Primary Care Visits in the USA and Australia 2000-2016.

BACKGROUND: There are major concerns about the sustainability of the US primary care (PC) system. OBJECTIVE: We use similar data from the USA and Australia on adult visits to primary care physicians to examine how primary care service delivery and content in the countries have changed since the year 2001. DESIGN/SETTING/PARTICIPANTS: Longitudinal analyses of nationally representative data collected in a similar manner on outpatient visits to PC in the USA (National Ambulatory Medical Care Survey, NAMCS) and Australia (Bettering the Evaluation and Care of Health, BEACH), 2001-2016. MAIN MEASURES: For each visit, we ascertained the problems/diagnoses managed; the length of the visit in minutes; what medications were recorded; whether counseling, advice, or education was provided; the rate of imaging and diagnostics tests; the laboratory tests ordered; and whether the visit resulted in a referral to another physician. KEY RESULTS: Between 2001 and 2016, there were 128,770 encounters with adult patients in NAMCS and 1,338,963 in BEACH. In the USA, the proportion of encounters with 3 or more problems managed increased from 28.7 to 54.8% whereas Australia started at a lower proportion (10.6%) and increased to just 14.1%. Visit times in the USA increased from 17.2 min in 2001 to 22.9 min in 2016 as compared to 14.4 min increasing to 15.2 in Australia. There were significantly more medications recorded over time in NAMCS than BEACH (2.02 in 2001 to 3.32 in 2016, USA, and 1.10 and 1.04, Australia), and US encounters resulted in imaging studies, lab tests, or referrals with relatively increasing frequency. CONCLUSION: Relative to Australia, PC visits in the USA increasingly entail more complexity with visits that have grown comparatively longer over time, with more problems addressed, and with more content.

Opioid prescribing in general practice: an Australian cross-sectional survey.

BACKGROUND: Prescribed opioid doses > 100 mg oral morphine equivalent (OME) and/or co-prescribing of sedating psychoactive medications increase the risk of unintentional fatal overdose. We describe general practice encounters where opioids are prescribed and examine high-risk opioid prescribing. METHODS: The 2006-2016 BEACH study data, a rolling national cross-sectional survey of randomly selected GPs, was analysed. RESULTS: Opioid prescribing increased 2006-2007 to 2015-2016, however, this plateaued across the latter half-decade. From 2012-2016 3,897 GPs recorded 389,700 encounters and at least one opioid was prescribed at 5.2%. Opioid encounters more likely involved males, those 45-64 years, concession card holders and the socioeconomically disadvantaged. GPs more likely to prescribe opioids were 55 years or older, male, Australian graduates, and in regional and remote areas. The most common problems managed with opioids involved chronic non-cancer pain. One-in-ten opioid prescribing episodes involved high-risk doses and 11% involved co-prescription of sedating psychoactive medications. Over one-third of GPs provided other (non-pharmacological) interventions at encounters with opioid prescriptions. CONCLUSIONS: Only 5% of GP encounters involved an opioid prescription. Of concern, were: prescribing for chronic non-cancer pain, potentially high-risk opioid encounters where > 100 OME daily dose was prescribed, and/or there was co-prescription of sedating psychoactive medication. However, approximately one-in-three opioid prescribing encounters involved non-pharmacological interventions.

Trends in management of hip and knee osteoarthritis in general practice in Australia over an 11-year window: a nationwide cross-sectional survey.

