Validation of electronic medical data: Identifying diabetes prevalence in general practice.

BACKGROUND:: Electronic medical records are increasingly used for research with limited external validation of their data. OBJECTIVE:: This study investigates the validity of electronic medical data (EMD) for estimating diabetes prevalence in general practitioner (GP) patients by comparing EMD with national Bettering the Evaluation and Care of Health (BEACH) data. METHOD:: A "decision tree" was created using inclusion/exclusion of pre-agreed variables to determine the probability of diabetes in absence of diagnostic label, including diagnoses (coded/free-text diabetes, polycystic ovarian syndrome, impaired glucose tolerance, impaired fasting glucose), diabetic annual cycle of care (DACC), glycated haemoglobin (HbA1c) > 6.5%, and prescription (metformin, other diabetes medications). Via SQL query, cases were identified in EMD of five Illawarra and Southern Practice Network practices (30,007 active patients; from 2 years to January 2015). Patient-based Supplementary Analysis of Nominated Data (SAND) sub-studies from BEACH investigating diabetes prevalence (1172 GPs; 35,162 patients; November 2012 to February 2015) were comparison data. SAND results were adjusted for number of GP encounters per year, per patient, and then age-sex standardised to match age-sex distribution of EMD patients. Cluster-adjusted 95% confidence intervals (CIs) were calculated for both datasets. RESULTS:: EMD diabetes prevalence (T1 and/or T2) was 6.5% (95% CI: 4.1-8.9). Following age-sex standardisation, SAND prevalence, not significantly different, was 6.7% (95% CI: 6.3-7.1). Extracting only coded diagnosis missed 13.0% of probable cases, subsequently identified through the presence of metformin/other diabetes medications (*without other indicator variables) (6.1%), free-text diabetes label (3.8%), HbA1c result* (1.6%), DACC* (1.3%), and diabetes medications* (0.2%). DISCUSSION:: While complex, proxy variables can improve usefulness of EMD for research. Without their consideration, EMD results should be interpreted with caution. CONCLUSION:: Enforceable, transparent data linkages in EMRs would resolve many problems with identification of diagnoses. Ongoing data quality improvement remains essential.

General practice encounters for young patients with autism spectrum disorder in Australia.

This study compared the patient demographics and reasons for encounter in general practice for patients <25 years with and without an autism spectrum disorder identified as a reason for encounter and/or problem managed. The Bettering the Evaluation and Care of Health programme collected information about clinical activities in Australian general practice. Each year, the programme recruited a random sample of 1000 general practitioners, each of whom collected data for 100 consecutive consultations (encounters). Encounters with patients <25 years, where at least one autism spectrum disorder was recorded as a reason for encounter and/or a problem managed (n = 579), were compared with all other encounters (n = 281,473) from April 2000 to March 2014 inclusive. Data were age-sex standardised. Patients at autism spectrum disorder encounters (compared to non-autism spectrum disorder encounters) were more likely to be younger and male. There was a dramatic rise in the number of general practitioner consultations at autism spectrum disorder encounters from 2000 to 2013. More reasons for encounter were recorded at autism spectrum disorder encounters than at non-autism spectrum disorder encounters (156.4 (95% confidence interval: 144.0-168.8) and 140.5 (95% confidence interval: 140.0-141.0), respectively). At autism spectrum disorder (vs non-autism spectrum disorder) encounters, there were more psychological, general and unspecified, and social reasons for encounter and fewer preventive and acute health reasons for encounter. People with an autism spectrum disorder have complex health care needs that require a skilled general practice workforce.

Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations.

