilot in Australia: a thematic analysis.

BACKGROUND: In Australia and other developed countries, chronic illness prevalence is increasing, as are costs of healthcare, particularly hospital-based care. Integrating healthcare and supporting illness management in the community can be a means of preventing illness, improving outcomes and reducing unnecessary hospitalisation. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health funded a range of key strategies through the Western Sydney Integrated Care Program (WSICP) to integrate care across hospital and community settings for patients with these illnesses. Complementing our previously reported analysis related to specific WSICP strategies, this research provided information concerning overall experiences and perspectives of WSICP implementation and integrated care generally. METHODS: We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners and primary care nurses, and program managers. Half of the participants (n = 42) were interviewed twice. We conducted an inductive, thematic analysis on the interview transcripts. RESULTS: Key themes related to the set-up and operationalising of WSICP; challenges encountered; and the added value of the program. Implementing WSICP was a large and time consuming undertaking but challenges including those with staffing and information technology were being addressed. The WSICP was considered valuable in reducing hospital admissions due to improved patient self-management and a focus on prevention, greater communication and collaboration between healthcare providers across health sectors and an increased capacity to manage chronic illness in the primary care setting. CONCLUSIONS: Patients, carers and health providers experienced the WSICP as an innovative integrated care model and valued its patient-centred approach which was perceived to improve access to care, increase patient self-management and illness prevention, and reduce hospital admissions. Long-term sustainability of the WSICP will depend on retaining key staff, more effectively sharing information including across health sectors to support enhanced collaboration, and expanding the suite of activities into other illness areas and locations. Enhanced support for general practices to manage chronic illness in the community, in collaboration with hospital specialists is critical. Timely evaluation informs ongoing program implementation.

Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs.

OBJECTIVES: The current COVID-19 pandemic, as well as the measures taken to control it, have a profound impact on healthcare. This study was set up to gain insights into the consequences of the COVID-19 outbreak on the core competencies of general practice, as they are experienced by general practitioners (GPs) on the frontline. DESIGN, SETTING, PARTICIPANTS: We performed a descriptive study using semistructured interviews with 132 GPs in Flanders, using a topic list based on the WONCA definition of core competencies in general practice. Data were analysed qualitatively using framework analysis. RESULTS: Changes in practice management and in consultation strategies were quickly adopted. There was a major switch towards telephone triage and consults, for covid-related as well as for non-covid related problems. Patient-centred care is still a major objective. Clinical decision-making is largely focused on respiratory assessment and triage, and GPs feel that acute care is compromised, both by their own changed focus and by the fact that patients consult less frequently for non-covid problems. Chronic care is mostly postponed, and this will have consequences that will extend and become visible after the corona crisis. Through the holistic eyes of primary care, the current outbreak-as well as the measures taken to control it-will have a profound impact on psychological and socioeconomic well-being. This impact is already visible in vulnerable people and will continue to become clear in the medium and long terms. GPs think that they are at high risk of getting infected. Dropping out and being unable to contribute their part or becoming virus transmitters are reported to be greater concerns than getting ill themselves. CONCLUSIONS: The current times have a profound impact on the core competences of primary care. Although the vast increase in patients soliciting medical help and the necessary separate covid and non-covid flows have been dealt with, GPs are worried about the continuity of regular care and the consequences of the anticovid measures. These may become a threat for the general health of the population and for the provision of primary healthcare in the near and distant future.

Do general practice management and/or team care arrangements reduce avoidable hospitalisations in Central and Eastern Sydney, Australia?

BACKGROUND: The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years. METHODS: This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006-2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage. RESULTS: Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years. CONCLUSIONS: The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.

Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes.

OBJECTIVE: Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement. METHOD: From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised ß coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers. RESULTS: Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The ß values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000. CONCLUSIONS: GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.

Talking about overweight and obesity in rural Australian general practice.

