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Preview: Family Practice - current issue

Family Practice Current Issue





Published: Thu, 13 Jul 2017 00:00:00 GMT

Last Build Date: Sat, 23 Sep 2017 02:44:24 GMT

 



Erratum

2017-07-13

How the ‘omics’ revolution can change primary care






Psychological issues and cognitive impairment in adults with familial hypercholesterolemia

2017-06-06

Abstract
A literature review about depression, anxiety, illness perception and neurocognitive impairment in adults with familial hypercholesterolemia (FH) was performed. Through PubMed and PsycINFO published studies from 1980 until March 2017 were searched. Two papers assessed depression and anxiety. Four papers explored illness perception. Five studies assessed cognitive impairment. Mean depression and anxiety scores were within normal range. From the reviewed research, it can be concluded that deficits in executive functioning and memory appear in FH patients between 18 and 40 years old, and mild cognitive impairment in older than 50. The research in the field of the present review is relatively recent: all the studies have been published in the current century. Further research should be done using complete standardized neuropsychological assessment and brain imaging techniques. Studies exploring the possible influence of cognitive deficits on adherence should be conducted also.



Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews

2017-05-09

Abstract
Purpose
To summarize the evidence comparing the effectiveness of short and long courses of oral antibiotics for infections treated in outpatient settings.
Methods
We identified systematic reviews of randomized controlled trials for children and adults with bacterial infections treated in outpatient settings from Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews and The Database of Review of Effects. Data were extracted on the primary outcome of clinical resolution and secondary outcomes.
Results
We identified 30 potential reviews, and included 9. There was no difference in the clinical cure for children treated with short or long course antibiotics for Group A streptococcal tonsillopharyngitis (OR 1.03, 95% CI:0.97, 1.11); community acquired pneumonia (RR 0.99, 95% CI:0.97, 1.01); acute otitis media [<2 years old OR: 1.09 (95% CI:0.76, 1.57); ≥2 years old OR: 0.85 (95% CI:0.60, 1.21)]; or urinary tract infection (RR 1.06, 95% CI:0.64, 1.76). There was no difference in the clinical cure for adults treated with short or long course antibiotics for acute bacterial sinusitis (RR 0.95, 95% CI:0.81, 1.21); uncomplicated cystitis in non-pregnant women (RR 1.10, 95% CI:0.96, 1.25), or elderly women (RR: 0.98, 95% CI:0.62, 1.54); acute pyelonephritis (RR 1.03, 95% CI:0.80, 1.32); or community acquired pneumonia (RR: 0.96, 95% CI:0.74, 1.26). We found inadequate evidence about the effect on antibiotic resistance.
Conclusions
This overview of systematic reviews has identified good quality evidence that short course antibiotics are as effective as longer courses for most common infections managed in ambulatory care. The impact on antibiotic resistance and associated treatment failure requires further study.






Primary care physicians’ use of the proposed classification of common mental disorders for ICD-11

2017-05-04

Abstract
Background
The World Health Organization is revising the classification of common mental disorders in primary care for ICD-11. Major changes from the ICD-10 primary care version have been proposed for: (i) mood and anxiety disorders; and (ii) presentations of multiple somatic symptoms (bodily stress syndrome). This three-part field study explored the implementation of the revised classification by primary care physicians (PCPs) in five countries.
Methods
Participating PCPs in Brazil, China, Mexico, Pakistan and Spain were asked to use the revised classification, first in patients that they suspected might be psychologically distressed (Part 1), and second in patients with multiple somatic symptoms causing distress or disability not wholly attributable to a known physical pathology, or with high levels of health anxiety (Part 2). Patients referred to Part 1 or Part 2 underwent a structured diagnostic interview. Part 3 consisted of feedback from PCPs regarding the classification.
Results
In Part 1, anxious depression was the most common disorder among referred patients. PCPs assigned the highest severity ratings to anxious depression, and the next highest to current depression; current anxiety was rated as least severe. Considerable overlap was found between bodily stress syndrome (BSS) and health anxiety (HA). The psychiatric interview recorded higher rates of mood and anxiety disorders diagnoses among patients with BSS than did PCPs. PCPs’ satisfaction with the revised classification was high.
Conclusions
Results generally supported the inclusion of the new categories of anxious depression, BSS and HA for ICD-11 PHC and suggested that PCPs could implement these categories satisfactorily.



