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Objectives As life expectancy increases, older people are living longer with multimorbidity (MM, co-occurrence of ≥2 chronic health conditions) and complex multimorbidity (CMM, ≥3 chronic conditions affecting ≥3 different body systems). We assessed the impacts of MM and CMM on healthcare service use in Australia, as little was known about this.Design Population-based cross-sectional data linkage study.Setting New South Wales, Australia.Participants 248 496 people aged ≥45 years who completed the Sax Institute’s 45 and Up Study baseline questionnaire.Primary outcome High average annual healthcare service use (≥2 hospital admissions, ≥11 general practice visits and ≥2 emergency department (ED) visits) during the 3-year baseline period (year before, year of and year after recruitment).Methods Baseline questionnaire data were linked with hospital, Medicare claims and ED datasets. Poisson regression models were used to estimate adjusted and unadjusted prevalence ratios for high service use with 95% CIs. Using a count of chronic conditions (disease count) as an alternative morbidity metric was requested during peer review.Results Prevalence of MM and CMM was 43.8% and 15.5%, respectively, and prevalence increased with age. Across three healthcare settings, MM was associated with a 2.02-fold to 2.26-fold, and CMM was associated with a 1.83-fold to 2.08-fold, increased risk of high service use. The association was higher in the youngest group (45–59 years) versus the oldest group (≥75 years), which was confirmed when disease count was used as the morbidity metric in sensitivity analysis.When comparing impact using three categories with no overlap (no MM/CMM, MM with no CMM, and CMM), CMM had greater impact than MM across all settings.Conclusion Increased healthcare service use among older adults with MM and CMM impacts on the demand for primary care and hospital services. Which of MM or CMM has greater impact on risk of high healthcare service use depends on the analytic method used. Ageing populations living longer with increasing burdens of MM and CMM will require increased Medicare funding and provision of integrated care across the healthcare system to meet their complex needs.

Introduction Potentially inappropriate medicine prescriptions and low-value diagnostic testing pose risks to patient safety and increases in health system costs. The aim of the Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice study was to evaluate a scalable online quality improvement intervention, integrating online education regarding a national shared electronic health record and rational prescribing, pathology and imaging ordering by Australian general practitioners (GPs).Methods The study was a parallel three-arm randomised trial comprising a prescribing education arm, a pathology education arm and an imaging education arm. Currently practising GPs in Australia were eligible to participate and randomised on a 1:1:1 basis to the study arms after consenting. The response to the intervention in reducing potentially unnecessary medicine prescriptions and tests in each arm was assessed using the other two arms as controls. The primary outcome was the cost per 100 consultations of predefined medication prescriptions, pathology and radiology test ordering 6 months following the intervention, compared with 6 months prior. Outcomes were assessed on intention-to-treat and post hoc per-protocol bases using multilevel regression models, with the analysts blinded to allocation.Results In total, 106 GPs were enrolled and randomised (prescribing n=35, pathology n=36, imaging n=35). Data were available for 97 GPs at the end of trial (prescribing n=33, pathology n=32, imaging n=32) with 44 fully completing the intervention. In intention-to-treat analysis, there were no significant differences in the rates of change in costs across the three arms. Per protocol, there was a statistically significant difference in the rate of change in pathology costs (p=0.03). In the pathology arm, the rate of increase in pathology costs was significantly lower by $A187 (95% CI −$A340, −$A33) than the prescribing arm, and non-significantly $A9 (95% CI −$A128, $A110) lower than the imaging arm.Discussion This study provides some evidence for reductions in costs for low-value pathology test ordering in those that completed the relevant online education. The study experienced slow uptake and low completion of the education intervention during the COVID-19 pandemic. Changes were not significant for the primary endpoint, which included all participants. Improving completion rates and combining real-time feedback on prescribing or test ordering may increase the overall effectiveness of the intervention. Given the purely online delivery of the education, there is scope for upscaling the intervention, which may provide cost-effectiveness benefits.Trial registration number ACTRN12620000010998.

IntroductionParticipation in lung cancer screening (LCS) trials and real-world programs is low, with many people at high-risk for lung cancer opting out of baseline screening after registering interest. We aimed to identify the potential drivers of participation in LCS in the Australian setting, to inform future implementation.MethodsSemi-structured telephone interviews were conducted with individuals at high-risk of lung cancer who were eligible for screening and who had either participated ('screeners') or declined to participate ('decliners') in the International Lung Screening Trial from two Australian sites. Interview guide development was informed by the Precaution Adoption Process Model. Interviews were audio-recorded, transcribed and analysed using the COM-B model of behaviour to explore capability, opportunity and motivation related to screening behaviour.ResultsThirty-nine participants were interviewed (25 screeners; 14 decliners). Motivation to participate in screening was high in both groups driven by the lived experience of lung cancer and a belief that screening is valuable, however decliners unlike their screening counterparts reported low self-efficacy. Decliners in our study reported challenges in capability including ability to attend and in knowledge and understanding. Decliners also reported challenges related to physical and social opportunity, in particular location as a barrier and lack of family support to attend screening.ConclusionOur findings suggest that motivation alone may not be sufficient to change behaviour related to screening participation, unless capability and opportunity are also considered. Focusing strategies on barriers related to capability and opportunity such as online/telephone support, mobile screening programs and financial assistance for screeners may better enhance screening participation. Providing funding for clinicians to support individuals in decision-making and belief in self-efficacy may foster motivation. Targeting interventions that connect eligible individuals with the LCS program will be crucial for successful implementation.

BACKGROUND:Cancer of unknown primary (CUP) is a late-stage malignancy with poor prognosis, but we know little about what diagnostic tests and procedures people with CUP receive prior to diagnosis. The purpose of this study was to determine how health service utilisation prior to diagnosis for people with cancer-registry notified CUP differs from those notified with metastatic cancer of known primary. METHODS:We identified people with a cancer registry notification of CUP (n = 327) from the 45 and Up Study, a prospective cohort of 266,724 people ≥45 years in New South Wales, Australia, matched with up to three controls with a diagnosis of metastatic cancer of known primary (n = 977). Baseline questionnaire data were linked to population health data to identify all health service use, diagnostic tests, and procedures in the month of diagnosis and 3 months prior. We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS:After adjusting for age and educational attainment, people with a cancer-registry notified CUP diagnosis were more likely to be an aged care resident (OR = 2.78, 95%CI 1.37-5.63), have an emergency department visit (OR = 1.65, 95%CI 1.23-2.21), serum tumor marker tests (OR = 1.51, 95%CI 1.12-2.04), or a cytology test without immunohistochemistry (OR = 2.01, 95%CI 1.47-2.76), and less likely to have a histopathology test without immunohistochemistry (OR = 0.43, 95%CI 0.31-0.59). Neither general practitioner, specialist, allied health practitioner or nurse consultations, hospitalisations, nor imaging procedures were associated with a CUP diagnosis. CONCLUSIONS:The health service and diagnostic pathway to diagnosis differs markedly for people notified with CUP compared to those with metastatic cancer of known primary. While these differences may indicate missed opportunities for earlier detection and appropriate management, for some patients they may be clinically appropriate.

