Achieving optimal self-management in hereditary haemochromatosis: Results from a community questionnaire.

BACKGROUND AND OBJECTIVES: Hereditary haemochromatosis is a chronic inherited iron overload disorder that is primarily treated with venesection. The aim of this study was to investigate factors associated with optimal haemochromatosis self-management. METHOD: A national online questionnaire was developed. Questions covered demographics, and individual haemochromatosis history and management. The theory of planned behaviour also guided question development. Two logistic regression models were developed for the binary outcomes of serum ferritin within target range and intention to continue venesection. RESULTS: There were 378 complete responses collected. Questions measuring factors of importance (P = 0.022; odds ratio [OR]: 2.284; 95% confidence interval [CI]: 1.125, 4.637), preventing complications (P = 0.017; OR: 2.967; 95% CI: 1.211, 7.265), feeling involved with doctors' decisions (P = 0.006; OR: 1.482; 95% CI: 1.121, 1.958) and control of iron levels (P <0.001; OR: 1.868; 95% CI: 1.399, 2.493) were positively associated with dependent variables. Significant factors related to having a positive attitude and perceived control over haemochromatosis management. DISCUSSION: A positive attitude and sense of behavioural control contribute to successful self-management. Doctors are in an important position to provide self-management support and education.

The voice of haemochromatosis journeys in regional Australia ­ A qualitative study exploring self-management

DISCUSSION: Hereditary haemochromatosis is a common inherited disorder of iron metabolism with avoidable long-term sequalae if it is detected early and managed well. Semi-structured focus group interviews were held in local community libraries. Data were transcribed verbatim, uploaded to NVivo data management software, descriptively coded and thematically analysed. Participants talked about living with haemochromatosis as an individual journey that requires balancing their changing symptoms, treatment and the demands of their daily life. Data analysis revealed four major themes: 'Discovering my haemochromatosis', 'Talking about venesection', 'Managing with diet', and 'Living with haemochromatosis'. People living with haemochromatosis had a positive attitude to the condition, but there were individual variations in the ways they engaged in self-management. A doctor–patient partnership is crucial in the management of haemochromatosis, especially in rural areas. Patients' symptom experiences and self­management decisions need to be seriously considered.

Recruiting general practitioners for surveys and other research: additional lessons learned.

This letter acknowledges the work of Parkinson et al. 'Recruiting general practitioners for surveys: reflections on the difficulties and some lessons learned' (Australian Journal of Primary Health, 2015, 21(2), 254-258), but contributes additional reflections and lessons learned from a successful practice-based research network.

Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors.

OBJECTIVES: To review the available literature regarding skills and competencies gained by junior doctors in rural and regional general practice placements and their alignment with the Australian Curriculum Framework for Junior Doctors (ACFJD). STUDY DESIGN: A comprehensive literature review using a three-phase process. Articles were initially identified from database searches in OvidSP and Scopus. Additional information was obtained after a hand search of contents pages from relevant journals and from reports, conference abstracts and grey literature. Documented skills and procedures were mapped against the competencies from the ACFJD. DATA SOURCES: We analysed 36 relevant articles written in English and published during 1997-2011. Articles referring to learning outcomes for junior doctors training with rural general practitioners were included. DATA SYNTHESIS: Evidence was available of the advantages of junior doctor rural general practice placements in gaining advanced skills in the areas of communication and professionalism, as well as developing autonomy in clinical management and decision making. Less evidence was available regarding exposure to particular clinical conditions and development of specific clinical skills. CONCLUSION: Rural and regional general practice placements for junior doctors are likely to comply with the ACFJD requirements and, further, provide excellent learning opportunities in several domains of the curriculum. However, there was little research published confirming learning outcomes for junior doctors in rural general practice settings.

Analysis of the psychological impact of a vascular risk factor intervention: results from a cluster randomized controlled trial in Australian general practice.