A pharmacy management service for adults with asthma: a cluster randomised controlled trial

2017-05-03

Abstract
Background
Although clinical guidelines are available for the management of asthma, this health condition is still poorly managed in many countries.
Objectives
To assess the effects of a Pharmacy Management Service (PharMS) on asthma control of adult patients.
Methods
This study comprised of a cluster randomised controlled trial (RCT) that was conducted from April 2014 to July 2015 at four government health clinics. The control participants received usual pharmacy service, while the intervention participants were recruited into the PharMS. Each participant was monitored for 6 months, and the outcome measures included asthma control using the Asthma Control Test (ACT), inhaler technique using a checklist and medication adherence using the Malaysian Medication Adherence Scale.
Results
A total of 157 participants were recruited: 77 in the control and 80 in the intervention group. At the end of the study, 90% of the intervention participants achieved well-controlled asthma compared to 28.6% in the control group (P < 0.001). The differences in the proportion of participants with correct inhaler technique was also significant, with an adjusted effect size of 0.953 (P < 0.001). In addition, the intervention participants showed significantly higher medication adherence than the control group (92.5% versus 45.5%, P < 0.001). The Generalised Estimated Equation analysis further confirmed that the PharMS (P < 0.001) was significantly related to an improvement in the ACT scores.
Conclusion
A community-based asthma management program, the PharMS, that provided asthma education and skill training by a trained pharmacist, resulted in positive and significant improvements in clinical and management outcomes of adult asthma patients.



General practitioners’ attitudes towards and experiences with referrals due to supplemental health insurance

2017-05-02

Abstract
Background
Supplemental health insurances (SHI) cover 38% of the Danish population. SHI can give faster access to, and additional treatment from, private health providers. However, this is contingent on a referral from the general practitioner (GP), further complicating clinical decision-making.
Objectives
To describe GPs’ attitudes to SHI and their experiences with patients holding SHI. Moreover, we analysed associations between different GP characteristics; e.g. gender, age, practice type, own SHI status and their attitudes to and experiences with SHI.
Methods
A questionnaire was mailed to 3321 GPs focusing on three issues: (i) Attitudes towards the public health care system. (ii) Perceptions of the impact of SHI. (iii) Experiences with patients holding SHIs.
Results
The response rate was 64%. Overall, GPs found that SHIs contribute to inequality (83%) and overtreatment (90%). However, 46% often feel under pressure to refer SHI patients to specialist care, even though not medically indicated, while 11% always or often refer SHI patients unconditionally. Both groups perceive SHI patients more insistent on getting referrals than patients without SHI.
Conclusion
Even though a majority of GPs associate SHI with overtreatment and inequality in health, many GPs feel under pressure to refer patients holding SHI for treatments or examinations that are not medically warranted. Some GPs even refer these patients without further examination or questioning. Insistent SHI patients may partly explain this paradox. Future research should illuminate SHI patients’ courses in the private as well as the public healthcare system with regards to medical indications and health outcome measures focusing on inequality and overtreatment.



