Evaluating the Digital Health Experience for Patients in Primary Care: Mixed Methods Study.

BACKGROUND: The digital health divide for socioeconomic disadvantage describes a pattern in which patients considered socioeconomically disadvantaged, who are already marginalized through reduced access to face-to-face health care, are additionally hindered through less access to patient-initiated digital health. A comprehensive understanding of how patients with socioeconomic disadvantage access and experience digital health is essential for improving the digital health divide. Primary care patients, especially those with chronic disease, have experience of the stages of initial help seeking and self-management of their health, which renders them a key demographic for research on patient-initiated digital health access. OBJECTIVE: This study aims to provide comprehensive primary mixed methods data on the patient experience of barriers to digital health access, with a focus on the digital health divide. METHODS: We applied an exploratory mixed methods design to ensure that our survey was primarily shaped by the experiences of our interviewees. First, we qualitatively explored the experience of digital health for 19 patients with socioeconomic disadvantage and chronic disease and second, we quantitatively measured some of these findings by designing and administering a survey to 487 Australian general practice patients from 24 general practices. RESULTS: In our qualitative first phase, the key barriers found to accessing digital health included (1) strong patient preference for human-based health services; (2) low trust in digital health services; (3) high financial costs of necessary tools, maintenance, and repairs; (4) poor publicly available internet access options; (5) reduced capacity to engage due to increased life pressures; and (6) low self-efficacy and confidence in using digital health. In our quantitative second phase, 31% (151/487) of the survey participants were found to have never used a form of digital health, while 10.7% (52/487) were low- to medium-frequency users and 48.5% (236/487) were high-frequency users. High-frequency users were more likely to be interested in digital health and had higher self-efficacy. Low-frequency users were more likely to report difficulty affording the financial costs needed for digital access. CONCLUSIONS: While general digital interest, financial cost, and digital health literacy and empowerment are clear factors in digital health access in a broad primary care population, the digital health divide is also facilitated in part by a stepped series of complex and cumulative barriers. Genuinely improving digital health access for 1 cohort or even 1 person requires a series of multiple different interventions tailored to specific sequential barriers. Within primary care, patient-centered care that continues to recognize the complex individual needs of, and barriers facing, each patient should be part of addressing the digital health divide.

A novel methodological approach to participant engagement and policy relevance for community-based primary medical care research during the COVID-19 pandemic in Australia and New Zealand.

Community-based primary care, such as general practice (GP) or urgent care, serves as the primary point of access to healthcare for most Australians and New Zealanders. Coronavirus disease 2019 (COVID-19) has created significant and ongoing disruptions to primary care. Traditional research methods have contributed to gaps in understanding the experiences of primary care workers during the pandemic. This paper describes a novel research design and method that intended to capture the evolving impact of the COVID-19 pandemic on primary care workers in Australia and New Zealand. Recurrent, rapid cycle surveys were fielded from May 2020 through December 2021 in Australia, and May 2020 through February 2021 in New Zealand. Rapid survey development, fielding, triangulated analysis and dissemination of results allowed close to real-time communication of relevant issues among general practice workers, researchers and policy-makers. A conceptual model is presented to support longitudinal analysis of primary care worker experiences during the COVID-19 pandemic in Australia and New Zealand, and key learnings from applying this novel method are discussed. This paper will assist future research teams in development and execution of policy-relevant research in times of change and may inform further areas of interest for COVID-19 research in primary care.

Risk of behavioural and developmental difficulties in early childhood in the Australian Capital Territory.

AIM: We aimed to estimate the prevalence of risk for developmental and behavioural problems for children in their first year of full-time primary education in the Australian Capital Territory (ACT). METHODS: We conducted an analysis of the 2014-2017 Kindergarten Health Check (KHC), an annual series of complete enumeration surveys of all children in their first year of full-time primary education in the ACT. Risk for developmental and behavioural problems was determined using the Parents' Evaluation of Developmental Status (PEDS) questionnaire. RESULTS: 19 414 children (mean age 5.56 years; 51.4% boys; 2.3% Aboriginal and Torres Strait Islander; 18.4% quintile of greatest relative disadvantage) who participated in the 2014-2017 KHC were included in the study (87%). More than half of ACT children in their first year of primary education had low/no developmental risk identified through the PEDS questionnaire, with 1 in 10 at high risk. CONCLUSIONS: Those more likely to have a high risk PEDS score were boys, those from the areas experiencing relative disadvantage, and Aboriginal and Torres Strait Islander children. While we can identify children at risk through screening, the greater challenge remains to identify and address the underlying causes of healthy inequalities, even within highly socioeconomically advantaged communities.