As many patients' sole point of contact with the health care system, primary health care physicians (general practitioners [GPs] in Australia) are often positioned as key players in responding to rates of overweight and obesity in dominant public discourse. However, research from Western industrialised countries suggests that GPs may not be prepared for, or confident in, having conversations about overweight and obesity with patients. Little attention has been given to this topic in Australia, particularly in the context of rural health. The aim of this study was to understand how GPs in two rural settings in Victoria, Australia talk about overweight and obesity with patients. Working from a multidisciplinary perspective, a qualitative study design was adopted, and semi-structured interviews were conducted with seven GPs and seven GP patients living in two rural communities between January and April, 2016. Data was coded manually and thematic analysis was used to explore the data. The findings of this study support the argument that, in contrast to dominant messages within public health discourses, GPs may not be best placed to act as the primary actors in responding to overweight and obesity as they are constructed in epidemiological terms. In fact, the perspectives of GP study participants suggest that to do so would compromise important dimensions of general medical practice that make it simultaneously a human practice. Instead, more balanced, holistic approaches to discussing and responding to overweight and obesity with patients could be taken up in local, interdisciplinary collaborations between different health professionals and patients, which utilise broader social supports. Focussing on long-term, incremental programs that consider the whole person within their particular socio-cultural environment would be a productive means of working with the complexities of overweight and obesity. However, structural level changes are required to ensure such initiatives are sustainable in rural practice.

Definition of whole person care in general practice in the English language literature: a systematic review.

OBJECTIVES: The importance of 'whole person' or 'holistic' care is widely recognised, particularly with an increasing prevalence of chronic multimorbidity internationally. This approach to care is a defining feature of general practice. However, its precise meaning remains ambiguous. We aimed to determine how the term 'whole person' care is understood by general practitioners (GPs), and whether it is synonymous with '[w]holistic' and 'biopsychosocial' care. DESIGN: Systematic literature review. METHODS: MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, Proquest Dissertations and Theses, Science.gov (Health and Medicine database), Google Scholar and included studies' reference lists were searched with an unlimited date range. Systematic or literature reviews, original research, theoretical articles or books/book chapters; specific to general practice; relevant to the research question; and published in English were included. Included literature was critically appraised, and data were extracted and analysed using thematic synthesis. RESULTS: Fifty publications were included from 4297 non-duplicate records retrieved. Six themes were identified: a multidimensional, integrated approach; the importance of the therapeutic relationship; acknowledging doctors' humanity; recognising patients' individual personhood; viewing health as more than absence of disease; and employing a range of treatment modalities. Whole person, biopsychosocial and holistic terminology were often used interchangeably, but were not synonymous. CONCLUSIONS: Whole person, holistic and biopsychosocial terminology are primarily characterised by a multidimensional approach to care and incorporate additional elements described above. Whole person care probably represents the closest representation of the basis for general practice. Health systems aiming to provide whole person care need to address the challenge of integrating the care of other health professionals, and maintaining the patient-doctor relationship central to the themes identified. Further research is required to clarify the representativeness of the findings, and the relative importance GPs' assign to each theme. PROSPERO REGISTRATION NUMBER: CRD42017058824.

General practitioners and emergency departments (GPED)-efficient models of care: a mixed-methods study protocol.

INTRODUCTION: Pressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system. METHODS AND ANALYSIS: The study will be divided into three work packages (WPs). WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination. ETHICS AND DISSEMINATION: The study has been approved by the National Health Service East Midlands-Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation. TRIAL REGISTRATION NUMBER: ISRCTN51780222.

Do NHS GP surgeries employing GPs additionally trained in integrative or complementary medicine have lower antibiotic prescribing rates? Retrospective cross-sectional analysis of national primary care prescribing data in England in 2016.

OBJECTIVE: To determine differences in antibiotic prescription rates between conventional General Practice (GP) surgeries and GP surgeries employing general practitioners (GPs) additionally trained in integrative medicine (IM) or complementary and alternative medicine (CAM) (referred to as IM GPs) working within National Health Service (NHS) England. DESIGN: Retrospective study on antibiotic prescription rates per STAR-PU (Specific Therapeutic group Age-sex weighting Related Prescribing Unit) using NHS Digital data over 2016. Publicly available data were used on prevalence of relevant comorbidities, demographics of patient populations and deprivation scores. SETTING: Primary Care. PARTICIPANTS: 7283 NHS GP surgeries in England. PRIMARY OUTCOME MEASURE: The association between IM GPs and antibiotic prescribing rates per STAR-PU with the number of antibiotic prescriptions (total, and for respiratory tract infection (RTI) and urinary tract infection (UTI) separately) as outcome. RESULTS: IM GP surgeries (n=9) were comparable to conventional GP surgeries in terms of list sizes, demographics, deprivation scores and comorbidity prevalence. Negative binomial regression models showed that statistically significant fewer total antibiotics (relative risk (RR) 0.78, 95% CI 0.64 to 0.97) and RTI antibiotics (RR 0.74, 95% CI 0.59 to 0.94) were prescribed at NHS IM GP surgeries compared with conventional NHS GP surgeries. In contrast, the number of antibiotics prescribed for UTI were similar between both practices. CONCLUSION: NHS England GP surgeries employing GPs additionally trained in IM/CAM have lower antibiotic prescribing rates. Accessibility of IM/CAM within NHS England primary care is limited. Main study limitation is the lack of consultation data. Future research should include the differences in consultation behaviour of patients self-selecting to consult an IM GP or conventional surgery, and its effect on antibiotic prescription. Additional treatment strategies for common primary care infections used by IM GPs should be explored to see if they could be used to assist in the fight against antimicrobial resistance.

