Administrative encounters in general practice: low value or hidden value care?

OBJECTIVE: To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care. DESIGN: Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset. SETTING: 1 568 100 GP-patient encounters in Australia, 2000-01 to 2015-16. PARTICIPANTS: An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients. MAIN OUTCOME MEASURES: Proportions of general practice encounters that were potentially low value care encounters (among the patient's reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015-16, we also examined other health care provided by GPs at these encounters. RESULTS: During 2015-16, 18.5% (95% CI, 17.7-19.3%) of 97 398 GP-patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0-7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5-4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4-13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7-3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases. CONCLUSION: Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.

When parents won't vaccinate their children: a qualitative investigation of australian primary care providers' experiences.

BACKGROUND: Increasingly, the experiences and perceptions of parents who decline vaccination are the subject of investigation. However, the experiences of clinicians who encounter these parents in the course of their work has received little academic attention to date. This study aimed to understand the challenges faced and strategies used when general practitioners and immunising nurses encounter parents who choose not to vaccinate their children. METHODS: Primary care providers were recruited from regions identified through the Australian Childhood Immunisation Register (ACIR) as having higher than national average rates of registered objection to childhood vaccination. Interviews began with an exploration of provider experiences with parents who accept, are hesitant towards, and who decline vaccination. Participants were asked specifically about how they addressed any difficulties they encountered in their interactions. Thematic analysis focused on encounters with parents - challenges and strategies. RESULTS: Twenty-six general practitioners (GPs), community and practice nurses (PNs) were interviewed across two regions in NSW, Australia. Providers' sense of professional identity as health advocates and experts became conflicted in their encounters with vaccine objecting parents. Providers were dissatisfied when such consultations resulted in a 'therapeutic roadblock' whereby provider-parent communication came to a standstill. There were mixed views about being asked to sign forms exempting parents from vaccinating their children. These ranged from a belief that completing the forms rewarded parents for non-conformity to seeing it as a positive opportunity for engagement. Three common strategies were employed by providers to navigate through these challenges; 1) to explore and inform, 2) to mobilise clinical rapport and 3) to adopt a general principle to first do no harm to the therapeutic relationship. CONCLUSIONS: Many healthcare providers find consultations with vaccine objecting parents challenging and some, particularly more experienced providers, employ successful strategies to address this. Primary care providers, especially those more junior, could benefit from additional communication guidance to better the outcome and increase the efficiency of their interactions with such parents.

Can consumers learn to ask three questions to improve shared decision making? A feasibility study of the ASK (AskShareKnow) Patient-Clinician Communication Model(®) intervention in a primary health-care setting.

OBJECTIVE: To test the feasibility and assess the uptake and acceptability of implementing a consumer questions programme, AskShareKnow, to encourage consumers to use the questions '1. What are my options; 2. What are the possible benefits and harms of those options; 3. How likely are each of those benefits and harms to happen to me?' These three questions have previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement. METHODS: This single-arm intervention study invited participants attending a reproductive and sexual health-care clinic to view a 4-min video-clip in the waiting room. Participants completed three questionnaires: (T1) prior to viewing the intervention; (T2) immediately after their consultation; and (T3) two weeks later. RESULTS: A total of 121 (78%) participants viewed the video-clip before their consultation. Eighty-four (69%) participants asked one or more questions, and 35 (29%) participants asked all three questions. For those making a decision, 55 (87%) participants asked one or more questions, while 27 (43%) participants asked all three questions. Eighty-seven (72%) participants recommended the questions. After two weeks, 47 (49%) of the participants recalled the questions. CONCLUSIONS: Enabling patients to view a short video-clip before an appointment to improve information and involvement in health-care consultations is feasible and led to a high uptake of question asking in consultations. PRACTICE IMPLICATIONS: This AskShareKnow programme is a simple and feasible method of training patients to use a brief consumer-targeted intervention that has previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement and use of evidence-based questions.

Shared decision making: what do clinicians need to know and why should they bother?

Shared decision making enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances. It is not a single step to be added into a consultation, but a process that can be used to guide decisions about screening, investigations and treatments. The benefits of shared decision making include enabling evidence and patients' preferences to be incorporated into a consultation; improving patient knowledge, risk perception accuracy and patient-clinician communication; and reducing decisional conflict, feeling uninformed and inappropriate use of tests and treatments. Various approaches can be used to guide clinicians through the process. We elaborate on five simple questions that can be used: What will happen if the patient waits and watches? What are the test or treatment options? What are the benefits and harms of each option? How do the benefits and harms weigh up for the patient? Does the patient have enough information to make a choice? Although shared decision making can occur without tools, various types of decision support tools now exist to facilitate it. Misconceptions about shared decision making are hampering its implementation. We address the barriers, as perceived by clinicians. Despite numerous international initiatives to advance shared decision making, very little has occurred in Australia. Consequently, we are lagging behind many other countries and should act urgently.

Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers.

BACKGROUND: Making evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients' risk perception and leads to better informed decision making. This paper summarises current "best practices" in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools. METHOD: An expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a "state of the art" summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results. RESULTS: The eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid "1 in x" formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience. CONCLUSION: A substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.

Which Test Is Best? A Cluster-Randomized Controlled Trial of a Risk Calculator and Recommendations on Colorectal Cancer Screening Behaviour in General Practice.

INTRODUCTION: This cluster-randomized controlled trial aimed to assess the effect of the "Which test is best?" tool on risk-appropriate screening (RAS) and colorectal cancer (CRC) screening uptake. METHODS: General practices in Sydney and Melbourne, Australia, and a random sub-sample of 460 patients (aged 25-74 years) per practice were invited by post. Clusters were computer randomized independently of the researchers to an online CRC risk calculator with risk-based recommendations versus usual care. Primary and secondary outcomes were RAS and screening uptake via self-reported 5-year screening behaviour after 12 months follow-up. The usual care group (UCG) also self-reported 5-year CRC screening behaviour at 12 month post-randomization. RESULTS: Fifty-six practices were randomized (27 to the intervention and 29 to the control, 55 practices participated) with 818 intervention and 677 controls completing the primary outcome measure. The intervention significantly increased RAS in high-risk participants compared with UCG (80.0% vs. 64.0%, respectively; OR = 3.14, 95% CI: 1.25-7.96) but not in average-risk (44.9% vs. 49.5%, respectively; OR = 0.97, 95% CI: 0.99-1.12) or moderate-risk individuals (67.9% vs. 81.1%, respectively; OR = 0.40, 95% CI: 0.12-1.33). Faecal occult blood testing uptake over 12 months was increased compared with the UCG (24.9% vs. 15.1%; adjusted OR = 1.66, 95% CI: 1.24-2.22), and there was a non-significant increase in colonoscopies during the same period (16.6% vs. 12.2%; adjusted OR = 1.42, 95% CI: 0.97-2.08). CONCLUSION: An online CRC risk calculator with risk-based screening recommendations increased RAS in high-risk participants and improved screening uptake overall within a 12-month follow-up period. Such tools may be useful for facilitating the uptake of risk-based screening guidelines.

Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia.

OBJECTIVE: To examine the costs and cost-effectiveness of full implementation of biennial bowel cancer screening for Australian residents aged 50-74 years. DESIGN AND SETTING: Identification of existing economic models from 1993 to 2010 through searches of PubMed and economic analysis databases, and by seeking expert advice; and additional modelling to determine the costs and cost-effectiveness of full implementation of biennial faecal occult blood test screening for the five million adults in Australia aged 50-74 years. MAIN OUTCOME MEASURES: Estimated number of deaths from bowel cancer prevented, costs, and cost-effectiveness (cost per life-year gained [LYG]) of biennial bowel cancer screening. RESULTS: We identified six relevant economic analyses, all of which found colorectal cancer (CRC) screening to be very cost-effective, with costs per LYG under $55,000 per year in 2010 Australian dollars. Based on our additional modelling, we conservatively estimate that full implementation of biennial screening for people aged 50-74 years would have gross costs of $150 million, reduce CRC mortality by 15%-25%, prevent 300-500 deaths from bowel cancer, and save 3600-6000 life-years annually, for an undiscounted cost per LYG of $25,000-$41,667, compared with no screening, and not taking cost savings as a result of treatment into consideration. The additional expenditure required, after accounting for reductions in CRC incidence, savings in CRC treatment costs, and existing ad-hoc colonoscopy use, is likely to be less than $50 million annually. CONCLUSIONS: Full implementation of biennial faecal occult blood test screening in Australia can reduce bowel cancer mortality, and is an efficient use of health resources that would require modest additional government investment.

Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts.

BACKGROUND: Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids. METHODS: As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version. RESULTS: Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates. DISCUSSION: More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles.

BACKGROUND: Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. METHODS: Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. RESULTS: Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. DISCUSSION: Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

What patients want to ask their doctors: Data analysis from Question Builder, an online question prompt list tool.