BACKGROUND: We aimed to describe trends in knee and hip OA management by general medical practitioners (GPs) in Australia. METHODS: We analysed cross-sectional survey data from the Bettering the Evaluation and Care of Health (BEACH) program (1,000 randomly-selected GPs annually recording 100 consecutive patient encounters) over two periods: Period one April 1, 2005-March 31, 2010 and period two April 1, 2010-March 31, 2016. This included data from 10,738 GPs and 1,073,800 patient encounters with 6,565 GPs and 9,196 patient encounters for hip/knee OA. Data were summarized using descriptive statistics and 95% confidence intervals around point estimates. FINDINGS: Rate of knee OA problems managed by GPs increased in period two (7•1 (6•9-7•4) vs 6•2 (95% CI 6•0-6•5) per 1,000 all encounters), with a similar trend for hip OA. Encounter rates rose for some subgroups but remained stable for vulnerable subgroups. Although use of Medicare chronic disease management items, referral to allied health professionals and advice/education and lifestyle management (knee OA) increased, rates remained low. Use of MRI imaging rose. Overall medication rates were stable but substantially higher than non-pharmacological treatments. Declining reliance on non-steroidal anti-inflammatory drugs and glucosamine and increased reliance on paracetamol (knee OA) and opioids were demonstrated. INTERPRETATION: GPs in Australia are more frequently managing knee and hip OA. While small changes in GP management actions occured, rates of recommended first-line non-pharmacological treatments remained low and imaging, medications, and surgical referral rates high. Strategies are needed to optimise lifestyle management and reduce low-value care, with attention to healthcare disparities. FUNDING: Funding was provided for this report by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Translational Research in Musculoskeletal Pain (#1079078).

Management of Whiplash Associated Disorders in Australian general practice.

BACKGROUND: Whiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments. METHODS: We analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters. Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines. RESULTS: Of 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8). CONCLUSIONS: GPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.

Assessment and management of asthma and chronic obstructive pulmonary disease in Australian general practice.

BACKGROUND: Dispensing data suggest potential issues with the quality use of medicines for airways disease. OBJECTIVE: The objective of this article was to describe the management of asthma and chronic obstructive pulmonary disease (COPD) in general practice, and investigate the appropriateness of prescribing. METHODS: The method used for this study consisted of a national cross­sectional survey of 91 Australian general practitioners (GPs) participating in the Bettering the Evaluation and Care of Health (BEACH) program. RESULTS: Data were available for 2589 patients (288 asthma; 135 COPD). For the patients with asthma, GPs classified asthma as well controlled in 76.4%; 54.3% were prescribed inhaled corticosteroids (ICS), mostly (84.9%) as combination therapy, and mostly at moderate-high dose; only 26.3% had a written action plan. GPs classified COPD as mild for 42.9%. Most patients with COPD (60.9%) were prescribed combination ICS therapy and 36.7% were prescribed triple therapy. DISCUSSION: There were substantial differences between guideline-based and GP- recorded assessment and prescription for asthma and COPD. Further research is needed to improve care and optimise patient outcomes with scarce health resources.

Management of chronic heart failure in general practice in Australia.

BACKGROUND: Chronic heart failure is a common clinical syndrome associated with high healthcare system use. OBJECTIVE: The aim of this study was to explore the management of chronic heart failure in Australian general practice. METHODS: Data from the Bettering the Evaluation and Care of Health program were used to determine the prevalence of chronic heart failure, use of natriuretic peptide testing, prescribing patterns, hospitalisation rates and referrals to community-based heart failure management programs in three study periods between 2010 and 2015. RESULTS: Data on 8989 patients from 308 general practitioners were analysed. Of these patients, 324 had chronic heart failure (prevalence 3.6%; 95% confidence interval [CI]: 3.1-4.2), 44% (95% CI: 34.5-53.6) of whom had been hospitalised for the condition. The mean number of prescribed heart failure medication agents was 2.26 (95% CI: 2.13-2.39) per patient. Discharge under community heart failure programs was not routine. DISCUSSION: Chronic heart failure is a significant burden in general practice. Strategies to optimise management and avoid hospitalisation, where possible, are needed.

Assessing patients' and GPs' ability to recognise overweight and obesity.

OBJECTIVE: To assess the ability of GPs and patients to recognise overweight and obesity, determine factors associated with accurate weight perception, and identify methods used by patients and GPs to manage patient overweight and obesity. METHODS: Data were collected in a substudy of the BEACH research program (a continuous, randomised, national cross-sectional survey of general practice activity in Australia). RESULTS: Of 1,599 sampled adult patients, 31.5% were overweight, 23.7% obese and 4.7% morbidly obese. One in four (26.8%) overweight/obese patients (BMI ≥25.0) did not consider themselves overweight. There was an association between patient age and sex and accurate weight perception. Overweight/obese females and those aged 45-64 years were most likely to recognise their overweight. GPs correctly identified 60.8% of overweight patients, but underestimated 35.7% as normal weight. They also identified 60.0% of obese patients, but incorrectly categorised 37.0% as overweight and 3.0% normal weight. There was no association between GP age and sex and accurate weight perception. CONCLUSIONS: Patients' and GPs' perception of weight can often be inaccurate, with many not recognising overweight and obesity. Improvement in recognition of overweight and obesity may increase management and encourage early intervention to prevent disease associated with these weight problems.