Low agreement among patients and clinicians about urgency and safety to wait for assessment in primary care after hours medical care: results of cross-sectional matched surveys.

BACKGROUND: Discordance between patient and clinician perceived urgency may drive "inappropriate" presentations to after-hours medical services. This paper investigates the level of agreement between patient and clinicians' perceptions of urgency and safety to wait for an assessment at after-hours primary care services in the ACT. METHODS: Cross-sectional survey voluntarily completed by patients and then clinicians at after-hours medical services in May/June, 2019. Agreement between patients and clinicians is measured by Fleiss kappa. Agreement is presented overall, within specific categories of urgency and safety to wait, and by after-hours service type. RESULTS: 888 matched records were available from the dataset. Overall inter-observer agreement between patients and clinicians on the urgency of presentations was slight (Fleiss kappa = 0.166; 95% CI 0.117-0.215, p < 0.001). Agreement within specific ratings of urgency ranged from very poor to fair. Overall inter-rater agreement on how long it would be safe to wait for assessment was fair (Fleiss kappa = 0.209; 95% CI 0.165-0.253, p < 0.001). Agreement within specific ratings ranged from poor to fair. By site type, agreement between patients and clinicians on urgency ranged from not significant to fair and agreement for safety to wait ranged from very poor to slight. Agreement on urgency of issue was more often reported among patients attending their usual health service or seeing their usual clinician compared to patients attending an unfamiliar health service or clinician (χ2(1) = 7.283, p = 0.007 and χ2(1) = 16.268, p < 0.001, respectively). CONCLUSIONS: Low levels of agreement between patients and clinicians on perceived urgency and safety to wait for issues to be assessed indicate potential inefficiency in primary care use after-hours. Agreement on urgency of issues was more common among patients attending a familiar health service or familiar clinician. Improving health literacy, particularly health system literacy, and supporting continuity of care may help to support patients to engage with the most appropriate level of care at the most appropriate time.

Parents' perceptions of their child's weight among children in their first year of primary school: a mixed-methods analysis of an Australian cross-sectional (complete enumeration) study.

BACKGROUND/OBJECTIVES: To describe trends in overweight/obesity in early childhood for all children and those whose parents are concerned about their weight. To describe parents' perceptions of their child's weight and differences by their child's anthropometric and sociodemographic factors. SUBJECTS/METHODS: Analysis of the Kindergarten Health Check, a survey of all children enrolled in their first year of primary education in the Australian Capital Territory. Analysis of detailed data for 2014-2017, including qualitative analysis of parents' comments on weight, and trends for 2001-2017. RESULTS: 71,963 children participated in the survey between 2001 and 2017 (20,427 between 2014 and 2017). The average age of children (2001-2017) was 5 years and 9.6 months at the time of their physical health check. 2377 children (3.5%) were classified as obese based on measured body mass index (BMI) between 2001 and 2017, and a further 7766 (11.6%) overweight. Similar proportions were seen for 2014-2017. Among children with overweight/obesity in 2014-2017, 86.4% of parents (2479/2868) described their children's weight as healthy and 13.3% (382/2868) as overweight/obese. Just 11.5% (339/2946) of parents whose children were later measured with overweight/obesity identified having a concern about their child's weight. Parental comments varied widely and were often incongruent with the known health risks associated with their child's measured BMI. Comments from parents whose children were measured as obese often were normalising e.g., "born big, always big. Definitely NOT overweight, just bigger all over", whilst parents of children in the healthy range expressed concerns about underweight. CONCLUSION: Parents do not accurately perceive their child's weight and few document concerns, even among children measuring in the obese BMI category. This lack of concern makes early interventions challenging as parents are in the "pre-contemplative" stage of behaviour change and may see public health campaigns or clinicians' attempts to address their child's weight as irrelevant or unhelpful.

Obesity management in primary care: systematic review exploring the influence of therapeutic alliance.

PURPOSE: To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care. METHOD: Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present. RESULTS: From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care. CONCLUSIONS: We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

Use of health and aged care services in Australia following hospital admission for myocardial infarction, stroke or heart failure.