Geographical variation in anti-diabetic prescribing in Ireland in 2013 and 2014: a cross-sectional analysis

2017-05-02

Abstract
Background
Several new medications for type 2 diabetes (T2DM) have been introduced, including dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists. Variation in the prescribing of these agents has implications for quality, safety and costs. We aimed to investigate geographical variation in the prescribing of anti-diabetic medications in Ireland.
Methods
Cross-sectional analyses were undertaken on the two main national pharmacy claims databases in Ireland in 2013 and 2014. Direct standardized rates of individual anti-diabetic medication prescribing per 100 000 population were calculated by geographical area. Variation in prescribing was assessed using the systematic component of variation (SCV) and classified as very high (>10), high (5.4–10), moderate (3–5.4) or low (<3). Estimated total costs of prescribing were calculated per geographical area using medication wholesale costs.
Results
Very high levels of geographical variation of GLP-1 agonists (SCV 11.4 and 10.3 in 2013 and 2014) and moderate variation of DPP-4 inhibitors (SCV 3.8 and 4.1) were found. There was low/moderate variation in the prescribing of sulphonylureas (SVC 2.8 and 3.6) and low variation in prescribing of metformin (SVC 1.7 and 2.0). Geographical variation in Ireland leads to an estimated total wholesale cost differential of €500 000 for GLP-1 agonists, per 100 000 population, between the highest and lowest prescribing areas.
Conclusions
There is substantial geographical variation in the prescribing of new T2DM medicines, particularly GLP-1 agonists. The prescribing variation which was identified may not only represent differences in the application of clinical guidelines, but also variation in professional opinion or patient preference.



Patient-reported impact of after-hours house-call services on the utilization of emergency department services in Australia

2017-05-02

Abstract
Objectives
This paper explores, from the patients’ perspective, the likely impact of the Australian after-hours house-call (AHHC) medical services on emergency department (ED) presentations. This has become imperative given the significant cost difference between patient presentations to either the AHHC or ED and their practical implications for health care funding.
Design, setting and participants
A cross-sectional, self-reported survey of all 10 838 patients in Australia known to have patronized AHHC services over the last week of January 2016.
Main outcome measure
The study used a validated, self-completion questionnaire, dispatched through a mixture of online and postal methods.
Results
A total of 1228 questionnaires were returned, of which 1211 included all relevant sections of the survey (11.2% response rate). Four hundred and eighty-six patients (40.1%) indicated that they would have gone to the ED on the same day or night of their illness had the AHHC not been available, with the elderly (≥65) and children (<16) accounting for nearly two-thirds of these (64.6%). Following their AHHC consultations, 103 (8.5%) patients eventually attended the ED, meaning that the service prevented 383 patients from attending the ED, a decrease of 78.8%. Stratification based on location showed that this impact was seen across all states and territories in Australia where AHHC services exist, ranging from a reduction of 73.9% in Western Australia to 85.0% in Tasmania. Similarly, the impact cuts across all patient demographics, including age ranges, gender and social divides.
Conclusions
Based on our respondents’ reports, AHHC services appear to be associated with a reduction in ED visits in Australia, with the impact cutting across all regions and patient demographics.



Managing transient ischaemic attacks in Australia: a qualitative study

2017-04-12

Abstract
Background
Stroke risk after transient ischaemic attack (TIA) is highest in the first few days. It is greatly reduced by commencing commonly used medications. Current Australian guidelines recommend that all TIAs be managed urgently by secondary-care specialists (mandatory for high-risk TIAs). The majority of TIAs present to general practice which creates a dilemma when specialist care is not readily accessible. There is a lack of evidence relating to the determinants of general practitioners’ (GPs) actions in this situation.
Objective
To explore GP management of TIA presentations.
Methods
A qualitative study using semi-structured interviews of a maximum variation sample of senior and trainee GPs from New South Wales, Australia. Data collection and thematic analysis were concurrent and iterative, employing constant comparison, co-coding, participant transcript review, reflexivity and continued until thematic saturation was achieved.
Results
Management of TIA was heterogeneous and depended upon the GP’s engagement with the individual case. The level of engagement was predicated on the GP’s predisposition toward managing transient neurological presentations generally, the clinical phenotype of the presentation and logistical or health system factors. Management was categorised as triage, guided collaboration, consultative collaboration and independent management. Collaboration with secondary care increased the GP’s capability to diagnose and manage future TIAs.
Conclusion
Heterogeneity of TIA management equates with variation from guideline recommendations. However, Australian guidelines may not be practicable due to variability in access to secondary-care specialists. Future models of care should consider systems approaches such as telemedicine to promote collaboration and assist GPs to comply with guidelines.