Introduction: To investigate the perspectives of people accessing a general medical practitioner (GP)-optometry model of collaborative care that was established to increase access to diabetes eye care., Methods: Qualitative study of patient barriers and facilitators to accessing primary diabetes eye care located in a metropolitan area in Australia. One-on-one interviews were recorded, transcribed and thematically analysed using a determinant framework on patient-centred access to health care., Results: Twenty-four people with type 2 diabetes, including 15 males and 9 females, who accessed the service between September 2021 and June 2022 agreed to participate. Mean (SD) age of the participants was 52 (12) years and 50% had been diagnosed with diabetes for <2 years. Facilitators to accessing diabetes eye care included a referral from a GP or GP nurse, fee-free consultations, availability of after-hours appointments and short waiting times. Barriers to access included perceived out-of-pocket costs, competing responsibilities and lack of awareness of diabetic retinopathy screening recommendations., Conclusion: Considering diabetic retinopathy may present asymptomatically, primary health practitioners (optometrists and GPs) are well positioned to raise patient awareness of the importance of routine eye examinations. In Australia, access to routine screening could be facilitated by fee-free eye checks and personalised text message reminders implemented at a health system level., (© 2024 The Author(s). Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Transitions are a period and a process, through which there is a longitudinal adaptation in response to changing circumstances in clinical practice and responsibilities. While the experience of the transition in medical student learning and in hospital-based specialty training programmes are well described and researched, the experience of the transition in community-based postgraduate general practitioner (GP) training has not been described comprehensively., Objective: We aimed to identify, and categorise, the formative experiences of transitions in GP training and their impacts on personal and professional development., Design: We adopted Levac et al 's scoping review methodology. Of 1543 retrieved records, 76 were selected for data extraction. Based on a combined model of the socioecological and multiple and multi-dimensional theories of transitions, data relating to the experiences of transitions were organised into contextual themes: being physical, psychosocial, organisational culture and chronological., Eligibility Criteria: Empirical studies focused on general practice trainees or training, that discussed the transitions experienced in general practice training and that were published in English were included., Information Sources: PubMed, MEDLINE and Web of Science databases were searched in January 2024 with no date limits for empirical studies on the transition experiences of GP into, and through, training., Results: Our findings describe context-dependent formative experiences which advance, or impede, learning and development. Time is a significant modulator of the factors contributing to more negative experiences, with some initially adverse experiences becoming more positive. Identification of the inflection point that represents a shift from initially adverse to more positive experiences of transitions may help moderate expectations for learning and performance at different stages of training., Conclusion: Challenges in training can either advance development and contribute positively to professional identity formation and clinical competency, or detract from learning and potentially contribute to burnout and attrition from training programmes. These findings will assist future research in identifying predictive factors of positive and adverse experiences of transitions and may strengthen existing and nascent GP training programmes. The findings are transferable to other community-based specialty training programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Statins are a group of medications that lower lipid and are used for primary and secondary prevention of cardiovascular diseases (CVD). Patients can either be partially (15%) or completely (5%) intolerant to statins. Symptoms of statin intolerance can include muscle aches (myalgia), weakness, cramps, myopathy, diabetes mellitus, and elevated creatine kinase levels. Decreasing statin intolerance also improves statin adherence, which in turn results in lower number of CVD events among patients. Studies on statin intolerance is often embedded within studies of statin adherence. However, relevant data can be obtained from digital health systems. This preliminary literature review looks at studies from the past 10 years to identify and determine the effectiveness of strategies to address statin intolerance. The NLA definition for statin intolerance was used in this review. The initial search results on EMBASE, PubMed, SCOPUS, and CINAHL showed 91 articles and applying the inclusion and exclusion criteria, four articles were used in this review and pooled analysis. The study patients were identified through electronic health records. The pooled analysis was done using the Metafor package in R, applying a random-effect model to estimate pooled effect size. The findings suggest that using fixed dose combination therapy and switching from a lipophilic statin to a hydrophilic statin, while correcting metabolic abnormalities, or initiating evolocumab alongside statin can address statin intolerance. The overall relative risk (RR) was 0.40 (95% CI, 0.09 to 1.70) with I2 90%, and the overall odds ratio (OR) was 0.11 (95% CI, 0.01 to 1.59) with I2 94%, suggesting that the interventions work well in addressing statin intolerance. Since statin intolerance is has a vast range of effects, further research works may be done on exploring the possibility of using digital health systems to identify and provide targeted interventions to patients.

Background and Objective: The majority of palliative care provision occurs in general practice, yet only 9% of palliative care clinical trials were conducted in this setting. Evidence from hospital and specialist settings is not readily transferable to general practice, as the population, context and care processes are vastly different. Conducting interventional palliative care research in general practice settings is subject to many challenges and barriers. This narrative review aims to describe the factors influencing the conduct of interventional research in general practice settings for patients with palliative care needs., Methods: A narrative review was performed to identify factors affecting the conduct of palliative care interventional studies in general practice. A literature search of MEDLINE was conducted on 26 September 2023, and data were synthesised utilising a narrative approach., Key Content and Findings: Sixteen articles were identified. Five thematic groupings were identified from the literature that affected the interventions: factors related to health care professionals (HCPs), patients and carers, general practices, health systems, and research design. HCPs and practices were focused on providing clinical care and struggled to incorporate research into their workload. Staff and patients often had negative perceptions in palliative care combined with limited research experience, often resulting in unwillingness to engage in interventions and gatekeeping. Engaging with general practice staff to design, participate and champion research were key facilitators of successful interventions., Conclusions: Palliative care interventions in general practice are invariably complex and challenging, yet acutely needed to address the care needs of patients in the community setting. Working together with patients, carers and clinicians to design and implement interventions appropriate for general practice settings is fundamental to their success.

