A randomised controlled trial of the outcome of health assessment of people aged 75 years and over.

OBJECTIVES: To measure the outcomes of a health assessment, conducted by a nurse, of people aged 75 years and older (75+HA) living independently in their own homes. DESIGN: Randomised controlled trial (RCT). SETTING: A convenience sample of six general practices within the Adelaide Western Division of General Practice (AWDGP). A random sample of 100 participants was drawn from practice age-sex registers. Data were collected in initial visits between 1 August 1998 and February 1999, then in follow-up visits one year later. PARTICIPANTS: Participants were aged 75 years and over on 1 August 1998 and living independently in the community. 145 eligible patients were invited to join the study, and 100 of these consented to enrol (69%). INTERVENTION: A 75+HA conducted in the participant's home by a nurse and reported to their usual general practitioner. MAIN OUTCOME MEASURES: Primary: number of problems in each group; number of participants with problems; and mortality. Secondary: physical function; psychological (including cognitive) function; falls; and admission to institution. RESULTS: There were no significant differences between the control and intervention groups at follow-up in the number of problems, the number of participants with problems, or mortality. In the intervention group, there was significant improvement in self-rated health, geriatric depression score (GDS 15), and number of falls. CONCLUSIONS: This RCT has not demonstrated improvement in health status of the intervention group which received a 75+HA compared with a control group left to usual care.

Establishing a practice based primary care research network. The University Family Practice Network in South Australia.

BACKGROUND: Practice based research networks enable the study of primary care problems in a primary care setting. To be successful, our experience indicates that a network will need to incorporate a number of key components. In South Australia, a University Family Practice Network has been established to undertake primary health care research and teaching and to contribute to the general practice workforce. The University Family Practice Network is composed of five practices and is managed jointly by the Department of General Practice, Adelaide University and the South Australian Centre for Rural and Remote Health, Adelaide University and the University of South Australia. OBJECTIVE: This article details the successful establishment of the University Family Practice Network in the hope of providing a model for other universities who may be interested in setting up a practice based research network. DISCUSSION: The characteristics of this network include fractional academic positions for general practitioners, computerised medical records, location in rural and urban sites, regular meetings and the appointment of a research fellow. A number of benefits have arisen since the network's establishment that will assist its future development and sustainability. These include collocation with allied health services, development of local expertise and workforce support.

Privacy considerations in the context of an Australian observational database.

Observational databases are increasingly acknowledged for their value in clinical investigation. Australian general practice in particular presents an exciting opportunity to examine treatment in a natural setting. The paper explores issues such as privacy and confidentiality--foremost considerations when conducting this form of pharmacoepidemiological research. Australian legislation is currently addressing these exact issues in order to establish clear directives regarding ethical concerns. The development of a pharmacoepidemiological database arising from the integration of computerized Australian general practice records is described in addition, to the challenges associated with creating a database which considers patient privacy. The database known as 'Medic-GP', presently contains more than 950,000 clinical notes (including consultations, pathology, diagnostic imaging and adverse reactions) over a 5-year time period and relates to 55,000 patients. The paper then details a retrospective study which utilized the database to examine the interaction between antibiotic prescribing and patient outcomes from a community perspective, following a policy intervention. This study illustrates the application of computerized general practice records in research.

Associations between rural background and where South Australian general practitioners work.