BACKGROUND: Screening for vascular disease, risk assessment and management are encouraged in general practice however there is limited evidence about the emotional impact on patients. The Health Improvement and Prevention Study evaluated the impact of a general practice-based vascular risk factor intervention on behavioural and physiological risk factors in 30 Australian practices. The primary aim of this analysis is to investigate the psychological impact of participating in the intervention arm of the trial. The secondary aim is to identify the mediating effects of changes in behavioural risk factors or BMI. METHODS: This study is an analysis of a secondary outcome from a cluster randomized controlled trial. Patients, aged 40-65 years, were randomly selected from practice records. Those with pre-existing cardiovascular disease were excluded. Socio-demographic details, behavioural risk factors and psychological distress were measured at baseline and 12 months. The Kessler Psychological Distress Score (K10) was the outcome measure for multi-level, multivariable analysis and a product-of-coefficient test to assess the mediating effects of behaviour change. RESULTS: Baseline data were available 384 participants in the intervention group and 315 in the control group. Twelve month data were available for 355 in the intervention group and 300 in the control group. The K10 score of patients in the intervention group (14.78, SD 5.74) was lower at 12 months compared to the control group (15.97, SD 6.30). K10 at 12 months was significantly associated with the score at baseline and being unable to work but not with age, gender, change in behavioural risk factors or change in BMI. CONCLUSIONS: The reduction of K10 in the intervention group demonstrates that a general practice based intervention to identify and manage vascular risk factors did not adversely impact on the psychological distress of the participants. The impact of the intervention on distress was not mediated by a change in the behavioural risk factors or BMI, suggesting that there must be other mediators that might explain the positive impact of the intervention on emotional wellbeing. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000423415.

Understanding the relationship between stress, distress and healthy lifestyle behaviour: a qualitative study of patients and general practitioners.

BACKGROUND: The process of initiating and maintaining healthy lifestyle behaviours is complex, includes a number of distinct phases and is not static. Theoretical models of behaviour change consider psychological constructs such as intention and self efficacy but do not clearly consider the role of stress or psychological distress. General practice based interventions addressing lifestyle behaviours have been demonstrated to be feasible and effective however it is not clear whether general practitioners (GPs) take psychological health into consideration when discussing lifestyle behaviours. This qualitative study explores GPs' and patients' perspectives about the relationship between external stressors, psychological distress and maintaining healthy lifestyle behaviours. METHODS: Semi-structured telephone interviews were conducted with 16 patients and 5 GPs. Transcripts from the interviews were thematically analysed and a conceptual model developed to explain the relationship between external stressors, psychological distress and healthly lifestyle behaviours. RESULTS: Participants were motivated to maintain a healthy lifestyle however they described a range of external factors that impacted on behaviour in both positive and negative ways, either directly or via their impact on psychological distress. The impact of external factors was moderated by coping strategies, beliefs, habits and social support. In some cases the process of changing or maintaining healthy behaviour also caused distress. The concept of a threshold level of distress was evident in the data with patients and GPs describing a certain level of distress required before it negatively influenced behaviour. CONCLUSION: Maintaining healthy lifestyle behaviours is complex and constantly under challenge from external stressors. Practitioners can assist patients with maintaining healthy behaviour by providing targeted support to moderate the impact of external stressors.

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial.

BACKGROUND: Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care. METHODS: This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program. RESULTS: A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance. CONCLUSION: Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals' health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation. TRIAL REGISTRATION: ACTRN12607000423415.

'Managing patient involvement': provider perspectives on diabetes decision-making.

BACKGROUND: Most studies of shared decision-making focus on acute treatment or screening decision-making encounters, yet a significant proportion of primary care is concerned with managing patients with chronic disease. AIM: To investigate provider perspectives on the role of patient involvement in chronic disease decision-making. DESIGN: A qualitative, grounded theory study of patient involvement in diabetes care planning. SETTING AND PARTICIPANTS: Interviews were conducted with 29 providers (19 general practitioners, eight allied health providers, and two endocrinologists) who participated in diabetes care planning. RESULTS: Providers described a conflict between their responsibilities to deliver evidence-based diabetes care and to respect patients' rights to make decisions. While all were concerned with providing best possible diabetes care, they differed in the emphasis they placed on 'treating to target' or practicing 'personalized care'. Those preferring to 'treat to target' were more assertive, while 'personalized care' meant being more accepting of the patient's priorities. Providers sought to manage patient involvement in decision-making according to their objectives. 'Treating to target' meant involving patients where necessary to tailor care to their needs and abilities, but limiting patient involvement in decisions about the overall agenda. 'Personalized care' meant involving patients to tailor care to patient preference. DISCUSSION AND CONCLUSIONS: Respecting a patient's autonomy and delivering high-quality diabetes care are important to providers. At times it may not be possible to do both, so a careful balance is required. Involving patients in decision-making may be a means to this end, rather than an end in itself.