Background: Current literature indicates low uptake of advance care planning (ACP) among the Chinese-speaking community in Australia. To increase the uptake of ACP among the Chinese-speaking community, a better understanding of their attitudes and perceptions on end-of-life (EOL) matters, and ACP is required., Objective: This study aimed to identify significant events and social and cultural factors that influence participants' values and characterize the attitudes and perceptions towards ACP among older Chinese-speaking Australians., Methods: A qualitative study explored participants' experiences through semi-structured one-to-one interviews. The interviews were conducted in Mandarin, Cantonese or English, then translated and transcribed into English. The transcripts were coded and analysed thematically., Results: Twenty participants were recruited (14 female, six male). Participants typically reported a preference to make health-related decisions autonomously. Their perspectives were grounded in past experiences of illnesses and EOL decision-making of loved ones, personal values, and perceived needs. Family dynamics and intimacy of relationships appeared to influence the role and responsibility of family members in EOL decision-making and ACP. Most participants perceived the need to engage in ACP only when encountering significant health changes or higher care needs., Conclusion: Healthcare professionals should initiate ACP discussion using culturally appropriate communication with consideration of personal values, past experiences and family dynamics. Efforts should be invested in raising public awareness of ACP within the Chinese-Australian community., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Primary care education is a unique clinical experience for medical students. It is community-based and provides an opportunity for students to learn consultation skills with multiple sources of workplace-based feedback. Meaningful and demonstrable utilisation of this feedback by students remains an educational challenge. We showcase achievable changes to educational tasks in an established curriculum, which aim to improve student feedback literacy and create a feedback loop which improves on previous provision of unidirectional, terminal feedback. The changes have been well-received, with student and educator engagement being positive. Students have demonstrated critical reflection on feedback, and development in consultation and clinical reasoning skills.

Background: Low dose computed tomography (LDCT) screening, targeted at those at high-risk, has been shown to significantly reduce lung cancer mortality and detect cancers at an early stage. Practical, attitudinal and demographic factors can inhibit screening participation in high-risk populations. This study aimed to explore stakeholders' views about barriers and enablers (determinants) to participation in lung cancer screening (LCS) in Australia., Methods: Twenty-four focus groups (range 2-5 participants) were conducted in 2021 using the Zoom platform. Participants were 84 health professionals, researchers, policy makers and program managers of current screening programs. Focus groups consisted of a structured presentation with facilitated discussion lasting about 1 hour. The content was analysed thematically and mapped to the Consolidated Framework for Implementation Research (CFIR)., Results: Screening determinants were identified across each stage of the proposed screening and assessment pathway. Challenges included participant factors such as encouraging participation for individuals at high-risk, whilst ensuring that access and equity issues were carefully considered in program design. The development of awareness campaigns that engaged LCS participants and health professionals, as well as streamlined referral processes for initial entry and follow-up, were strongly advocated for. Considering practical factors included the use of mobile vans in convenient locations., Conclusions: Participants reported that LCS in Australia was acceptable and feasible. Participants identified a complex set of determinants across the proposed screening and assessment pathway. Strategies that enable the best chance for program success must be identified prior to implementation of a national LCS program., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-23-623/coif). M.L.Y. reports the funding from an NHMRC Investigator Grant (APP 2018108). E.S. has received honoraria for lectures from AstraZeneca, Merck Sharp & Dohme, and The Limbic, support to attend meetings from AstraZeneca LOBES 2022 and has received ad hoc advisory board payment from Bristol Myers Squibb. She holds leadership roles as Deputy Board Chair for the Thoracic Oncology Group of Australasia and Editor in Chief of JTO Clinical and Research Reports. She is the past Co-Convenor of the Tobacco and Related Substances Special Interest Group, Thoracic Society of Australasia. H.M. is supported by a Metro North Hospital and Health Service (Queensland, Australia) Clinical Academic Fellowship and an NHMRC Investigator Grant, and has received honoraria for lectures from AstraZeneca, funding for travel from International Association for the Study of Lung Cancer (IASLC), and holds leadership roles for the Thoracic Society of Australia and New Zealand (Convenor of Tobacco and Related Substances Special Interest Group) and IASLC (committee member). NMR reports the funding from an Australian National Health and Medical Research Council (NHMRC) Ideas Grant (2019/GA65812). The other authors have no conflicts of interest to disclose., (2024 Translational Lung Cancer Research. All rights reserved.)

Background: Relationships between alcohol consumption and health are complex and vary between countries, regions, and genders. Previous research in Australia has focused on estimating the effect of alcohol consumption on mortality. However, little is known about the relationships between alcohol consumption and health-related quality of life (QoL) in Australia. This study aimed to investigate the levels of alcohol intake and QoL in males and females in rural, regional and metropolitan areas of Australia., Method: Participants (n = 1717 Australian adults) completed an online cross-sectional study. Males and females were compared on measures including the AUDIT-C and WHOQOL-BREF. Data were stratified into risk of alcohol use disorder (AUD) and associations were examined between alcohol consumption and QoL, adjusting for sociodemographic variables., Results: Males had higher alcohol consumption and were at greater risk of AUD than females (20% vs 8%). Relationships between alcohol consumption and QoL were positive or non-significant for low-moderate AUD risk categories and negative in the severe AUD risk category. Males in regional communities reported higher alcohol consumption (AUDIT-C score 6.6 vs 4.1, p < 0.01) than metropolitan areas. Regression analyses identified that after adjusting for sociodemographic variables, alcohol consumption was positively related to overall, environmental, and physical QoL and general health., Conclusion: The results indicate that alcohol consumption is negatively related to QoL only in those with severe risk of AUD. Males in regional areas reported higher alcohol consumption than those in metropolitan areas. These results provide further information about relationships between alcohol intake and health in Australia that can help inform prevention, screening and delivery of interventions., (© 2023. The Author(s).)

Statin is a group of lipid/cholesterol-lowering medications that is commonly used for primary and secondary prevention of cardiovascular diseases (CVD). In Australia, this is the first line of pharmacological therapy for CVD risk management. High-risk patients who do not adhere to lipid-modifying medicines have an increased risk of CVD mortality, hospitalization, and revascularization. However, studies show that 67% of patients are non-adherent to statins. As such, improving statin adherence through various strategies is very important. This literature review delves into the studies from the past 10 years to identify the various strategies used and their effectiveness to improve statin adherence. The initial search results on PubMed showed 157 articles and based on the inclusion and exclusion criteria, 7 articles were finally used for this review. The patients in the studies were identified through electronic health records. The findings suggest that education, counselling and motivation through face-to-face interaction, phone calls or text messages, reminder messages and frequent follow-up visits are good strategies to improve statin adherence. Alongside these, simplifying regimens, switching combinations of medicines, or using alternate dosing have also been shown to improve statin adherence. In summary, counselling and face-to-face interaction are effective methods for improving statin adherence. The use of electronic health record (EHR) systems combined with targeted interventions delivered to patients identified to be non-adherent to statin may further improve statin adherence.

Background: There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future., Methods: This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework., Results: Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions., Conclusions: Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education., Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020)., (© 2023. The Author(s).)

