Practitioner perceptions of the feasibility of common frailty screening instruments within general practice settings: a mixed methods study.

BACKGROUND: Frailty is a highly prevalent clinical syndrome increasing older people's vulnerability to risk of adverse outcomes. Better frailty identification through expanded screening implementation has been advocated within general practice settings, both internationally and within Australia. However, little is known about practitioner perceptions of the feasibility of specific instruments, and the underlying motivations behind those perceptions. Consequently, the purpose of this study was to explore the attitudes and perceptions of a convenience and volunteer sample of Australian general practitioners (GPs) and practice nurses (PNs) towards common frailty screening instruments. METHODS: The feasibility of several frailty screening instruments (PRISMA-7 [P7], Edmonton Frail Scale [EFS], FRAIL Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC] and Timed Up and Go [TUG]) to 43 Australian GPs and PNs was assessed. The study adopted a concurrent embedded mixed-methods design incorporating quantitative (ranking exercise) and qualitative (content analysis) data collection integrated during the analysis phase. RESULTS: Practitioners assessed multi-dimensional instruments (EFS, GFI, KC) as having relatively higher clinical utility, better integration into existing assessment processes and stronger links to intervention over uni-dimensional (GST, TUG) and simple (FQ, P7) instruments. CONCLUSIONS: While existing frailty screening instruments show promise as an initial step in supporting better care for older people, all the included instruments were associated with perceived advantages and disadvantages. Ultimately, clinicians will need to weigh several factors in their selection of the optimal screening instrument. Further translational research, with a focus on contextual fit, is needed to support clinical decision-making on the selection of instruments for frailty screening.

General practitioners' perceptions, attitudes and experiences of frailty and frailty screening.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) are uniquely positioned to support frailty identification and management. However, awareness of frailty and its treatment remains an emergent concept for many. Consequently, our aim was to explore GPs' perceptions, attitudes and experiences of frailty and frailty screening. METHOD: A qualitative focus group study was conducted with 22 South Australian GPs. GPs were recruited through a combination of purposive, convenience and snowball sampling. Data were analysed using a thematic analysis approach. RESULTS: GPs saw frailty as a cycle of worsening decline punctuated by experience of negative outcomes. Participants largely felt that they already knew who their frail patients were without the need for formal screening. Consequently, there was varied support for formal screening, largely dependent on its intended purpose. Few GPs had actively intervened to prevent the onset or progression of frailty, with most strategies aimed at stabilisation and management. DISCUSSION: This study suggests that Australian GPs may be open to a proactive approach to frailty assessment and treatment, given appropriate training and resources.

Should we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review.

With older adults living longer, health service providers have increasingly turned their attention towards frailty and its significant consequences for health and well-being. Consequently, frailty screening has gained momentum as a possible health policy answer to the question of what can be done to prevent frailty's onset and progression. However, who should be screened for frailty, where and when remains a subject of extensive debate. The purpose of this narrative review is to explore the dimensions of this question with reference to Wilson and Jungner's time-tested and widely accepted principles for acceptable screening within community settings. Although the balance of the emerging evidence to support frailty screening is promising, significant gaps in the evidence base remain. Consequently, when assessed against Wilson and Jungner's principles, extensive population screening does not appear to be supported by the evidence. However, screening for the purpose of case-finding may prove useful among older adults.

Patients' experiences of referral for colorectal cancer.

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

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

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

Discharge-planning for long-term care needs: the values and priorities of older people, their younger relatives and health professionals.