A cluster randomised controlled trial of vascular risk factor management in general practice.

OBJECTIVE: To evaluate the impact of a lifestyle intervention in Australian general practice to reduce the risk of vascular disease. DESIGN, SETTING AND PARTICIPANTS: Stratified cluster randomised controlled trial among 30 general practices in New South Wales from July 2008 to January 2010. Patients aged 40-64 years were invited to participate. The subgroup who were 40-55 years of age were included only if they had either hypertension or dyslipidaemia. INTERVENTION: A general practice-based health-check with brief lifestyle counselling and referral of high-risk patients to a program consisting of one to two individual visits with an exercise physiologist or dietitian, and six group sessions. MAIN OUTCOME MEASURES: Outcomes at baseline, 6 and 12 months included the behavioural and physiological risk factors for vascular disease - self-reported diet and physical activity, and measured weight, body mass index, waist circumference, blood lipid and blood sugar levels, and blood pressure. RESULTS: Of the 3128 patients who were invited, 958 patients (30.6%) responded and 814 were eligible to participate. Of these, 699 commenced the study, and 655 remained in the study at 12 months. Physical activity levels increased to a greater extent in the intervention group than the control group at 6 and 12 months (P = 0.005). There were no other changes in behavioural or physiological outcomes or in estimated absolute risk of cardiovascular disease at 12 months. Of the 384 enrolled in the intervention group, 117 patients (30.5%) attended the minimum number of group program sessions and lost more weight (mean weight loss, 1.06 kg) than those who did not attend the minimum number of sessions (mean weight gain, 0.73 kg). CONCLUSION: While patients who received counselling by their general practitioner increased self-reported physical activity, only those who attended the group sessions sustained an improvement in weight. However, more research is needed to determine whether group programs offer significant benefits over individual counselling in general practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000423415.

Predictors of primary care referrals to a vascular disease prevention lifestyle program among participants in a cluster randomised trial.

BACKGROUND: Cardiovascular disease accounts for a large burden of disease, but is amenable to prevention through lifestyle modification. This paper examines patient and practice predictors of referral to a lifestyle modification program (LMP) offered as part of a cluster randomised controlled trial (RCT) of prevention of vascular disease in primary care. METHODS: Data from the intervention arm of a cluster RCT which recruited 36 practices through two rural and three urban primary care organisations were used. In each practice, 160 eligible high risk patients were invited to participate. Practices were randomly allocated to intervention or control groups. Intervention practice staff were trained in screening, motivational interviewing and counselling and encouraged to refer high risk patients to a LMP involving individual and group sessions. Data include patient surveys; clinical audit; practice survey on capacity for preventive care; referral records from the LMP. Predictors of referral were examined using multi-level logistic regression modelling after adjustment for confounding factors. RESULTS: Of 301 eligible patients, 190 (63.1%) were referred to the LMP. Independent predictors of referral were baseline BMI ≥ 25 (OR 2.87 95%CI:1.10, 7.47), physical inactivity (OR 2.90 95%CI:1.36,6.14), contemplation/preparation/action stage of change for physical activity (OR 2.75 95%CI:1.07, 7.03), rural location (OR 12.50 95%CI:1.43, 109.7) and smaller practice size (1-3 GPs) (OR 16.05 95%CI:2.74, 94.24). CONCLUSIONS: Providing a well-structured evidence-based lifestyle intervention, free of charge to patients, with coordination and support for referral processes resulted in over 60% of participating high risk patients being referred for disease prevention. Contrary to expectations, referrals were more frequent from rural and smaller practices suggesting that these practices may be more ready to engage with these programs. TRIAL REGISTRATION: ACTRN12607000423415.

