Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review.

BACKGROUND: Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance. OBJECTIVES: To determine antibiotic prescribing patterns by early-career GPs for common acute infections. METHODS: A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing. RESULTS: Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context. CONCLUSIONS: Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.

Stability of anticholinergic load in Australian community-dwelling older people: a longitudinal analysis.

BACKGROUND: It is recommended that anticholinergic medication is avoided in older people, especially those with cognitive impairment. OBJECTIVE: To investigate anticholinergic load (ACL) over time in older primary care patients with and without cognitive impairment. METHODS: Community-dwelling general practice patients at baseline (n = 1768), at year one (n = 1373) and a restricted cohort (with possible or definite cognitive impairment) at year two (n = 370) had medication regimens documented by a research nurse during a home visit. Anticholinergic medicines were categorized as levels 1-3 (low-high potency) and summed for each participant as a measure of their ACL. RESULTS: Most participants had no change in ACL over time, but there was some turnover in the anticholinergic medications used. The mean change in ACL was 0.012 ± 0.99 from baseline to 12 months and -0.04 ± 1.3 from baseline to 24 months. Cardiovascular drugs were the most commonly used level 1 anticholinergics, followed by antidepressants and opioids. Antidepressants and urologicals were the most commonly used level 3 anticholinergics. The rate of anticholinergic deprescribing was equivalent to the rate of anticholinergic initiation, and commonly involved the level 1 drugs warfarin, furosemide and temazepam, and the level 3 drugs amitriptyline and oxybutynin. People with dementia had a higher ACL at baseline and year one compared with other participants. CONCLUSION: ACL of community-dwelling older people was very stable over time. This may represent lost opportunities for deprescribing as well as potentially inappropriate prescribing, particularly in those with cognitive impairment.

Configurations for obtaining in-consultation assistance from supervisors in general practice training, and patient-related barriers to trainee help-seeking: a survey study.

BACKGROUND: General practice (GP) trainees may seek supervisor assistance to complete their patient consultations. This in-consultation assistance plays a key role in the supervisory oversight of trainees and in trainee learning. It may be obtained face-to-face, or using phone or messaging systems, and either in front of patients or outside their hearing. Trainee concerns about decreased patient impressions of their competence, and discomfort presenting patients within their hearing, act as barriers to seeking help during consultations. Little is known about the frequency and associations of trainee concerns about these patient-related barriers, or the various trainee-supervisor-patient configurations used to obtain in-consultation assistance. METHODS: Australian GP trainees rated their frequency of use of five specific configurations for obtaining in-consultation assistance, perceived change in patient impressions of their competence after this assistance, and relative trainee comfort presenting patients outside, compared to within, patients' hearing. Statistical analyses included descriptive statistics and multivariable logistic regression. RESULTS: Responses were received from 778 Australian GP trainees (response rate 89%). Help-seeking configurations did not differ between trainees at different training stages, except for greater use of electronic messaging in later stages. In-consultation assistance was most commonly provided by phone between trainee and supervisor consulting rooms, or outside the trainee's patient's hearing. Supervisor assistance in the trainee's room face-to-face with the patient was reported as either never or rarely obtained by 12% of respondents. More trainees (25%) perceived that patient impressions of their competence increased after help-seeking than perceived that these impressions decreased (19%). Most trainees (55%) preferred to present patients outside their hearing. Trainee age was the only variable associated with both patient-related barriers. CONCLUSION: Supervisors appear to have considerable influence over trainee help-seeking, including which configurations are used and trainee perceptions of patient-related barriers. In-consultation supervision may actually increase trainee perceptions of patient impressions of their competence. Many supervisors and trainees may benefit from additional educational and workplace interventions to facilitate comfortable and effective trainee help-seeking in front of patients. More work is required to understand the clinical and educational implications of different help-seeking configurations when trainees require 'just in time' supervisor assistance.

General practice training in regional and rural Australia: A cross-sectional analysis of the Registrar Clinical Encounters in Training study.