OBJECTIVE: To compare the current rate of antibiotic prescribing for acute respiratory infections (ARIs) in Australian general practice with the recommendations in the most widely consulted therapeutic guidelines in Australia (Therapeutic Guidelines). DESIGN AND SETTING: Comparison of general practice activity data for April 2010 - March 2015 (derived from Bettering the Evaluation and Care of Health [BEACH] study) with estimated rates of prescribing recommended by Therapeutic Guidelines. MAIN OUTCOME MEASURES: Antibiotic prescribing rates and estimated guideline-recommended rates per 100 encounters and per full-time equivalent (FTE) GP per year for eight ARIs; number of prescriptions nationally per year. RESULTS: An estimated mean 5.97 million (95% CI, 5.69-6.24 million) ARI cases per year were managed in Australian general practice with at least one antibiotic, equivalent to an estimated 230 cases per FTE GP/year (95% CI, 219-240 cases/FTE/year). Antibiotics are not recommended by the guidelines for acute bronchitis/bronchiolitis (current prescribing rate, 85%) or influenza (11%); they are always recommended for community-acquired pneumonia (current prescribing rate, 72%) and pertussis (71%); and they are recommended for 0.5-8% of cases of acute rhinosinusitis (current prescribing rate, 41%), 20-31% of cases of acute otitis media (89%), and 19-40% cases of acute pharyngitis or tonsillitis (94%). Had GPs adhered to the guidelines, they would have prescribed antibiotics for 0.65-1.36 million ARIs per year nationally, or at 11-23% of the current prescribing rate. Antibiotics were prescribed more frequently than recommended for acute rhinosinusitis, acute bronchitis/bronchiolitis, acute otitis media, and acute pharyngitis/tonsillitis. CONCLUSIONS: Antibiotics are prescribed for ARIs at rates 4-9 times as high as those recommended by Therapeutic Guidelines. Our data provide the basis for setting absolute targets for reducing antibiotic prescribing in Australian general practice.

No abatement of steroid injections for tennis elbow in Australian General Practice: A 15-year observational study with random general practitioner sampling.

OBJECTIVE: Evaluate general practitioner (GP) management of tennis elbow (TE) in Australia. METHODS: Data about the management of TE by GPs from 2000 to 2015 were extracted from the Bettering the Evaluation of Care of Health program database. Patient and GP characteristics and encounter management data were classified by the International Classification of Primary Care, version 2, and reported using descriptive statistics with point estimates and 95% confidence intervals. RESULTS: TE was managed by GPs 242,000 times per year on average. Patients were mainly female (52.3%), aged between 35 and 64 years (mean: 49.3 yrs), had higher relative risks of concomitant disorders (e.g. carpal tunnel syndrome and other tendonitis) and their TE was 10 times more likely to be work related than problems managed for patients who did not have TE. Use of diagnostic tests was low, implying a clinical examination based diagnosis of TE. Management was by procedural treatments (36 per 100 TE problems), advice, education or counselling (25 per 100), and referral to other health care providers (14 per 100, mainly to physiotherapy). The rate of local injection did not change over the 15 years and was performed at similar rates as physiotherapy referral. CONCLUSION: The high risk of comorbidities and work relatedness and no abatement in the reasonably high rate of local injections (which is contrary to the evidence from clinical trials) provides support for the development and dissemination of TE clinical guidelines for GPs.

Estimating non-billable time in Australian general practice.

OBJECTIVES: To quantify the time that general practitioners spend on patient care that is not claimable from Medicare (non-billable) and the monetary value of this work were it claimable, and to identify variables independently associated with non-billable time. DESIGN: Prospective, cross-sectional survey, April 2012 - March 2014. SETTING: Australian general practice; a substudy of the national Bettering the Evaluation and Care of Health (BEACH) program. PARTICIPANTS: 1935 randomly sampled GPs (77.4% participation rate) from across Australia provided filled questionnaires on 66 458 patient encounters. MAIN OUTCOME MEASURES: Non-billable time spent on patient care since patient's previous consultation; duration of and reasons for non-billable time; estimate of its monetary value were it claimable from Medicare; variables associated with non-billable time. RESULTS: 69.5% of GPs reported non-billable care outside patient visits; 8019 patient encounters (12.1%) were associated with an occasion of non-billable time. Mean time spent per occasion was 10.1 min (range, 1-240 min). Reasons for non-billable time included arranging tests and referrals, consulting specialists or allied health professionals, medication renewals, and advice and education, and encompassed all International Classification of Primary Care Version 2 chapters. The notional average annual value per GP of this work was $10 525.95 (level A rebate) to $23 008.05 (level B). Non-billable time was independently associated with female GPs, younger GPs (under 55 years), female patients, patients aged 65 years or more, and one or more chronic problems being managed at the recorded encounter. CONCLUSION: Most GPs spend a significant amount of unpaid time on patient care between consultations, an inherent problem of the fee-for-service system. This work should inform discussions of future funding models.

