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Background: In Australia, tobacco smoking rates have declined but inequalities remain with significantly higher smoking prevalence among low-socioeconomic populations. Clinical trial data suggest vaporized nicotine products (VNPs) aid smoking cessation. Most VNP trials have used refillable tank systems, but newer generation (pod) devices now comprise the largest market share yet have limited clinical trial evidence on safety and effectiveness. This study evaluates the effectiveness, safety and cost-effectiveness of VNPs (pod and tank device) compared with nicotine replacement therapy ([NRT]-gum or lozenge) for smoking cessation.Methods: This is a two-arm, open-label, superiority, parallel group, randomized controlled trial (RCT) with allocation concealment and blinded outcome assessment. The RCT is conducted at the National Drug and Alcohol Research Centre at the University of New South Wales, Sydney, Australia. Participants are people who smoke daily, are interested in quitting and receive a government pension or allowance (N = 1058). Participants will be randomized (1:1 ratio) to receive 8 weeks of free: VNPs, with pod (40 mg/mL nicotine salt) and tank device (18 mg/mL freebase nicotine) in mixed flavours; or NRT (gum or lozenge; 4 mg). All participants will receive daily text message behavioural support for 5 weeks. Assessments will be undertaken by telephone at baseline, with three follow-up calls (two check-in calls within the first month and final follow-up at 7 months post randomization) to ascertain smoking status, treatment adherence and adverse events. The primary outcome is 6-month continuous abstinence verified by carbon monoxide breath test of ≤5ppm at 7-month follow-up. Safety and cost-effectiveness of VNPs versus NRT will also be evaluated.Discussion: Further data are required to strengthen certainty of evidence for VNPs aiding smoking cessation, particularly for newer generation pod devices. To our knowledge, this trial is the first to offer choice of VNPs and no comparative effectiveness trial data exists for new pod devices. If effective, the findings can inform wider implementation of VNPs to aid smoking cessation in a priority group.Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12621000076875. Registered on 29 January 2021.  https://www.anzctr.org.au. [ABSTRACT FROM AUTHOR]

To evaluate the impact of general practice nurse‐led interventions for blood pressure control and cardiovascular disease risk factor reduction in patients with hypertension. Systematic review and meta‐analysis of randomized control trials. CINAHL, Medline and Scopus databases were searched to identify peer‐reviewed studies published between 2000 and 2021. A systematic review of randomized control trials was conducted using a structured search strategy. The Meta‐Analysis of Statistics Assessment and Review Instrument (JBI‐MAStARI) was used to appraise study quality. Meta‐analysis and narrative synthesis were performed to determine the effectiveness of the included interventions. Eleven trials comprising of 4454 participants were included in the review. Meta‐analysis showed significant reductions in both systolic and diastolic blood pressure in trials with 6 months or less follow‐up. Improvements were also demonstrated in reducing blood lipids, physical activity, general lifestyle measures and medication adherence. Evidence for dietary improvements and reduction in alcohol and smoking rates was inconclusive. Nurse‐led interventions for patients with hypertension are heterogeneous in terms of the nature of the intervention and outcomes measured. However, nurse‐led interventions in general practice demonstrate significant potential to improve blood pressure and support cardiovascular disease risk factor reduction. Future research should be directed towards elucidating the successful elements of these interventions, evaluating cost‐effectiveness and exploring translation into usual care. This review provides evidence that nurses in general practice could enhance current hypertension management through nurse‐led interventions. [ABSTRACT FROM AUTHOR]

Background and objective: Use of in-laboratory polysomnography (PSG) to diagnose obstructive sleep apnoea (OSA) is cost and resource intensive. Questionnaires, physical measurements and home monitors have been studied as potential simpler alternatives. This study aimed to develop a diagnostic model for OSA for use in primary care. Methods: Primary care practitioners were trained to recognize symptoms of sleep apnoea and recruited patients based on the clinical need to investigate OSA. Assessment was by symptom questionnaires, anthropomorphic measurements, digital facial photography, and a single-channel nasal flow monitor (Flow Wizard ©, DiagnoseIT, Sydney, Australia) worn at home for 3 nights. The in-laboratory PSG was the reference test, with OSA defined as apnoea-hypopnoea index (AHI) =10 events/h. Results: In the model development phase, 25 primary care practitioners studied 315 patients in whom they suspected OSA, of which 57% had AHI=10 and 22% had AHI=30. Published OSA questionnaires provided low to moderate prediction of OSA (area under the curve [AUC] 0.53-0.73). The nasal flow monitor alone yielded high accuracy for predicting OSA with AUC of 0.87. Sensitivity was 0.87 and specificity 0.77 at a threshold respiratory event index (REI) of 18 events/h. A model adding age, gender, symptoms and BMI to the nasal flow monitor REI only modestly improved OSA prediction (AUC 0.89), with similar AUC (0.88) confirmed in the validation population of 114 patients. Conclusion: Sleep apnoea can be diagnosed in the primary care setting with a combination of clinical judgement and portable monitor test outcomes. [ABSTRACT FROM AUTHOR]

