The second is a top-down approach, whereby ISPRN researchers and collaborators extend an invitation to members to become investigators on the research team, so that they can learn and developwhilst learning and developing their research capacity skills.
Summaries of ISPRN research projects are listed below.
The doctor’s visit to the residential care home: the experience of residents, their family, staff and general practitioners (GPs)
Clinical Associate Professor Russell Pearson was the lead investigator on this project. He is also the Graduate School of Medicine’s Phase Three Regional Academic Leader for the Shoalhaven region.
Phase one of this project ascertained the views of GPs who provide care to residential aged care facilities (RACF). The idea for this project came about when Dr Pearson came across a job advertisement for a GP position that guaranteed no nursing home visiting. It was this advertisement that prompted Dr Pearson to investigate GP attitudes toward nursing home visits, and more recently, the views of RACF staff, residents and their families about GP visits.
As part of this project, 35 semi-structured interviews were undertaken. The findings highlighted the importance of good communication and collaboration between the GPs, the RACF staff, the residents and their families to achieve the best outcomes for everyone. The project also found that regular planned visits by GPs helped to improve RACF staff and GP cooperation in addition to improving informational continuity of care.Participants recognized greater informational continuity when information sharing took place between the wider care team, which included RACF staff, GPs, the residents and their families.It is hoped the results from this project will help inform improvements in GP involvement in patient care in RACFs.
“No afterhours…no nursing homes”
Clinical A/Prof Russell Pearson, Dr Eniko Ujvary, Prof Andrew Bonney, Prof Judy Mullan, Ms Bridget Dijkmans-Hadley
The aim of this project was to discover what GPs behaviours/attitudes were towards providing care in residential aged care facilities (RACF) and what they perceive to be barriers and enablers to patient care in this setting.
The views of a purposive sample of 26 GPs and GP Registrars working in rural and regional NSW were captured through focus group discussions and one-on-one interviews.Analysis of the qualitative data revealed that GP attitudes towards RACF visiting fell into five key themes: pleasure, duty, remuneration, hesitation and frustration.
The data also revealed that the overriding emotion GPs felt about RACF visitation was frustration with the avoidable delays and inefficiencies associated with the work.Despite the pleasure GPs derived from their work in RACFs and their sense of obligation to be involved, their hesitation and frustration was compounded by the work’s perceived poor remuneration. The researchers commented on the need for further research to help improve GP engagement in RACF visits.
This project was funded by CCCGPT and the Graduate School of Medicine. (GSM)
Knowledge, beliefs and attitudes of General Practitioners and Nurses regarding influenza vaccination
The Chief Investigator on this project was Mrs Haley Frew, who works in the Public Health Unit, Immunisation, for the Illawarra Shoalhaven Local Health District (ISLHD).
The aim of this study was to understand the beliefs and attitudes of GPs and practice nurses (GPN) with respect to influenza vaccination in young children. The research also examined the opinions of participants with respect to the NSW Government’s initiative to continue to fund the influenza vaccine for this age group. The research team developed a survey, which was completed by one hundred and twenty-one GPs and GPNs working in the Illawarra Shoalhaven Local Health District.
Study participants showed a high level of support and positive attitude for annual vaccination for seasonal influenza in young children aged between 6 months and 5 years.
A majority also agreed or strongly agreed that a recommendation by a health professional helps to increase the uptake of the influenza vaccination.
The majority also agreed or strongly agreed that they were more likely to promote the vaccination if it was freely available. They also believed that if the vaccine was no longer free that parents would be less likely to vaccinate their children against influenza. The results of the study will assist local health agencies in advocating for access to influenza vaccine for patients.
This study was funded by the Illawarra Shoalhaven Local Health District (ISLHD).
Assessing the feasibility of an electronic reminder system in the general practice (GP) setting to improve cardiometabolic screening for patients with serious mental illness (SMI)
The chief investigator for this study was the Graduate School of Medicine’s Regional Academic Leader for the Illawarra, Dr Fiona Williams.
Previous research indicates that patients with serious mental illness (SMI) die on average 10-15 years earlier than those without SMI. This is primarily due to ischemic heart disease and complications of metabolic syndrome.
Reasons for the increased incidence of cardiometabolic syndrome in patients with SMI are multifactorial which include; lifestyle factors, increased incidence of smoking, obesity, and an increase in metabolic syndrome associated with antipsychotics.
The purpose of the study was to investigate the acceptability and practicality of an electronic reminder system for cardiometabolic screening of patients with SMI.
Three GP practices were recruited to take part in the study. Electronic medical records were audited to establish current rates of cardio-metabolic screening in accordance to the NICE Guidelines. These guidelines include screening for blood sugar, lipids, blood pressure (BP), smoking status, waist circumference and body mass index (BMI).
The primary investigator provided each practice with an education session around the implementation of the screening guidelines. Practice nurses were then asked to set up a reminder system within their practice software to flag when a patient living with SMI was due for screening.After 6 months, patient notes were re-audited to ascertain if screening rates had changed as a result of the recall process.