BACKGROUND: Cardiovascular diseases (CVD), including myocardial infarction (MI), stroke and heart failure (HF) are the leading cause of death amongst the older population worldwide. The aim of this study is to investigate trajectories of use of health and aged care services after hospital admission for MI, stroke or HF among community-dwelling people not previously receiving aged care services. METHODS: The study population comprised people aged 65+ years from the 45 and Up Study with linked records for hospital stays, aged care services and deaths for the period 2006-14. Among those with an index hospital admission for MI, stroke or HF, we developed Sankey plots to describe and visualize sequences and trajectories of service use (none, re-hospitalization, community care, residential care, death) in the 12 months following discharge. We used Cox proportional hazards models to estimate hazard ratios (HRs), for commencing community care and entering residential care (and the other outcomes) within 3, 6 and 12 months, compared to a matched group without MI, stroke or HF. RESULTS: Two thousand six hundred thirty-nine, two thousand five hundred and two thousand eight hundred seventy-three people had an index hospitalization for MI, stroke and HF, respectively. Within 3 months of hospital discharge, 16, 32 and 29%, respectively, commenced community care (multivariable-adjusted HRs: 1.26 (95%CI:1.18-1.35), 1.53 (95%CI:1.44-1.64) and 1.39 (95%CI:1.32-1.48)); and 7, 18 and 14%, respectively, entered residential care (HRs: 1.25 (95%CI:1.12-1.41), 2.65 (95%CI:2.42-2.91) and 1.50 (95%CI:1.37-1.65)). Likewise, 26, 15 and 28%, respectively, were rehospitalized within 3 months following discharge (multivariable-adjusted HRs: 4.78 (95%CI:4.31-5.32), 3.26 (95%CI:2.91-3.65) and 4.94 (95%CI:4.47-5.46)). CONCLUSIONS: Older people hospitalized for major CVD may be vulnerable to transition-related risks and have poor health trajectories, thus emphasizing the value of preventing such events and care strategies targeted towards this at-risk group.

Adaption and validation of the Working Alliance Inventory for General Practice: qualitative review and cross-sectional surveys.

BACKGROUND: Relational aspects of primary care are important, but we have no standard measure for assessment. The 'working alliance' incorporates elements of the therapeutic relationship, shared decision-making, goal setting and communication skills. The Working Alliance Inventory (short form) (WAI-SF) has been used in adult psychology, and a high score on the survey is associated with improved outcomes for clients. OBJECTIVE: To adapt the WAI-SF for use between GPs and patients and to test its concurrent validity with measures of shared decision-making and the doctor-patient relationship and discriminant validity with measures of social desirability. METHODS: Two rounds of online survey feedback from 55 GPs and 47 patients were used to adapt the WAI-SF-the WAI-GP. The tool was then completed by 142 patients in waiting rooms after seeing their GP and by 16 GPs at the end of their session. Concurrent validity with measures of shared decision-making and patient-doctor depth of relationship was determined using Spearman Rho correlations. Patients also completed two social desirability surveys, and discriminant validity with WAI-GP was assessed. RESULTS: Following feedback, the survey was re-worded to remove phrases that were perceived as judgmental or irrelevant. The patient measure of the WAI-GP was strongly correlated with Dyadic OPTION (rho = 0.705, P = 0.0001) and Patient-Doctor Depth of Relationship scale (rho = 0.591, P = 0.0001) and not with measures of social desirability. CONCLUSION: The psychometric properties of the WAI-GP support its use for measuring GP-patient alliance. Possibilities for use include assessing the influence of therapeutic alliance on the effectiveness of interventions.

Sexual assault and harassment of doctors, by doctors: a qualitative study.

CONTEXT: Although sexual harassment frequently occurs in medical education and medical workplaces, doctors who have been sexually harassed or assaulted by other doctors remain a largely invisible population. This study aimed to identify, using personal accounts, the impact on doctors of sexual harassment and assault by doctors in the workplace. METHODS: This narrative study used in-depth interviews, legal reports and victim impact statements, tracing trajectories from the event's pre-history to its aftermath and impact on professional practice. Participants were six Australian women doctors who had been subjected to one or more non-consensual sexual acts through coercion or intimidation by another doctor in their working environments, within hospital training programmes. RESULTS: All women identified long-term personal and professional impacts of their experience. Three women had never reported the abuse. The meaning and impact of sexual abuse for the doctors followed a trajectory with discrete phases: prelude, assault, limbo, exposure and aftermath. Discounting the event and its impacts, and returning to the workplace were characterised as 'being professional'. Those who sought legal restitution said it damaged their personal well-being and their standing among fellow doctors. DISCUSSION: Understanding the phases of experience of abuse enables the development of effective interventions for different phases. Interventions to minimise the risk of occurrence of sexual abuse must be distinguished from interventions to increase reporting rates, and interventions to mitigate harm and impact on victims' futures. Idealised notions of professionalism can act as obstacles to doctors responding to sexual abuse.