Background: The 75+ health assessment has been identified as a suitable trigger to introduce advance care planning (ACP) to general practice patients. Australian general practitioners (GPs) were surveyed to explore their perceptions, attitudes and practices in introducing ACP during 75+ health assessments., Methods: A cross-sectional postal survey of Australian GPs covering their personal, professional and workplace characteristics, their current practice regarding ACP within a 75+ health assessment, and their attitude towards ACP. Multivariate logistic regression was used to analyse the factors associated with routinely discussing ACP as part of the 75+ health assessment., Results: A total of 185 (19.2%) out of 964 eligible GPs returned a completed survey. Most GPs reported that patients interested in ACP were supported by the GPs or the practice nurse. Two factors, (1) attitude that ACP is an essential component of the 75+ health assessment, and (2) regional or rural location of the practice, had a statistically and clinically significant association with the GP's self-reported discussion of ACP during 75+ health assessments., Conclusions: GPs showed a high level of support and involvement in discussing ACP during 75+ health assessments. ACP support during 75+ health assessments was often provided directly by the GP or via the practice nurse. Given the international evidence that ACP training programs improve skills and knowledge, and foster positive attitudes towards ACP, there is an important need to continue funding ACP training programs for GPs and practice nurses.

Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization ( p  < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.

Background: The National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research and updated Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research provide guidance for primary care researchers., Objective: This paper describes a step-by-step approach to ethics applications for research projects in primary care for new or inexperienced researchers, or those new to primary care research., Discussion: Domains that may enhance ethics applications include increased consumer involvement; comprehensive literature reviews; evidence of researcher training in ethical research and clinical trials; the use of online platforms for participant information, consent processes and surveys; and consideration of the risks of genomic research or research in subpopulations. This paper discusses steps required when preparing ethics applications to ensure the community, clinicians and researchers are protected.

Objective: To identify challenges and strategies to improve the provision of end-of-life (EOL) cancer care in an underserved rural and regional Australian local health district (LHD) from the perspective of general practitioners (GPs) and specialist clinicians while exploring the benefits of adopting a generalist health care approach to delivering EOL care in rural and regional communities., Setting: Rural and regional Australia., Participants: General practitioners and palliative care and cancer care specialists (medical and nursing) involved in the provision of EOL care to people with advanced cancer in the rural and regional areas of an Australian LHD., Design: Qualitative descriptive study involving 22 participants in four face-to-face and online focus groups. Thematic analysis of the transcripts identified key issues affecting EOL care for people with advanced cancer in rural and regional areas of the LHD., Results: Four themes including geographical remoteness, system structures, medical management and expertise and training emerged from the focus groups. Key barriers to effective EOL care included insufficient remuneration for GPs and other clinicians (especially home visits), resource limitations, limited community awareness of palliative care and lack of confidence and training of clinicians. Continuity of care was identified as an important facilitator to effective EOL care. Participants suggested greater Medicare rebates for palliative care and home visits, adequate equipment and resources, technology-enabled clinician training and greater rural-based training for specialist PC clinicians may improve the provision of EOL care in regional and rural communities., Conclusions: Rural-based clinicians delivering EOL cancer care appear to be disproportionately affected by geographical challenges including resource and funding limitations. A multi-pronged strategy aimed at greater interdisciplinary collaboration, community awareness and greater resourcing and funding could help to improve the provision of EOL care in underserved rural and remote communities of Australia., (© 2023 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Background: Lung cancer is the number one cause of cancer death worldwide. Although international trials demonstrate that targeted screening using low dose computed tomography (LDCT) significantly reduces lung cancer mortality, implementation of screening in the high-risk population presents complex health system challenges that need to be thoroughly understood to support policy change., Aim: To elicit health care providers' and policymakers' views about the acceptability and feasibility of lung cancer screening (LCS) and barriers and enablers to implementation in the Australian setting., Methods: We conducted 24 focus groups and three interviews (22 focus groups and all interviews online) in 2021 with 84 health professionals, researchers, and current cancer screening program managers and policy makers across all Australian states and territories. Focus groups included a structured presentation about lung cancer and screening and lasted approximately one hour each. A qualitative approach to analysis was used to map topics to the Consolidated Framework for Implementation Research., Results: Nearly all participants considered LCS to be acceptable and feasible but identified a wide range of implementation challenges. Topics (five specific to health systems and five cross-cutting with participant factors) identified were mapped to CFIR constructs, of which 'readiness for implementation', 'planning' and 'executing' were most salient. Health system factor topics included delivery of the LCS program, cost, workforce considerations, quality assurance and complexity of health systems. Participants strongly advocated for streamlined referral processes. Practical strategies to address equity and access, such as using mobile screening vans, were emphasised., Conclusions: Key stakeholders readily identified the complex challenges associated with the acceptability and feasibility of LCS in Australia. The barriers and facilitators across health system and cross-cutting topics were clearly elicited. These findings are highly relevant to the scoping of a national LCS program by the Australian Government and a subsequent recommendation for implementation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Dodd et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Method: Three focus groups were held as part of an existing initiative, 'Ask, Share, Know: Rapid Evidence for General Practice Decisions'. Data were analysed using an inductive thematic approach; themes identified informed adaptation of the conversation guide., Results: Five key themes were identified: 1. general practice provides the optimal context for ACP discussions; 2. ACP priorities differ between GPs; 3. healthcare professionals' roles in ACP vary; 4. confusion exists regarding ACP practice; and 5. the adapted conversation guide provides a useful structure for ACP., Discussion: ACP practice varies between GPs. GPs preferred the adapted conversation guide, but further evaluation is required prior to implementation into practice.

Background and Objectives: Women living in rural Australia have worse survival rates for breast cancer compared with their urban counterparts. Identifying factors that contribute to delayed presentation could help to reduce this disparity. This study aimed to identify and explore the differences in help-seeking behaviours between rural and urban women with non-screen-detected breast cancer., Method: We conducted a qualitative study consisting of semi-structured interviews with 20 women from New South Wales with non-screen detected breast cancer that was diagnosed within the past five years., Results: There was little difference between rural and urban groups in terms of symptom appraisal and monitoring, social interactions, and personal and environmental factors. However, the presence of stoicism as a barrier was unique to rural women. Rural women also faced significant barriers in accessing general practice services that pertained to availability, cost and distance., Discussion: GPs play a critical role in facilitating earlier presentation, and more research into rural stoicism is required. Continued investment in the rural primary care workforce will be key to improving access issues.