Prior to the instigation of the reminder system, smoking was recorded in 89% of cases, BMI in 45% of patients, waist circumference in 0% patients, BP in 72% of patients, glucose in 55% of patients and lipids in 45% of patients.
Following the instigation of the reminder system, Smoking was recorded for 93% of patients, BMI in 76% of patients, waist circumference in 32% of patients, BP in 86% of patients, glucose in 76% of patients and lipids in 76% of patients.
The study highlighted that an automated reminder system could improve adherence to best practice recommendations for cardio-metabolic screening and that such a system was acceptable, practical and simple to integrate into a general practice setting.
Overall, the use of the electronic reminder system and education session appeared to be feasible and resulted in a positive impact on both patients and general practice staff.
This study was funded by COORDINARE.
Do health literacy levels affect the use of complementary and alternative medicine (CAM) use in rural Australian communities?
Dr Dora von Conrady, Professor Andrew Bonney, Clinical A/Prof Bastian Seidel, Prof Judy Mullan, Mr Jason Nunes
This study investigated whether health literacy affects the use of complementary and alternate medicine (CAM) in urban, regional and rural Australian general practice.
Health literacy refers to the degree to which individuals understand basic health information to make appropriate health decisions.
Complementary and alternate medicine refers to a set of health care practices that are not part of conventional medicine.
A questionnaire was developed and piloted in Tasmania. This questionnaire was refined and distributed among patients of eight general practices. The questionnaire was completed by 377 participants.
The questionnaire asked participants about visits to complementary practitioners; (chiropractors, homeopaths, acupuncturists, herbalists and spiritual healers). It also questioned patients on treatments received from medical doctors; the use of herbal and dietary supplements; and the use of self-help practices.
Participants were asked to indicate which treatments were used and how often. They were asked the main reason for use of the treatment and how helpful they found it.
The results of the study showed that participants who could read and understand health information well were less likely to use CAM (odds ratio 0.46, 95% CI 0.3-0.7, P<0.001).
The researchers commented that patient education remains a cornerstone of the medical consultation and may result in more thoughtful use of CAM.
This project was funded by Grand Pacific Health.
Rural GP referral process for Isotretinoin treatment in moderate to severe acne
Dr Munther Zureigat, Professor Andrew Bonney, Prof Judy Mullan, Dr Jo-Ann See, Dr Jenna Rayner, Ms Athena Hammond, Ms Karen Fildes, Mr Luke Dalla
Acne Vulgaris is one of the most common dermatological presentations in General practice. Acne scarring is a known major consequence of late referrals for Isotretinoin treatment - a drug that can only be prescribed by dermatologists for patients with moderate to severe acne. Isotretinoin has been shown to be very effective in preventing scarring if started at the optimal time.
Acne scarring has long-term psychological impact on patients (mainly adolescents) and is strongly related to poor body image, depression and possibly suicide.
The aim of this project was to investigate GP experiences around the barriers and facilitators of referral to dermatologists for isotretinoin treatment.
Twenty GPs participated in a telephone interview on the topic. Six GPs practiced in metropolitan areas in and around Wollongong (30%), seven were from regional areas in the Shoalhaven area (35%), and seven were from rural areas (mostly from Milton-Ulladulla) (35%).
Multiple factors were mentioned by participants in determining when to escalate to specialist dermatologist care, in particular, the patients’ level of distress was mentioned by the majority of those interviewed.
Major barriers to referrals included long waiting times, cost of seeing a specialist and travel. Multiple participants brought up the need to have more urgent appointments for severe acne or very distressed patients. GPs should be encouraged to discuss acne with their patients and provide patients with educational resources.
This project concluded that investing in GP education about treating acne, early recognition of acne scarring and referrals to dermatology care has the potential to improve the outcomes of acne treatment.
This project was funded by Grand Pacific Health.
Electronic Medical Data Benchmarking Project
Dr Stephen Barnett, Dr Adam Hodgkins, Mr Abhijeet Ghosh, Mr Chris Harrison, Dr Joan Henderson, Ms Bridget Dijkmans-Hadley
The aim of this project was to collect de-identified data from electronic records of a sample of ISPRN practices as a ‘benchmarking’ study, comparing the data from these practices with the Bettering Evaluation and Care of Health (BEACH) national data set. The results will inform the design and interpretation of future studies, particularly in regard to the generalisability of findings.
Demonstrating the value of raw clinical Electronic Medical Data for primary care research: a benchmarking study on chronic disease prevalence in primary care
Dr Stephen Barnett, Dr Adam Hodgkins, Mr Abhijeet Ghosh, Dr Khin Win, Mr Chris Harrison, Ms Joan Henderson, Dr Allan Pollack, Dr Khin Than Win, Dr Pippa Burns, Prof Liz Halcomb, Dr Lucie Stanford, Mr Jack Bird
The second phase of this project (first stage above) utilised Electronic Medical Data from six general practices to benchmark data with the national BEACH data for chronic disease prevalence using proxy markers for condition.
