Life, death, and statins: association of statin prescriptions and survival in older general practice patients.

AIMS: This study serves as an exemplar to demonstrate the scalability of a research approach using survival analysis applied to general practice electronic health record data from multiple sites. Collection of these data, the subsequent analysis, and the preparation of practice-specific reports were performed using a bespoke distributed data collection and analysis software tool. BACKGROUND: Statins are a very commonly prescribed medication, yet there is a paucity of evidence for their benefits in older patients. We examine the relationship between statin prescriptions for general practice patients over 75 and all-cause mortality. METHODS: We carried out a retrospective cohort study using survival analysis applied to data extracted from the electronic health records of five Australian general practices. FINDINGS: The data from 8025 patients were analysed. The median duration of follow-up was 6.48 years. Overall, 52 015 patient-years of data were examined, and the outcome of death from any cause was measured in 1657 patients (21%), with the remainder being censored. Adjusted all-cause mortality was similar for participants not prescribed statins versus those who were (HR 1.05, 95% CI 0.92-1.20, P = 0.46), except for patients with diabetes for whom all-cause mortality was increased (HR = 1.29, 95% CI: 1.00-1.68, P = 0.05). In contrast, adjusted all-cause mortality was significantly lower for patients deprescribed statins compared to those who were prescribed statins (HR 0.81, 95% CI 0.70-0.93, P < 0.001), including among females (HR = 0.75, 95% CI: 0.61-0.91, P < 0.001) and participants treated for secondary prevention (HR = 0.72, 95% CI: 0.60-0.86, P < 0.001). This study demonstrated the scalability of a research approach using survival analysis applied to general practice electronic health record data from multiple sites. We found no evidence of increased mortality due to statin-deprescribing decisions in primary care.

The Australian health workforce: Disproportionate shortfalls in small rural towns.

INTRODUCTION: The distribution of health care workers differs greatly across Australia, which is likely to impact health delivery. OBJECTIVE: To examine demographic and workplace setting factors of doctors, nurses and midwives, and allied health professionals across Modified Monash Model (MMM) regions and identify factors associated with shortfalls in the health care workforce. DESIGN: Descriptive cross-sectional analysis. The study included all health professionals who were registered with the Australian Health Practitioner Regulation Agency in 2021, and who were working in Australia in their registered profession. The study examined number of registrations and full-timed equivalent (FTE) registrations per MMM region classification, adjusted for population. Associated variables included age, gender, origin of qualification, Indigenous status and participation in the private or public (including government, non-government organisation and not-for-profit organisations) sectors. FINDINGS: Data were available for 31 221 general practitioners, 77 277 other doctors, 366 696 nurses and midwives, and 195 218 allied health professionals. The lowest FTE per 1000 people was seen in MM5 regions for general practitioners, other doctors, nurses and midwives, and allied health professionals. Demographic factors were mostly consistent across MM regions, although MM5 regions had a higher percentage of nurses and midwives and allied health professionals aged 55 and over. In the private sector, FTE per 1000 people was lowest in MM5-7 regions. In the public sector, FTE per 1000 people was lowest in MM5 regions. DISCUSSION: A disproportionate shortfall of health workers was seen in MM5 regions. This shortfall appears to be primarily due to low FTE per capita of private sector workers compared with MM1-4 regions and a low FTE per capita of public sector workers compared with MM6-7 regions. CONCLUSION: In Australia, small rural towns have the lowest number of health care workers per capita which is likely to lead to poor health outcomes for those regions.

A comparison of rural and regional work locations and speciality choices between graduates from the University of Wollongong and all Australian medical schools using the Medical Schools Outcomes Database.