General practitioners' prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians, 2001-2013.

OBJECTIVE: To examine the prescribing of lipid-lowering medications during general practitioner encounters with Indigenous and non-Indigenous Australians from 2001 to 2013. DESIGN, SETTING AND PARTICIPANTS: Observational time trend study, using data from the Bettering the Evaluation and Care of Health (BEACH) survey, of 9594 primary care encounters with Indigenous patients and 750 079 encounters with non-Indigenous patients aged 30 years or over. MAIN OUTCOME MEASURE: Prescription of at least one lipid-lowering medication. RESULTS: The age-sex standardised proportion of encounters that resulted in at least one lipid-lowering medication being prescribed was 5.5% (95% CI, 4.7%-6.3%) for Indigenous patients and 4.6% (95% CI, 4.5%-4.7%) for non-Indigenous patients. The proportion of encounters with Indigenous patients at which a lipid-lowering medication was prescribed increased significantly from 4.1% during 2001-2005 to 6.4% during 2009-2013 (P = 0.013 for trend). For encounters with non-Indigenous patients, the proportion increased significantly from 3.8% during 2001-2005 to 5.2% during 2009-2013 (P < 0.01). For encounters during which GPs managed diabetes, hypertension or ischaemic heart disease, the proportion of Indigenous encounters during which lipid-lowering medication was prescribed was similar to that for non-Indigenous patients. For encounters in which GPs managed a lipid disorder, however, the age-sex standardised proportion was significantly greater for Indigenous (78.4%; 95% CI, 72.6%-84.2%) than for non-Indigenous patients (65.2%; 95% CI, 64.5%-65.8%). CONCLUSION: We detected substantial increases in the prescribing of lipid-lowering medications from 2001 to 2013 for both Indigenous and non-Indigenous patients seen in Australian general practice. Providers were more likely to prescribe lipid-lowering medications for Indigenous than for non-Indigenous patients, suggesting some measure of success in expanding access to medications and reducing cardiovascular risk among Indigenous people.

Respiratory tract infections among children younger than 5 years: current management in Australian general practice.

OBJECTIVE: To explore the current management in Australian general practice of common respiratory tract infections (RTIs) in children younger than 5 years. DESIGN, SETTING AND PARTICIPANTS: Analysis of data from a sample of 4522 general practitioners who participated in the Bettering the Evaluation and Care of Health (BEACH) cross-sectional survey, April 2007 to March 2012. Consultations with children younger than 5 years were analysed. MAIN OUTCOME MEASURES: GPs' management of four common RTIs (acute upper RTI [URTI], acute bronchitis/bronchiolitis, acute tonsillitis, and pneumonia) in association with six management options: antibiotic medications; prescribed or supplied non-antibiotic medications; medications advised for over-the-counter purchase; referrals; pathology testing; and counselling. RESULTS: Of 31 295 encounters recorded, at least one of the four selected paediatric RTIs was managed at 8157 encounters. URTI was managed 18.6 times per 100 GP patient encounters, bronchitis/bronchiolitis 4.2 times, acute tonsillitis 2.7 times, and pneumonia 0.6 times per 100 encounters. Antibiotics were prescribed most frequently for tonsillitis and least frequently for URTI. Male GPs prescribed antibiotics for URTI significantly more often than female GPs, while older GPs prescribed antibiotics for URTI more often than younger GPs. CONCLUSION: GP management of paediatric RTIs in Australia varied according to the clinical problem and with age and sex of the GP. Further research into parents' and health professionals' attitudes and practices regarding the role of antibiotics, over-the-counter medications, and hygiene will help maintain favourable management practices.