How do stroke survivors and their carers use practitioners’ advice on secondary prevention medications? Qualitative study of an online forum

2017-04-10

Abstract
Background
Secondary prevention medications reduce risk of stroke recurrence, yet many people do not receive recommended treatment, nor take medications optimally.
Objective
Exploring how patients report making use of practitioners’ advice on secondary prevention medicines on an online forum and what feedback was received from other participants.
Methods
Thematic analysis of the archive of Talkstroke (2004–2011), UK. Posts including any secondary prevention medication terms, General Practitioner (GP) and their replies were identified.
Results
Fifity participants talked about practitioners’ advice on secondary prevention medications in 43 discussion threads. Patients consulted practitioners for reassurance and dealing with side effects. Practitioners’ advice varied from altering to maintaining current treatment. Three main themes emerged from the use of practitioners’ advice: patients following advice (reassured, happy when side effects made tolerable, or still retaining anxiety about treatment); patients not following advice (admitting adherence on-off or stopping medications as side effects still not tolerable); asking other participants for feedback on advice received. Practitioners’ advice was disregarded mainly when related to dealing with statin side effects, after one or two consultations. Themes for feedback involved sharing experience, directing back to practitioners, or to external evidence.
Conclusions
Side effects of secondary prevention medications and statins in particular, cause anxiety and resentment in some patients, and their concerns are not always addressed by practitioners. Practitioners could consider more proactive strategies to manage such side effects. Forum feedback was appropriate and supportive of the practitioners’ advice received. Our findings from peer-to-peer online conversations confirm and widen previous research.



Adaptation to European Spanish and psychometric properties of the Patient Activation Measure 13 in patients with chronic diseases

2017-03-31

Abstract
Background
The 13-item Patient Activation Measure (PAM-13) is an instrument that assesses people’s knowledge, skills and confidence for self-management of their health and health care. Scores on the PAM-13 have been shown to predict adherence to health behaviours, health-related outcomes and health care costs.
Objectives
To develop a European Spanish adaptation of the original PAM-13 and to examine its psychometric properties in a sample of chronic patients.
Methods
The PAM-13 was forward-backward translated and then completed by chronic patients attending a primary health care centre. Data were analysed with a Rasch model. We assessed the functioning of the rating scale, its reliability, the item goodness-of-fit, differential item functioning (DIF), local dependence, unidimensionality and correlation analysis.
Results
A total of 208 patients (80%) completed the questionnaire. Data showed a fit to the Rasch model. More than 50% of patients endorsed all the items. Item rank for the Spanish sample was similar to the original, with few differences. We found significant differences (P < 0.05) in PAM-13 measures according to adherence to prescribed medicines and positive correlations with self-efficacy and physical quality of life.
Conclusions
The European Spanish PAM-13 is a reliable and valid instrument for assessing activation in patients with chronic disease in Spain. We suggest adding new items to the instrument so as to examine patients with higher activation levels in the future. Further studies are needed to evaluate the usefulness of this new Spanish PAM-13 in different settings and populations, as well as to examine the relationship between PAM-13 scores and other health-related outcomes.



Diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care

2017-03-30

Abstract
Introduction
We must study alternatives to structure an effective diabetic retinopathy screening program for Brazilian public health system.
Objectives
Evaluate the diagnostic performance of retinal digital photography for diabetic retinopathy screening in primary care, accuracy of the family physician in diabetic retinopathy identification compared to the ophthalmologist, and the need for dilation.
Methodology
In a primary care service were performed retinal photographs with non-mydriatic Retinal Camera in 219 type 2 diabetic patients with and without medication mydriasis. We evaluated the performance of the diagnostic of the photos graded by three family physicians with training compared to two ophthalmologists (gold standard), and explore related factors with the need for mydriasis pharmacologically.
Results
The prevalence of diabetic retinopathy and proliferative diabetic retinopathy was 19.2% and 1.5%, respectively. The sensitivity of family physicians to evaluate diabetic retinopathy averaged 82.9% (66.7–94.8%); specificity, 92% (90.2–93.3%); the accuracy, 90.3% (88.2–93%) and positive predictive value, 71.2% (68–75.5%). The agreement calculated using the kappa adjusted coefficient was from 0.74 to 0.8 for retinopathy and 0.88 to 0.92 for macular edema. Without drug mydriasis the photos were unreadable by 14.8%, when using mydriatic collyrium this number decreased to 8.7% (McNemar test, P < 0.005). Patients with more than 65 years old has more readability after drug mydriasis (McNemar test, P = 0.011).
Conclusion
Trained family physician reached a good performance for evaluation of retinography for diabetic retinopathy. There was improvement in readability with pupil dilation in older patients.



Diagnostic performance and clinical feasibility of a point-of-care test for respiratory viral infections in primary health care

2017-03-24

Abstract
Background
Inappropriately high levels of antibiotics are still prescribed in primary health care for respiratory tract infections (RTIs). Access to diagnostic point-of-care tests (POCTs) for RTIs might reduce this over-prescription.
Objective
The purpose of our study was to determine the diagnostic performance and clinical feasibility of a recently developed diagnostic POCT for respiratory viruses, the mariPOC®, in a Dutch primary healthcare setting.
Methods
In patients with RTI symptoms presenting to a family practice during the 2015–2016 winter season, we determined the test’s sensitivity and specificity relative to polymerase chain reaction (PCR) testing performed in a laboratory. The clinical feasibility of the POCT was evaluated by interviewing general practitioners (GPs).
Results
One or more respiratory viruses were detected in 54.9% of the patients (n = 204). For influenza A virus (n = 24), sensitivity of the POCT was 54.2% and specificity was 98.9%; for influenza B virus (n = 18), sensitivity was 72.2% and specificity 99.5%; and for respiratory syncytial virus (RSV) (n = 12), sensitivity was 50.0% and specificity 100%. In samples with higher viral load, sensitivity was 85.7% for influenza A, 78.6% for influenza B and 85.7% for RSV. The availability of a diagnostic test for respiratory viruses was appreciated by both patients and GPs.
Conclusions
Our study shows that diagnostic POCTs for respiratory viruses might contribute to a precise and evidence-based diagnosis of RTIs and could positively influence prescription of antibiotics by GPs. However, before implementation in primary healthcare, diagnostic accuracy of the POCT needs improvement and it is impact on clinical decision making should be further assessed.



General practitioner trainees’ in-consultation generation of clinical questions for later answering: prevalence and associations

2017-03-24

Abstract
Background
As well as generating patient-specific questions, patient consultations are a rich source of questions relating to clinicians’ need to acquire or maintain wider clinical knowledge. This is especially so for GP trainees.
Objectives
To establish the prevalence and associations of GP trainees’ generation of ‘learning goals’ (LGs: questions generated during clinical consultations for intended post-consultation answering). Also, to characterize the type of learning goals generated.
Methods
A cross-sectional analysis (2010–15) of an ongoing cohort study of Australian GP trainees’ consultations. Once each 6-month training term, trainees record detailed data of 60 consecutive consultations. The primary outcome was generation of an LG. Analysis was at the level of individual problem/diagnosis managed. The secondary outcome was the problems/diagnoses to which the LGs related.
Results
One thousand one hundred and twenty-four trainees contributed data for 154746 consultations including 222307 problems/diagnoses. LGs were generated for 16.6% [95% confidence intervals (CI) = 16.4–16.7] of problems/diagnoses, in 22.1% (95% CI = 21.9–22.3%) of consultations. Associations of LGs included patient factors: younger age and having seen the trainee previously; trainee factors: earlier training stage, being overseas-trained and the trainee’s training organization; consultation factors: longer duration, addressing a chronic disease, referring the patient, organizing follow-up, organizing investigations and accessing in-consultation information. LGs were commonly generated for skin (12.9% of all learning goals), musculoskeletal (12.7%) and respiratory (8.7%) problems. LGs were generated for 31.8% of male genital, 27.0% of neurological and 23.3% of eye problems.
Conclusion
Australian GP trainees frequently generate questions in-consultation to be pursued post-consultation. Prevalence, ‘complexity’ and familiarity of clinical topic area influenced LG generation.