OBJECTIVE: To determine the association between rural background on practice location of general practitioners (GPs) (rural or urban). DESIGN: Comparison of data from two postal surveys. SUBJECTS: 268 rural and 236 urban GPs practising in South Australia. MAIN OUTCOME MEASURES: Association between practice location (rural or urban) and demographic characteristics, training, qualifications, and rural background. RESULTS: Rural GPs were younger than urban GPs (mean age 47 versus 50 years, P < 0.01) and more likely to be male (81% versus 67%, P = 0.001), to be Australian-born (72% versus 61%, P = 0.01), to have a partner (95% versus 85%, P = 0.001), and to have children (94% versus 85%, P = 0.001). Similar proportions of rural and urban GPs were trained in Australia and were Fellows of the Royal Australian College of General Practitioners, but more rural GPs were vocationally registered (94% versus 84%, P = 0.001). Rural GPs were more likely to have grown up in the country (37% versus 27%, P = 0.02), to have received primary (33% versus 19%, P = 0.001) and secondary (25% versus 13%, P = 0.001) education there, and to have a partner who grew up in the country (49% versus 24%, P = 0.001). In multivariate analysis, only primary education in the country (odds ratio [OR], 2.43; 95% CI, 1.09-5.56) and partner of rural background (OR, 3.14; 95% CI, 1.96-5.10) were independently associated with rural practice. CONCLUSION: Our findings support the policy of promoting entry to medical school of students with a rural background and provide an argument for policies that address the needs of partners and maintain quality primary and secondary education in the country.

Acupuncture in Australian general practice: patient characteristics.

OBJECTIVE: To ascertain the incidence of acupuncture claims and the characteristics of patients claiming for acupuncture. DESIGN: Secondary analysis of Health Insurance Commission data on claims for acupuncture performed by a medical practitioner. PARTICIPANTS: A summary of all Medicare acupuncture claims for financial years 1984-85 to 1996-97 and a random sample of patients claiming a Medicare rebate in calendar year 1996. MAIN OUTCOME MEASURES: Claims for acupuncture by patients' State, sex, age, and the socioeconomic disadvantage index of patients' residences. RESULTS: Between 1984-85 and 1996-97 the number of acupuncture claims increased, but declined as a proportion of total Medicare claims. In 1996, 1.16% of patients claimed for acupuncture, which constituted 0.5% of all Medicare claims. Adjusting for age and socioeconomic disadvantage, women were more likely than men to claim for acupuncture (odds ratio, 1.40; 95% confidence interval, 1.36-1.45). This sex difference is proportionately greater than that for all medical services. Propensity to claim for acupuncture increased with age, peaking at 65-69 years, then declining. Acupuncture claims were more likely in areas just above those assessed as having the greatest social disadvantage. CONCLUSION: The number of acupuncture claims has increased since 1984. As a proportion of all Medicare claims, acupuncture has remained stable since declining in 1991-92. This suggests that acupuncture is now an established complementary medical practice.

Acupuncture in Australian general practice: practitioner characteristics.

OBJECTIVES: To ascertain the extent of the use of acupuncture and the characteristics of general practitioners using acupuncture. DESIGN: Secondary analysis of 1996 Health Insurance Commission data on claims by all non-specialist medical practitioners for Medicare Benefits Schedule items for an attendance where acupuncture was performed by a medical practitioner. MAIN OUTCOME MEASURES: Use of acupuncture by general practitioners and the practitioners' sex, age, place of primary medical qualification, and the socioeconomic disadvantage index of the practitioners' practice. RESULTS: 15.1% of general practitioners claimed for acupuncture. Acupuncture was more likely to be provided by male practitioners, by those aged 35-54 years, and by practitioners who have an overseas primary medical qualification. The socioeconomic index of the practice did not significantly affect the number of claims for acupuncture. CONCLUSION: Acupuncture is used by about one in seven general practitioners. Its use is associated with middle-aged practitioners, who presumably have more clinical experience. This level of use by experienced doctors suggests that a critical review of the appropriate role of acupuncture in general practice should be considered.

Trials of providing costing information to general practitioners: a systematic review.