OBJECTIVES: Question prompt lists (QPLs) are one strategy to increase patient participation in healthcare decisions but the extent to which consumers might access them in the 'real world' is largely unknown. This study measured usage of a passively-promoted, government-funded web-based patient-generated QPL tool, called Question Builder (Australia) (QB) hosted on healthdirect.gov.au, a consumer health information website. METHODS: 12.5months of post-launch Google Analytics data from QB were analysed. Two existing coding frameworks (RIAS and ACEPP) were used to code QB questions thematically and 107 user-generated lists were analysed further to determine the questions chosen and prioritised. RESULTS: QB was accessed 8915 times, 4000 question lists were commenced and 1271 lists completed. Most lists were for general practice (GP) consultations (2444) rather than specialist consultations (1556). The most frequently chosen question was "Do I need any tests?". Shared decision-making questions (SDM) made up 40% of questions prioritised e.g. "Do I need any treatment and what are my treatment options?" CONCLUSIONS: There is active use of this online QPL, with strong interest in creating lists for GP consultations. Question Builder users prioritised questions which facilitate SDM. PRACTICE IMPLICATIONS: More research is required to assess the utilisation of QB in practice and health professionals' views of QB.

Randomized trial of a self-administered decision aid for colorectal cancer screening.

OBJECTIVE: Previous studies have not assessed whether evidence-based information about the outcomes of colorectal cancer screening increases informed choice among people from a range of socioeconomic backgrounds nor have they assessed whether this can be administered away from a health-care provider. METHODS: Randomized controlled trial in six primary care locations. Three hundred and fourteen people aged 50-74 years received a self-administered decision aid (DA) booklet about outcomes of biennial faecal occult blood testing (FOBT) screening or government consumer guidelines (G). RESULTS: Significantly more DA recipients (20.9%) were 'informed' compared with G recipients (5.8%) (P = 0.0001, OR 4.32; 95% CI 2.49 to 7.52); the DA did not affect values clarity (61.9% clear after DA versus 59.1% after G) nor screening decisions overall (87.3% would screen after DA versus 90.5% after G). Test uptake at one month was uniformly low (5.2% DA versus 6.6% G); mostly due to being 'too busy'. DA recipients were more likely to make decisions 'integrating' knowledge with values (10.4% DA versus 1.5% G). Decisions not to screen were equally uncommon in both groups but more likely to be uninformed in G (P = 0.03). More DA recipients from all education levels were 'informed' (P = 0.02), particularly in lower education (50.0% DA versus 17.8% G) and university-educated groups (79.4% DA versus 32.1% G). CONCLUSION: Detailed absolute risk and benefit information about FOBT screening can be effectively used at home by people to increase informed choice. The DA was effective in people with lower education levels. TRIAL REGISTRATION: Unique Protocol ID 211705 ClinicalTrials.gov ID NCT 00148226.

What Is the Effectiveness of Patient Decision Aids for Cancer-Related Decisions? A Systematic Review Subanalysis.

PURPOSE: To determine the effectiveness of patient decision aids when used with patients who face cancer-related decisions. PATIENTS AND METHODS: Two reviewers independently screened the 105 trials in the original 2017 Cochrane review to identify eligible trials of patient decision aids across the cancer continuum. Primary outcomes were attributes of the choice and decision-making process. Secondary outcomes were patient behavior and health system effects. A meta-analysis was conducted for similar outcome measures. RESULTS: Forty-six trials evaluated patient decision aids for cancer care, including 27 on screening decisions (59%), 12 on treatments (26%), four on genetic testing (9%), and three on prevention (6%). Common decisions were aboutprostate cancer screening (30%), colorectal cancer screening (22%), breast cancer treatment (13%), and prostate cancer treatment (9%). Compared with the control groups (usual care or alternative interventions), the patient decision aid group improved the match between the chosen option and the features that mattered most to the patient as demonstrated by improved knowledge (weighted mean difference, 12.88 of 100; 95% CI, 9.87 to 15.89; 24 trials), accurate risk perception (risk ratio [RR], 1.77; 95% CI, 1.22 to 2.56; six trials), and value-choice agreement (RR, 2.76; 95% CI, 1.57 to 4.84; nine trials). Compared with controls, the patient decision aid group improved the decision-making process with decreased decisional conflict (weighted mean difference, -9.56 of 100; 95% CI, -13.90 to -5.23; 12 trials), reduced clinician-controlled decision making (RR, 0.57; 95% CI, 0.41 to 0.79; eight trials), and fewer patients being indecisive (RR, 0.59; 95% CI, 0.45 to 0.78; nine trials). CONCLUSION: Patient decision aids improve the attributes of the choice made and decision-making process for patients who face cancer-related decisions.