OBJECTIVE: We aimed to investigate registrar, practice and consultation characteristics associated with varying degrees of GP registrars' practice rurality. DESIGN: A cross-sectional analysis of 12 rounds of data collection (2010-2015) from the longitudinal Registrar Clinical Encounters in Training study, an ongoing, cohort study of Australian GP registrars. The principal analysis used was a generalised ordered logistic regression. SETTING/PARTICIPANTS: GP registrars in training practices within five of 17 GP regional training providers in five Australian states. MAIN OUTCOME MEASURE: Degree of rurality of the practice in which the registrar undertook training terms was calculated from the practice postcode using the Australian Standard Classification-Remoteness Area classification. RESULTS: A total of 1161 registrars contributed data for 166 998 patient consultations (response rate 95.5%). Of these, 56.9% were in major city practices (ASGC-RA1), 25.7% were in inner-regional practices (ASGC-RA2) and 17.4% were in outer-regional/rural practices (ASGC-RA3-5). Several statistically significant associations (P = < .001) were found within regional/rural practices (ASGC-RA2-5), when compared with major city practices (ASGC-RA1). These included registrar characteristics such as being in Term 1, being medically trained overseas, and having worked at the practice previously; patient characteristics such as the patient being an existing patient, being older and being Aboriginal or Torres Strait Islander; and consultation characteristics such as performance of procedures. CONCLUSION: Our findings suggest that registrars are undertaking rural practice early in their GP training and are being exposed to a rich and challenging mix of clinical and educational practice.

Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary.

INTRODUCTION: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. MAIN RECOMMENDATIONS: Our recommendations aim to assist clinicians to: identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and taper treatment and monitor individuals during the deprescribing process. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE: Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by: ▶determining their treatment goals; ▶discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and ▶engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation. This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.

Focus on early-career GPs: qualitative evaluation of a multi-faceted educational intervention to improve antibiotic prescribing.

Background: We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. Objectives: To explore the participants' experiences with the intervention. Methods: A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. Results: Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. Conclusion: The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care.

Changes in pathology test ordering by early career general practitioners: a longitudinal study.

OBJECTIVE: To assess the number of pathology tests ordered by general practice registrars during their first 18-24 months of clinical general practice. DESIGN: Longitudinal analysis of ten rounds of data collection (2010-2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%. MAIN OUTCOME MEASURE: Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms. RESULTS: 876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8-15%; P < 0.001) per training term. CONCLUSIONS: Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns.

An evaluation of the additional benefit of population screening for dementia beyond a passive case-finding approach.

OBJECTIVE: General practitioners (GPs) fail to identify more than 50% of dementia cases using the existing passive case-finding approach. Using data from the "Ageing in General Practice" study, we sought to establish the additional benefit of screening all patients over the age of 75 for dementia beyond those patients already identified by passive case-finding. METHOD: Patients were classified as "case-finding" (n = 425) or "screening" (n = 1006) based on their answers to four subjective memory related questions or their GP's clinical judgement of their dementia status. Cognitive status of each patient was formally assessed by a research nurse using the Cambridge Cognition Examination (CAMCOG-R). Patients then attended their usual GP for administration of the GP assessment of Cognition (GPCOG) dementia screening instrument, and follow-up care and/or referral as necessary in light of the outcome. RESULTS: The prevalence of dementia was significantly higher in the case-finding group (13.6%) compared to the screening group (4.6%; p < 0.01). The GPCOG had a positive predictive value (PPV) of 61% in the case-finding group and 39% in the screening group; negative predictive value was >95% in both groups. GPs and their patients both found the GPCOG to be an acceptable cognitive assessment tool. The dementia cases missed via case-finding were younger (p = 0.024) and less cognitively impaired (p = 0.020) than those detected. CONCLUSION: There is a very limited benefit of screening for dementia, as most people with dementia could be detected using a case-finding approach, and considerable potential for social and economic harm because of the low PPV associated with screening.

Managing transient ischaemic attacks in Australia: a qualitative study.

Background: Stroke risk after transient ischaemic attack (TIA) is highest in the first few days. It is greatly reduced by commencing commonly used medications. Current Australian guidelines recommend that all TIAs be managed urgently by secondary-care specialists (mandatory for high-risk TIAs). The majority of TIAs present to general practice which creates a dilemma when specialist care is not readily accessible. There is a lack of evidence relating to the determinants of general practitioners' (GPs) actions in this situation. Objective: To explore GP management of TIA presentations. Methods: A qualitative study using semi-structured interviews of a maximum variation sample of senior and trainee GPs from New South Wales, Australia. Data collection and thematic analysis were concurrent and iterative, employing constant comparison, co-coding, participant transcript review, reflexivity and continued until thematic saturation was achieved. Results: Management of TIA was heterogeneous and depended upon the GP's engagement with the individual case. The level of engagement was predicated on the GP's predisposition toward managing transient neurological presentations generally, the clinical phenotype of the presentation and logistical or health system factors. Management was categorised as triage, guided collaboration, consultative collaboration and independent management. Collaboration with secondary care increased the GP's capability to diagnose and manage future TIAs. Conclusion: Heterogeneity of TIA management equates with variation from guideline recommendations. However, Australian guidelines may not be practicable due to variability in access to secondary-care specialists. Future models of care should consider systems approaches such as telemedicine to promote collaboration and assist GPs to comply with guidelines.