What predicts patient-reported GP management of smoking, nutrition, alcohol, physical activity and weight?

This study aimed to describe patient-reported management of behavioural risk factors in Australian general practice. Six hundred and ninety-eight eligible patients from 30 general practices in two rural and three urban Divisions of General Practice responded to a mailed invitation to participate and completed a questionnaire. Data were analysed using univariate and multi-level multivariate methods. The prevalence of risk factors varied between 12.6% for smoking and 72.6% for at-risk diet (56.2% were overweight). Most patients were at the action or maintenance phases of their readiness to change their risky behaviours. General practitioners (GPs) provided education or advice to between one-quarter and one-third of those at risk for each risk factor; 9.2% and 9.6% of patients reported having been referred for diet or physical activity interventions. Patient body mass index was associated with increased likelihood of receiving GP advice or referral for diet and physical activity interventions. Having poor diet or physical activity levels and being more ready for change were not associated with the likelihood of GP referral. The major challenge for general practice is to ensure that effective lifestyle interventions are provided to those who will most benefit. Patient-reported GP behavioural risk factor advice and referral is less frequent than is optimal. Priority needs to be given to those most at risk and ready to change their behaviour.

Socio-demographic factors, behaviour and personality: associations with psychological distress.

BACKGROUND: Anxiety, psychological distress and personality may not be independent risk factors for cardiovascular disease; however they may contribute via their relationship with unhealthy lifestyle behaviours. This study aimed to examine the association between psychological distress, risk behaviours and patient demographic characteristics in a sample of general practice patients aged 40-65 years with at least one risk factor for cardiovascular disease. DESIGN: Cross-sectional analytic study. METHODS: Patients, randomly selected from general practice records, completed a questionnaire about their behavioural risk factors and psychological health as part of a cluster randomized controlled trial of a general practice based intervention to prevent chronic vascular disease. The Kessler Psychological Distress Score (K10) was the main outcome measure for the multilevel, multivariate analysis. RESULTS: Single-level bi-variate analysis demonstrated a significant association between higher K10 and middle age (p = 0.001), high neuroticism (p = 0), current smoking (p = 0), physical inactivity (p = 0.003) and low fruit and vegetable consumption (p = 0.008). Socioeconomic (SES) indicators of deprivation (employment and accommodation status) were also significantly associated with higher K10 (p = 0). No individual behavioural risk factor was associated with K10 on multilevel multivariate analysis; however indicators of low SES remained significant (p < 0.001). CONCLUSIONS: When all factors were considered, psychological distress was not associated with behavioural risk factors for cardiovascular disease. Other underlying factors, such as personality type and socioeconomic status, may be associated with both the behaviours and the distress.

Patient and general practitioner attitudes to healthy lifestyle behaviours and medication following coronary heart disease: an exploratory study.

Patients with coronary heart disease often engage in unhealthy lifestyle behaviours. We explored patients' and general practitioners' (GPs') perceptions about the effectiveness of healthy behaviours and medications for the prevention of further cardiovascular disease. This exploratory study used semi-structured interviews with eight Sydney GPs and 13 of their patients with coronary heart disease. Patients perceived medications to be more effective than healthy behaviours in improving specific aspects of cardiovascular health, such as angina symptoms, cholesterol and blood pressure, whilst GPs perceived that medications were more effective in patients they considered at highest cardiovascular risk, patients with uncontrolled risk factors, or where adherence to healthy behaviours was poor. Among patients we found a negative perception of the effort required to adhere to healthy behaviours and possible underestimation of their future cardiovascular risk. Patients valued support from peers and family. This study opens up avenues for investigation in further research, including whether patient adherence to healthy behaviours may be enhanced by the exploration oftheir perceptions about behaviour effectiveness, barriers and cardiovascular risk and by GP facilitation of practical supports.

Osteoarthritis - management options in general practice.