Primary care providers, including general practice teams (GPTs), are well positioned within the community to integrate cancer survivorship care into ongoing health management. However, roles of GPT members in delivery of cancer survivorship care have not been explored. The purpose of this study is to explore these roles from the perspectives of General Practitioners (GPs), Practice Nurses (PNs) and Practice Managers (PMs). An interpretive qualitative study using semi-structured in-depth telephone interviews with ten GPs, nine PNs and five PMs was conducted. Interviews were recorded, transcribed and analysed using grounded theory methods. Perspectives of roles in delivery of cancer survivorship care were highly variable. Variation was evident among perceptions of needs of cancer survivors, individual team members' scopes of practice, and individual professional knowledge and skills. A lack of clarity in roles and responsibilities of GPT members was thought to contribute to a lack of consistency in survivorship care. Reducing variations in perceptions of survivorship care in the primary care setting should be a priority. Such efforts may include development of practical guidance to support GPT members to clarify scopes of practice within the team. In addition to accessible comprehensive education programs, other innovative, tailored individualised education approaches may be helpful. System-level support in clarifying and supporting the roles of the primary care team is needed to facilitate a survivorship delivery system at general practice level where those within GPT can ensure that individual patients' needs are met in a timely and effective manner., (© 2021 John Wiley & Sons Ltd.)

Primary care settings are ideal for initiating advance care planning (ACP) conversations and assessing palliative and supportive care needs. However, time constraints and a lack of confidence to sensitively and efficiently initiate such discussions are noted barriers. The Advance Project implemented a national multicomponent training package to support Australian general practice nurses (GPNs) to work with GPs to initiate ACP and palliative care conversations in their practice. This paper reports on semistructured interviews conducted with 20 GPNs to explore barriers and facilitators to implementing the Advance Project model. Participants identified a range of factors that affected implementation, including lack of time, limited support from colleagues, lack of knowledge about systems and funding processes in general practice and a need for better alignment of the Advance Project resources and practices with general practice information management platforms. Barriers related to professional roles, particularly the lack of clarity and/or limitations in the scope of practice of GPNs, highlighted the importance of defining and supporting the roles that different primary health practice staff could play to support implementation of the model. The findings underline the need for complementary training in the Advance Project model for GPs and practice managers to enable a team-based approach to implementation.

Background and Objectives: In April 2020, a group of general practice leaders in NSW, Australia, established a COVID-19 virtual community of practice (VCoP) to facilitate rapid transfer and implementation of clinical guidance into practice. This research aimed to gain an understanding of the experience and effectiveness of the VCoP from leaders and members., Method: The study used a qualitative participatory action research methodology. A framework analysis was applied to focus group discussion, semi-structured interview and open-text written response data., Results: Thirty-six participants contributed data. In addition to a positive evaluation of the effectiveness of information transfer and support, a key finding was the importance of the role of the VCoP in professional advocacy. Areas for improvement included defining measures of success., Discussion: This study has reinforced the potential for VCoPs to aid health crisis responses. In future crisis applications, we recommend purposefully structuring advocacy and success measures at VCoP establishment.

Objectives: Initiation of advance care planning (ACP) and palliative care (PC) assessments in general practice is key to quality end-of-life care. The Advance Project promotes a team-based approach to initiating ACP and PC needs assessment in general practices through training, resources and practical support for implementation from local primary health networks (PHNs). This paper aims to understand: (1) general practice participants' experiences of undertaking Advance Project training and implementing the Advance Project resources in their practices; (2) barriers and facilitators to implementation of Advance Project resources; and (3) PHN staff experiences of supporting general practices through training and practical support for implementation of the Advance Project resources., Design: Qualitative study using semistructured interviews and thematic analysis., Setting: Twenty-one general practices and four PHNs from three Australian states were recruited between June 2019 and May 2020., Participants: General practitioners (GPs), general practice nurses, practice managers (PMs) and PHN staff., Results: 45 participants comprising 13 GPs, 13 general practice nurses, 9 PMs, 3 allied health staff and 7 PHN staff were interviewed. The general practice participants generally agreed that the Advance Project training/resources led to changes in their own behaviour and increased their awareness of the importance of ACP/PC discussion with their patients. Participants reported the following benefits for patients: increased awareness of ACP; engagement with families/carers and peace of mind. Key facilitators for successful implementation were a team-based approach, the role of the PHN, the role of practice champions, training facilitators' ability to influence peers and facilitate change, and mentoring support. Barriers to implementation included issues related to workplace culture, cost, time/workload, patients and health system., Conclusion: Findings suggest that the Advance Project approach facilitated successful implementation of ACP and PC needs assessment into usual care in general practices that encouraged teamwork among GPs and general practice nurses. The ability of the practice to make the best use of practical support and guidance available to them through their local PHN both before and during implementation was a key factor in integration of Advance Project resources into routine practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Financial toxicity (FT) describes financial distress or hardship as an outcome of cancer and its treatment. Minimising the impact of FT requires early assessment and intervention. General practice plays a significant role in the support of a person with cancer and may have an important role in the management of FT. The purpose of this study was to understand perspectives of general practitioners (GP) on addressing FT in the primary care setting, which may then help inform strategies to further support collaborative efforts to address FT., Methods: A qualitative interpretive approach was utilised for this study. GPs were recruited through a GP conference and other professional networks using purposive, snowballing sampling techniques. Data collection continued until sufficient rich data had been obtained. Interviews were recorded and transcribed verbatim. The data were analysed using inductive analysis techniques., Results: Twenty (n = 20) GPs participated in semi-structured in-depth telephone interviews. GPs identified that their role positions them well to provide some FT support, but there are limitations. Perceptions and philosophies about cancer management were drivers of referrals and financial conversations. Priorities for care of FT by GPs included improved cost information provision and accessible support., Conclusion: GPs can play an important role in helping to address FT associated with cancer and its treatments if supported with the right information., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives and importance of study: Interventions are needed to help general practitioners (GPs) better support clients living with age-related hearing loss. This project canvassed stakeholder views regarding how GPs might better support people with hearing loss., Study Type: A group concept-mapping approach was used to identify enablers to improving the way in which GPs could support people with age-related hearing loss., Methods: Concept-mapping techniques were used to gather the perspectives of GPs (n = 7), adults with hearing loss (n = 21), and professionals working with GPs (n = 4) in Australia. Participants generated statements in response to the question, "What would enable GPs to better support people with hearing loss?" Participants then grouped and ranked these statements via an online portal., Results: Five concepts were identified: 1) making hearing assessment part of routine care; 2) asking questions and raising concerns; 3) listening with empathy and respect; 4) having knowledge and understanding; 5) being connected to expert hearing professional networks. Statements contained within all five concepts were deemed to be highly beneficial in this context, with no individual concept identified to be more or less beneficial than any of the other four concepts., Conclusions: A wide range of hearing-specific and general communication approaches were identified that could potentially help GPs to better support their adult patients with age-related hearing loss., Competing Interests: None declared.