Procedural skills of Australian general practice registrars: A cross-sectional analysis.

BACKGROUND: Procedural skills are an essential component of general practice vocational training. The aim of this study was to investigate the type, frequency and rural or urban associations of procedures performed by general practice registrars, and to establish levels of concordance of procedures performed with a core list of recommended procedural skills in general practice training. METHODS: A cross-sectional analysis of a cohort study of registrars' consultations between 2010 and 2016 was undertaken. Registrars record 60 consecutive consultations during each six-month training term. The outcome was any procedure performed. RESULTS: In 182,782 consultations, 19,411 procedures were performed. Procedures (except Papanicolaou [Pap] tests) were performed more often in rural than urban areas. Registrars commonly sought help from supervisors for more complex procedures. The majority of procedures recommended as essential in registrar training were infrequently performed. DISCUSSION: Registrars have low exposure to many relevant clinical procedures. There may be a need for greater use of laboratory-based training and/or to review the expectations of the scope of procedural skills in general practice.

Changes in early-career family physicians' antibiotic prescribing for upper respiratory tract infection and acute bronchitis: a multicentre longitudinal study.

BACKGROUND: Inappropriate antibiotic prescription and subsequent antibacterial resistance are major threats to health worldwide. OBJECTIVES: We aimed to establish whether early-career 'apprenticeship-model' experience in family practice influences antibiotic prescribing for respiratory tract infections and to also establish other associations of antibiotic prescribing changes during this early-career experience. METHODS: A longitudinal analysis (2010-2014) of a cohort study of Australian GP registrars' (vocational trainees') consultations. Registrars from five regional training programs recorded data from 60 consecutive consultations, once each 6-month training Term, including the diagnoses managed and medications prescribed. The outcomes were whether an antibiotic was prescribed for the diagnoses 'upper respiratory tract infection (URTI)' and 'acute bronchitis/bronchiolitis'. Generalized linear mixed modelling was used to account for repeated measures on registrars and to include the time component: 'Term'. RESULTS: A total of 856 registrars recorded 108759 consultations, including 8715 'URTI' diagnoses (5.15% of diagnoses) and 2110 'acute bronchitis/bronchiolitis' diagnoses (1.25%). Antibiotics were prescribed in 16.3% [95% confidence interval (CI) 14.9-17.8] of URTI and 72.2% (95% CI 69.6-74.6) of acute bronchitis/bronchiolitis diagnoses. Moving from an earlier to later term did not significantly influence registrars' antibiotic prescribing for URTI [adjusted odds ratio (OR) 0.95; 95% CI 0.87, 1.04, P = 0.27] or acute bronchitis/bronchiolitis [OR 1.01 (95% CI 0.90-1.14), P = 0.86]. Significant associations of antibiotic prescribing for URTIs were the registrar being non-Australian educated, greater patient age, practices not privately billing patients, pathology being ordered, longer consultation duration and the registrar seeking in-consultation information or advice (including from their supervisor). CONCLUSIONS: Early-career experience/training failed to produce rational antibiotic prescribing for URTI and acute bronchitis/bronchiolitis. Our findings suggest that prescribing interventions could target the registrar-supervisor dyad.

Changing the Antibiotic Prescribing of general practice registrars: the ChAP study protocol for a prospective controlled study of a multimodal educational intervention.

BACKGROUND: Australian General Practitioners (GPs) are generous prescribers of antibiotics, prompting concerns including increasing antimicrobial resistance in the community. Recent data show that GPs in vocational training have prescribing patterns comparable with the high prescribing rate of their established GP supervisors. Evidence-based guidelines consistently advise that antibiotics are not indicated for uncomplicated upper respiratory tract infections (URTI) and are rarely indicated for acute bronchitis. A number of interventions have been trialled to promote rational antibiotic prescribing by established GPs (with variable effectiveness), but the impact of such interventions in a training setting is unclear. We hypothesise that intervening while early-career GPs are still developing their practice patterns and prescribing habits will result in better adherence to evidence-based guidelines as manifested by lower antibiotic prescribing rates for URTIs and acute bronchitis. METHODS/DESIGN: The intervention consists of two online modules, a face-to-face workshop for GP trainees, a face-to-face workshop for their supervisors and encouragement for the trainee-supervisor dyad to include a case-based discussion of evidence-based antibiotic prescribing in their weekly one-on-one teaching meetings. We will use a non-randomised, non-equivalent control group design to assess the impact on antibiotic prescribing for acute upper respiratory infections and acute bronchitis by GP trainees in vocational training. DISCUSSION: Early-career GPs who are still developing their clinical practice and prescribing habits are an underutilized target-group for interventions to curb the growth of antimicrobial resistance in the community. Interventions that are embedded into existing training programs or are linked to continuing professional development have potential to increase the impact of existing interventions at limited additional cost. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12614001209684 (registered 17/11/2014).