BACKGROUND: Osteoarthritis, characterised by joint pain and stiffness, is a common and significant chronic disease, reducing mobility and causing considerable impact on quality of life. Multiple evidence based management options are available. OBJECTIVE: The aim of this article is to summarise the main management options suggested in The Royal Australian College of General Practitioners Guideline for the nonsurgical management of hip and knee osteoarthritis and to also highlight those that are not recommended. DISCUSSION: Following diagnosis based primarily on history and examination, management focuses on optimising quality of life by providing self management advice combined with appropriate pharmacological and nonpharmacological strategies, aiming to reduce acute exacerbations, prevent complications and delay progression.

Health improvement and prevention study (HIPS) - evaluation of an intervention to prevent vascular disease in general practice.

BACKGROUND: The Health Improvement and Prevention Study (HIPS) study aims to evaluate the capacity of general practice to identify patients at high risk for developing vascular disease and to reduce their risk of vascular disease and diabetes through behavioural interventions delivered in general practice and by the local primary care organization. METHODS/DESIGN: HIPS is a stratified randomized controlled trial involving 30 general practices in NSW, Australia. Practices are randomly allocated to an 'intervention' or 'control' group. General practitioners (GPs) and practice nurses (PNs) are offered training in lifestyle counselling and motivational interviewing as well as practice visits and patient educational resources. Patients enrolled in the trial present for a health check in which the GP and PN provide brief lifestyle counselling based on the 5As model (ask, assess, advise, assist, and arrange) and refer high risk patients to a diet education and physical activity program. The program consists of two individual visits with a dietician or exercise physiologist and four group sessions, after which patients are followed up by the GP or PN. In each practice 160 eligible patients aged between 40 and 64 years are invited to participate in the study, with the expectation that 40 will be eligible and willing to participate. Evaluation data collection consists of (1) a practice questionnaire, (2) GP and PN questionnaires to assess preventive care attitudes and practices, (3) patient questionnaire to assess self-reported lifestyle behaviours and readiness to change, (4) physical assessment including weight, height, body mass index (BMI), waist circumference and blood pressure, (5) a fasting blood test for glucose and lipids, (6) a clinical record audit, and (7) qualitative data collection. All measures are collected at baseline and 12 months except the patient questionnaire which is also collected at 6 months. Study outcomes before and after the intervention is compared between intervention and control groups after adjusting for baseline differences and clustering at the level of the practice. DISCUSSION: This study will provide evidence of the effectiveness of a primary care intervention to reduce the risk of cardiovascular disease and diabetes in general practice patients. It will inform current policies and programs designed to prevent these conditions in Australian primary health care. TRIAL REGISTRATION: ACTRN12607000423415.

Attitudes, norms and controls influencing lifestyle risk factor management in general practice.

BACKGROUND: With increasing rates of chronic disease associated with lifestyle behavioural risk factors, there is urgent need for intervention strategies in primary health care. Currently there is a gap in the knowledge of factors that influence the delivery of preventive strategies by General Practitioners (GPs) around interventions for smoking, nutrition, alcohol consumption and physical activity (SNAP). This qualitative study explores the delivery of lifestyle behavioural risk factor screening and management by GPs within a 45-49 year old health check consultation. The aims of this research are to identify the influences affecting GPs' choosing to screen and choosing to manage SNAP lifestyle risk factors, as well as identify influences on screening and management when multiple SNAP factors exist. METHODS: A total of 29 audio-taped interviews were conducted with 15 GPs and one practice nurse over two stages. Transcripts from the interviews were thematically analysed, and a model of influencing factors on preventive care behaviour was developed using the Theory of Planned Behaviour as a structural framework. RESULTS: GPs felt that assessing smoking status was straightforward, however some found assessing alcohol intake only possible during a formal health check. Diet and physical activity were often inferred from appearance, only being assessed if the patient was overweight. The frequency and thoroughness of assessment were influenced by the GPs' personal interests and perceived congruence with their role, the level of risk to the patient, the capacity of the practice and availability of time. All GPs considered advising and educating patients part of their professional responsibility. However their attempts to motivate patients were influenced by perceptions of their own effectiveness, with smoking causing the most frustration. Active follow-up and referral of patients appeared to depend on the GPs' orientation to preventive care, the patient's motivation, and cost and accessibility of services to patients. CONCLUSION: General practitioner attitudes, normative influences from both patients and the profession, and perceived external control factors (time, cost, availability and practice capacity) all influence management of behavioural risk factors. Provider education, community awareness raising, support and capacity building may improve the uptake of lifestyle modification interventions.