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.

Consultations conducted in languages other than English in Australian general practice.

This study sought to determine the need for, and use of, professional interpreters in general practice. This is a sub-study of the Bettering the Evaluation and Care of Health (BEACH) program - a continuous, national, cross-sectional survey of Australian general practitioner (GP) activity. Data were provided by 206 randomly sampled GPs between December 2013 and March 2014. Of 6074 patients sampled, there were 986 (16.2%; 95% confidence interval [CI]: 13.2-19.3) who reported speaking a language other than English (LOTE) at home. Five per cent of all GP consultations involved communicating in a LOTE. Of these, 1% involved professional interpreters, 82.3% were conducted by multilingual GPs who spoke the patient's language, and 17.7% involved a family member or friend. GPs thought a professional interpreter would/may have improved the quality of 27.8% of these consultations. Our study suggests that GPs see the opportunity to improve the quality of LOTE consultations by using professional interpreters to replace family member/friend interpreters.

Management of childhood asthma in general practice.

BACKGROUND: Inhaled corticosteroids (ICS) are recommended for children with moderate or severe persistent asthma. The aims of this paper were to determine changes in childhood asthma management rates between 2004-14, and to examine current medication use and level of control in children attending general practice. METHODS: National BEACH data were used to investigate childhood (<15 years) asthma management rate. Prevalence, medication use and asthma control (Global Initiative for Asthma guidelines) were recorded for a subset of children. RESULTS: The management rate did not change over time. Prevalence was 13.7%. ICS were taken by 42.8% of children. Asthma was well controlled for 51.8%, partly controlled for 30.4% and uncontrolled for 17.9% of children. This study highlights the need to monitor appropriate medication use, particularly ICS/long-acting ß-agonist use, for asthma control in children.

The cost of freezing general practice.

OBJECTIVES: We aimed to assess the effect on general practitioners' income, and the amount of any copayment required for GPs to recoup lost income, of two policies (individually and combined) proposed by the Australian Government: a continued indexation freeze of Medicare schedule fees; and a $5 rebate reduction (now retracted). DESIGN, SETTING AND PARTICIPANTS: Analysis of data from the Bettering the Evaluation and Care of Health (BEACH) program, a continuous cross-sectional, national study of GP activity in Australia. We used data for April 2013 to March 2014 on direct encounters between patients and GPs for which at least one Medicare Benefits Schedule or Department of Veterans' Affairs general practice consultation item was claimable. MAIN OUTCOME MEASURES: The reduction in GP rebate income due to the policies and the size of any copayment needed to address this loss. RESULTS: The $5 rebate reduction would have reduced GPs' income by $219.53 per 100 consultations. This would have required a $4.81 copayment at all non-concessional patient consultations to recoup lost income. The freeze would cost GPs $384.32 in 2017-18 dollars per 100 consultations, requiring an $8.43 copayment per non-concessional patient consultation. Total estimated loss in rebate income to GPs would have been $603.85 in 2017-18 per 100 encounters, a reduction of 11.2%. The non-concessional consultation copayment required to cover lost income from both policies would have been $7-$8 in 2015-16, and $12-$15 by 2017-18. CONCLUSION: If both policies had gone ahead, GPs would have needed to charge substantially more than the suggested $5 copayment for consultations with non-concessional patients in order to maintain 2014-15 relative gross income. Even though the rebate reduction has been retracted, the freeze will have greater impact with time - nearly double the amount of the rebate reduction by 2017-18. For economic reasons, the freeze may still force GPs who currently bulk bill to charge copayments.

Travel advice and vaccination.