Optimizing Stroke Prevention in Patients With Atrial Fibrillation: A Cluster-Randomized Controlled Trial of a Computerized Antithrombotic Risk Assessment Tool in Australian General Practice, 2012-2013.

INTRODUCTION: Clinicians have expressed a need for tools to assist in selecting treatments for stroke prevention in patients with atrial fibrillation. The objective of this study was to evaluate the impact of a computerized antithrombotic risk assessment tool (CARAT) on general practitioners' prescribing of antithrombotics for patients with atrial fibrillation. METHODS: A prospective, cluster-randomized controlled trial was conducted in 4 regions (in rural and urban settings) of general practice in New South Wales, Australia (January 2012-June 2013). General practitioner practices were assigned to an intervention arm (CARAT) or control arm (usual care). Antithrombotic therapy prescribing was assessed before and after application of CARAT. RESULTS: Overall, the antithrombotic therapies for 393 patients were reviewed by 48 general practitioners; we found no significant baseline differences in use of antithrombotics between the control arm and intervention arm. Compared with control patients, intervention patients (n = 206) were 3.1 times more likely to be recommended warfarin therapy (over any other treatment option; P < .001) and 2.8 times more likely to be recommended any anticoagulant (in preference to antiplatelet; P = .02). General practitioners agreed with most (75.2%) CARAT recommendations; CARAT recommended that 75 (36.4%) patients change therapy. After application of CARAT, the proportion of patients receiving any antithrombotic therapy was unchanged from baseline (99.0%); however, anticoagulant use increased slightly (from 89.3% to 92.2%), and antiplatelet use decreased (from 9.7% to 6.8%). CONCLUSION: Tools such as CARAT can assist clinicians in selecting antithrombotic therapies, particularly in upgrading patients from antiplatelets to anticoagulants. However, the introduction of novel oral anticoagulants has complicated the decision-making process, and tools must evolve to weigh the risks and benefits of these new therapy options.

'If they're your doctor, they should care about you': Women on release from prison and general practitioners.

BACKGROUND: Nearly half of the people leaving prison see a general practitioner (GP) within a month of release, which provides an opportunity to promote health for this vulnerable group. OBJECTIVE: The objective of this article is to examine the expectations and experiences of GP care of women leaving prison. METHODS: Semi-structured interviews pre-release and post-release from prison were analysed using inductive thematic analysis. RESULTS: Sixty-nine interviews were conducted with 40 women while they were still in prison and 29 of these women after they were released. Women perceived GPs as lacking interest in their social support needs and believed GPs needed more skills in substance misuse management. Given the fear of stigma, women may not disclose recent incarceration, affecting the continuity of healthcare initiated in prison. DISCUSSION: GPs' acknowledgement of, and assistance with, the broad issues that have an impact on the health and wellbeing of women after release is valued. Whole-person care also requires GP accessibility, management of substance misuse, continuity of care and understanding of the stigma associated with incarceration.

Referral rates of general practice registrars for behavioural or mental health conditions in children.

BACKGROUND: There is concern about whether general practice registrars gain sufficient exposure to, and confidence in caring for, many pae-diatric conditions during their apprenticeship training. General practice registrars' referral patterns for paediatric conditions over-all or for specific conditions, including behavioural or mental health diagnoses, are unknown. OBJECTIVE: The aim of this study was to assess the relative rates of referral by general practice registrars for children, compared with adults, specifically for those with behavioural or mental health diagnoses. METHODS: A secondary analysis of 83,445 encounters from the Registrar Clinical Encounters in Training (ReCEnT) dataset was undertaken. RESULTS: More than half of children (52%) with a behavioural or mental health problem were referred to specialty care, compared with only 23% of adults. For all other conditions, only 9% of children received specialty referral, compared with 12% of adults. DISCUSSION: Although a certain proportion of behavioural or mental health issues in children may require either diagnostic assistance or aid in management, it is unclear whether more than half are unable to be cared for by a general practice registrar without referral.

Anticholinergic burden in older women: not seeing the wood for the trees?