Chronic diseases require a multidisciplinary approach to provide patients with optimal care in general practice. This often involves general practitioners (GPs) referring their patients to allied health professionals (AHPs). The Team-link study explored the impact of an intervention to enhance working relationships between GPs and AHPs in general practice regarding the management of two chronic diseases: diabetes and is chaemic heart disease (IHD) or hypertension. The Measure of Multidisciplinary Linkages (MoML) questionnaire was developed to assess professional interactions and satisfaction with various aspects of the multidisciplinary relationship. Questionnaires were completed at baseline and 6 months by GPs (n = 29) participating in the Team-link project and by AHPs (n = 39) who had a current working relationship with these GPs. The Chronic CareTeamProfile (CCTP) and Clinical Linkages Questionnaire (CLQ) were also completed by GPs. There were significant changes from baseline to 6 months after the intervention measures for individual items and overall MoML scores for GPs, especially items assessing 'contact', 'shared care' and 'satisfaction with communication'. The comparable item in the CLQ, 'Shared Care', also showed significant improvement. However, there were no statistically significant correlations between the change in overall 'Referral Satisfaction' scores in the GPMoMLand the CLQ. TheCCTPalso improved and was a weak negative correlation between the GP MoML and two of the subscores of this instrument. There were no changes in AHP measure. This study demonstrates that the instrument is sensitive to differences between providers and conditions and is sensitive to change over time following an intervention. There were few associations with the other measures suggesting that the MoML might assess other aspects of teamwork involving practitioners who are not collocated or in the same organisation. [ABSTRACT FROM AUTHOR]

The article reports on satisfaction with referral relationships between general practice and allied health professionals in primary health care in Australia. It report the development and use of the Measure of Multidisciplinary Linkages (MoML) questionnaire, to evaluate the relationships between GPs and AHPs participating in the Team-link project, an intervention study that aimed to facilitate multidisciplinary teamwork between general practitioners (GPs) and AHPs outside the practice.

Identification of mental health risk is important for optimising diabetes care in type 2 diabetes mellitus (T2DM). Personality is linked to diabetes health and may assist detection of individuals with T2DM most at risk of chronic mental health difficulties. This study examined the moderator effect of personality factors on changes in psychological distress and functioning in adults with T2DM and mild-to-moderate depressive symptoms across a 12-month period. Data were obtained from participants in a randomised controlled trial of adults with T2DM. Participants completed measures of depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), general functioning (Work and Social Adjustment Scale), diabetes distress (Diabetes Distress Scale), and diabetes self-management (Self-Management Profile for Type 2 Diabetes) at baseline, 3-, 6- and 12-months. Glycaemic control (HbA1c) was measured at baseline, 6- and 12-months. Two hundred trial completers agreed to complete a personality inventory (Big Five Inventory). Low neuroticism was linked with reduced depression, anxiety, functional impairment and diabetes distress over the year. High extraversion was associated with decreased anxiety and functional impairment. High conscientiousness was linked to increased healthy eating. No personality trait moderated HbA1c levels. Personality screening may help identify mental health risk and guide medical carer approach in T2DM patients. [ABSTRACT FROM AUTHOR]

Hypertension is a preventable risk factor for cardiovascular disease, the leading cause of death globally. When hypertension is present with tobacco smoking, poor nutrition, physical inactivity or excessive alcohol consumption, risk of cardiovascular disease is increased. Given the prolonged engagement and ongoing relationship with patients, general practice nurses are ideally situated to actively engage with patients about optimal blood pressure control and lifestyle risk reduction. This study will test the effectiveness of a nurse-led intervention to reduce blood pressure in adults with hypertension and high cardiovascular risk. A multi-site, cluster randomised control trial where the general practice is the unit of randomisation. General Practices (n = 20) will be block randomised to the intervention or usual care group. Adults with hypertension and high cardiovascular risk will be identified through an audit of electronic medical records and invited to attend an assessment visit. Eligible consenting patients will be recruited to the study. The intervention involves three face-to-face consultations and two telephone consultations with the nurse to assess lifestyle risk and develop an action plan. An appointment with the general practitioner will optimise pharmacotherapy. The primary outcome is blood pressure, with secondary outcomes of lifestyle risk factors; smoking, nutrition, alcohol and physical activity body mass index and medication adherence. Patients will have outcome measures evaluated at 6 and 12 months. ImPress is innovative in its proactive approach of identifying those at greatest risk of cardiovascular disease in combination with the emerging role of the general practice nurse to target care towards improved blood pressure control. If successful, findings from this trial could enhance the nursing role, improve health outcomes, inform health policy and provide an evidence base from which to transform blood pressure management in general practice. This trial has been registered with the Australian and New Zealand Clinical Trials Registry as ACTRN12618000169246. [ABSTRACT FROM AUTHOR]