Discharge-planning decisions about long-term care (LTC) can be difficult and distressing for older people, families and discharge-planning health professionals. Retrospective research suggests that despite good intentions and a shared focus on the best interests of the older person, stakeholders may hold very different values about good outcomes and how to decide them. We aimed to compare the opinions and values of frail elders living at home, younger relatives and health professionals experienced in discharge-planning, prospectively: before, not after, a LTC decision. We interviewed three types of stakeholders (10 older people, 8 relatives and 18 health professionals) using a hypothetical vignette about a frail elder leaving hospital. In a mixed methods design, we quantitatively compared the discharge plans and decision-makers that stakeholders suggested, and qualitatively analysed the 36 interview transcripts for participants' articulation of underlying values during these discussions. Older participants often suggested safe restrictive options (residential care, proxy decision-making) for the hypothetical frail elder, while advocating autonomy for themselves. Younger people generally endorsed autonomous decision-making and less restrictive discharge options especially if the elder was mentally competent, but reported difficult ethical tensions between safety and autonomy. Individual personality and preferences, mental capacity, and the importance of personal care in supporting autonomy were central themes consistent with the Ecological Theory of Aging. Accordingly, discharge planners can usefully articulate the balance of safety and autonomy, conceptualizing home care as maintaining independence rather than accepting dependence. Ethical training should incorporate sophisticated models of practice specifying both psychological and physical safety as components of beneficence. Few elders adopt a consumer approach to LTC: health professionals can encourage mid-life adults to consider later care needs when planning for retirement.

General practice education and training: past experiences, current issues and future challenges.

Reflection on past achievements and future challenges 10 years after the establishment of the Australian General Practice Training program.

Development of an accreditation program for Point of Care Testing (PoCT) in general practice.

OBJECTIVES: To describe the development and evaluation of an accreditation program for Point of Care Testing (PoCT) in general practice, which was part of the PoCT in general practice (GP) Trial conducted in 2005-07 and funded by the Australian Government. SETTING AND PARTICIPANTS: Thirty general practices based in urban, rural and remote locations across South Australia, New South Wales and Victoria, which were in the intervention arm of the PoCT Trial were part of the accreditation program. A PoCT accreditation working party was established to develop an appropriate accreditation program for PoCT in GP. A multidisciplinary accreditation team was formed consisting of a medical scientist, a general practitioner or practice manager, and a trial team representative. METHODOLOGY AND SEQUENCE OF EVENTS: To enable practices to prepare for accreditation a checklist was developed describing details of the accreditation visit. A guide for surveyors was also developed to assist with accreditation visits. Descriptive analysis of the results of the accreditation process was undertaken. OUTCOMES: Evaluation of the accreditation model found that both the surveyors and practice staff found the process straightforward and clear. All practices (i.e. 100%) achieved second-round accreditation. DISCUSSION AND LESSONS LEARNED: The accreditation process highlighted the importance of ongoing education and support for practices performing PoCT.

Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice.

OBJECTIVE: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice. DESIGN AND SETTING: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics. MAIN OUTCOME MEASURES: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores. RESULTS: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not. CONCLUSIONS: Findings were consistent with the purpose of TCAs--to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

A tool to measure whether business management capacity in general practice impacts on the quality of chronic illness care.

Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

Systematic care for asthma in Australian general practice: a randomised controlled trial.

OBJECTIVE: To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma. DESIGN AND SETTING: Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group. PARTICIPANTS: 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids. MAIN OUTCOME MEASURES: Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months. RESULTS: Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0-3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators. CONCLUSION: We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12605000091606.

The cost-effectiveness of point of care testing in a general practice setting: results from a randomised controlled trial.

BACKGROUND: While point of care testing (PoCT) for general practitioners is becoming increasingly popular, few studies have investigated whether it represents value for money. This study aims to assess the relative cost-effectiveness of PoCT in general practice (GP) compared to usual testing practice through a pathology laboratory. METHODS: A cost-effectiveness analysis based on a randomized controlled trial with 4,968 patients followed up for 18 months and fifty-three general practices in urban, rural and remote locations across three states in Australia.The incremental costs and health outcomes associated with a clinical strategy of PoCT for INR, HbA1c, lipids, and ACR were compared to those from pathology laboratory testing. Costs were expressed in year 2006 Australian dollars. Non-parametric bootstrapping was used to generate 95% confidence intervals. RESULTS: The point estimate of the total direct costs per patient to the health care sector for PoCT was less for ACR than for pathology laboratory testing, but greater for INR, HbA1c and Lipids, although none of these differences was statistically significant. PoCT led to significant cost savings to patients and their families. When uncertainty around the point estimates was taken into account, the incremental cost-effectiveness ratio (ICER) for PoCT was found to be unfavourable for INR, but somewhat favourable for ACR, while substantial uncertainty still surrounds PoCT for HbA1c and Lipids. CONCLUSIONS: The decision whether to fund PoCT will depend on the price society is willing to pay for achievement of the non-standard intermediate outcome indicator. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12605000272695.