Overcoming the data drought: exploring general practice in Australia by network analysis of big data.

OBJECTIVES: To investigate the organisation and characteristics of general practice in Australia by applying novel network analysis methods to national Medicare claims data. DESIGN: We analysed Medicare claims for general practitioner consultations during 1994-2014 for a random 10% sample of Australian residents, and applied hierarchical block modelling to identify provider practice communities (PPCs). PARTICIPANTS: About 1.7 million patients per year. MAIN OUTCOME MEASURES: Numbers and characteristics of PPCs (including numbers of providers, patients and claims), proportion of bulk-billed claims, continuity of care, patient loyalty, patient sharing. RESULTS: The number of PPCs fluctuated during the 21-year period; there were 7747 PPCs in 2014. The proportion of larger PPCs (six or more providers) increased from 32% in 1994 to 43% in 2014, while that of sole provider PPCs declined from 50% to 39%. The median annual number of claims per PPC increased from 5000 (IQR, 40-19 940) in 1994 to 9980 (190-23 800) in 2014; the proportion of PPCs that bulk-billed all patients was lowest in 2004 (21%) and highest in 2014 (29%). Continuity of care and patient loyalty were stable; in 2014, 50% of patients saw the same provider and 78% saw a provider in the same PPC for at least 75% of consultations. Density of patient sharing in a PPC was correlated with patient loyalty to that PPC. CONCLUSIONS: During 1994-2014, Australian GP practice communities have generally increased in size, but continuity of care and patient loyalty have remained stable. Our novel approach to the analysis of routinely collected data allows continuous monitoring of the characteristics of Australian general practices and their influence on patient care.

Feasibility and acceptability of a physician-delivered weight management programme.

BACKGROUND: Primary health care requires new approaches to assist patients with overweight and obesity. This is a particular concern for patients with limited access to specialist or allied health services due to financial cost or location. The Change Program is a toolkit that provides a structured approach for GPs working with patients on weight management. OBJECTIVE: To assess the acceptability and feasibility of a GP-delivered weight management programme. METHODS: A feasibility trial in five Australian general practices with 12 GPs and 23 patients. Mixed methods were used to assess the objective through participant interviews, online surveys and the NOrmalization MeAsure Development (NoMAD) tool based on Normalization Process Theory. Content analysis of interviews is presented alongside Likert scales, free text and the NoMAD tool. RESULTS: The Change Program was acceptable to most GPs and patients. It was best suited to patient-GP dyads where the patient felt a strong preference for GP involvement. Patients' main concerns were the time and possible cost associated with the programme if run outside a research setting. For sustainable implementation, it would have been preferable to recruit a whole practice rather than single GPs to enable activation of systems to support the programme. CONCLUSION: A GP-delivered weight management programme is feasible and acceptable for patients with obesity in Australian primary health care. The addition of this structured toolkit to support GPs is particularly important for patients with a strong preference for GP involvement or who are unable to access other resources due to cost or location.

Experiencing integration: a qualitative pilot study of consumer and provider experiences of integrated primary health care in Australia.

BACKGROUND: The terms integration and integrated care describe the complex, patient-centred strategies to improve coordination of healthcare services. Frameworks exist to conceptualise these terms, but these have been developed from a professional viewpoint. The objective of this study was to explore consumers' and providers' concepts, expectations and experience of integrated care. A key focus was whether frameworks developed from a professional perspective are effective models to explore people's experiences. METHODS: A qualitative pilot study was undertaken at one Australian multidisciplinary primary health care centre. Semi-structured interviews were conducted with consumers (N = 19) and staff (N = 10). Data were analysed using a framework analysis approach. RESULTS: Consumers' experience of integrated care tended to be implicit in their descriptions of primary healthcare experiences more broadly. Experiences related to the typologies involved clinical and functional integration, such as continuity of providers and the usefulness of shared information. Staff focused on clinical level integration, but also talked about a cultural shift that demonstrated normative, professional and functional integration. CONCLUSIONS: Existing frameworks for integration have been heavily influenced by the provider and organisational perspectives. They are useful for conceptualising integration from a professional perspective, but are less relevant for consumers' experiences. Consumers of integrated primary health care may be more focussed on relational aspects of care and outcomes of care.

