What do patients with diabetes and providers think of an innovative Australian model of remote diabetic retinopathy screening? A qualitative study.

BACKGROUND: Diabetic retinopathy (DR) is the commonest cause of preventable blindness in working age populations, but up to 98% of visual loss secondary to DR can be prevented with early detection and treatment. In 2012, an innovative outreach DR screening model was implemented in remote communities in a state of Australia. The aim of this study was to explore the acceptability of this unique DR screening model to patients, health professionals and other key stakeholders. METHODS: This descriptive qualitative study used semi-structured interviews with patients opportunistically recruited whilst attending DR screening, and purposefully selected health care professionals either working within or impacted by the programme. Interviews were audiotaped, transcribed and analysed using NVIVO. An iterative process of thematic analysis was used following the principles of grounded theory. RESULTS: Interviews were conducted with fourteen patients with diabetes living in three remote communities and nine health professionals or key stakeholders. Nine key themes emerged during interviews with health professionals, key stakeholders and patients: i) improved patient access to DR screening; ii) efficiency, financial implications and sustainability; iii) quality and safety; iv) multi-disciplinary diabetes care; v) training and education; vi) operational elements of service delivery; vii) communication, information sharing and linkages; viii) coordination and integration of the service and ix) suggested improvements to service delivery. CONCLUSIONS: The Remote Outreach DR Screening Service is highly acceptable to patients and health professionals. Challenges have primarily been encountered in communication and coordination of the service and further development in these areas could improve the programme's impact and sustainability in remote communities. The service is applicable to other remote communities nationally and potentially internationally.

Triggering change in diabetes care delivery in general practice: a qualitative evaluation approach using the clinical microsystem framework.

BACKGROUND: In 2008, the Sunshine Coast Division of General Practice (SCDGP) in Queensland, Australia initiated a highly successful Improved Diabetes Management (IDM) program with general practices in a regional area. The IDM program was evaluated against the 10 elements of a high functioning clinical microsystem framework as identified by Nelson et al. (2007) in order to determine key factors contributing to the successful adoption and uptake of the program in participating general practices. METHODS: The evaluation focussed on in-depth key informant interviews with 10 SCDGP staff and general practitioners (GPs) involved in the IDM program. A thematic analysis was undertaken and common emergent themes were reviewed against the 10 elements of high performing clinical microsystem. RESULTS: While all aspects of the clinical microsystem approach appeared effective in the design, implementation and adoption of the IDM program, several characteristics were crucial. The identification of champions of change in both the division and participating practices, the celebration of positive achievements and the use 'real data' from practices to demonstrate improved health outcomes for patients from the practice were instrumental in motivating participating GPs to both implement and sustain changes in their diabetes care delivery. CONCLUSION: In designing and redesigning health care, the clinical microsystems approach offers a pathway for the effective uptake of innovation in Australian primary health care; a means of integrating structure, process and outcomes of a care framework for reviewing improvements in the health care delivery process and could lead to improvements in patient health outcomes.

Patients' experiences of referral for colorectal cancer.

BACKGROUND: Outcomes for colorectal cancer patients vary significantly. Compared to other countries, Australia has a good record with patient outcomes, yet there is little information available on the referral pathway. This paper explores the views of Australian patients and their experiences of referral for colorectal cancer treatment following diagnosis; the aim was to improve our understanding of the referral pathway and guide the development of future interventions. METHODS: A purposive sampling strategy was used, recruiting 29 patients representing urban and rural areas from 3 Australian states who participated in 4 focus groups. Seven patients provided individual interviews to supplement the data. Recordings were transcribed verbatim, data was coded with NVivo software and analysed thematically before deductive analysis. RESULTS: Four aspects of the referral process were identified by patients, namely detection/diagnosis, referral for initial treatment/specialist care, the roles of the GP/specialist, and the patient's perceived involvement in the process. The referral process was characterised by a lack of patient involvement, with few examples of shared decision-making and few examples of limited choice. However, patients did not always feel they had the knowledge to make informed decisions. Information exchange was highly valued by patients when it occurred, and it increased their satisfaction with the process. Other factors mediating care included the use of the public versus private health system, the quality of information exchange (GP to specialist and GP to patient), continuity of care between GP and specialist, and the extent of information provision when patients moved between specialist and GP care. CONCLUSIONS: Patients described poor GP continuity, ad hoc organisational systems and limited information exchange, at both interpersonal and inter-organisational levels, all leading to sub-optimal care. Implementation of a system of information feedback to GPs and engagement with them might improve information exchange for patients, enabling them to be more involved in improved referral outcomes.

Referral pathways in colorectal cancer: an audit of surgeons's records.