INTRODUCTION: The shortfall in medical workers in rural and remote Australia has led to health discrepancies in these regions. The University of Wollongong's medical program was designed to encourage graduates to work in these regions to address this shortfall. OBJECTIVE: To compare rural and regional locations of work and choices of speciality between University of Wollongong's graduates and graduates from all Australian universities. DESIGN: We conducted a longitudinal analysis on data available from the Medical Schools Outcome database, with graduate exit surveys linked to registrations of location and speciality. Rural and remote locations were identified as MM2-7 regions using the Modified Monash Model. In total, 716 graduates from the University of Wollongong and 26 915 graduates from all Australian medical schools completed the MSOD exit survey in 2010-2021 and registered with the Australian Health Practitioner Regulation Agency in 2022. The main outcome was the relative likelihood (relative risk) of cohorts working in rural and regional areas and of cohorts choosing general practice as their speciality. FINDINGS: University of Wollongong's medical graduates were 1.51 times or 51% more likely to work in regional or rural areas (RR 1.51, 95% CI 1.34 to 1.71, p < 0.0001). Respondents who were 10 or more years post graduation were 1.57 times or 57% more likely to specialise in general practice than all other Australian medical graduates (RR 1.57 95% CI: 1.40 to 1.79, p < 0.0001). DISCUSSION: The University of Wollongong's medical school is producing graduates to meet Australia's rural health workforce needs. This may be due to a higher intake of rural students, and a higher percentage of students taking rural placements. CONCLUSIONS: Rural health workforce needs can be addressed through rural-focussed education strategies.

Alcohol consumption and health-related quality of life in regional, rural and metropolitan Australia: analysis of cross-sectional data from the Community Health and Rural/Regional Medicine (CHARM) study.

BACKGROUND: Relationships between alcohol consumption and health are complex and vary between countries, regions, and genders. Previous research in Australia has focused on estimating the effect of alcohol consumption on mortality. However, little is known about the relationships between alcohol consumption and health-related quality of life (QoL) in Australia. This study aimed to investigate the levels of alcohol intake and QoL in males and females in rural, regional and metropolitan areas of Australia. METHOD: Participants (n = 1717 Australian adults) completed an online cross-sectional study. Males and females were compared on measures including the AUDIT-C and WHOQOL-BREF. Data were stratified into risk of alcohol use disorder (AUD) and associations were examined between alcohol consumption and QoL, adjusting for sociodemographic variables. RESULTS: Males had higher alcohol consumption and were at greater risk of AUD than females (20% vs 8%). Relationships between alcohol consumption and QoL were positive or non-significant for low-moderate AUD risk categories and negative in the severe AUD risk category. Males in regional communities reported higher alcohol consumption (AUDIT-C score 6.6 vs 4.1, p < 0.01) than metropolitan areas. Regression analyses identified that after adjusting for sociodemographic variables, alcohol consumption was positively related to overall, environmental, and physical QoL and general health. CONCLUSION: The results indicate that alcohol consumption is negatively related to QoL only in those with severe risk of AUD. Males in regional areas reported higher alcohol consumption than those in metropolitan areas. These results provide further information about relationships between alcohol intake and health in Australia that can help inform prevention, screening and delivery of interventions.

CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change?

BACKGROUND: There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS: This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS: Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS: Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).

Randomised trial of general practitioner online education for prescribing and test ordering.

INTRODUCTION: Potentially inappropriate medicine prescriptions and low-value diagnostic testing pose risks to patient safety and increases in health system costs. The aim of the Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice study was to evaluate a scalable online quality improvement intervention, integrating online education regarding a national shared electronic health record and rational prescribing, pathology and imaging ordering by Australian general practitioners (GPs). METHODS: The study was a parallel three-arm randomised trial comprising a prescribing education arm, a pathology education arm and an imaging education arm. Currently practising GPs in Australia were eligible to participate and randomised on a 1:1:1 basis to the study arms after consenting. The response to the intervention in reducing potentially unnecessary medicine prescriptions and tests in each arm was assessed using the other two arms as controls. The primary outcome was the cost per 100 consultations of predefined medication prescriptions, pathology and radiology test ordering 6 months following the intervention, compared with 6 months prior. Outcomes were assessed on intention-to-treat and post hoc per-protocol bases using multilevel regression models, with the analysts blinded to allocation. RESULTS: In total, 106 GPs were enrolled and randomised (prescribing n=35, pathology n=36, imaging n=35). Data were available for 97 GPs at the end of trial (prescribing n=33, pathology n=32, imaging n=32) with 44 fully completing the intervention. In intention-to-treat analysis, there were no significant differences in the rates of change in costs across the three arms. Per protocol, there was a statistically significant difference in the rate of change in pathology costs (p=0.03). In the pathology arm, the rate of increase in pathology costs was significantly lower by $A187 (95% CI -$A340, -$A33) than the prescribing arm, and non-significantly $A9 (95% CI -$A128, $A110) lower than the imaging arm. DISCUSSION: This study provides some evidence for reductions in costs for low-value pathology test ordering in those that completed the relevant online education. The study experienced slow uptake and low completion of the education intervention during the COVID-19 pandemic. Changes were not significant for the primary endpoint, which included all participants. Improving completion rates and combining real-time feedback on prescribing or test ordering may increase the overall effectiveness of the intervention. Given the purely online delivery of the education, there is scope for upscaling the intervention, which may provide cost-effectiveness benefits. TRIAL REGISTRATION NUMBER: ACTRN12620000010998.

