Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study.

The contribution of travellers visiting friends and relatives to notified infectious diseases in Australia: state-based enhanced surveillance.

Immigrants and their children who return to their country of origin to visit friends and relatives (VFR) are at increased risk of acquiring infectious diseases compared to other travellers. VFR travel is an important disease control issue, as one quarter of Australia's population are foreign-born and one quarter of departing Australian international travellers are visiting friends and relatives. We conducted a 1-year prospective enhanced surveillance study in New South Wales and Victoria, Australia to determine the contribution of VFR travel to notifiable diseases associated with travel, including typhoid, paratyphoid, measles, hepatitis A, hepatitis E, malaria and chikungunya. Additional data on characteristics of international travel were collected. Recent international travel was reported by 180/222 (81%) enhanced surveillance cases, including all malaria, chikungunya and paratyphoid cases. The majority of cases who acquired infections during travel were immigrant Australians (96, 53%) or their Australian-born children (43, 24%). VFR travel was reported by 117 (65%) travel-associated cases, highest for typhoid (31/32, 97%). Cases of children (aged <18 years) (86%) were more frequently VFR travellers compared to adult travellers (57%, P < 0·001). VFR travel is an important contributor to imported disease in Australia. Communicable disease control strategies targeting these travellers, such as targeted health promotion, are likely to impact importation of these travel-related infections.

Cardiovascular risk assessment among rural population: findings from a cohort study in a peripheral region of Bangladesh.

OBJECTIVES: The incidences of non-communicable diseases including cardiovascular diseases (CVDs) is increasing in Bangladesh. The reasons for this increasing trend need to be explored. The aim of this study is to assess the risk of CVDs among a peripheral rural Bangladeshi population and to explore the sociodemographic, anthropometric and clinical variables associated with increased risk. STUDY DESIGN: Cohort study. METHODS: From a cohort of 190,471 individuals of all ages, originally included in a diabetic eye disease program initiated in 2008-2009, a purposive sub-cohort of 66,710 individuals, aged 31-74 years was recruited. During 2011-2012 these participants were assessed for CVDs using the WHO's risk assessment tool designed for primary care settings in low resource societies. Participant characteristics associated with higher risk were explored using univariable and multivariable regression analysis. RESULTS: Out of all (95.5% participation rate) participants 1170 (1.84%) were found to be at high risk for CVD. The prevalence of hypertension (HTN), pre-HTN, obesity, underweight and self-reported DM were 8.9%, 15.2%, 9.6%, 7.8% and 0.5% respectively, among the study population. In multivariable regression analysis female sex, older age, temporary housing structure (i.e., tin shed), extremes of BMI (both underweight and obese) and central obesity were associated with higher risk for CVDs. CONCLUSIONS: The prevalence of CVD risk factors and high CVD risk individuals in this cohort was found to be lower than previous studies. It may be the effects of urbanization are yet to reach this relatively traditional rural population. This study adds to the literature on use of the WHO risk assessment tool.

Medical practitioners' knowledge and self-reported practices of substitute decision making and implementation of advance care plans.

BACKGROUND: Advance care planning (ACP) provides patients with the ability to make their decisions known about how they would like to be treated if they lose capacity. Medical practitioners have a key role to play in providing information on ACP to their patients. This research explores their knowledge and attitudes to advance care planning and how this affects their practice. AIM: The objective of this study is to assess the NSW medical practitioners' knowledge and self-reported practice of ACP. METHODS: A postal survey of a random sample of 650 general practitioners plus 350 medical specialists from specialties most often involved in end-of-life decisions was conducted. Respondents' work location post codes were subsequently used to assign respondents to one of the eight NSW Area Health Services. The main outcome measures were medical practitioners' knowledge of and practice pertaining to ACP. RESULTS: Thirty-four per cent of specialists (n = 110) and 24% of general practitioners (n = 150) responded; the majority of respondents had heard of all ACP options. However, respondents' understanding of the uses and legal requirements of the relevant ACP options vary widely. CONCLUSIONS: Respect for patient wishes expressed in advance directives is reassuringly high. The findings suggest significant misunderstanding by medical practitioners of terminologies and systems around substitute decision-making for incompetent persons. Further education and standardisation of terminologies and systems across different jurisdictions would assist in addressing these issues. Low response rate, relating to only one legal jurisdiction, means results may not be generalisable.