Epidemiology of latent tuberculosis infection among patients with and without diabetes mellitus

2017-03-23

Abstract
Background
Individuals with type 2 diabetes mellitus (DM) are at a greater risk of tuberculosis (TB) reactivation. There is a paucity of information about the risk factors associated with latent tuberculosis infection (LTBI) in patients with diabetes.
Objective
We conducted an observational study to compare the prevalence and risk factors associated with LTBI factors in Malaysian adults with and without DM.
Methods
Four hundred and four patients with DM and 359 patients with non-DM at a regional primary care clinic were recruited as participants in this case–control study. The tuberculin sensitivity test (TST) was performed. The presence of LTBI was defined by a TST value of 10 mm in DM patients and 10 mm in the non-DM group. A logistic regression model was used to identify variables associated with LTBI.
Results
There was no statistical significant difference in the prevalence rates seen between the DM and non-DM group of the study. LTBI prevalence among patients with DM was 28.5%. The proportion of patients in the non-DM group with LTBI was 29.2%. When a critical cut-off of 8 mm was used, the adjusted odds ratio of LTBI in DM patients was 1.88 (95% confidence interval: 1.22–2.82). Smoking was an independent risk factor for LTBI regardless of DM status. HbA1c levels or anthropometric measurements were not associated with LTBI in diabetic patients.
Conclusions
There is no significant risk of contracting LTBI in DM patients using the standard 10-mm TST cut-off. Nonetheless, using lower cut-offs in a DM population appear valid. Smoking is an important predictor of LTBI.



Late-life depression and the association with multimorbidity and polypharmacy: a cross-sectional study

2017-03-23

Abstract
Background
Late-life depression often coincides with chronic somatic diseases and, consequently, with polypharmacy, which may complicate medical treatment.
Objective
To determine the associations between patients diagnosed with late-life depression in primary care and multimorbidity and polypharmacy.
Methods
This cross-sectional observational study was performed using 2012 primary care data. Depressed patients aged ≥60 years were compared to age and gender matched patients diagnosed with other psychological diagnoses and mentally healthy controls. Morbidity and prescription data were combined, and regression analyses were performed for the associations between depression and chronic disease and chronic drug use.
Results
We included 4477 patients; 1512 had a record of depression, 1457 of other mental health or psychological diagnoses and 1508 were controls. Depressed patients had a 16% [Prevalence Ratio (PR) 1.16; 95% confidence interval (95% CI) 10%–24%] higher rate of chronic somatic disease and higher odds for multimorbidity (OR 1.55; 95% CI 1.33–1.81) compared with controls. No differences existed between depressed patients and patients with other psychological diagnoses. Compared with controls, depressed patients had a 46% (95% CI 39–53%) higher rate of chronic drug use and higher odds for polypharmacy (OR 2.89; 95% CI 2.41–3.47). Depressed patients also had higher rates of chronic drug use and higher odds for polypharmacy compared with patients with other psychological diagnoses (PR 1.26; OR 1.75; both P < 0.001).
Conclusions
Late-life depression in primary care patients is associated with more chronic drug use, even beyond the increased rates of comorbid somatic diseases. General practitioners should consider medication reviews to prevent unnecessary drug-related problems in these patients.