OBJECTIVE: To determine if providing general practitioners (GPs) with costing information can change their clinical behaviour and reduce medical costs. DATA SOURCES: MEDLINE, CINAHL, Health Plan and EMBASE and citations in review articles were searched for studies published between 1980 and 1996. STUDY SELECTION: Studies were included if they provided costing information to GPs with the aim of decreasing costs by changing behaviour, included an objective measure of GP performance or clinical care, and used a randomised or quasi-randomised controlled design, crossover design or a controlled time series. DATA EXTRACTION: Data extracted included study design, intervention used and measure of GP performance/clinical care (including test ordering, drug prescribing, hospital and primary care visits and costs). DATA SYNTHESIS: Six studies met the inclusion criteria. Computerised feedback on drug costs increased generic prescribing, and "academic detailing" decreased inappropriate prescribing of target drugs. Providing costing information also decreased ordering of diagnostic tests. "Gatekeeper" physicians reduced use of hospital and specialist services. Only two studies found the changes were sustained for nine months or longer and only one evaluated health outcomes. CONCLUSION: The provision of costing information can change GP behaviour in all service areas. Sustainability of these changes and linking of cost savings to health outcomes have not been well studied.

Reported use of asthma management plans in South Australia.

OBJECTIVE: To examine the use of asthma management plans (AMPs) and specific elements of AMPs in a South Australian community. DESIGN: Cross-sectional questionnaire survey by experienced interviewers. PARTICIPANTS AND SETTING: 307 adults with current asthma, confirmed by a doctor, who were among 3001 respondents of a representative sample of 4065 South Australian adults recruited by multistage systematic clustered area sampling for a larger study in March 1995. MAIN OUTCOME MEASURES: Prevalence of reported use of AMPs and of specific elements of AMPs, such as knowledge of trigger factors and having an action plan, and the proportion of adults with asthma receiving what we defined as "good management". RESULTS: 46% reported having an AMP; 63% had discussed trigger factors with their doctors and 39.5% had action plans. 82% had been told the severity of their asthma, and 23.3% were receiving good management. CONCLUSION: Less than half of people with asthma use AMPs, although certain elements within the AMPs are reportedly being used more frequently. More research is required on why AMPs are not more generally used and, more importantly, on what elements within the AMP model are useful and effective for people with asthma and likely to be used by their general practitioners (GPs).

Training, skills and approach to high-risk obstetrics in rural GP obstetricians.

One hundred and sixty seven (82%) of the 204 practising South Australian rural GP obstetricians responded to a questionnaire on training, skills and approach to high-risk obstetrics. The mean length of training was 8.5 months; 78% of GP obstetricians held a diploma. There was a mean of 13 years experience and 22 deliveries per year. However, 26.3% of practitioners had stopped obstetrics in the previous 12 months and cited indemnity insurance and lifestyle factors as the main reason for stopping. The GPs practised a wide range of skills; forceps (96%), Caesarean section (42%) and had good access to epidural services (83.6%), blood transfusions (91%) and specialist advice. High-risk obstetrics such as twin pregnancy, fetal growth retardation, insulin-dependent diabetes and preterm labour, are avoided by most rural GP obstetricians. The mean visual analogue comfort score for providing obstetric care was 7.46 (2.16) and correlated with length of training (p = 0.008) and number of deliveries per year (p = 0.02). Health authorities must continue to support and encourage country GP obstetricians to provide this essential service to rural women.

General practitioner attitudes to recall systems for cervical screening.

OBJECTIVES: To document the factors associated with general practitioner (GP) use of Pap smear reminder/recall systems and to canvass options for coordinating these GP-based systems with similar centrally based schemes. METHODS: A questionnaire survey of a random sample of South Australian GPs. RESULTS: 259 (78%) of 334 GPs returned questionnaires. 117 (45.2%) GPs had practice-based reminder/recall systems, with a higher prevalence among metropolitan GPs with a computer and who had been in practice for less than 20 years. 91.9% of GPs reported that the central register would be of some help in ensuring regular cervical screening. 38.2% of the GPs preferred reminder letters from the register to be sent to their practice; 27.8% preferred them to be sent directly to women and 22.8% opted for letters to be sent from the register via the laboratories to their practice. 61.4% of respondents had a method of recording women with abnormal smears and 95.6% of these actively recalled such women. CONCLUSION: Substantial variation exists in the use of practice-based reminder/recall systems among GPs. A central register would assist most GPs by providing a back-up reminder service to follow-up women for cervical screening.