PURPOSE: To explore the referral pathways of patients with newly diagnosed colorectal cancer to surgeons. METHOD: Australian surgeons from three states completed a questionnaire and their records were audited. RESULTS: Thirty-three surgeons provided data on 530 patients seen in the preceding 12 months. The median time between colonoscopy and first surgical consult was 10 days, with 19% of patients waiting more than 28 days. After adjustment for clustering, no surgeon factors were associated with the number of days between colonoscopy and surgery. A report back to the general practitioner (GP) was found in 78% of patients' records. This feedback varied between surgeons but none of the specific surgeon characteristics examined could explain this. CONCLUSION: Surgeons usually communicated with GP regardless of whether they were the referral source. However, communication with GP varied considerably among surgeons, with no evidence of a report to the GP in one-fifth of cases.

An Innovative Australian Outreach Model of Diabetic Retinopathy Screening in Remote Communities.

Background. Up to 98% of visual loss secondary to diabetic retinopathy (DR) can be prevented with early detection and treatment. Despite this, less than 50% of Australian and American diabetics receive appropriate screening. Diabetic patients living in rural and remote communities are further disadvantaged by limited access to ophthalmology services. Research Design and Methods. DR screening using a nonmydriatic fundal camera was performed as part of a multidisciplinary diabetes service already visiting remote communities. Images were onforwarded to a distant general practitioner who identified and graded retinopathy, with screen-positive patients referred to ophthalmology. This retrospective, descriptive study aims to compare the proportion of remote diabetic patients receiving appropriate DR screening prior to and following implementation of the service. Results. Of the 141 patients in 11 communities who underwent DR screening, 16.3% had received appropriate DR screening prior to the implementation of the service. In addition, 36.2% of patients had never been screened. Following the introduction of the service, 66.3% of patients underwent appropriate DR screening (p = 0.00025). Conclusion. This innovative model has greatly improved accessibility to DR screening in remote communities, thereby reducing preventable blindness. It provides a holistic, locally appropriate diabetes service and utilises existing infrastructure and health workforce more efficiently.

Medical family support needs and experiences in rural Queensland.

INTRODUCTION: Family issues have been recognised as major contributors to both rural GP retention in, and loss to, rural practice. This qualitative interview survey of rural medical spouses sought to identify and understand the support requirements and experiences that could be used to formulate strategies that may positively influence rural medical family retention. A concurrent key informant interview of 14 agencies associated with rural medical practitioner support sought information on those agencies' specific spouse/family support strategies. AIMS: The study's specific aims were to: investigate the experiences and needs of families in terms of support to settle and remain in rural and remote areas; and identify the range and type of formal and informal support strategies available to, and used by, rural medical families. METHODS: This was a qualitative study with two independent, but complementary, components: (1) in-depth, semi-structured interviews with families of 15 purposively selected rural GPs; and (2) information provided by 14 support organisations. RESULTS AND DISCUSSION: Medical family support needs and experiences varied with time in a rural setting. The most frequently mentioned early difficulties included integrating into a community (9/15); childcare and schooling (8/15); being seen as the 'doctors spouse' (ie, loss of own identity) (7/15); and housing and housing maintenance (7/15). Support needs changed over time as respondents established their own support networks. Increasingly, support was required for timeout from the community (5/15), and to keep abreast of changing practice management requirements (4/15). Few formal support strategies were reported as known or used by spouses. Informal support strategies included partners of other GPs; hospital functions and informal social gatherings; clubs and organisations; local church groups, and friendships with other itinerants in the community. Spouses indicated important potential sources of support (both when new to community and later on) as a need for a 'head start' with local and regional networks (14/15); ability to talk to other spouses in similar situations (12/15); support for timeout or leave (12/15); access to a GP other than the GP spouse (10/15); information about childcare (9/15); practice and business management (8/15); and dealing with housing issues (6/15). Additionally, an orientation package was seen as a means of assisting new arrivals to get settled (12/15). The survey of agencies/organisations providing direct and indirect support revealed that there is little directly-funded family support in Queensland, although a number of bodies either have support activities in place or planned. The potential number of players presents a risk of duplication of effort unless there is effective inter-agency dialogue. CONCLUSIONS: Like their medical partners, spouses appreciate and value peer support and understanding. Strategies aimed at rural GP retention should consider the rural medical family as a unit for support purposes. Support organisations and rural communities must recognise and cater for changing support needs over time. The agency interviews provided some hope for the future, although funding for support activities appears to be limited. Perhaps of greater concern is the possibility for duplication of effort and activity, particularly in some areas, and potentially at the risk of ignoring others.