GPs want tailored, user friendly evidence summaries--a cross sectional study in New South Wales.

BACKGROUND: This study aimed to measure the use of, and barriers to, using evidence among general practitioners since computerisation of general practice; GP preference for patient involvement in health care decisions; and GPs' preferred strategies to increase the use of evidence. METHODS: A cross sectional, open ended telephone survey was conducted with 107 (out of 155) New South Wales GPs randomly selected from the New South Wales Medical Board register. The survey sought self report to open ended questions about information sources informing decisions, perceived barriers to using evidence, and suggested strategies to improve clinical decisions, plus Degner scale for patient involvement. RESULTS: Evidence based sources remained the least likely to be used for informing decisions about patient care (23.4%). Opinion based sources were most commonly used (50.5%), with industry sponsored sources second (27.1%). Rural GPs were more likely to use opinion based sources (OR=1.55, 95% CI: 1.00-2.40). The most common perceived barriers were 'a lack of time' (22.0%), 'a lack of evidence or conflicting evidence' (13.1%), 'not knowing where to look' (10.3%) and 'not being able to tailor evidence to individual patients' (9.3%). The majority of GPs (72.0%) preferred patients to have some role in decision making. The most common suggestions for improving decision making were 'simply formatted evidence summaries' (28.0%) and 'mechanisms for tailoring evidence with individual patients' (13.1%). DISCUSSION: The use of evidence based sources for clinical decision making in general practice remains limited. Potential strategies to overcome this should focus on providing more user friendly evidence summaries, involving patients in evidence based decision making, and finding mechanisms to tailor evidence to individual patients.

Problem-based learning in public health workforce training: a discussion of educational principles and evidence.

Problem-based learning (PBL) has been implemented within numerous undergraduate health curricula but less so in workforce training. Public health practice requires many of the skills that PBL aims to develop such as teamwork, self-directed learning and the integration of multiple sources of information within problem solving. This paper summarises the historical development of PBL and the educational principles underpinning it. It hypothesises that the public health workforce would benefit from some exposure to this type of learning and highlights some of the practical issues for its implementation.

Implementation of a lung cancer multidisciplinary team standardised template for reporting to general practitioners: a mixed-method study.

OBJECTIVES: Few interventions have been designed that provide standardised information to primary care clinicians about the diagnostic and treatment recommendations resulting from cancer multidisciplinary team (MDT) (tumour board) meetings. This study aimed to develop, implement and evaluate a standardised template for lung cancer MDTs to provide clinical information and treatment recommendations to general practitioners (GPs). Specific objectives were to (1) evaluate template feasibility (acceptability, appropriateness and timeliness) with GPs and (2) document processes of preimplementation, implementation and evaluation within the MDT setting. DESIGN: A mixed-method study design using structured interviews with GPs and qualitative documentation of project logs about implementation processes. SETTING: Two hospitals in Central Sydney, New South Wales, Australia. PARTICIPANTS: 61 GPs evaluated the template. Two lung cancer MDTs, consisting of 33 clinicians, and eight researchers participated in template development and implementation strategy. RESULTS: The MDT-reporting template appears to be a feasible way of providing clinical information to GPs following patient presentation at a lung cancer MDT meeting. Ninety-five per cent of GPs strongly agreed or agreed that the standardised template provided useful and relevant information, that it was received in a timely manner (90%) and that the information was easy to interpret and communicate to the patient (84%). Implementation process data show that the investment made in the preimplementation stage to integrate the template into standard work practices was a critical factor in successful implementation. CONCLUSIONS: This study demonstrates that it is feasible to provide lung cancer MDT treatment recommendations to GPs through implementation of a standardised template. A simple intervention, such as a standardised template, can help to address quality gaps and ensure that timely information is communicated between tertiary and primary care healthcare providers.

Experiences of food insecurity among urban soup kitchen consumers: insights for improving nutrition and well-being.

Adequate nutrition is an essential determinant of health. Disadvantaged individuals within the cities of developed countries continue to have poor health, yet the role of food insecurity in such groups is poorly understood. This cross-sectional study describes such experiences among 22 randomly selected participants who participated in interviews at a charity-run soup kitchen in urban Sydney, Australia. Interviews explored four constructs of food insecurity (quantitative, qualitative, psychological, and social), identifying related barriers and coping strategies. Reliable access to food was limited. Low income; high rents; poor health; and addictions to cigarettes, alcohol, illicit drugs, and gambling were associated with dependence on charities. Poor dentition and lack of food storage and cooking facilities were important barriers to adequate nutrition. Meals were missed and quantities restricted as a coping strategy. Participants demonstrated adequate knowledge and a desire to eat healthful food. Opportunities for social interaction and trust in soup kitchen staff were important motivators of attendance. Strategies to reduce food insecurity among seriously disadvantaged city dwellers should focus less on education and more on practical solutions, such as accessing affordable healthful food for those without kitchen facilities, improving dentition, and reducing addictions. It is also important to facilitate social networks with trusted support organizations.