Over the decade to June 2014, the number of annual short-term resident departures from Australia more than doubled, from 3.9 million to 8.9 million per year. A large number of these journeys involved destinations with known risk of exposure to vector-borne and enteric diseases. Many of these disease risks are preventable if travellers seek advice about the areas they choose to visit, and are vaccinated in the appropriate time frame before their departure. Vaccination is an essential component of national control of travel-associated infectious diseases. General practitioners (GPs) are well-placed to inform patients about potential disease risks in their intended travel regions and to vaccinate patients before their departure.

'The kids are alright' - Changes in GP consultations with children 2000-15.

The ageing of Australia's population has led to a focus on the health resources required for older patients, and there has been concern that this might be at the expense of children's healthcare. Over the past few decades the number of children in Australia has increased, but has steadily declined as a proportion of the population. This has paralleled an increase in the absolute number of general practitioner (GP) encounters with children aged <15 years, but a decline in the percentage of GP workload from 14.3% in 2000-01 to 11.2% in 2013-14. There are disparities in the use of general practice services by age, with children making up a greater proportion of the population (19.3%) than of GP visits (13.0%), while people aged 65 years and older accounted for 13.0% of the population and 26.5% of visits in 2006. It is unclear whether the decline in the proportion of GP workload accounted for by children reflects a change in the way children use these general practice services, or a redistribution based on the ageing of the patient population. Over time, there have been marked changes in the types of problems managed in children. From the 1990s to 2001, Australia's children became well vaccinated and decreasingly likely to have 'traditional' childhood illnesses (notably infections). More recently, there has been significant growth in the management of child mental health problems in general practice, although mental health problems account for a small proportion of childhood problems managed. We examined children's use of general practice services and the problems managed in 2000-03 and 2012-15 to determine whether their service use has been influenced by the demands associated with the management of older Australians, and whether trends in problems managed identified in early studies have continued.

Testing for gluten sensitivity.

There has been both medical and lay interest in the association of gluten with gastrointestinal conditions.

Drugs causing adverse events in patients aged 45 or older: a randomised survey of Australian general practice patients.

OBJECTIVE: To determine prevalence of adverse drug events (ADEs) in patients aged 45 years or older presenting to Australian general practitioners (GPs) and identify drug groups related to ADEs, their severity and manifestation. DESIGN: Substudy of the Bettering the Evaluation and Care of Health continuous survey of Australian GP clinical activity in which randomly selected GPs collected survey data from patients. Data are reported with 95% CIs. SETTING: General practice in Australia. MAIN OUTCOME MEASURES: Prevalence in the preceding 6 months, type, implicated drugs, severity (including hospitalisation) and manifestation of ADEs. PARTICIPANTS: From three survey samples, January-October 2007, and two samples, January-March 2010, responses were received from 482 GPs about 7561 patients aged 45 years or older. RESULTS: Of a final sample of 7518 patients (after duplicate patients removed), 871 (11.6%) reported ADEs in the previous 6 months. The type of ADE was recognised side effect (75.8%, 95% CI 72.0 to 79.7), drug sensitivity (9.9%, 95% CI 7.2 to 12.7) and drug allergy (7.4%, 95% CI 4.7 to 10.1). Drug interaction (1.0%, 95% CI 0.1 to 1.8), overdose (0.8%, 95% CI 0.0 to 1.5) and contraindications (0.2%, 95% CI 0.0 to 0.6) were very infrequent. A severity rating was provided for 846 patients. Almost half (45.9%, 95% CI 42.0 to 49.7) were rated as 'mild' events, 42.2% (95% CI 38.8 to 45.6) 'moderate', 11.8% (95% CI 9.5 to 14.1) severe and 5.4% (95% CI 3.8 to 7.0) had been hospitalised as a result of the most recent ADE. Thirteen commonly prescribed drug groups accounted for 58% of all ADEs, opioids being the group most often implicated. CONCLUSION: ADEs in patients aged 45 or older are frequent and are associated with significant morbidity. Most of ADEs result from commonly prescribed drugs at therapeutic dosage. The list of causative agents bears little relationship to published lists of 'inappropriate medications'.