Population-based analysis of sociodemographic predictors, health-related quality of life and health service use associated with obstructive sleep apnoea and insomnia in Australia.

Although there is growing recognition of the effects of living with sleep disorders and the important role of primary care in their identification and management, studies indicate that the detection of sleep apnoea (OSA) and insomnia may still be low. This large representative community-based study (n=2977 adults) used logistic regression models to examine predictors of self-reported OSA and current insomnia and linear regression models to examine the association of these sleep conditions with both mental and physical components of health-related quality of life (HRQoL) and health service use. Overall, 5.6% (95% confidence interval (CI) 4.6-6.7) and 6.8% (95% CI 5.7-7.9) of subjects self-reported OSA (using a single-item question) and current insomnia (using two single-item questions) respectively. Many sociodemographic and lifestyle predictors for OSA and insomnia acted in different directions or showed different magnitudes of association. Both disorders had a similar adverse relationship with physical HRQoL, whereas mental HRQoL was more impaired among those with insomnia. Frequent consultations with a doctor were associated with a lower physical HRQoL across these sleep conditions; however, lower mental HRQoL among those frequently visiting a doctor was observed only among individuals with insomnia. The adverse relationship between sleep disorders and physical and mental HRQoL was substantial and should not be underestimated.

Sharing risk management: an implementation model for cardiovascular absolute risk assessment and management in Australian general practice.

PURPOSE: Despite considerable work in developing and validating cardiovascular absolute risk (CVAR) algorithms, there has been less work on models for their implementation in assessment and management. The aim of our study was to develop a model for a joint approach to its implementation based on an exploration of views of patients, general practitioners (GPs) and key informants (KIs). METHODS: We conducted six focus group (three with GPs and three with patients) and nine KI interviews in Sydney. Thematic analysis was used with comparison to highlight the similarities and differences in perspectives of participants. RESULTS: Conducting CVAR was seen as more acceptable for regular patients rather than new patients for whom GPs had to attract their interest and build rapport before doing so at the next visit. GPs' interest and patients' positive attitude in managing risk were important in implementing CVAR. Long consultations, good communication skills and having a trusting relationship helped overcome the barriers during the process. All the participants supported engaging patients to self-assess their risk before the consultation and sharing decision making with GPs during consultation. Involving practice staff to help with the patient self-assessment, follow-up and referral would be helpful in implementing CVAR assessment and management, but GPs, patients and practices may need more support for this to occur. CONCLUSIONS: Multiple strategies are required to promote the better use of CVAR in the extremely busy working environment of Australian general practice. An implementation model has been developed based on our findings and the Chronic Care Model. Further research needs to investigate the effectiveness of the proposed model.

Erratum: Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG.

A correction to this article has been published and is linked from the HTML version of this article.

Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG.

Tobacco smoking is the world's leading cause of premature death and disability. Global targets to reduce premature deaths by 25% by 2025 will require a substantial increase in the number of smokers making a quit attempt, and a significant improvement in the success rates of those attempts in low, middle and high income countries. In many countries the only place where the majority of smokers can access support to quit is primary care. There is strong evidence of cost-effective interventions in primary care yet many opportunities to put these into practice are missed. This paper revises the approach proposed by the International Primary Care Respiratory Group published in 2008 in this journal to reflect important new evidence and the global variation in primary-care experience and knowledge of smoking cessation. Specific for primary care, that advocates for a holistic, bio-psycho-social approach to most problems, the starting point is to approach tobacco dependence as an eminently treatable condition. We offer a hierarchy of interventions depending on time and available resources. We present an equitable approach to behavioural and drug interventions. This includes an update to the evidence on behaviour change, gender difference, comparative information on numbers needed to treat, drug safety and availability of drugs, including the relatively cheap drug cytisine, and a summary of new approaches such as harm reduction. This paper also extends the guidance on special populations such as people with long-term conditions including tuberculosis, human immunodeficiency virus, cardiovascular disease and respiratory disease, pregnant women, children and adolescents, and people with serious mental illness. We use expert clinical opinion where the research evidence is insufficient or inconclusive. The paper describes trends in the use of waterpipes and cannabis smoking and offers guidance to primary-care clinicians on what to do faced with uncertain evidence. Throughout, it recognises that clinical decisions should be tailored to the individual's circumstances and attitudes and be influenced by the availability and affordability of drugs and specialist services. Finally it argues that the role of the International Primary Care Respiratory Group is to improve the confidence as well as the competence of primary care and, therefore, makes recommendations about clinical education and evaluation. We also advocate for an update to the WHO Model List of Essential Medicines to optimise each primary-care intervention. This International Primary Care Respiratory Group statement has been endorsed by the Member Organisations of World Organization of Family Doctors Europe.