A systematic review on communicating with patients about evidence.

OBJECTIVE: To conduct a systematic search for (1) the effectiveness of evidence-based communication tools to increase patient understanding of evidence, (2) effective formats for representing probabilistic information and (3) effective strategies for eliciting patient preferences about evidence. A case scenario is used to illustrate some of the difficulties of putting these results into practice. DATA SOURCES: Systematic search of The Cochrane Library, Medline, Psychinfo, Embase and Cancerlit. REVIEW METHODS: Systematic reviews of randomized controlled trials (RCTs) and high quality RCTs were included. Studies were excluded if they did not address the question, were focused on behavioural outcomes without attempting to increase understanding, were concerned with counselling as a therapeutic intervention, or were specific to communication regarding clinical trial participation. RESULTS: We found 10 systematic reviews of RCTs and 30 additional RCTs addressing our questions. Communication tools in most formats (verbal, written, video, provider-delivered, computer-based) will increase patients' understanding but are more likely to do so if structured, tailored and/or interactive. Probabilistic information is best represented as event rates (natural frequencies) in relevant groups of people, rather than words, probabilities or summarized as effect measures such as relative risk reduction. Illustrations such as cartoons, or graphs (vertical bar charts) appear to aid understanding. Values clarification exercises may be better than standard utility techniques for eliciting preferences in individual decision making. Looking for effective evidence-based communication tools for prostatic specific antigen testing highlighted the challenges for clinicians and consumers in accessing tools that are evidence-based in design as well as content. CONCLUSION: There is an increasing body of evidence supporting the design of effective evidence-based communication tools but variable access to such tools in practice.

Self-directed learning in population health. a clinically relevant approach for medical students.

BACKGROUND: In this article, we describe the education model used to integrate population health learning into a new 4-year medical program at the University of Sydney. METHOD: Our two-pronged approach aims to prepare third-year students to integrate population health thinking into their day-to-day clinical reasoning and to equip them with skills to investigate specific population health topics. We provide an example of a student-led, small-group session on health issues for disadvantaged populations, along with an outline of our assessment and evaluation methods. This innovative course illustrates one approach to the challenge of motivating students to bridge the gap between their interest in the medical care of individual patients and the healthcare needs of whole populations. RESULTS/CONCLUSIONS: Students performed adequately in the assessments required for progression to the next year of the program. Students rated the case-based exercises; self-directed learning; on-line and library resources; tutor facilitation; and student-led, small-group sessions as effective methods for learning.

Implementing what works: a case study of integrated primary health care revitalisation in Timor-Leste.

BACKGROUND: Revitalising primary health care (PHC) and the need to reach MDG targets requires developing countries to adapt current evidence about effective health systems to their local context. Timor-Leste in one of the world's newest developing nations, with high maternal and child mortality rates, malaria, TB and malnutrition. Mountainous terrain and lack of transport pose serious challenges for accessing health services and implementing preventive health strategies. METHODS: We conducted a non-systematic review of the literature and identified six components of an effective PHC system. These were mapped onto three countries' PHC systems and present a case study from Timor-Leste's Servisu Integrado du Saude Comunidade (SISCa) focussing on MDGs. Some of the challenges of implementing these into practice are shown through locally collected health system data. RESULTS: An effective PHC system comprises 1) Strong leadership and government in human rights for health; 2) Prioritisation of cost-effective interventions; 3) Establishing an interactive and integrated culture of community engagement; 4) Providing an integrated continuum of care at the community level; 5) Supporting skilled and equipped health workers at all levels of the health system; 6) Creating a systems cycle of feedback using data to inform health care. The implementation case study from Timor-Leste (population 1 million) shows that in its third year, limited country-wide data had been collected and the SISCa program provided over half a million health interactions at the village level. However, only half of SISCa clinics were functional across the country. Attendances included not only pregnant women and children, but also adults and older community members. Development partners have played a key role in supporting this implementation process. CONCLUSION: The SISCa program is a PHC model implementing current best practice to reach remote communities in a new developing country. Despite limited resources, village level healthcare and engagement can be achieved but takes a long-term commitment and partnership.