Impact of clinic follow-up visits on body weight control in people with prediabetes or diabetes mellitus: Japanese nonelderly cohort study

2017-03-23

Abstract
Background
Body weight control is considered essential for the management of diabetes mellitus. Clinicians have an important role in educating and guiding patients with diabetes to control their body weight. The aim of the present study was to clarify if clinic visits influenced body weight control of people with prediabetes or diabetes mellitus.
Objective
To examine whether individuals with diabetes mellitus who visit clinics show better weight control.
Method
We used a large Japanese database (Japan Medical Data Center, Tokyo, Japan) of screening for lifestyle disease linked with administrative claim data to retrospectively identify people with prediabetes or diabetes mellitus based on their fasting plasma glucose and glycated haemoglobin (HbA1c) concentration. We collected data on their baseline characteristics (including age, sex, body mass index and disease history) and their lifestyles. We used propensity-score inverse probability of treatment weighted generalized estimating equations to examine the association between clinic visits and change in body mass index.
Results
Between 2013 and 2014, we identified 11004 individuals with prediabetes or diabetes. The proportions visiting clinics after the first diagnosis made at screening was 27.8%. Clinic visit was significantly associated with lower body mass index after adjustment for baseline patient characteristics a year after first screening (−0.17 kg/m2; 95% confidence interval, −0.22 to −0.12).
Conclusion
In Japanese people found to have prediabetes or diabetes during an annual health screen, those who visited clinics after their first diagnosis were likely to have better body weight control.



Adherence and persistence of patients using oral bone sparing drugs in primary care

2017-03-08

Abstract
Aim
Studies based on pharmacy medication records have shown suboptimal adherence and persistence of osteoporosis treatment with oral bone sparing drugs (OBSD). Little is known about adherence and persistence of OBSD treatment in primary care. We assessed adherence and persistence of OBSD use of patients in general practices and identified associated factors.
Methods
Using electronic medical records, adherence and persistence of newly prescribed treatment with OBSD in patients from 16 general practices was retrospectively assessed. The Medication Possession Ratio (MPR) was calculated as a proxy for adherence (MPR > 75%), persistence rates were estimated using survival analysis. Determinants of adherence and persistence using logistic regression and Cox regression analysis were assessed.
Results
OBSD treatment was initiated in 957 patients. Seventy-five percent and 45% of the patients persisted OBSD treatment for one and five years, respectively. Being adherent in the first year decreased the risk of long-term non-persistence [hazard ratio (HR) 0.41; 95% confidence interval (CI) 0.3–0.57; P < 0.001]. Patients receiving the majority of their prescriptions by a specialist tended to be more non-persistent (HR 1.37; 96%; CI 0.96–1.94; P = 0.08). Adherence was 62.5% in the first year and 60.8% in the overall treatment period. Non-adherence was associated with the specialist being the main prescriber [odds ratio (OR) 3.76; 95% CI 2.43–5.82; P < 0.001] and younger age (<65 years, OR 1.44; 95% CI 1.01–2.08; P = 0.04).
Conclusion
Older age of the patients and the GP prescribing the majority of medication were associated with better adherence and persistence. Good adherence in the first prescription year was associated with better persistence.



Understanding collaboration in general practice: a qualitative study

2017-03-08

Abstract
Background
An increased incidence of chronic and complex conditions in the community is placing pressure on human resources in general practice. Improving collaboration between GPs and registered nurses may help alleviate workforce stressors and enhance health outcomes.
Objective
To explore the facilitators and challenges of collaboration between GPs and registered nurses in Australian general practice.
Methods
Eight GPs and 14 registered nurses from general practices in New South Wales, Australia, participated in semi-structured face-to-face interviews. Recordings were transcribed verbatim and underwent thematic analysis.
Results
The overarching theme ‘Understanding collaboration in general practice’ comprises four sub-themes, namely (i) interpreting collaboration in general practice, (ii) modes of communication, (iii) facilitators of collaboration and (iv) collaboration in practice.
Conclusion
Our findings suggest that regular, formal avenues of communication, professional development and non-hierarchical environments facilitated collaboration between nurses and GPs. Implementing strategies to promote these features has the potential to improve inter-professional collaboration and quality of care within primary care.