Objective: To examine general practitioners' views about how health assessments for older people should be conducted., Methods: General practitioners were randomly sampled from a national database of medical practitioners and invited to complete a survey. Survey items explored general practitioners' views about essential components of a 75+ Health Assessment and who should assess each component, consultation time, use of standardised templates and tools, and home visits., Results: Overall, 185 (19.2%) general practitioners participated. Of 61 items presented, 24 were rated 'essential' by ≥70% of practitioners, with an average estimated consultation time of 65 minutes. Of the 24 essential items, it was perceived that 21 could be assessed by either a general practitioner or clinic nurse. Most practitioners indicated a standardised template (86%) and standardised tools for complex issues (79%) should be used, and home visits conducted (75%)., Conclusions: General practitioners agreed on 24 items as essential for every health assessment, with assessments estimated to take more than one hour. Implications for public health: Increases to remuneration for prolonged assessments or mechanisms for improving efficiency and quality of assessments are needed. Acceptable mechanisms may include standardised patient-reported tools, standardised templates and the use of non-medical staff to assist with assessments., (© 2021 The Authors.)

Background: There is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system., Methods: The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention., Discussion: The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice., Trial Registration: ClinicalTrials.gov ACTRN12620000010998 . Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry., (© 2021. The Author(s).)

Annual vaccination is effective in reducing the harms associated with seasonal influenza. However, the uptake of influenza vaccine has historically been low in children. This paper reports a descriptive survey that sought to explore the beliefs, attitudes, and knowledge of general practitioners (GPs) and general practice nurses (GPNs) towards influenza vaccination in young children. Both GPs and GPNs working in the Illawarra Shoalhaven Local Health District (ISLHD) in NSW, Australia, were invited via email, fax and social media to participate in the study. A total of 121 participants completed the survey. Most participants had a high level of support and knowledge of influenza immunisation in young children. Barriers to influenza immunisation in young children included perceived hesitancy in parents and competing clinical demands. The participants strongly supported funding of the vaccine, with 90.9% feeling that parents would be less likely to vaccinate their children if the vaccine were no longer free. Both GPs and GPNs differed in the use of influenza vaccination resources. The participants had a positive attitude to influenza immunisation in young children and strongly supported continued funding of the vaccine. Dedicated young children's influenza vaccination clinics run by general practices or in the community could reduce the impact of competing clinical demands.

Background: Informal caregivers (family or friends of people with cancer) are a group of highly important people who support those diagnosed with cancer to remain at home and out of hospital, but this comes at a significant personal cost. Understanding strategies to support cancer caregivers is critical., Objective: This article will present an overview of cancer caregiving and how the caregivers involved can be assisted by general practitioners (GPs). Two key approaches to general practice teams supporting caregivers will be explored: acknowledging and integrating caregivers as part of the care team and providing referrals into services and supports., Discussion: The general practice team is ideally positioned to assist in the support of cancer caregivers. GPs can assist caregivers by acknowledging them as valid and important members of the care team and referring them into existing support programs. These strategies are central to supporting this important, but often forgotten, group of people affected by cancer.

Background: Advances in cancer treatment have not benefited all patients equally, underscoring the need for a personalised approach to care., Objective: The aim of this article is to outline the key elements of personalised cancer care, including delivery of goal-directed care, self-management and self-management support, care integration, focus on access and equity, reduction in cost and promotion of health literacy and e-health literacy., Discussion: Achievement of personalised cancer care requires a system-wide approach that targets the patient, healthcare provider and healthcare system with data informing practice. Primary care providers, including general practitioners (GPs) and practice nurses, play an important and growing part in the provision of personalised cancer care through support, advocacy, coordination, holistic care and health promotion. Cancer care systems can facilitate GPs' involvement in care through early input into multidisciplinary management, timely communication, rapid access to acute care and training opportunities.

The important first step in the critical appraisal of a randomised trial is not an evaluation of the statistical analyses. The most important aspect to consider when reviewing a study of a new drug is the appropriateness and quality of the trial design and methods The next most important aspect is the effect size of different treatments and its clinical significance. Rather than reporting statistical significance, studies should report the difference between treatments and its precision Over-reliance on statistical significance and p values may lead to incorrect conclusions. Trial reports about drugs should therefore avoid the term statistical significance and quote p values with caution., Competing Interests: Conflicts of interest: none declared, ((c) NPS MedicineWise.)

Background: Survival rates for lymphoma are highest amongst hematological malignancies. In 2019, it was estimated that over 6400 Australians were diagnosed with lymphoma, a group of hematological malignancies with a high 5-year survival rate of ~ 76%. There is an increased focus on the promotion of wellness in survivorship and active approaches to reducing morbidity related to treatment; however, current models of follow-up care heavily rely on hospital-based specialist-led care. Maximizing the potential of general practitioners (GPs) in the ongoing management of cancer is consistent with the national health reform principles and the Cancer Council Australia's Optimal Care Pathways. GPs are well positioned to provide guideline-based follow-up care and are more likely to address comorbidities and psychosocial issues and promote healthy lifestyle behaviors. This study aims to test the feasibility of the GOSPEL I intervention for implementing an integrated, shared care model in which cancer center specialists and community-based GPs collaborate to provide survivorship care for patients with lymphoma., Methods: We describe a protocol for a phase II, randomized controlled trial with two parallel arms and a 1:1 allocation. Sixty patients with Hodgkin's and non-Hodgkin's lymphoma will be randomized to usual specialist-led follow-up care (as determined by the treating hematologists) or a shared follow-up care intervention (i.e., GOSPEL I). GOSPEL I is a nurse-enabled, pre-specified shared care pathway with follow-up responsibilities shared between cancer center specialists (i.e., hematologists and specialist cancer nurses) and GPs. Outcome measures assess feasibility as well as a range of patient-reported outcomes including health-related quality of life as measured by the Functional Assessment of Cancer Therapy-Lymphoma, patient experience of care, symptom distress, comorbidity burden, dietary intake, physical activity behaviors, financial distress/interference, and satisfaction of care. Safety indicators including hospital admission and unscheduled lymphoma clinic visits as well as process outcomes such as intervention fidelity and economic indicators will be analyzed., Discussion: This trial is designed to explore the feasibility and acceptability of a new model of shared care for lymphoma survivors. Patient-reported outcomes as well as potential barriers to implementation will be analyzed to inform a larger definitive clinical trial testing the effects and implementation of a shared care model on health-related quality of life of lymphoma survivors., Trial Registration: Australia and New Zealand Clinical Trials Registry ACTRN12620000594921 . Registered on 22 May 2020.