An automated protocol for assessing career rurality outcomes of Australian health professionals using retrospective data.

INTRODUCTION: Addressing the imbalance of the health workforce between metropolitan and rural areas requires a clear understanding of trends in choices of work location of health care staff. OBJECTIVE: Here, we provide an automated and highly reproducible protocol to examine the location of health care workers over multiple years using medical graduates as a case study. DESIGN: Data linkage cohort study. The study cohort examined was University of Wollongong Medical graduates from 2010 to 2021 who were registered to practice in Australia. The main outcome measure was graduate location of practice in Modified Monash regsions MM1 or MM2-7 across multiple postgraduate years. This protocol used R Markdown. FINDINGS: An automated and reproducible protocol was used to analyse choices of work location for the University of Wollongong's medical graduates. Over 90% of graduates were registered with AHPRA. Around 25%-30% of graduates were found to work in MM2-7 regions across their careers, exceeding the national average. DISCUSSION: The protocol presented allows for a fast and reproducible analysis of work location by region for health care workers. This will allow comparisons of outcomes between universities or health professions.

Stress, burnout, and parenting: a qualitative study of general practice registrars.

BACKGROUND: Early career medical professionals experience stress and burnout at higher levels than the wider community. Burnout can arise with competing demands of life and career, which is evident in early career development, where family planning can coincide with specialty training. General practice may be seen as a family friendly career option; however, few studies examine the experience of general practice trainees with stress and burnout and the impact that parenting has on their experience. This study aims to explore the experience of stress and burnout in general practice registrars and the exacerbating and protective factors, with a focus on the experiences of two groups of registrars, those that have children, and those that do not. METHODS: A qualitative study was conducted with 14 participants, who were interviewed with questions exploring experiences of stress and burnout. Participants were grouped into those with children and those without children. The transcripts were thematically analysed. RESULTS: Themes were identified as those that contributed to stress and burnout (such as time, financial concerns and isolation) and those factors that reduced stress and burnout (such as support from others and being respected and valued within the workplace). Parenting was identified as both a factor that could contribute to and reduce stress and burnout. CONCLUSIONS: Stress and burnout are important foci for future research and policy to ensure the sustainability of general practice. System based and individual focused policies, including individualising training to support parenting, are required to ensure that registrars are supported through their training years and beyond.

Cluster-randomised trial of the Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP): Prescribing of medicines outcomes.