Learning Through Boundary Crossing: Professional Identity Formation of Pharmacists Transitioning to General Practice in the Netherlands.

PURPOSE: To unravel boundary crossing as it relates to professional identity formation in pharmacists transitioning from a community pharmacy to working as nondispensing clinical pharmacists in general practice, with the aim of optimizing their education. METHOD: This was a multiple-case study, including two-stage interviews, peer feedback, and individual reflection, that collected data in 2014-2016 from eight clinical pharmacists working in general practice in the Netherlands. These pharmacists acted-without a workplace role model-as pharmaceutical care providers in general practices during a 15-month training program. In within-case and cross-case analysis, data were collected regarding pharmacists' role development in practice and perceptions of learning processes, and examined through the lens of professional identity formation and boundary crossing. RESULTS: Analysis of data collected during and after the training program demonstrated that the clinical pharmacists who applied the learning mechanisms of reflection and transformation developed a patient-care-oriented professional identity. Some clinical pharmacists, who learned mainly through the mechanism of identification, did not integrate the new patient-care-oriented role into their professional identity. They felt that their workplace provided limited opportunities for reflection and transformation. Learning with peers on formal training days was seen as highly valuable for professional identity formation; it counterbalanced the lack of a role model in the workplace. CONCLUSIONS: Professional identity formation in the transition from community pharmacist to clinical pharmacist in general practice benefited from reflective, on-the-job training. This permitted transformative, boundary-crossing learning with peers and supported professional identity formation oriented to providing practice-based pharmaceutical care.

Factors affecting general practice collaboration with voluntary and community sector organisations.

Collaborative working between general practice (GP) and voluntary and community sector (VCS) organisations is increasingly championed as a means of primary care doing more with less and of addressing patients' "wicked problems". This paper aims to add to the knowledge base around collaborative practice between GPs and VCS organisations by examining the factors that aid or inhibit such collaboration. A case study design was used to examine the lived-experience of GPs and VCS organisations working collaboratively. Four cases, each consisting of a GP and a VCS organisation with whom they work collaboratively, were identified. Interviews (n = 18) and a focus group (n = 1) were conducted with staff within each organisation. Transcribed data were analysed thematically. Whilet there are similarities across cases in their use of, for example, Health Trainers and social prescribing, the form and function of GP-VCS collaborations were unique to their local context. The identified factors affecting GP-VCS collaboration reflect those found in previous service evaluations and the broader literature on partnership working; shared understanding, time and resources, trust, strong leadership, operational systems and governance and the "negotiation" of professional boundaries. While the current political environment may represent an opportunity for collaborations to develop, there are issues yet to be resolved before collaboration-especially more holistic and integrated approaches-becomes systematically embedded into practice.

[General Practice in a University Emergency Department - Concept, Implementation and Evaluation]. / Allgemeinmedizin in einer universitären Notaufnahme ­ Konzept, Umsetzung und Evaluation.

Background: Accident and emergency departments (A&E) are facing increasing numbers of patients. While hospitalization rates have remained nearly constant, there has been an increase in outpatient cases. Therefore, at Hannover Medical School (MHH), general practitioners (GPs) have been integrated in A&E. Methods: In 2014, all GP contacts within the A&E were evaluated on the basis of hospital routine data and by an additional questionnaire. It contained questions about who initiated the admission, about medical examinations and tests and the patient-related admission decisions. Results: In 2014, GPs in A&E treated 1 646 patients. 76% of the patients were self-referrals and 23% referrals from primary care physicians. The most prevalent diagnoses were back pain, gastroenteritis and hypertension. GPs in A&E did not need any additional specialist involvement in most cases. 81% of the patients were sent home, most of them with the advice to consult their GPs (59%), and 22% to consult a specialist. Repeated visits were scarce. Conclusion: Deploying GPs in A&E represents a promising concept to cope with the rising number of patients in A&E. However, further studies are needed to examine the accuracy of the GPs' diagnosis-related decisions and patient satisfaction.