The role of travel in measles outbreaks in Australia - An enhanced surveillance study.

Many developed countries, like Australia, maintain a high population level immunity against measles, however, there remains a risk of acquisition of measles in non-immune travellers and subsequent importation into Australia leading to localised outbreaks. In this study, we estimate the incidence of measles and describe characteristics including immunisation and pre-travel health seeking behaviour of notified cases of measles in New South Wales and Victoria, Australia between February 2013 and January 2014. Cases were followed up by telephone interview using a questionnaire to collect information of demographic and travel characteristics. In NSW, the incidence was highest in age group 0-9years (20/million population) whereas in Victoria the highest incidence was observed in 10-19 (23/million population) years group. Out of 44 cases interviewed, 25 (56.8%) had history of travel outside of Australia during or immediately prior to the onset of measles. Holiday (60%) was the main reason for travel with 44% (11/25) reporting visiting friends and relatives (VFR) during the trip. The major reason described for not seeking prior medical advice before travel were "no perceived risk of diseases" (41%) and "previous overseas travel without any problem" (41%). Of the 25 measles cases with recent overseas travel during the incubation period, one reported a measles vaccine prior to their recent trip. Four cases were children of parents who refused vaccination. Twenty out of 25 (80.0%) had attended mass gathering events. Young adults and VFR travellers should be a high priority for preventive strategies in order to maintain measles elimination status.

Management of children after presenting to hospital with acute asthma but not requiring admission.

OBJECTIVE: To examine the treatment of asthma in children aged 4-15 years in the 12 months following presentation to hospital with acute asthma but not requiring admission. METHOD: Questionnaire based survey addressing the child's use of health services, contact with general practitioners before presentation, use of asthma management plans, symptom frequency, and management of asthma. RESULTS: Sixty-six parents (response rate 50%) completed questionnaires. Children usually experienced infrequent episodic symptoms of asthma, and had good or excellent health (68%). Twenty-two children reported no medical follow up post-emergency department (ED). Of the 39 children who had been reviewed by their GP post-ED, 51% (n = 20) recalled discussing the reasons for presentation to ED with the GP, 41% (n = 16) had a lung function measurement and 64% (n = 25) had discussed ways to better manage the child's asthma to avoid the need for future ED attendance. Most parents of children with asthma (n = 57, 86%) recalled the GP explaining how to manage their child's asthma, but only 35 (61.4%) recalled the GP ever writing down these instructions. CONCLUSION: Children with acute asthma who do not require admission may be better managed in the community if there is greater recourse to GP care, use of written management guidelines and opportunities for additional community care are taken up. Further work is needed to identify strategies that will enable GPs to do this.

Evaluation of an educational program in rational prescribing for GP trainees.

Education on rational prescribing is receiving increased emphasis but the effectiveness of this education is not well researched. This study used a randomised trial to evaluate a seminar for general practice trainees on rational prescribing of antibiotics and benzodiazepines, two important areas of general practice prescribing. Results show a decrease in prescribing of antibiotics by the group of trainees attending the seminar but no effect on an already low level of benzodiazepine prescribing. The study provides evidence that group educational approaches to influencing prescribing behaviour can be effective.

Implementation of the enhanced primary care items requires ongoing education and evaluation.