Six practices from the Illawarra and Southern Practice Research Network (ISPRN) agreed to participate in the study. Data was obtained by running an SQL query on medical records stored in Best Practice Software. Data from a number of fields were extracted, including patient age, sex, smoking status, residential postcode as well as medical indicators for diabetes mellitus.
A sample of 30,007 patients, with a median age of 47 years was obtained. A total of 1,953 patients (6.5%) were estimated to have diabetes (either type 1 or type 2).
As part of this study the researchers developed an incremental assessment model, which can be used by primary care planners and other researchers to provide an accurate estimate of diabetes from general practice clinical electronic records.
In summary, this study demonstrates the value of ‘uncleaned’ data from primary care electronic medical records. With the addition of proxies for diabetes, the disease prevalence rates appear highly accurate.
These findings could be built on by developing proxy ‘maps’ for a range of chronic diseases. In addition, there is the potential to use this approach to develop an accurate diabetes ‘cohort’ for longitudinal observational or even intervention studies.
This project was funded by Grand Pacific Health.
Wellbeing in student and established medical practitioners: formative research
Prof Andrew Bonney, Dr Andrew Dalley, Prof Lindsay Oades, Dr Min Ko Ko Thaung, Ms Bridget Dijkmans-Hadley, Ms Alyssa Horgan, Dr Louise Wright, Dr Fiona Williams and Mr Jason Nunes
A career in medicine can be very stressful and stressors can commence as early as medical school. This research aimed to measure the wellbeing and career intentions among Phase 1 and Phase 3 medical students at UOW.
The results indicated that factors such as the ability to balance work and family life was very important for both cohorts, when considering a specialty. Reassuringly the students reported overall high levels of wellbeing with similar scores between cohorts. These findings were in contrast to previous research suggesting increased rates of poor psychological health in medical students.
Satisfaction with and importance of information within hospital discharge summaries
Dr Carl Mahfouz, Prof Andrew Bonney, Prof Judy Mullan, Ms Bridget Dijkmans-Hadley, Dr Warren Rich
The aim of this study was to develop a discharge summary assessment tool to explore the attitudes of General Practitioners (GPs) to hospital discharge summaries and to pilot the tool to measure the satisfaction of GPs with components of the discharge summaries in comparison with the importance of those components to patient care.
A literature review helped to inform the development of the tool. Each item was presented in a 5-point likert-style format; ranging from very unimportant to very important and very unsatisfied to very satisfied for each set respectively. An open response section collected respondents’ additional written comments.
GPs rated core clinical and management data as the most important features of discharge summaries. The top three elements ranked important or very important were: reason for admission to hospital; list of diagnoses on discharge and reasons for medication change.
GPs were most frequently unsatisfied with the changes in medication component. Other top-ranked unsatisfied/very unsatisfied items were prioritisation of pathology results and efficiency of the format of the discharge summary.
This project was funded by Illawarra Shoalhaven Medicare Local.
Feasibility study for a randomised controlled trial of shared-continuity for Type 2 Diabetes Management in primary care
Prof Andrew Bonney, Prof Sandra Jones, Dr Lyn Phillipson, Dr Chris Magee
The primary care system in Australia is under significant pressure to effectively manage the burgeoning caseload of chronic disease management. This caseload is projected to contribute to workforce shortages in the primary care setting in the short-, medium- and long-term. General practice registrars (GPRs) will increasingly need high level skills in chronic disease management as our population continues to age. However, both Australian and international data demonstrate that GPRs see relatively fewer older patients and patients with chronic diseases than established GPs, reducing training opportunities in chronic disease management.
This study aimed to investigate older patient attitudes to General Practice Registrars and Practice Nurses providing care for the management of their Type 2 Diabetes Mellitus. Patients were randomised to either participate in usual care or the intervention component.
Patients were allocated to either the usual care arm that continued with the same care that they received at their general practice or were allocated to the intervention component where they were seen by a practice nurse and GP registrar, with their usual doctor checking in on the consultation at the end of their appointment.
All participants completed a baseline survey and a survey at the end of the study with regards to their attitudes towards General Practice Registrars and Practice Nurses providing care for the management of their Type 2 Diabetes Mellitus.
The study highlighted the increased need for chronic disease management training for GP Registrars (GPRs). This pilot provides evidence that it is feasible to undertake an adequately powered randomised controlled trial of shared continuity in GP training practices for chronic disease management training. The intervention, as adapted in each practice, was acceptable to the majority of participants and indicated positive educational outcomes for GPRs. Despite the limitations of a pilot study, there was no measured negative impact on patients’ clinical parameters.
Why are GPs asked to remove Implanon contraceptive implants early?