Background: Despite the advances in End-of-life (EOL) cancer care, disparities remain in the accessibility and utilisation of EOL cancer care resources. Often explained by socio-demographic factors, geographic variation exists in the availability and provision of EOL cancer care services among EOL cancer decedents across urban versus rural settings. This systematic review aims to synthesise mortality follow-back studies on the patterns of EOL cancer care resource use for adults (>18 years) during end-of-life cancer care., Methods: Five databases were searched and data analysed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria involved; a) original research; b) quantitative studies; c) English language; d) palliative care related service use in adults (>18 years) with any malignancy excluding non-melanoma skin cancers; e) exclusive end of life focus; f) urban-rural focus. Narrative reviews and discussions were excluded., Results: 24 studies met the inclusion criteria. End-of-life cancer care service utilisation patterns varied by rurality and treatment intent. Rurality was strongly associated with higher rates of Emergency Department (ED) visits and hospitalisations and lower rates of hospice care. The largest inequities between urban and rural health service utilisation patterns were explained by individual level factors including age, gender, proximity to service and survival time from cancer diagnosis., Conclusions: Rurality is an important predictor for poorer outcomes in end-of-life cancer care. Findings suggest that addressing the disparities in the urban-rural continuum is critical for efficient and equitable palliative cancer care. Further research is needed to understand barriers to service access and usage to achieve optimal EOL care for all cancer patient populations.

The ongoing COVID-19 pandemic is having a significant impact on people with palliative care needs.

General practice is arguably the ideal setting to initiate advance care planning (ACP), but there are many barriers. This pilot study was designed to assess the feasibility, acceptability and perceived utility of a nurse-facilitated screening interview to initiate ACP with older patients in general practice. Patients were recruited from four general practices in Sydney, Australia. General practice nurses administered the ACP screening interview during routine health assessments. Patients and nurses completed a follow-up questionnaire consisting of questions with Likert responses, as well as open-ended questions. Descriptive statistics and content analysis were used to analyse the data. Twenty-four patients participated; 17 completed the follow-up questionnaire. All patients found the ACP screening interview useful and most felt it would encourage them to discuss their wishes further with their family and general practitioner. Several patients were prompted to consider legally appointing their preferred substitute decision-maker. All six participating nurses found the screening interview tool useful for initiating discussions about ACP and substitute decision-making. This nurse facilitated screening tool provides a simple, acceptable and feasible approach to introducing ACP to older general practice patients during routine health assessments.

Background: Key Information Summaries (KIS) were introduced throughout Scotland in 2013 so that anticipatory care plans written by general practitioners (GPs) could be routinely shared electronically and updated in real time, between GPs and providers of unscheduled and secondary care., Aims: We aimed to describe the current reach of anticipatory and palliative care, and to explore GPs' views on using KIS., Methods: We studied the primary care records of all patients who died in 2014 in 9 diverse Lothian practices. We identified if anticipatory or palliative care had been started, and if so how many weeks before death and which aspects of care had been documented. We interviewed 10 GPs to understand barriers and facilitating factors., Results: Overall, 60% of patients were identified for a KIS, a median of 18 weeks before death. The numbers identified were highest for patients with cancer, with 75% identified compared with 66% of those dying with dementia/frailty and only 41% dying from organ failure. Patients were more likely to die outside hospital if they had a KIS. GPs identified professional, patient and societal challenges in identifying patients for palliative care, especially those with non-cancer diagnoses., Conclusions: GPs are identifying patients for anticipatory and palliative care more equitably across the different disease trajectories and earlier in the disease process than they were previously identifying patients specifically for palliative care. However, many patients still lack care planning, particularly those dying with organ failure., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: This study examined advance care planning as delivered by general practice registrars and recently fellowed GPs in New South Wales rural settings. The facilitators and barriers to advance care planning uptake in these areas were investigated, as well as the state of general practice training on advance care planning., Design: Qualitative descriptive methodology, involving semi-structured face-to-face and telephone interviews., Setting: Primary care., Participants: General practice registrars and recently fellowed GPs in New South Wales rural settings. Definition of rural using the Australian Standard Geographical Classification - Remoteness Area. Thirteen participants were included in the study., Main Outcome Measures: Thematic analysis of interview transcripts elucidated key issues emerging from participants' accounts., Results: Key barriers included doctor-dependent uptake, demands on doctor's time and the limited relevant resources available. Facilitators recognised were patient control in end-of-life care and long-standing relationships between GPs and their patients. Uptake among patients was low, and minimal training on advance care planning reported., Conclusion: The lack of training opportunities in advance care planning during vocational training, especially when combined with the essential role played by rural GPs in initiating advance care planning and providing end-of-life care, appears to be a major problem that might contribute to poor uptake among patients in rural areas. This study demonstrated, however, the significant benefits that advance care planning could bring in patients living in rural communities if delivered effectively. Given that rural GPs face a number of barriers to providing routine health care, these results highlight an important need to provide GPs and rural communities with support, education, incentive, better administrative tools, options and greater awareness of advance care planning., (© 2019 National Rural Health Alliance Ltd.)

Objectives: How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?, Design: A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting., Setting: Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews., Results: The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging., Conclusion: Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice., Prospero Registration Number: CRD42018088838., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Advance care planning (ACP) can offer benefits to patients and their families, especially when delivered in outpatient settings, but uptake remains low. Common barriers for health professionals include a perceived lack of time and adequate training, experience, and confidence in conducting ACP. Patient-reported barriers include a lack of awareness of ACP or discomfort initiating or engaging in discussions about end-of-life., Methods: We aimed to explore patients' perspectives of an ACP intervention designed to address common barriers to uptake in the general practice setting. We provided training and support to doctors and general practice nurses (GPNs) to initiate and lead ACP discussions at their respective practices (2014 to 2015). Following the intervention, we conducted interviews with patients to explore their experience of engaging in ACP in the general practice setting. Thematic analysis was used to inductively code transcripts and identify key themes from semi-structured interviews with patients., Results: Six major themes relating to patient experiences of GPN-facilitated ACP were identified: working through ideas, therapeutic relationship with nurses, significance of making wishes known, protecting family from burden, autonomy in decision-making, and challenges of family communication. The patients valued the opportunity to speak about issues that are important to them with the GPN who they found to be compassionate and caring. The patients felt that ACP would lead to significant benefits not only to themselves but also for their family. Despite encouragement to involve other family members, most patients attended the ACP discussions alone or as a couple; many did not see the relevance of their family being involved in the discussions. Some patients felt uncomfortable or reluctant in communicating the results of their discussion with their family., Conclusions: With adequate training and support, GPNs are able to initiate and facilitate ACP conversations with patients. Their involvement in ACP can have significant benefits for patients. Psychosocial and relational elements of care are critical to patient satisfaction. Our findings show that some patients may feel uncomfortable or reluctant to communicate the results of their ACP discussions with their family. A future larger study is required to verify the findings of this pilot study.