A synthesis of selected national Australian guidelines on the general practice management of adult patients who are overweight or obese.

BACKGROUND: A general practitioner's (GP's) daily workload includes an ever-increasing number of patients who are overweight and obese. A number of Australian guidelines are aimed at assisting GPs who are managing this group of adult patients. OBJECTIVE: The objective of this article is to synthesise selected national Australian guidelines for GPs in the management of adults who are overweight or obese. METHODS: Relevant national guidelines were chosen and reviewed by three GPs. The recommendations were amalgamated and any discrepancies were discussed within the research team. RESULTS: We presented a synthesis of the guidelines under headings that will assist GPs in a structured approach to managing patients who are overweight and obese. DISCUSSION: This synthesis forms the basis for developing a practical toolkit to assist GPs in managing adult patients who are overweight and obese.

Obesity management in Australian primary care: where has the general practitioner gone?

Obesity is a chronic condition with significant health and economic consequences that requires more effective management in Australia. General practitioners (GPs) currently act as care co-ordinators in line with national guidelines for overweight and obesity. Australian patients indicate that they would appreciate more involvement from their GP in the management of obesity, and this is in line with international findings. Not all patients have access to specialist obesity services or affordable allied health care because of location, cost and time, particularly in rural and remote areas where there is a greater prevalence of obesity. Empowering GPs to use their skills as expert generalists to manage obesity is an option that should be explored to improve access for all individuals. GPs will require evidence-based tools to assist them in structuring obesity management within their own general practice environment.

Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia.

BACKGROUND: Geographic rates of preventable hospitalization are used internationally as an indicator of accessibility and quality of primary care. Much research has correlated the indicator with the supply of primary care services, yet multiple other factors may influence these admissions. OBJECTIVE: To quantify the relative contributions of the supply of general practitioners (GPs) and personal sociodemographic and health characteristics, to geographic variation in preventable hospitalization. METHODS: Self-reported questionnaire data for 267,091 participants in the 45 and Up Study, Australia, were linked with administrative hospital data to identify preventable hospitalizations. Multilevel Poisson models, with participants clustered in their geographic area of residence, were used to explore factors that explain geographic variation in hospitalization. RESULTS: GP supply, measured as full-time workload equivalents, was not a significant predictor of preventable hospitalization, and explained only a small amount (2.9%) of the geographic variation in hospitalization rates. Conversely, more than one-third (36.9%) of variation was driven by the sociodemographic composition, health, and behaviors of the population. These personal characteristics explained a greater amount of the variation for chronic conditions (37.5%) than acute (15.5%) or vaccine-preventable conditions (2.4%). CONCLUSIONS: Personal sociodemographic and health characteristics, rather than GP supply, are major drivers of preventable hospitalization. Their contribution varies according to condition, and if used for performance comparison purposes, geographic rates of preventable hospitalization should be reported according to individual condition or potential pathways for intervention.

Increasing Pap smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement.

This article describes translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to Pap smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS). Rapid Plan-Do-Study-Act (PDSA) cycles were conducted, informed by client surveys, a data collection tool, focus groups and internal research. There was a statistically significant increase in Pap smear numbers during PDSA cycles, continuing at 10 months follow up. The use of TR with CQI appears to be an effective and acceptable way to affect Pap smear screening. Community and service collaboration should be at the core of research in Aboriginal and Torres Strait Islander health settings. This model is transferrable to other settings and other health issues.

Recruiting general practitioners for surveys: reflections on the difficulties and some lessons learned.

Surveys of GPs are essential to facilitate future planning and delivery of health services. However, recruitment of GPs into research has been disappointing with response rates declining over recent years. This study identified factors that facilitated or hampered GP recruitment in a recent survey of Australian GPs where a range of strategies were used to improve recruitment following poor initial responses. GP response rates for different stages of the survey were examined and compared with reasons GPs and leaders of university research networks cited for non-participation. Poor initial response rates were improved by including a questionnaire in the mail-out, changing the mail-out source from an unknown research team to locally known network leaders, approaching a group of GPs known to have research and training interests, and offering financial compensation. Response rates increased from below 1% for the first wave to 14.5% in the final wave. Using a known and trusted network of professionals to endorse the survey combined with an explicit compensation payment significantly enhanced GP response rates. To obtain response rates for surveys of GPs that are high enough to sustain external validity requires an approach that persuades GPs and their gatekeepers that it is worth their time to participate.