General practitioner consultations at residential aged‐care facilities

To examine changes between 1991 and 2003 in the characteristics of active recognised general practitioners in Australia. We compared self-reported GP characteristics from the 1990-91 Australian Morbidity and Treatment Survey (AMTS) with those from the 1999 and 2003 Bettering the Evaluation and Care of Health (BEACH) surveys, after standardisation for age and sex to the respective sample frames. AMTS and BEACH are cross-sectional, paper-based, national surveys. Three random samples of 473 (1990-91), 980 (1998-99) and 1008 (2002-03) GPs who had claimed at least 1500 A1 (ie, general practice) Medicare items in the preceding year (in the AMTS) or 375 general practice Medicare items in the preceding 3 months (in the BEACH surveys). Changes in distribution of GP sex, GP age, number of sessions per week, practice size and location, country of graduation, and postgraduate training. Between 1991 and 2003, the proportion of female GPs rose from 19.3% to 35.2%; GPs aged < 35 years dropped from 22.3% to 10.0%, and those aged >or= 55 years increased from 21.4% to 31.6%. Between 1999 and 2003, the proportion of male GPs working < 6 sessions/week increased from 6.1% to 11.4%, while the proportion working >or= 11 sessions/week fell from 23.8% to 17.1%. Between 1991 and 2003, the proportion of solo practitioners nearly halved (25.5% v 13.7%); the proportion of GPs in practices of >or= 4 partners increased from 34.3% to 59.8%; the proportion of Australian graduates fell from 81.4% to 72.2%; and the proportion of graduates from Asia and Africa increased. Over the same period, the proportion of GPs with Fellowship of the Royal Australian College of General Practitioners more than doubled (17.8% v 36.4%). All of these differences were statistically significant (P < 0.001). Changes in characteristics of the practising GP population will affect consultative services and the balance between supply and demand for these services. These changes should be considered in future workforce planning.

Domestic violence: it is time for the medical profession to play its part.

General practitioner referrals to exercise physiologists during routine practice: A prospective study

To investigate decision-making around hospital transfer and/or referral of residents to a Residential InReach (RiR) service in north-eastern metropolitan Melbourne, Australia, from the perspectives of residential aged care facility (RACF) staff, general practitioners (GPs) and RiR registered nurses (RNs). Thirty-one staff from eight RACFs, five GPs and four RiR RNs participated in individual or group interviews. Residential aged care facility staff and GPs valued and relied upon RiR to manage unwell residents. Thematic analysis identified RiR utilisation was driven by the following: (i) complexity of decision-making processes in RACFs; (ii) variability in facility-based medical and nursing care; and (iii) impact of RiR service outcomes on patients and referrers. Availability of timely and appropriate medical and nursing care in RACFs was reported to influence transfers to the hospital and/or referrals to RiR. RiR was used to complement or substitute usual care available to residents. Further research and improvements in RACF and RiR resources are required.

To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). A cross-sectional survey of GP-patient encounters. The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters. Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44-0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49-0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter. Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.

People with an intellectual disability (ID) have more complex and different patterns of health care needs than the general population. They experience a greater burden of multi-morbidity, high levels of undetected and unmanaged health issues, and premature mortality than the general population. Primary care has a key role in the health care of people with an ID. Currently, very little is known about the consultation type and length, problems managed, and how general practitioners (GPs) manage these problems for people with an ID compared with the general population. This information would provide valuable insights into how GPs are achieving the health guidelines and facilitating people with an ID to achieve the highest attainable standard of health. A secondary analysis of data was collected from January 2003 to December 2012 from the Bettering the Evaluation and Care of Health (BEACH) programme. Consultation type, consultation length in minutes, problem(s) managed during the consultation, medications, treatments provided, and referrals made, pre and post age-sex standardisation, at all GP encounters with people identified in the encounter record as having an ID ('ID' encounters, n=690) were compared with those at 'non-ID' encounters (n=970641). Statistical significance was tested with 95% confidence intervals. This study identified significant differences in consultation types, consultation length, problem(s) managed during the consultation, medications, treatments provided, and referrals made at 'ID' encounters compared with 'non-ID' encounters. 'ID' encounters had more indirect encounters, longer consultations, more problems managed, but an under management of common health conditions in people with an ID. Administrative rather than medically related actions dominated clinical treatments for people at 'ID' encounters, and they received fewer procedural treatments, referrals to specialists, and medications compared with those at 'non-ID' encounters. The significant differences in consultations, problems identified and managed suggest that GPs may require additional support to (1) identify and manage common medical conditions experienced by people with an ID; (2) manage the increased time required for consultations; and (3) directly consult with people with an ID. Further research is required to determine why GPs managed problems in a significantly different way for people with an ID.