Published evidence for the role of participatory art in supporting health and well-being is growing. The Arts on Prescription model is one vehicle by which participatory art can be delivered. Much of the focus of Arts on Prescription has been on the provision of creative activities for people with mental health needs. This Arts on Prescription program, however, targeted community-dwelling older people with a wide range of health and wellness needs. Older people were referred to the program by their healthcare practitioner. Professional artists led courses in visual arts, photography, dance and movement, drama, singing, or music. Classes were held weekly for 8-10 weeks, with six to eight participants per class, and culminated with a showing of work or a performance. Program evaluation involved pre- and postcourse questionnaires, and focus groups and individual interviews. Evaluation data on 127 participants aged 65 years and older were available for analysis. We found that Arts on Prescription had a positive impact on participants. Quantitative findings revealed a statistically significant improvement in the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) as well as a statistically significant increase in the level of self-reported creativity and frequency of creative activities. Qualitative findings indicated that the program provided challenging artistic activities which created a sense of purpose and direction, enabled personal growth and achievement, and empowered participants, in a setting which fostered the development of meaningful relationships with others. This evaluation adds to the evidence base in support of Arts on Prescription by expanding the application of the model to older people with a diverse range of health and wellness needs., (© 2018 The Authors. Health and Social Care in the Community Published by John Wiley & Sons Ltd.)

Introduction: It is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a randomised controlled trial (RCT) to examine if ACP undertaken with patients with advanced illnesses attending hospital outpatient clinics can reduce unplanned hospital admissions and improve patient and caregiver well-being., Methods and Analysis: Pragmatic RCT involving patients from subspecialty outpatient clinics at five clinical sites in Sydney, Australia. Participants will be ≥18 years screened as potentially having palliative care needs and at risk of dying in 6-12 months. The patients will be randomised to intervention or control group. Intervention group will undertake ACP discussions facilitated by a trained health professional. The control group will receive written information on ACP, representing the current standard of care. The primary outcome is the number of unplanned hospital admissions at the 6-month follow-up. Secondary outcomes include: (i) patient's health-related quality-of-life and quality of chronic disease care; (ii) caregiver's health-related quality-of-life and caregiver burden and (iii) other health outcomes including ambulance usage, emergency department presentations, hospital admissions, resuscitation attempts, intensive care unit admissions, deaths, documentation of patient wishes in patient records and audit of ACP discussions and documents. The staff's self-reported attitudes and knowledge of ACP will also be measured. The data will be collected using self-report questionnaires, hospital records audit, audit of ACP documentation and data linkage analysis. Semistructured interviews and focus group discussions with patients, caregivers and healthcare professionals will explore the acceptability and feasibility of the intervention., Ethics and Dissemination: Approved by South-East Sydney Local Health District Human Research Ethics Committee and NSW Population and Health Services Research Ethics Committee. Results will be disseminated via conference presentations, journal publications, seminars and invited talks., Trial Registration Number: ACTRN12617000280303., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Advance care planning (ACP) is an important component of quality care for patients with chronic and advanced diseases. General practititoners are ideally placed to initiate ACP because of their role in care coordination of chronic and advanced diseases, and the longstanding relationship they develop with patients., Objectives: This paper outlines the key barriers to general practice involvement in ACP and describes useful strategies for incorporating ACP into patient care., Discussion: Barriers to ACP are many and involve health professionals, patients and the healthcare system. To successfully incorporate ACP into patient care, there should be: (i) a commitment from the whole practice to incorporate ACP into patient care; (ii) a focus on building capacity for ACP in the practice; and (iii) efforts to implement and optimise the process of ACP. The outcomes of ACP (eg Advance Care Directives) should be disseminated appropriately to enable them to improve patient care.

Background and Objectives: Researchers and clinicians have been criticised for frequently misinterpreting and misusing P values. This study sought to understand how general practitioners (GPs) in Australia and New Zealand conceptualise P values presented in the manner typically encountered in a medical publication., Methods: This mixed-methods study used quantitative and qualitative questions embedded in an online questionnaire and delivered through an Australian and New Zealand GP-specific Facebook group in 2017. It included questions that elaborated on the participant’s conceptualisation of ‘P = 0.05’ within a scenario and tested their P value interpretation ability and confidence., Results: There were 247 participants who completed the questionnaire. Participant conceptualisations of P values were described using six thematic categories. The most common (and erroneous) conceptualisation was that P values numerically indicated a ‘real-world probability’. No demographic factor, including research experience, seemed associated with better interpretation ability. A confidence–ability gap was detected., Discussion: P value misunderstanding is pervasive and might be influenced by a few central misconceptions. Statistics education for clinicians should explicitly address the most common misconceptions.

Background: Standard setting is one of the most contentious topics in educational measurement. Commonly-used methods all have well reported limitations. To date, there is not conclusive evidence suggesting which standard setting method yields the highest validity., Methods: The method described and piloted in this study asked expert judges to estimate the scores on a real MCQ examination that they consider indicated a clear pass, clear fail, and pass mark for the examination as a whole. The mean and SD of the judges responses to these estimates, Z scores and confidence intervals were used to derive the cut-score and the confidence in it., Results: In this example the new method's cut-score was higher than the judges' estimate. The method also yielded estimates of statistical error which determine the range of the acceptable cut-score and the estimated level of confidence one may have in the accuracy of that cut-score., Conclusions: This new standard-setting method offers some advances, and possibly advantages, in that the decisions being asked of judges are based on firmer constructs, and it takes into account variation among judges.

Background: Most assessments in health professions education consist of knowledge-based examinations as well as practical and clinical examinations. Among the most challenging aspects of clinical assessments is decision making related to borderline grades assigned by examiners. Borderline grades are commonly used by examiners when they do not have sufficient information to make clear pass/fail decisions. The interpretation of these borderline grades is rarely discussed in the literature. This study reports the application of the Objective Borderline Method (version 2, henceforth: OBM2) to a high stakes Objective Structured Clinical Examination undertaken at the end of the final year of a Medicine program in Australia., Methods: The OBM2 uses all examination data to reclassify borderline grades as either pass or fail. Factor analysis was used to estimate the suitability of data for application of OBM2. Student's t-tests, utilising bootstrapping, were used to compare the OBM2 with 'traditional' results. Interclass correlations were used to estimate the association between the grade reclassification and all other grades in this examination., Results: The correlations between scores for each station and pass/fail outcomes increased significantly after the mark reclassification, yet the reclassification did not significantly impact on students' total scores. Examiners, students and program leaders expressed high levels of satisfaction and the Faculty's Curriculum Development Committee has decided that the OBM2 will be used for all future clinical examinations. Implications of the OBM2 are discussed., Conclusions: The OBM2 provides a feasible, defensible and acceptable solution for classification of borderline grades as either pass or fail.