Dr Meike Flore, Dr Lily Chen, Prof Andrew Bonney, Dr Adam Hodgkins, Ms Bridget Dijkmans-Hadley, Dr Kate Manderson, Ms Gail Lloyd, Ms Gina Evans, Ms Haley Frew
This aim of the study was to discover the reasons why women ask for early removal of Implanon (progesterone only contraceptive) implants (that is, prior to its 3 year expiration dates). The findings may inform advice given to women prior to insertion of Implanon and/or lead to discussion around alternative forms of contraception.
Interviews were undertaken with 19 women aged between 18 to 50 years of age regarding their experiences with Implanon™. Bleeding side-effects were the main cause for early removal of the contraceptive device. Interestingly, mood swings and weight gain were also common factors for early removal.
Patients felt they hadn’t been as well informed about their side effects. The study found that women would be less likely to remove their Implanon™ early if they were made aware of potential side effects.
This project was funded by Grand Pacific Health.
The attitude of patients over 65yrs to ceasing long-term sleeping tablets
Dr Fiona Williams, Prof Andrew Bonney, Dr Carl Mahfouz, Clinical A/Prof Russell Pearson, Clinical A/Prof Bastian Seidel
The aim of this project was to assess elderly patient’s use and knowledge of sleeping tablets and their attitude to stopping them.
Seventeen patients aged over 65yrs from four Australian General Practices took part in telephone interviews.
Many patients in the study had been taking sleeping tablets for some time despite limited benefit.
The majority of patients showed a willingness to cease medication however did not see a need to as they were not aware of side effects or addictive nature of sleeping tablets.
The researchers commented that GPs need to recognize the importance of spending time with patients presenting for repeat prescriptions of sleeping tablets. They stated that GPs need to discuss the cause of sleep disturbance, potential side effects of the medication and alternative options for insomnia. Discussing these strategies may reduce the use of this potentially harmful medication in the elderly.
This project was funded by CCCGPT.
Factors affecting medical students’ sense of belonging in a longitudinal integrated clerkship
Dr George Albert, Prof Andrew Bonney, Prof Nicky Hudson, Dr Patricia Knight-Billington
The aim of this study was to investigate the experience of students undertaking a longitudinal integrated clerkship from the perspective of belonging in order to identify areas of improvement. Findings indicate that there is a complex interaction of factors relating in a positive or negative experience such as academic leadership, external (general practice) environment and intrinsic (student) factors.
Development and validation of an insulin proficiency assessment tool for insulin self management in adults with type 2 diabetes mellitus
Ms Dianna Fornasier, Ms Bridget Dijkmans-Hadley, Ms Alyssa Horgan, Prof Judy Mullan, Prof Peter Caputi, Mr Jason Nunes, Ms Cheryl Nanikvell, Mr Simon Scott- Findlay, Ms Helen Hulme-Jones, Ms Bronwyn Henderson, Ms Angela Clark, Ms Christine Campbell
Research has identified gaps in insulin self management outcomes, particularly for patients with type 2 diabetes mellitus (T2DM) over the age of 65. The research team developed a 26 item tool to be used in assessing a T2DM patients’ knowledge and self-management of their T2DM and administration of insulin.
The tool demonstrated high accuracy in identifying patients who have inadequate knowledge of hypoglycaemia and hyperglycaemia management. The research also found that there were gaps in patients’ knowledge around insulin self-management.
This project was funded by the Department of Health and Ageing.
What is the effect on weight of regularly weighing 20-70 year old general practice attendees: a pilot study
Dr Duncan Mackinnon, Prof Andrew Bonney, Mr Darren Mayne
The aim of this pilot study was to establish the feasibility of whether weighing patients at every consultation, followed by usual care, has an impact on healthy weight maintenance of 20-70 year old general practice attendees. Lessons from this study, and preliminary data, will be used to support a proposed larger scale study in the future.
The results indicate that obese patients lost 3.3kg more than underweight or normal weight patients and lost 2.8kg more than overweight patients. This study demonstrated a weight loss of 0.8kg overall and a significant 2.5kg weight loss in obese patients. This small intervention could have nationwide benefits with minimal costs for national health services.
Dr Mackinnon presented an academic poster on his research project at the Primary Health Care Research Information Service Conference in July 2014, where he was presented with the award for Best Poster.
Chaperone use in Australian general practice: current practice and attitudes of general practitioners and patients
Dr Lucie Stanford, Prof Andrew Bonney, Dr Rowena Ivers, Prof Judy Mullan
A cross-sectional survey completed by 732 adult patients, between August-November 2012, was used to investigate Australian patients attitudes toward chaperone use for intimate physical examinations in a GP setting. The study findings suggested that both male and female patient participants (aged between 18-95 years) were significantly more likely to want a chaperone present when their usual GP was conducting an intimate physical examination (e.g. genital or ano-rectal examinations), as compared to when a GP they did not know well was conducting the examination (p<0.05).