Objective: Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS–long-acting β2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Methods: Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. Results: GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS–LABA combinations over ICS alone because they perceived that ICS–LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. Conclusion: The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. What is known about the topic?: Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS–LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. What does this paper add?: This qualitative study found that GPs favoured combination ICS–LABA inhalers over ICS alone because they perceived ICS–LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners?: This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated. [ABSTRACT FROM AUTHOR]

The aim of this study is to investigate the utilisation of Medicare Benefit Scheme items for chronic disease in the management of cardiovascular disease (CVD) in general practice and to compare characteristics of CVD patients with and without a General Practice Management Plan (GPMP). Subgroup analysis of Treatment of Cardiovascular Risk using Electronic Decision Support (TORPEDO) baseline data was collected in a cohort comprising 6123 patients with CVD. The mean age (s.d.) was 71 (±13) years, 55% were male, 64% had a recorded diagnosis of coronary heart disease, 31% also had a diagnosis of diabetes and the mean number of general practice (GP) visits (s.d.) was 11 (±9) in 12 months. A total of 1955/6123 (32%) received a GPMP in the 12 months before data extraction; 1% received a Mental Health Plan. Factors associated with greater likelihood of receiving a GPMP were: younger age, had a diagnosis of diabetes, BMI > 30kgm-2, prescription of blood pressure-lowering therapy and more than ten general practice visits. Enhancing utilisation of existing schemes could augment systematic follow up and support of patients with CVD. [ABSTRACT FROM AUTHOR]

Significant gaps remain between recommendations of evidence-based guidelines and primary health care practice in Australia. This paper aims to evaluate factors associated with the use of guidelines reported by Australian GPs. Secondary analysis was performed on a survey of primary care practitioners which was conducted by the Commonwealth Fund in 2009: 1016 general practitioners responded in Australia (response rate 52%). Two-thirds of Australian GPs reported that they routinely used evidence-based treatment guidelines for the management of four conditions: diabetes, depression, asthma or chronic obstructive pulmonary disease and hypertension -- a higher proportion than in most other countries. Having non-medical staff educating patients about self-management, and a system of GP reminders to provide patients with test results or guideline-based intervention or screening tests, were associated with a higher probability of guidelines use. Older GP age was associated with lower probability of guideline usage. The negative association with age of the doctor may reflect a tendency to rely on experience rather than evidence-based guidelines. The association with greater use of reminders and self-management is consistent with the chronic illness model. [ABSTRACT FROM AUTHOR]

Background: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession. Methods: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews. Discussion: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations. [ABSTRACT FROM AUTHOR]

Objective: Multidisciplinary care has been shown as the most effective option for chronic disease. The aim of the Team-link study was to assess the effectiveness of an intervention to improve teamwork among general practitioners (GPs), practice staff and allied health professionals (AHPs). This paper describes changes to teamwork using qualitative data collected in the study.Design: Qualitative data about changes in internal and external professional collaboration were collected from facilitators' observations, GPs' reports and responses to a survey of AHPs assessing multidisciplinary teamwork.Setting: Multidisciplinary teams within general practices and external collaborations with AHPs including dietitians, diabetic educators, exercise physiologists, podiatrists, psychologists and physiotherapists.Participants: GPs, practice nurses, practice staff, AHPs.Intervention: A 6-month intervention consisting of an educational workshop and structured facilitation using specially designed materials, backed up by informal telephone support, was delivered to 26 practices.Main Outcome Measure: Data were analysed thematically using an approach based on identifying actors and associated collaborative actions.Results: New and enhanced communication pathways were observed between GPs, practice staff, patients and AHPs following the intervention. The enhanced information sharing expedited communication and improved interprofessional collaboration within general practices and with AHPs. There was evidence of increased patient participation and empowerment in the care process and improved collaboration by practice staff and allied health providers.Conclusion: The Team-link intervention improved professional collaboration among GPs, practice staff, AHPs and patients, increasing understanding and trust and enhancing multidisciplinary teamwork for chronic disease care in primary care settings. [ABSTRACT FROM AUTHOR]