Assessing agreement between point of care and pathology laboratory results for INR: experiences from the Point of Care Testing in General Practice Trial.

AIMS: To assess the level of agreement between international normalised ratio (INR) results obtained from pathology laboratories and point of care testing (PoCT) devices used in a general practice setting. METHODS: INR pathology results were collected from multiple pathology laboratories and CoaguChek S PoCT devices over a 6 month period. Agreement was assessed using both clinically relevant agreement and the Bland Altman method. RESULTS: Analysis was based on 1664 dual measurements collected on 417 patients from 26 general practices across Australia. The percentage of dual measurements satisfying the expanded and narrow agreement criteria were 91% and 89%, respectively. The mean difference in results and the 95% limits of agreement depended on the average INR result: mean difference = -0.30 + 0.08 x average; 95% limits of agreement = -0.30 + 0.08 x average +/- 0.77. CONCLUSIONS: The current study provides further evidence that PoCT is an acceptable alternative to pathology laboratory testing in a general practice setting. The Bland Altman method is a useful and flexible tool for assessing agreement. Limits of agreement should be reported in future method comparison studies to assist clinicians in patient management.

Assessing agreement between point of care and laboratory results for lipid testing from a clinical perspective.

OBJECTIVES: Investigate agreement between lipid pathology results from point-of-care testing (PoCT) devices and laboratories. DESIGN AND METHODS: Agreement was assessed using the Bland-Altman method. RESULTS: : Mean difference (limits of agreement) were: -0.28 mmol/L (-1.04, 0.48) for total cholesterol, -0.09 mmol/L, (-0.55, 0.36) for HDL-C. Median difference (nonparametric limits of agreement) were 0.07 mmol/L, (-0.40, 3.04) for triglycerides. CONCLUSIONS: The clinical acceptability of the variation between lipid PoCT and laboratory test results is debatable but our work provides baseline data for further research.

Does point-of-care testing lead to the same or better adherence to medication? A randomised controlled trial: the PoCT in General Practice Trial.

OBJECTIVE: To compare the clinical effectiveness of point-of-care testing (PoCT) with that of pathology laboratory testing, as measured by patients' adherence to medication. DESIGN: Multicentre, cluster randomised controlled trial using non-inferiority analysis. Medication adherence was assessed twice (in April 2006 and January 2007) by a self-administered questionnaire using the five-item Medication Adherence Report Scale (MARS-5). SETTING: 53 Australian general practices in urban, rural and remote areas across three Australian states, September 2005 to February 2007. PARTICIPANTS: 4968 patients with established type 1 or type 2 diabetes, established hyperlipidaemia, or requiring anticoagulant therapy were recruited to the study. Of these, 4381 were included in the analysis (2585 in the intervention group and 1796 in the control group). INTERVENTION: The intervention group (3010 patients in 30 practices) had blood and urine samples tested using PoCT devices within their general practices. The control group (1958 patients in 23 practices) had samples tested by their usual pathology laboratories. MAIN OUTCOME MEASURES: The proportion of questionnaire responses indicating medication adherence overall and by condition. RESULTS: PoCT was non-inferior to pathology laboratory testing in relation to the proportion of questionnaire responses indicating medication adherence (39.3% v 37.0%) (difference, 2.3% [90% CL, - 0.1%, 4.6%]; P < 0.001). Non-inferiority could also be concluded separately for patients with diabetes (38.5% v 37.3%) (difference, 1.2% [90% CL, -2.5%, 5.0%]; P = 0.01); hyperlipidaemia (38.3% v 37.3%) (difference, 1.0% [90% CL, -1.5%, 3.5%]; P < 0.001) and for patients requiring anticoagulant therapy (44.5% v 41.4%) (difference, 3.1% [90% CL, -2.1%, 8.3%]; P = 0.01). CONCLUSIONS: Having access to immediate test results through PoCT is associated with the same or better medication adherence compared with having test results provided by a pathology laboratory. PoCT used in general practice can provide general practitioners and patients with timely and complete clinical information, facilitating important self-management behaviours such as medication adherence. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN 12605000272695.