BACKGROUND: The Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP) study investigated whether targeted financial incentives promoting access to a preferred general practitioner, post-hospitalisation follow-up and longer consultations, increase patient-perceived relational continuity in primary care. Secondary outcomes included the use of medicines. OBJECTIVE: To evaluate whether introducing a general practice-level service model incorporating enrolment and continuous and graded quality improvement incentives influenced the total prescriptions written and potentially inappropriate prescribing of medicines. METHODS: A 12-month cluster-randomised controlled trial, whereby participating patients within intervention practices were offered enrolment with a preferred general practitioner, a minimum of three longer appointments, and review within seven days of hospital admission or emergency department attendance. Control practice patients received usual care. Differences between intervention and control groups pre-post trial for total prescriptions were analysed, as an indicator of polypharmacy, along with prescriptions for four groups of drugs known to have common quality of medicines issues: antibiotics, benzodiazepines, opioids and proton pump inhibitors (PPIs). RESULTS: A total of 774 patients, aged 18-65 years with a chronic illness or aged over 65 years, from 34 general practices in metropolitan, regional and rural Australia participated. The mean number of medicine prescriptions per month at baseline was 4.19 (SD 3.27) and 4.34 (SD 3.75) in the control and intervention arms, respectively, with no significant between-group differences in changes pre-post trial and also no significant between-group or within-group differences of prescription rates for antibiotics, benzodiazepines, opioids or PPIs. CONCLUSIONS: Total prescribing volume and the use of key medicines were not influenced by quality-linked financial incentives for offering longer consultations and early post-hospital review for enrolled patients.

"A cross-sectional study of burnout among Australian general practice registrars".

OBJECTIVE(S): To identify if gender and parenting factors are associated with burnout in Australian general practice (GP) registrars. DESIGN: Cross sectional study. The main outcome measure was the Maslach Burnout Inventory, included as part of the GPRA (General Practice Registrars Australia) biannual online survey. PARTICIPANTS: GP registrars, 2019 cohort, undertaking fellowship training in Australia. RESULTS: In 2019 a total of 366 GP registrars completed the online survey. Over 75% of registrars experienced moderate to high levels of burnout (emotional exhaustion scale). Several demographic factors were associated with an increased risk for reporting higher levels of burnout. Increasing age was associated with lower levels of personal accomplishment (P-value < 0.01), being female was associated with higher levels of emotional exhaustion (p-value < 0.001) and increasing numbers of children were associated with lower levels of burnout, independent of hours worked (p-value < 0.001). CONCLUSION: This study suggests that being a parent is associated with a reduced risk of burnout, irrespective of hours worked. However, being female and increased age were associated with increased levels of burnout. With increasing numbers of females entering medical training, and the decreasing desirability of general practice training, this paper reviews the complexities around parenting during training and associations with burnout. There is a need to examine this interaction further to understand the causation for these findings, and to ensure appropriate policies, opportunities and workplace supports are developed to ensure GP training is optimised to attract and support the next generation.

Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP) cluster randomized trial: impact on patient-reported experience.

BACKGROUND: Relational continuity, 'a therapeutic relationship between a patient and provider/s that spans health care events', has been associated with improved patient outcomes. OBJECTIVES: To evaluate whether an intervention incorporating patient enrolment and a funding model for higher-risk patients influenced patient-reported experience measures, particularly relational continuity. METHODS: Cluster-randomized controlled trial over 12 months (1 August 2018-31 July 2019). Participating patients within intervention practices were offered enrolment with a preferred general practitioner, a minimum of 3 longer appointments, and review within 7 days of hospital admission or emergency department attendance. Intervention practices received incentives for longer consultations (dependent on reducing unnecessary prescriptions and tests), early post-hospital follow-up, and hospitalization reductions. The primary outcome was patient-reported relational continuity, measured by the Primary Care Assessment Tool Short Form. RESULTS: A total of 774 patients, aged 18-65 years with a chronic illness or aged over 65 years, from 34 general practices in metropolitan, regional, and rural Australia across 3 states participated. Response rates for questionnaires were >90%. From a maximum of 4.0, mean baseline scores for relational continuity were 3.38 (SE 0.05) and 3.42 (SE 0.05) in control and intervention arms, respectively, with no significant between-group differences in changes pre-post trial. There were no significant changes in other patient-focussed measures. CONCLUSION: Patient-reported relational continuity was high at baseline and not influenced by the intervention, signalling the need for caution with policies incorporating patient enrolment and financial incentives. Further research is required targeting at-risk patient groups with low baseline engagement with primary care.