In addition, the study found that even though 45.3% of the study participants had no preference with regard to whether or not the chaperone was outside or inside of the curtain during the examination, as many as 41.3% responded that they wanted the chaperone to remain outside the curtain and just over an eight (11.3%) preferred that the chaperone remain inside the curtain.
This project was funded by the Department of Health and Ageing.
Cross-sectional survey of older patients’ views regarding multidisciplinary care for chronic conditions in general practice
Prof Andrew Bonney, Dr Chris Magee, Clinical A/Prof Russell Pearson
This project aimed to establish preliminary data on the views of older patients in the Illawarra/Shoalhaven towards community-based team care for chronic conditions. The project also seeks to assess the utility of a cross-sectional survey methodology for this topic and investigate the psychometric properties of an instrument adapted for this purpose. If successful, a further aim is to secure external, competitive funding for a multi-centre, mixed methods research project addressing this topic. Findings indicated that older patients support important features of health care reform in general practice, including co-location of health professionals in general practices, multidisciplinary chronic disease management teams and advanced roles for practice nurses. Results also demonstrate the importance to older patients of interpersonal continuity of care with their GP.
Effective collaborations and research partnerships have been a key strength of ISPRN.
Our list of research projects (below) demonstrates a wide range of collaborations with individual researchers from various University of Wollongong faculties and schools. ISPRN also has major research partnerships with various institutions around Australia and internationally including: the University of Newcastle, the Illawarra Health and Medical Research Institute (IHMRI), University of New England, University of Notre Dame, University of Queensland, Deakin University and the University of Montreal.
Effectiveness of Quality Incentive Payments in General Practice Trial (EQUIP-GP)
The aim of this study was to evaluate the impact of a new funding model in primary care that provides incentives for consultations, same day access and follow-up after hospitalisation.
The project was a collaboration between the University of Wollongong, Monash University and the University of Tasmania. It was funded by the Royal Australian College of General Practitioners (RACGP).
The funding model trial tested incentives for specific quality improvement factors in high-risk chronic disease populations, and provided payment incentives proportional to the expected health system cost savings resulting from the improvement of that patient.
A total of 981 participants took part in the trial from 33 general practices. Half of the practices were randomly allocated to a control (usual care) or the intervention arm (testing the financial model.
Participants were recruited into one of three groups. Those groups were those aged 18-65 years who had a chronic illness, those aged over 65 and children aged 16 and under who were at increased risk of hospitalization.
The research team wanted to investigate the impact of an incentivised practice-level service model on patient perceived relational continuity, preventable hospitalisations and emergency department attendances for selected ambulatory care for the 18-65 and over 65 participants.
They also wanted to examine whether participants experienced an improved quality use of medicines, reduced prescriptions and less referrals for radiology and pathology. In the under 16s group the team investigated the effect of access to same day care.
Development of a COVID-19 general practitioner leadership virtual community of practice in New South Wales (COVID-19 GP VCoP)
General practice is key to successful community management of COVID-19. However, this is a new environment, with a large amount of new and evolving information to be absorbed by practice teams.
As a contribution to addressing the COVID-19 crisis in Australia, a group of GP leaders in NSW have established a Virtual Community of Practice (VCoP).
The goal of the VCoP is to facilitate rapid implementation of necessary changes in general practice through widespread sharing of knowledge and experience in practice.
ISPRN is leading a multi-institution research project to investigate the effectiveness of the GP Leadership VCoP.
The study will employ a ‘virtual community of practice’ (VCoP) framework, which offers a mechanism for studying the aims of simultaneously disseminating new and complex information. It will also allow for the facilitation and contextualization through the exchange of both knowledge and lived experience; or ‘know what’ and ‘know how’.
Qualitative data has been collected from 36 participants (four leaders and 32 members) between June and October 2020.
Quantitative data has also been collected on the content of topics, number of replies, resources and links uploaded of forum conversations.The expected outcomes of this research are enhanced effectiveness and the rapid dissemination of the experience. Initial outcomes of the NSW centric COVID-19 GP VCoP will assist in addressing the COVID-19 Crisis both nationally and internationally.
Patient Centered Medical Home Innovation Projects
Seven general practices were funded by the South Eastern NSW Primary Health Network (PHN), COORDINARE, to develop innovation projects that focused on the implementation of Patient Centered Medical Homes (PCMH).
‘PCMH’ describes a team-based healthcare delivery model which aims to provide comprehensive and continuous medical care to patients.
An evaluation of the effectiveness of COORDINARE in facilitating the implementation of PCMH change, based on the innovation projects, was conducted by ISPRN.
To undertake the evaluation, a logic model was co-created by COORDINARE and ISPRN.
The logic model was created to help inform local PCMH development and proposed a theoretical chain of events (cause and effect) which could be navigated by COORDINARE to assist general practices to move from their initial environment towards PCMH models of care.
The data collection included: 49 semi-structured interviews; 17 participants who attended evaluation workshops; and formal in-practice observations.