Objective Multidisciplinary care has been shown as the most effective option for chronic disease. The aim of the Team-link study was to assess the effectiveness of an intervention to improve teamwork among general practitioners (GPs), practice staff and allied health professionals (AHPs). This paper describes changes to teamwork using qualitative data collected in the study. Design Qualitative data about changes in internal and external professional collaboration were collected from facilitators’ observations, GPs’ reports and responses to a survey of AHPs assessing multidisciplinary teamwork. Setting Multidisciplinary teams within general practices and external collaborations with AHPs including dietitians, diabetic educators, exercise physiologists, podiatrists, psychologists and physiotherapists. Participants GPs, practice nurses, practice staff, AHPs. Intervention A 6-month intervention consisting of an educational workshop and structured facilitation using specially designed materials, backed up by informal telephone support, was delivered to 26 practices. Main Outcome Measure Data were analysed thematically using an approach based on identifying actors and associated collaborative actions. Results New and enhanced communication pathways were observed between GPs, practice staff, patients and AHPs following the intervention. The enhanced information sharing expedited communication and improved interprofessional collaboration within general practices and with AHPs. There was evidence of increased patient participation and empowerment in the care process and improved collaboration by practice staff and allied health providers. Conclusion The Team-link intervention improved professional collaboration among GPs, practice staff, AHPs and patients, increasing understanding and trust and enhancing multidisciplinary teamwork for chronic disease care in primary care settings. [ABSTRACT FROM AUTHOR]

Background: This paper describes the development and implementation of an intervention to facilitate teamwork between general practice and outside allied and community health services and providers. Methods: A review of organizational theory and a qualitative study of 9 practices was used to design an intervention which was applied in four Divisions of General Practice and 26 urban practices. Clinical record review and qualitative interviews with participants were used to determine the key lessons from its implementation. Results: Facilitating teamwork across organizational boundaries was very challenging. The quality of the relationship between professionals was of key importance. This was enabled by joint education and direct communication between providers. Practice nurses were key links between general practices and allied and community health services. Conclusions: Current arrangements for Team Care planning provide increased opportunities for access to allied health. However the current paper based system is insufficient to build relationships or effectively share roles as part of a patient care team. Facilitation is feasible but constrained by barriers to communication and trust. [ABSTRACT FROM AUTHOR]

In the original publication of this article [1], the first name of the 3rd author is wrong. [ABSTRACT FROM AUTHOR]

Background: There is international interest in whether improved primary care, in particular for patients with chronic or complex conditions, can lead to decreased use of health resources and whether financial incentives help achieve this goal. This trial (EQuIP-GP) will investigate whether a funding model based upon targeted, continuous quality incentive payments for Australian general practices increases relational continuity of care, and lessens health-service utilisation, for high-risk patients and children.Methods: We will use a mixed methods approach incorporating a two-arm pragmatic cluster randomised control trial with nested qualitative case studies. We aim to recruit 36 general practices from Practice-Based Research Networks (PBRN) covering urban and regional areas of Australia, randomised into intervention and control groups. Control practices will provide usual care while intervention practices will be supported to implement a new service model incorporating incentives for relational continuity and timely access to appointments. Patients will comprise three groups: older (over 65 years); 18-65 years with chronic and/or complex conditions; and those aged less than 16 years with increased risk of hospitalisation. The funding model includes financial incentives to general practitioners (GPs) for providing longer consultations, same day access and timely follow-up after hospitalisation to enrolled patients. The payments are proportional to expected health system savings associated with improved quality of GP care. An outreach facilitator will work with practices to help incorporate the incentive model into usual work. The main outcome measure is relational continuity of care (Primary Care Assessment Tool short-form survey), with secondary outcomes including health-related quality of life and health service use (hospitalisations, emergency presentations, GP and specialist services in the community, medicine prescriptions and targeted pathology and imaging ordering). Outcomes will be initially evaluated over a period of 12 months, with ongoing data collection for 5 years.Discussion: The trial will provide robust evidence on a novel approach to providing continuous incentives for improving quality of general practice care, which can be compared to block payment incentives awarded at target quality levels of pay-for-performance, both within Australia and also internationally.Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000105246. Registered on 23 January 2018. [ABSTRACT FROM AUTHOR]

Background: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession.Methods: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews.Discussion: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations. [ABSTRACT FROM AUTHOR]

Background: This paper describes the development and implementation of an intervention to facilitate teamwork between general practice and outside allied and community health services and providers.Methods: A review of organizational theory and a qualitative study of 9 practices was used to design an intervention which was applied in four Divisions of General Practice and 26 urban practices. Clinical record review and qualitative interviews with participants were used to determine the key lessons from its implementation.Results: Facilitating teamwork across organizational boundaries was very challenging. The quality of the relationship between professionals was of key importance. This was enabled by joint education and direct communication between providers. Practice nurses were key links between general practices and allied and community health services.Conclusions: Current arrangements for Team Care planning provide increased opportunities for access to allied health. However the current paper based system is insufficient to build relationships or effectively share roles as part of a patient care team. Facilitation is feasible but constrained by barriers to communication and trust. [ABSTRACT FROM AUTHOR]