OBJECTIVE: The study aimed to evaluate the uptake and usage of the Federal Government's Enhanced Primary Care (EPC) items by general practitioners in outer urban general practice. METHOD: Faxed questionnaire with telephone follow up of a random sample of 347 GPs in South West Sydney, in March and April 2000. RESULTS: There was a response rate of 70.6%. Seventy-three percent of respondents reported they had heard of the EPC package and 27% of all the respondents had used one or more of the items. Twenty-three percent had claimed for health assessments (median number 3), 4.5% for care plans (median number 3) and 4% for case conferences (median number 1). Just under half of the GPs who had claimed for health assessments had conducted them in the patient's home. Most GPs either had no system for the use of the items or planned to use them opportunistically. Forty-nine percent of GPs had an age-sex register and those who did were more likely to have claimed for an EPC item and to have specific plans for their use. CONCLUSION: While most GPs had heard of the EPC items, only a minority had used them and few planned to use them systematically within their practice. There is a need to address barriers to the uptake of the EPC items and to provide greater support to GPs and health professionals involved with their implementation, especially for care plans and case conferences. Evaluation of the EPC items needs to be an integral part of the implementation process.

Benzodiazepine prescribing by GP registrars. A trial of educational outreach.

BACKGROUND: Despite ongoing concern about adverse effects and dependence on benzodiazepines, approximately 2% of Australians are still taking them on a regular basis. The aim of this study was to evaluate the effectiveness of an educational outreach or 'academic detailing' program about prescribing of benzodiazepines. METHOD: In this randomised trial general practice registrars (n = 157) in New South Wales were allocated to an intervention group (n = 79), which received a 20 minute educational outreach visit; or a control group (n = 78) which received an intervention on an unrelated topic. Prescribing behaviour was monitored by a pre-intervention and two post-intervention practice activity surveys. MAIN OUTCOME MEASURES: These were the rate of benzodiazepine prescribing for all indications, for anxiety and for sleep disorders. RESULTS: Overall benzodiazepine prescribing by the intervention group declined from 2.3 to 1.7 per 100 encounters, while the control group also declined from 2.2 to 1.6 per 100 encounters. Analysis of variance showed this was a significant drop over time (P = 0.042) but there was no difference between groups (P = 0.99). The prescribing decrease observed was in continuing rather than initial prescriptions. CONCLUSIONS: A marked decrease in benzodiazepine prescribing was seen over the course of the study in both intervention and control groups but no differential effect due to the educational outreach visit was found.

Evaluating the introduction of the enhanced primary care 75+ annual health assessments.

AIM: The study aimed to evaluate what effect the introduction of the enhanced primary care (EPC) health assessments has on the management of elderly patients. METHOD: The study was conducted across five Divisions of General Practice in South West Sydney. Twenty-one general practitioners participated in the study following response to an initial faxed questionnaire survey. An audit of patients' health assessments in conjunction with their records was conducted between June and August 2000. RESULTS: There were significant increase in the documentation of nonmedical problems and of patients' immunisation status. However, there was no increase in plans to refer patients to psychologists, mental health teams or social workers. Also no assessments resulted in a case conference and very few in a care plan. DISCUSSION: Health assessments are unlikely to improve clinical outcomes if they do not result in multidisciplinary care, including care plans, for patients with psychosocial and functional needs. CONCLUSION: Support strategies need to be implemented which assist general practitioners' management of psychosocial and functional problems.

Travelling with medications and medical equipment across international borders.

The international traveller needs to plan ahead to ensure medicines are available and used as directed for optimal therapeutic outcome. The planning needs to take account of legal and customs requirements for travelling with medicines for personal use. The standard advice by travel health providers is that travellers should check with the country of destination for requirements when travelling into the country with medicines for personal use. This is akin to introducing a barrier to care for this category of travellers. Innovative method of care for this group of traveller is needed.

A randomised controlled trial of a consumer-focused e-health strategy for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) study protocol.