The findings from this project indicated that PHNs can successfully assist practices to implement innovative PCMH change. However, it was also found that practice motivation for change was a universal pre-requisite for engagement in PCMH change efforts.
Practices perceived patient acceptance of the innovative change as key, and were motived by the desire to improve patient outcomes. The findings from the project are being used by COORDINARE to help inform practice support activities.
The “My Health Record” Study
The roll-out of My Health Record (MyHR) provides a powerful opportunity to combine training in the use of this centralised health record with evidence-based prescribing and test ordering for practitioners.
Seventy one general practitioners have participated in a three-arm pragmatic, educational trial. The three arms included de-prescribing, pathology-ordering and diagnostic-imaging. The study explored and reinforced the role of MyHR in realising the potential health care benefits and integration of MyHR into clinical practice.
By the end of the education sessions, there was a change in knowledge, skills and behaviours regarding the use of MyHR and evidence-based deprescribing, imaging and pathology ordering.
The evaluation demonstrated that the intervention can improve confidence in, and use of, MyHR. It also shows potential to achieve change in clinical reasoning and some reduction in unnecessary health care expenditure.
Stage two of this project is underway, whereby over 90 GPs are undertaking the education Australia wide.
This study was funded by Medcast.
Hip and knee osteoarthritis: acceptability of multidisciplinary non-surgical management and case conferencing as an approach to care
The aim of this study was to develop a standardised, evidence-based, multi-disciplinary care package that could be utilised to translate the current clinical care guidelines for osteoarthritis of the knee and hip into a real-world general practice setting.
The research took place in the Illawarra, and involved 17 Patients, two General Practitioners, two Accredited Exercise Physiologists and two Accredited Practicing Dietitians across two General Practices. Patients completed questionnaires on their current activity levels and current pain and disability they experienced from their osteoarthritis. They also undertook physical assessments including height, BMI, waist circumference, lower limb muscle strength and physical function of their affected limb/s.
A case conference took place with the GP, exercise physiologist, dietitian and patient and it was during this appointment that treatment goals were developed and agreed upon. Following this, patients received three treatment sessions with an Accredited Exercise Physiologist and three with an Accredited Practicing Dietician. Patients then completed a self-management phase, supported by personalised text messages from the treating clinicians.
The intervention resulted in statistically significant reductions in body mass and joint pain for participants, in addition to non-statistically significant improvements in physical activity levels and physical function. The multidisciplinary care package was overwhelmingly accepted by patients and was generally feasible for clinicians.
ADVANCE CARE PLANNING IN OUTPATIENT CLINICS
Advance Care Planning (ACP) is a process of reflection, discussion and communication that enables a person to plan for their future medical treatment and other care, for a time when they are not competent to make, or communicate, decisions for themselves. ACP could significantly improve quality of care whilst allowing patients to receive patient centred care and to avoid unwanted and inappropriate hospital admissions and interventions.
Hospital wards are not an ideal setting for ACP because decisions made when acutely unwell may not truly reflect the patient’s true wishes. Outpatient clinics are a better setting to conduct ACP. However, there is paucity of evidence on the benefits of ACP conducted in patients with advanced diseases attending hospital outpatient clinics. There is also a lack of studies examining the benefits of ACP over a longer time period (e.g. 18 months), and there is lack of Australian evidence base examining the health economics benefits of ACP.
This research aims to understand whether an ACP intervention, provided to patients with advanced diseases attending hospital outpatient clinics identified as being at risk of dying in the next 12 months reduce unplanned hospital admissions at 6 and 18 months, improve patient care and encourage health professionals to incorporate ACP into routine care. Positive results obtained from this study will provide the necessary evidence to policymakers and health service managers to enable them to make additional investments and therefore implement ACP in a larger scale. A/Prof Joel Rhee is the research lead and Dr Diane Harland is the research fellow on this project, along with researchers; Caplan, G, Meller, A, Gonski, P, Hayen, A, Cullen,J, Naganathan,V, Zwar, N, O’Keefe, J, Krysinska, K, Kenny, P & Perry, L.
Illawarra Health and Medical Research Institute (IHMRI) collaborative projects
Southern IML Pathology Research Cohort Study
The SIMLR Cohort Study is a partnership between Southern IML Pathology and the Illawarra Health and Medical Research Institute (IHMRI). The project utilises Southern IML Pathology’s large, longitudinal, community-derived database to analyse and identify health risk indicators and where those risks are clustered geographically.
Older patients and their involvement in the decisions concerning their health care.
Prof Andrew Bonney, Prof Judy Mullan, Ms Athena Hammond
Older people are more likely than others to experience chronic illness and, as they age, commonly develop multiple chronic illnesses - known as multimorbidity. The aim of this study was to explore the experience of multidisciplinary healthcare for community dwelling older people with multimorbidity, in order to understand their involvement in decision making processes about their health.
Four General Practices, forty patients and 23 health care providers participated in the study. Data were collected from participants who had experience of receiving multidisciplinary care and providers who had experienced delivering care as part of a multidisciplinary team.