Relational continuity, 'a therapeutic relationship between a patient and provider/s that spans health care events', has been associated with improved patient outcomes. This study aimed to evaluate whether patient enrolment with a preferred general practitioner (GP) and a funding model for higher-risk patients influenced patient-reported experience measures, particularly relational continuity. The trial was randomized by practice and ran over 12 months (1 August 2018­31 July 2019). Participating patients within intervention practices were offered enrolment with a preferred GP, a minimum of 3 longer appointments, and review within 7 days of hospital discharge. Intervention practices received incentives for longer consultations (with quality improvements), early post-hospital follow-up, and hospitalization reductions. We measured patient experience using the Primary Care Assessment Tool­Short Form at baseline and completion. A total of 774 patients, aged 18­65 years with a chronic illness or aged over 65 years, from 34 general practices in metropolitan, regional, and rural Australia participated. Patient-reported relational continuity was high at baseline and not influenced by the intervention. There were no significant changes in other patient-focussed measures. We advise caution with policies incorporating patient enrolment and financial incentives. Further research is required targeting at-risk patient groups with low baseline engagement with primary care.

Patient self-management and empowerment for multiple sclerosis: The implications of dietary lifestyle management for primary care.

BACKGROUND: Multiple sclerosis (MS) is a chronic neurological condition of increasing prevalence. Many people living with MS will trial various alternative therapies, including changed patterns of eating, to try to gain control over their condition. New clinical guidelines advise reducing the time between first clinical symptoms and treatment. It is the support of the healthcare team that can empower the person in their healthcare journey. OBJECTIVE: The aim of this article is to provide insights into the role of diet as an element of lifestyle management of MS and describe the implications of diet as a first-line treatment for MS. DISCUSSION: Many 'MS diets' have been promoted to persons diagnosed with MS, yet evidence-based advice is necessitated by an expressed need. Although health risks of short-term exploration of specific diets are not likely to cause concern, lifestyle management should be included in communication plans, with referrals to other healthcare professionals as appropriate.

Development of a COVID-19 virtual community of practice in New South Wales: A qualitative study.

BACKGROUND AND OBJECTIVES: In April 2020, a group of general practice leaders in NSW, Australia, established a COVID-19 virtual community of practice (VCoP) to facilitate rapid transfer and implementation of clinical guidance into practice. This research aimed to gain an understanding of the experience and effectiveness of the VCoP from leaders and members. METHOD: The study used a qualitative participatory action research methodology. A framework analysis was applied to focus group discussion, semi-structured interview and open-text written response data. RESULTS: Thirty-six participants contributed data. In addition to a positive evaluation of the effectiveness of information transfer and support, a key finding was the importance of the role of the VCoP in professional advocacy. Areas for improvement included defining measures of success. DISCUSSION: This study has reinforced the potential for VCoPs to aid health crisis responses. In future crisis applications, we recommend purposefully structuring advocacy and success measures at VCoP establishment.

Giving Asthma Support to Patients (GASP) program evaluation.

BACKGROUND AND OBJECTIVES: The Giving Asthma Support to Patients (GASP) program, developed in New Zealand, guides practice nurses to provide structured asthma care. This study assessed GASP in the context of Australian general practice. METHOD: The study used a pre-post design and was conducted in 19 practices in Western Sydney and Illawarra/Shoalhaven. Patients aged 5-70 years with moderate-to-severe asthma were invited to participate. Of the 289 patients who attended an initial GASP consultation, 153 attended for one or more follow-up visits. Outcomes were exacerbations requiring medical intervention in the previous 12 months, asthma control in the previous four weeks and quality of asthma care at the time of GASP consultation. RESULTS: There was a decrease in patients having one or more exacerbations (113 [74%] versus 80 [52%], P <0.001), and an increase in patients with good asthma control (21 [14%] versus 40 [26%], P <0.005). There was no significant change in the quality of asthma care variable. DISCUSSION: Implementation of the GASP program was associated with improvement in asthma outcomes.

Exploring consumer perspectives about the Health Care Home model of primary care provision: A qualitative study.