Rates of psychotropic medicine prescribing in paediatric populations in Australian general practice from 2000-2016

BackgroundThere is scope to improve the quality of life (QOL) of people with dementia living in residential care facilities (RCF). The DIRECT study will determine if delivery of education to General Practitioners (GPs) and care staff improves the quality of life of residential care recipients with cognitive impairment.Methods/DesignA prospective randomised controlled trial conduced in residential aged care facilities in the metropolitan area of Perth, Western Australia. Participants are care facility residents, aged 65 years and older and with mini-mental state examination scores less than 25. GPs and care facility staff have been independently randomised to intervention or control groups. An education programme, designed to meet the perceived needs of learners, will be delivered to GPs and care staff in the intervention groups. The primary outcome of the study will be quality of life of the people with dementia, measured using the QOL-Alzheimer's Disease Scale (QOL-AD) and Alzheimer Disease Related QOL Scale (ADRQL), 4 weeks and 6 months after the conclusion of the education intervention.ResultsRecruitment of 351 people with dementia, cared for by staff in 39 residential facilities and 55 GPs, was undertaken between May 2007 and July 2008. Collection of baseline data is complete. Education has been delivered to GPs and Care staff between September 2008 and July 2009. Follow- up data collection is underway.DiscussionThe study results will have tangible implications for proprietors, managers and staff from the residential care sector and policy makers. The results have potential to directly benefit the quality of life of both patients and carers.Trial registrationThese trial methods have been prospectively registered (ACTRN12607000417482).

The purpose of this paper is to establish the relationship between organisational culture and psychotropic medication use in residential care. Cross-sectional analyses of staff and resident's record survey in residential aged care facilities in Auckland, New Zealand (NZ). The competing values framework categorised organisational culture as clan, hierarchical, market driven or adhocracy and was completed by all staff. The treatment culture tool categorised facilities as having resident centred or traditional culture and was completed by registered nursing staff and general practitioners (GP). Functional and behavioural characteristics of residents were established by staff report and health characteristics and medications used were ascertained from the health record. Multiple regression was used to test for associations between measures of culture with psychotropic medication use (anxiolytics, sedatives, major tranquillisers). In total 199 staff, 27 GP and 527 residents participated from 14 facilities. On average 8.5 medications per resident were prescribed and 42 per cent of residents received psychotropic medication. Having a diagnosis of anxiety or depression (odds ratio (OR) 3.18, 95 per cent confidence interval (CI) 1.71, 5.91), followed by persistent wandering (OR 2.53, 95 per cent CI 1.59, 4.01) and being in a dementia unit (OR 2.45, 95 per cent CI 1.17, 5.12) were most strongly associated with psychotropic use. Controlling for resident- and facility-level factors, health care assistants' assignation of hierarchical organisational culture type was independently associated with psychotropic medication use, (OR 1.29, CI 1.08, 1.53) and a higher treatment culture score from the GP was associated with lower use of psychotropic medication (OR 0.95, CI 0.92, 0.98). Psychotropic medication use remains prevalent in residential care facilities in NZ. Interventions aimed at changing organisational culture towards a less hierarchical and more resident-centred culture may be another avenue to improve prescribing in residential aged care.

People with dementia at times exhibit threatening and physically aggressive behavior toward care staff in residential aged care facilities (RACFs). Current clinical guidelines recommend judicious use of antipsychotic (AP) medications when there is an immediate risk of harm to care staff in RACFs and non-pharmacological interventions have failed to avert the threats. This article examines an account of how this recommendation can be ethically defensible: caregivers in RACFs may have a prima facie ethical justification, in certain cases, to use APs as an act of self-defense. The author examines whether such uses of APs meet the three commonly invoked conditions of ethically permissible acts of self-defense-namely, the conditions of liability, proportionality, and necessity-and argues that such conditions obtain only in a restricted range of cases. The liability constraint can be satisfied if residents are the only ones who are causally responsible for the threats they pose. Further, the condition of proportionality obtains if there is sufficient objective ground to demonstrate that the harm of using the medications does not outweigh the good to be secured. Lastly, the necessity condition obtains when the medications are used at their lowest effective dosage and caregivers in RACFs can reasonably assume that, for the purpose of averting threats posed by residents, the use of APs is the only available course of action. Not meeting any of these fairly stringent conditions renders uses of APs as acts of self-defense in RACFs morally impermissible actions.