To understand more about patients’ experience of receiving multidisciplinary care, a technique known as Pictor was used to generate visual representations of a patients’ multidisciplinary care team. To make the charts, patients were asked to name all of the people and providers that they believed were involved in their health care ‘team’.
Findings from the study demonstrated that a patients’ intention and capacity to be involved in decision making is changeable dependent on context and circumstances. Approaches to decision making are influenced by family, cultural and generational beliefs. Therefore, decision making is a flexible process that must be negotiated at an individual level, across multiple time points and in changing circumstances. Flexible shared decision making is supported by thre echaracteristics of patient/provider relationships: mutuality, human connection and trust.
This project was funded by the Illawarra Retirement Trust.
The effect of targeted social marketing resources on older patient attitudes towards GP registrars
Prof Andrew Bonney, Dr Lyn Phillipson, Ms Julie Hall, Ms Elizabeth Smyth, Dr Pippa Burns
This study used targeted information resources to better inform older patients and then assess older patients’ attitudes and behaviours regarding GP registrars.
Ten general practices displayed brochures and posters about GP registrars for a six month period. Nine general practices did not display any resources during this time to act as a comparison.
Patients who were exposed to the brochures and posters demonstrated a significant improvement in trusting their GP registrar. They were also more comfortable in having a GP registrar treat them for a complex or chronic condition.
Dr Chris Darragh
Academic GP Registrar
Dr Chris Darragh joined the team in Shoalhaven in 2020 as a GP Academic Registrar.
Dr Darragh has spent his academic term undertaking a systematic literature review into the quality of General practice to Emergency Department communication.
Dr Darragh has always had an interest in education and enjoys teaching in addition to working. It has been his goal to continue to be able to do both. He is grateful for the opportunity to undertake GP training as it allows for this flexibility, as well as providing avenues for engaging in research.
Dr Darragh's academic training placement was funded through a partnership with GP Synergy.
Dr Darran Foo
Academic GP Registrar
Dr Darran Foo has joined the team in February 2021 as an Academic GP Registrar. He is supervised by A/Prof Joel Rhee.
Darran's current research focuses on the impact of rurality and other factors that may influence the decision-making process for women to seek help for possible breast cancer symptoms. He is particularly interested in identifying any differences between rural and urban groups.
Darran is also passionate about teaching and medical education. The Academic Post has allowed him to be involved with teaching within the Graduate Medicine program at UOW.
His long-term goal is to continue to pursue a career within Academic General Practice.
Darran's Academic Post is supported by the Royal Australian College of General Practitioners with funding from the Australian Government under the Australian General Practice Training program."
Mr Tim Miller
Supervisors: Dr Deirdre McGhee, Prof Andrew Bonney & Prof Judy Mullan
Title: Conservative Management of Hip and Knee Osteoarthritis: Feasibility and Effectiveness of a Multidisciplinary Case Conference Model
This mixed methods study will provide evidence regarding the feasibility and acceptability of a novel multidisciplinary case conference model for the conservative management of hip and knee osteoarthritis within the primary care setting. It is anticipated that the data will assist in the development of an improved model of care for the conservative management of lower limb osteoarthritis within general practice. Should the model prove to be feasible and acceptable, potential further research should investigate the suitability of such a model in improving conservative management of other chronic disease population groups.
Dr Rebekah Hoffman
Primary supervisor: Prof Andrew Bonney, Secondary Supervisor: Prof Judy Mullan
Title: Effects of parenting on burnout in GP registrars, including those in rural settings
Dr Hoffman’s PhD is investigating Motherhood and Medicine. She has been specifically looking at experiences of being both a mother and a doctor. The aims of her research are to identify what is known about the experiences that women face embarking upon a career in medicine, specifically general practice. She will be comparing whether the experiences of women doctors who are mothers, are different of those women doctors who are not. The research will also analyse how these experiences impact on the work-life balance of women and mothers across the general practice community.
Mrs Renin Melkias Baby Selvi Toms
Primary supervisor: Prof Andrew Bonney, Co-supervisor Dr Xiaoqi Feng, Associate Supervisor: Dr Darren Mayne
Title: An epidemiological and geospatial study of cardiometabolic risk factors in the Illawarra-Shoalhaven region of NSW, Australia.
Renin has completed her PhD, which analysed fasting blood sugar level, diabetes status, kidney function, total cholesterol and body mass index for individuals who had routine pathology tests between 2012 and 2017.
Outcomes of the research confirmed the relationship between socioeconomically disadvantaged areas and prevalence of cardiometabolic risk factors across the Illawarra-Shoalhaven, but with important differences in geographic distribution.
This study assist in visually mapping out cardio- metabolic risks within the region, which can assist to inform health service planning.