INTRODUCTION: Fewer than half of all people at highest risk of a cardiovascular event are receiving and adhering to best practice recommendations to lower their risk. In this project, we examine the role of an e-health-assisted consumer-focused strategy as a means of overcoming these gaps between evidence and practice. Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) aims to test whether a consumer-focused e-health strategy provided to Aboriginal and Torres Strait Islander and non-indigenous adults, recruited through primary care, at moderate-to-high risk of a cardiovascular disease event will improve risk factor control when compared with usual care. METHODS AND ANALYSIS: Randomised controlled trial of 2000 participants with an average of 18 months of follow-up to evaluate the effectiveness of an integrated consumer-directed e-health portal on cardiovascular risk compared with usual care in patients with cardiovascular disease or who are at moderate-to-high cardiovascular disease risk. The trial will be augmented by formal economic and process evaluations to assess acceptability, equity and cost-effectiveness of the intervention. The intervention group will participate in a consumer-directed e-health strategy for cardiovascular risk management. The programme is electronically integrated with the primary care provider's software and will include interactive smart phone and Internet platforms. The primary outcome is a composite endpoint of the proportion of people meeting the Australian guideline-recommended blood pressure (BP) and cholesterol targets. Secondary outcomes include change in mean BP and fasting cholesterol levels, proportion meeting BP and cholesterol targets separately, self-efficacy, health literacy, self-reported point prevalence abstinence in smoking, body mass index and waist circumference, self-reported physical activity and self-reported medication adherence. ETHICS AND DISSEMINATION: Primary ethics approval was received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences CLINICAL TRIALS REGISTRATION NUMBER: ACTRN12613000715774.

Antibiotic and benzodiazepine prescribing by general practice trainees.

OBJECTIVE: To study the prescribing of antibiotics and benzodiazepines by a group of general practice trainees. METHODS: Forty-six trainees in their general practice term with the Royal Australian College of General Practitioners Training Program and 495 experienced general practitioners were compared with regard to patients managed, prescribing of antibiotics for respiratory tract infections and prescribing of benzodiazepines for anxiety, sleep disorders and depression. RESULTS: Trainees saw more young patients and patients with acute respiratory infections, and fewer patients with psychological problems, than the experienced practitioners. Trainees prescribed antibiotics less often for undifferentiated upper respiratory tract infection and their prescribing for tonsillitis was more frequently in agreement with prescribing guidelines. Trainees were less likely to prescribe a benzodiazepine for anxiety or sleep problems. CONCLUSIONS: General practice trainees were relatively conservative prescribers of antibiotics and benzodiazepines. At times both groups did not prescribe in accordance with antibiotic prescribing guidelines and an appreciable number of patients continue to be prescribed benzodiazepines on a long term basis.

Influencing antibiotic prescribing in general practice: a trial of prescriber feedback and management guidelines.

BACKGROUND: The extent of use of antibiotics to treat upper respiratory infections in general practice is an area for concern due to the increasing problem of bacterial resistance. Effective educational strategies to promote rational prescribing are needed. OBJECTIVES: We aimed to examine the effectiveness of prescriber feedback and management guidelines in reducing antibiotics prescribing by GP trainees for undifferentiated upper respiratory tract infection, and in improving the choice of antibiotic for tonsillitis/streptococcal pharyngitis. The research tested a stepwise approach to targeting educational input to high prescribers. METHOD: General Practice trainees in New South Wales (n = 157) were randomly allocated to a treatment group (n = 78) which received an education intervention on antibiotic use, or to a control group (n = 79) which received an intervention on an unrelated topic. Trainees completed three practice activity surveys, each of 110 consecutive patient encounters, with 6-month intervals between surveys. Prescriber feedback and management guidelines on use of antibiotics for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis were delivered in a written form between surveys 1 and 2. An educational outreach visit to high prescribers occurred between surveys 2 and 3. Outcome measures were the rate of antibiotic prescribing for all indications, for URTI and prescribing of select antibiotics for tonsillitis/streptococcal pharyngitis. RESULTS: Antibiotic prescribing by the intervention group declined over three occasions from 25.0 to 23.3 to 19.7 per 100 URTI problems, while the control group increased from 22.0 to 25.0 to 31.7 per 100 URTI problems (P = 0.002). Prescribing in agreement with accepted guidelines for tonsillitis/streptococcal pharyngitis increased over time in the intervention group from 55.6 to 69.8 to 73.0 per 100 problems, but decreased in the control group from 59.6 to 57.5 to 58.5 (P = 0.05). CONCLUSION: Prescriber feedback and management guidelines were shown to influence antibiotic prescribing for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis. This study provides a model for targeting educational input to those prescribers who most need to change their behaviour.