The 45 year old health check - feasibility and impact on practices and patient behaviour.

BACKGROUND: The 45 year old health check (MBS item 717) for patients aged 45-49 years was introduced in 2006. This study evaluated its impact on preventive care and patient reported risk factors. METHODS: A quantitative and qualitative study was conducted in eight general practices in Sydney, New South Wales. It involved follow up surveys of 118 patients taken both before the check and 3 months after. Practice staff were trained and supported to conduct the health checks and appropriate interventions. RESULTS: There was ambivalence among some of the general practitioners toward the health check, but most found it feasible. The reported frequency of GP advice relating to each of the SNAP (smoking, nutrition, alcohol, and physical activity) risk factors increased; patient referrals, however, were infrequent. Patients' readiness to change their diet and exercise habits improved as a result of the check, with respondents showing an increase in both the consumption of vegetables and the frequency of physical activity. There was no change in body mass index, smoking or alcohol consumption. DISCUSSION: The health check was associated with a short term improvement in diet and physical activity behaviours. Mechanisms to enhance referral need to be developed.

Study protocol for a randomized controlled trial: the feasibility and impact of cardiovascular absolute risk assessment in Australian general practice.

BACKGROUND: Although cardiovascular absolute risk (CVAR) assessment has been recommended for use in Australian general practice for a number of years, there is continuing uncertainty about its implementation and impact. Our previous work has developed a multifaceted implementation model. This study aims to investigate both the feasibility of using this model and the impact of CVAR assessment and management on general practice clinical processes and patient care. STUDY DESIGN: This cluster randomized controlled trial will be conducted in general practices in Sydney, involving general practitioners (GPs), other practice staff, and patients aged 45 to 69 years without existing cardiovascular disease. METHODS: A total of 32 practices (40 GPs) and 1,320 patients will be recruited. Randomization will be conducted at the practice level. The intervention group of GPs will be trained to use a CVAR implementation model, whereas the control group of GPs will continue usual care. Study outcomes include clinical processes, patient risk, use of lifestyle intervention, and prescription of antihypertensive and lipid-lowering medications. Data will be collected and analyzed using mixed methods. Study outcomes before and after the intervention will be compared, and the 2 groups will also be compared after adjusting for baseline difference and clustering factors. DISCUSSION: This trial will be the first study in Australian general practice and one of few international studies to evaluate the impact of implementing CVAR assessment and management. Results of this study will help improve the primary prevention of cardiovascular disease and inform guidelines for clinical practice and the implementation of other health initiatives.

Multidisciplinary care plans for diabetes: how are they used?

OBJECTIVE: To understand how multidisciplinary care plans are being used in the management of patients with diabetes, and to explore the role of collaboration in care planning. DESIGN: Grounded theory interview study. SETTING: Primary care, June 2005 to October 2006. PARTICIPANTS: Thirty-eight people from three New South Wales Divisions of General Practice: 19 general practitioners, eight diabetes-related allied health providers, two endocrinologists, and nine adults with type 2 diabetes. Sampling was purposeful then theoretical. RESULTS: GPs use care plans to organise clinical care and help patients access allied health providers. Written plans are used to educate patients about their care and to motivate change. GPs rarely discuss care plans with other providers, and providers are unlikely to change their approach to patients on the basis of care plans. Patients do not expect to participate in care planning. CONCLUSIONS: Care planning may increase evidence-based multidisciplinary care for patients with diabetes, but it rarely results in genuine collaboration between providers and patients. This suggests a difference may exist between Australian policymakers' and providers' definitions of patients with complex needs. Care plans could facilitate patient self-management by including more personalized information. Further research is needed to clarify which patients would benefit from a truly collaborative approach to their care.