To examine the prescribing of lipid-lowering medications during general practitioner encounters with Indigenous and non-Indigenous Australians from 2001 to 2013. Observational time trend study, using data from the Bettering the Evaluation and Care of Health (BEACH) survey, of 9594 primary care encounters with Indigenous patients and 750 079 encounters with non-Indigenous patients aged 30 years or over. Prescription of at least one lipid-lowering medication. The age-sex standardised proportion of encounters that resulted in at least one lipid-lowering medication being prescribed was 5.5% (95% CI, 4.7%-6.3%) for Indigenous patients and 4.6% (95% CI, 4.5%-4.7%) for non-Indigenous patients. The proportion of encounters with Indigenous patients at which a lipid-lowering medication was prescribed increased significantly from 4.1% during 2001-2005 to 6.4% during 2009-2013 (P = 0.013 for trend). For encounters with non-Indigenous patients, the proportion increased significantly from 3.8% during 2001-2005 to 5.2% during 2009-2013 (P < 0.01). For encounters during which GPs managed diabetes, hypertension or ischaemic heart disease, the proportion of Indigenous encounters during which lipid-lowering medication was prescribed was similar to that for non-Indigenous patients. For encounters in which GPs managed a lipid disorder, however, the age-sex standardised proportion was significantly greater for Indigenous (78.4%; 95% CI, 72.6%-84.2%) than for non-Indigenous patients (65.2%; 95% CI, 64.5%-65.8%). We detected substantial increases in the prescribing of lipid-lowering medications from 2001 to 2013 for both Indigenous and non-Indigenous patients seen in Australian general practice. Providers were more likely to prescribe lipid-lowering medications for Indigenous than for non-Indigenous patients, suggesting some measure of success in expanding access to medications and reducing cardiovascular risk among Indigenous people.

BackgroundAdvance care planning (ACP) is a priority in Australian health policy, legislation and accreditation standards. ACP supports people to consider and communicate their future treatment preferences and document them in...

To characterize the changes in management of snoring and obstructive sleep apnea (OSA) in general practice in Australia. The Bettering the Evaluation And Care of Health (BEACH) study is a nationally representative rolling cross-sectional survey of general practice activity in Australia. We analyzed all adult (age 18+ y) encounters for OSA or snoring, annually from 2000 to 2014 (approximately 1,000 general practitioners (GPs) per year recording approximately 100,000 patient encounters per year). The management rate of OSA rose from 94 to 296 per 100,000 encounters, whereas management rate of snoring remained steady at approximately 15 to 25 per 100,000 encounters. The majority of patients managed for OSA were: middle-aged (25-64 y; 71.3% of all patients); overweight (90%); male (62%), although there was a trend for an increase in the proportion being female over the study period (21 to 37 per 100 encounters). Referral rates were high for both OSA (59 per 100 problems managed) and snoring (69 per 100), although medical referrals (to a sleep clinic or respiratory physician) were significantly higher for patients managed for OSA than for snoring (90% vs. 60% of all referrals). Surgical referrals were higher for snoring than for OSA (37% vs. 3% of all referrals). The management rate for OSA tripled from 2000 to 2014, while the rate for snoring remained steady. GPs significantly relied on the advice of other health professionals to manage OSA; however, their referral patterns aligned with what most specialists would recommend. A commentary on this article appears in this issue on page 1081.

To assess the extent to which general practitioners in Australia are engaged in identifying age-related hearing loss and facilitating its management. Cross-sectional analysis of data collected between 1998 and 2000 from the Blue Mountains Hearing Study (BMHS), a representative population-based cohort of people aged >or= 50 years in two postcode areas west of Sydney. Also analysed were data collected between 2003 and 2008 from random samples of Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) study, a national continuous cross-sectional survey of GP activity. Rate of facilitating management and identification of hearing loss in older patients; content of GP-patient encounters with hearing-impaired people; characteristics of participants seeking help from their GP. Of older people in the BMHS with measured (objective) bilateral hearing loss, about a third reported seeking help from their GP. BEACH survey data showed that only about 3 per 1,000 GP consultations with patients aged >or= 50 years involved management of age-related hearing loss. For every 100 age-related hearing problems managed, GPs undertook 12 procedural treatments, provided 20 referrals to specialists, and made 29 referrals to allied health professionals. In their routine consultations with patients, GPs have opportunities to identify hearing loss and appropriately refer patients to specialists or allied health professionals. Although GPs are responding to patient presentations for hearing loss, referring around 50% of cases, there appear to be relatively few cases in which hearing loss is identified opportunistically. Levels of identification and management of hearing loss by GPs in Australia are relatively low.

Objectives: To describe the content of general practitioners’ (GP) encounters with patients aged 65 years or more, and to determine any differences in the way problems are managed between the 65–74 and 75 years and over age groups. Method: A secondary analysis of data collected through the Bettering the Evaluation and Care of Health (BEACH) program was carried out. Results: Encounters with older patients accounted for 25.0% of a GP's total workload. Circulatory conditions, in particular hypertension, were the most frequently managed, with cardiovascular medications the most frequently prescribed. Numerous differences exist in the characteristics and management of older patients when divided into those aged 65–74 and 75 years and over, with patients aged 75 years or more receiving investigations and non‐pharmacological treatments significantly less often. Conclusion: The present study provides a baseline measure of the management of older patients in general practice.