BACKGROUND AND OBJECTIVES: Australia's health system faces challenges in the management and prevention of chronic disease. Models of primary care delivery, such as the Health Care Home (HCH) model, have been proposed to help meet these challenges. The aim of this study was to explore pre-implementation consumer perspectives of the HCH model. METHOD: Qualitative data were collected from focus groups and semi-structured interviews with 38 general practice patients diversified across rural and urban areas and patient demographics. RESULTS: The qualitative findings revealed that consumers were confused about the name of the model. They were sceptical about potential hidden costs associated with the model and concerned about hidden agendas and where things in general practice are headed. DISCUSSION: The findings indicate that consumers may not readily embrace the HCH model. To aid consumer acceptance, the authors recommend the terminology be clarified and the concepts, financial implications and expected outcomes of the model be clearly communicated.

Analysis of current maternity leave policies for doctors in training.

Objective This study reviewed the maternity leave policies in Australian general practice speciality training and compared them to hospital-based speciality training policies. Methods Nine general practice regional training organisations' maternity leave policies were audited and compared to 11 Australian hospital speciality training maternity leave policies. Data pertaining to each component of Cheung's health policy analysis tool were reviewed. Results Across all specialities there was a lack of evidence-informed policy design and evidence-based goal setting. Compared with other specialities, general practice was the only speciality where trainees did not receive paid maternity leave. Conclusions This study highlights the need to improve maternity leave policies in line with evidence and best practice for both general practice and hospital-based speciality registrars. What is known about the topic? There is an increasing number of females graduating from medical degrees and planning parenting and speciality medical training simultaneously. The balance of these two roles is dependent on the policies and protocols of the training providers, who need to ensure that parenting and a medical career are compatible. What does this paper add? This paper reports on the findings of an audit of the current maternity leave policies for general practice and hospital-based medical registrar trainees in Australia. It identifies key areas within the policies that need to be addressed. What are the implications for practitioners? This paper identifies that all policies lack evidence of being evidence based in their design. This audit has demonstrated that most policies do not meet the World Health Organization's recommendations for maternity leave. Specifically, general practice trainees are the only doctors who do not have a policy that requires paid maternity leave. However, as the training of general practice registrars moves towards being undertaken by the Royal Australian College of General Practitioners, there is an opportunity for a review of this policy so that it becomes aligned with other Australian medical registrar training policies.

Clinical and healthcare improvement through My Health Record usage and education in general practice (CHIME-GP): a study protocol for a cluster-randomised controlled trial.

BACKGROUND: There is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system. METHODS: The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention. DISCUSSION: The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice. TRIAL REGISTRATION: ClinicalTrials.gov ACTRN12620000010998 . Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry.

Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia.

BACKGROUND: With an ageing population and an increase in chronic disease burden in Australia, Patient Centred Medical Home (PCMH) models of care have been identified as potential options for primary care reform and improving health care outcomes. Adoption of PCMH models are not well described outside of North America. We examined the experiences of seven general practices in an Australian setting that implemented projects aligned with PCMH values and goals supported by their local Primary Health Network (PHN). METHOD: Qualitative and quantitative data were collected over a twelve month period, including semi-structured interviews, participant observation, and practice data to present a detailed examination of a subject of study; the implementation of PCMH projects in seven general practices. We conducted 49 interviews (24 pre and 25 post) with general practitioners, practice managers, practice nurses and PHN staff. Framework analysis deploying the domains of a logic model was used to synthesis and analyse the data. RESULTS: Facilitators in implementing successful, sustainable change included the capacity and willingness of practices to undertake change; whole of practice engagement with a shared vision towards PCMH change; engaged leadership; training and support; and structures and processes required to provide team-based, data driven care. Barriers to implementation included change fatigue, challenges of continued engaged leadership and insufficient time to implement PCMH change. CONCLUSIONS: Our study examined the experiences of implementing PCMH initiatives in an Australian general practice setting, describing facilitators and barriers to PCMH change. Our findings provide guidance for PHNs and practices within Australia, as well as general practice settings internationally, that are interested in undertaking similar quality improvement projects.