OBJECTIVES: To identify medicines contributing to and describe predictors of anticholinergic burden among community-dwelling older Australian women. DESIGN, SETTING AND PARTICIPANTS: Retrospective longitudinal analysis of data from the Australian Longitudinal Study on Women's Health linked to Pharmaceutical Benefits Scheme medicines data from 1 January 2008 to 30 December 2010; for 3694 women born in 1921-1926. MAIN OUTCOME MEASURES: Anticholinergic burden calculated from Anticholinergic Drug Scale (ADS) scores derived from ADS levels (0 to 3) for all medicines used by each woman, summed over each 6-month period (semester), medicines commonly used by women with high semester ADS scores (defined as 75th percentile of scores). RESULTS: 1126 women (59.9%) used at least one medicine with anticholinergic properties. The median ADS score was 4 or 5 across all semesters. Most anticholinergic medicines used by women who had a high anticholinergic burden (ADS score, ≥ 9) had a low anticholinergic potency (ADS level 1). Increasing age, cardiovascular disease, and number of other medicines used were predictive of a higher anticholinergic burden. CONCLUSIONS: A high anticholinergic medicines burden in this group was driven by the use of multiple medicines with lower anticholinergic potency rather than the use of medicines with higher potency. This is a novel and important finding for clinical practice as doctors would readily identify the risk of a high anticholinergic burden for patients using high potency medicines, but may be less likely to identify this risk for users of multiple medicines with low anticholinergic potency.

Pathology test-ordering behaviour of Australian general practice trainees: a cross-sectional analysis.

OBJECTIVE: In the context of increasing over-testing and the implications for patient safety, to establish the prevalence and nature of pathology test-ordering of GP trainees, and to describe the associations of this test-ordering. DESIGN: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) cohort study. SETTING: Five of Australia's 17 general practice regional training providers, encompassing urban-to-very remote practices. PARTICIPANTS: GP trainees. MAIN OUTCOME MEASURES: The number of pathology tests ordered per problem/diagnosis managed. RESULTS: A total of 856 individual trainees (response rate 95.2%) contributed data from 1832 trainee-terms, 108 759 encounters and 169 304 problems. Pathology test-ordering prevalence was 79.3 tests (95% CI: 78.8-79.8) per 100 encounters, 50.9 (95% CI: 50.6-51.3) per 100 problems, and at least 1 test was requested in 22.4% of consultations. Most commonly ordered was full blood count (6.1 per 100 problems). The commonest problem prompting test-ordering was 'check-up' (18.6%). Test-ordering was significantly associated, on multivariable analysis, with the trainee having worked at the practice previously; the patient being adult, male and new to both trainee and practice; the practice being urban; the problem/diagnosis being new; imaging being ordered; referral being made and follow-up being arranged. Trainees were significantly less likely to order tests for problems/diagnoses for which they had sought in-consultation information or advice. CONCLUSIONS: Compared with the established GPs, trainees order more pathology tests per consultation and per problem managed, and in a higher proportion of consultations. Our findings will inform educational policy to enhance quality and safety in general practice training.

Preparing pharmacists to deliver a targeted service in hypertension management: evaluation of an interprofessional training program.

BACKGROUND: Non-adherence to medicines by patients and suboptimal prescribing by clinicians underpin poor blood pressure (BP) control in hypertension. In this study, a training program was designed to enable community pharmacists to deliver a service in hypertension management targeting therapeutic adjustments and medication adherence. A comprehensive evaluation of the training program was undertaken. METHODS: Tailored training comprising a self-directed pre-work manual, practical workshop (using real patients), and practice scenarios, was developed and delivered by an inter-professional team (pharmacists, GPs). Supported by practical and written assessment, the training focused on the principles of BP management, BP measurement skills, and adherence strategies. Pharmacists' experience of the training (expectations, content, format, relevance) was evaluated quantitatively and qualitatively. Immediate feedback was obtained via a questionnaire comprising Likert scales (1 = "very well" to 7 = "poor") and open-ended questions. Further in-depth qualitative evaluation was undertaken via semi-structured interviews several months post-training (and post service implementation). RESULTS: Seventeen pharmacists were recruited, trained and assessed as competent. All were highly satisfied with the training; other than the 'amount of information provided' (median score = 5, "just right"), all aspects of training attained the most positive score of '1'. Pharmacists most valued the integrated team-based approach, GP involvement, and inclusion of real patients, as well as the pre-reading manual, BP measurement workshop, and case studies (simulation). Post-implementation the interviews highlighted that comprehensive training increased pharmacists' confidence in providing the service, however, training of other pharmacy staff and patient recruitment strategies were highlighted as a need in future. CONCLUSIONS: Structured, multi-modal training involving simulated and inter-professional learning is effective in preparing selected community pharmacists for the implementation of new services in the context of hypertension management. This training could be further enhanced to prepare pharmacists for the challenges encountered in implementing and evaluating services in practice.