Dr Sanaz Khanlari
Primary supervisor: A/Prof Joel Rhee, Co-Supervisor: Dr Pippa Burns
Title: ‘Euthanasia and Physician Assisted Suicide in Australia - A Study of Consumer and Psychiatrist Perspectives’
Dr Khanlari’s PhD aims to identify the effect of question phrasing when it comes to consumer opinion on euthanasia in Australia.
She will investigate opinions on euthanasia and the factors that influence them. Finally, this research will explore the attitudes and preparedness of Victorian psychiatrists to provide capacity assessments for people applying for physician assisted suicide under the Voluntary Assisted Dying Act 2017.
Dr Khanlari anticipates that her research will indicate that current practices are inadequate to draw conclusions from the public opinion on euthanasia and that a more nuanced approach is required in order to inform policy in Australia.
Ms Jessica Cerni
Primary: Supervisor: A/Prof. Joel Rhee,
Title: Geographic Variation in the Patterns of End-Of-Life Cancer Care Provision; exploring the extent to which geographic accessibility and primary physician supply influences healthcare utilisation amongst cancer decedents in NSW, Australia.
This project aims to investigate the influence of geographic variation on the patterns of End-of-Life cancer care provision as well as the role primary health care has in End-of-Life cancer care. Using a mixed methods approach, both quantitative and qualitative data sourced from secondary health administrative data and focus group data will be used to measure the association between travel times to hospitals and cancer centres, the supply of primary health care as part of the ISLHD and the patterns of End-of-Life cancer care among its population.
Dr Adam Hodgkins
Primary supervisor: Prof Andrew Bonney, Co-supervisors: Prof Judy Mullan, Dr Darren Mayne
Title: ‘The use of electronic medical data for research in primary care: A study of lipid lowering medication in the elderly as a case model’
Dr Hodgkins has undertaken several individual studies as part of his PhD. The first investigated the feasibility of utilising longitudinal electronic health record (EHR) data analysis to address clinically relevant outcomes and uses the relationship between lipid medication prescription and all-cause mortality in the elderly as an exemplar for the validity of this methodology.
This single-practice study presented 6840 patient years of data which demonstrated the feasibility and potential of analysing EHR data to address important clinical issues, such as the relationship between all-cause mortality and lipid medication prescription in the elderly.
He has also undertaken research into the attitudes of Australian General Practitioners with regards to the use of EHR for clinical research.
Dr Hodgkins’ research is now focusing on the use of EHR to examine mortality and statin use in the elderly.
Ms Margaret Jordan
Primary Supervisor: Prof Tim Chen & Co-supervisor: Prof Judy Mullan
Title: Reducing the risk from ‘high-risk’ medicines in primary care -High-risk medicines, notably opioids, in primary care and investigating potential improvements in management.
During the first year as a general practice pharmacist, in collaboration with the general practice team, Margaret’s study focused on introducing safer practices for the management of people prescribed opioids. Her first publication was stimulated by this work and was a scoping review into the activities of pharmacists in the management of opioids in primary care. Opioid medicines management in primary care settings: A scoping review of quantitative studies of pharmacist activities
Data on reductions in opioid prescribing achieved and the feedback from the GPs and other personnel of the general practice will comprise quantitative and qualitative perspectives for her next two publications. The quantitative data were presented in three multidisciplinary national symposia in 2020 and one international pharmacy (online) conference (International Pharmaceutical Federation). Her recorded presentation for this conference was selected to promote International Pharmacy Day, 2020.
Ms Robyn Gillespie
Primary Supervisors: Prof Judy Mullan and Dr Lindsey Harrison
Title: Attitudes and practices regarding deprescribing (ceasing medication) in primary care with a focus on the role of health literacy in deprescribing discussions.
This mixed methods study included surveys and individual interviews with GPs and autonomous, community living older adults using five or more medications.
Structural factors were found to prevent deprescribing discussions including short consultation times in which to manage multimorbidity, poor quality communication about medications between health care professionals and a lack of clear lines of authority to deprescribe. Access to GP services for frail older adults was poor, resulting in missed opportunities to consider deprescribing.
Older adults had generally good health literacy specific to the daily management of their often complex medication regimens. However, health literacy had a limited role in deprescribing shared decision making as skills were generally not acknowledged or applied during consultations.
The study identified opportunities for change that would allow existing health literacy capacities of older adults to be utilised to greater effect within deprescribing shared decision-making. It also described the pragmatic decision making criteria used by older adults and GPs when considering deprescribing.
Gillespie, R., Mullan, J. and Harrison, L., 2019. Deprescribing for older adults in Australia: factors influencing GPs. Australian Journal of Primary Health, 24(6), pp.463-469.
Gillespie, R., Mullan, J. and Harrison, L., 2019. Attitudes towards deprescribing and the influence of health literacy among older Australians. Primary Health Care Research & Development, 20.
Gillespie, R.J., Harrison, L. and Mullan, J., 2018. Deprescribing medications for older adults in the primary care context: a mixed studies review. Health Science Reports, 1(7), p.e45.