Type 2 diabetes continuing medical education for general practitioners: what works? A systematic review.

AIMS: To perform a systematic review of studies that have assessed the effectiveness of interventions designed to improve healthcare professionals' care of patients with diabetes and to assess the effects of educational interventions targeted at general practitioners' diabetes management. METHODS: A computer search was conducted using the Cochrane Library, PubMed, Ovid MEDLINE, Scopus, EMBASE, Informit, Google scholar and ERIC from the earliest date of each database up until 2013. A supplementary review of reference lists from each article obtained was also carried out. Measured changes in general practitioners' satisfaction, knowledge, practice behaviours and patient outcomes were recorded. RESULTS: Thirteen out of 1255 studies met the eligibility criteria, but none was specifically conducted in rural or remote areas. Ten studies were randomized trials. Fewer than half of the studies (5/13, 38.5%) reported a significant improvement in at least one of the following outcome categories: satisfaction with the programme, knowledge and practice behaviour. There was little evidence of the impact of general practitioner educational interventions on patient outcomes. Of the five studies that examined patient outcomes, only one reported a positive impact: a reduction in patient HbA1c levels. CONCLUSIONS: Few studies examined the effectiveness of general practitioner Type 2 diabetes education in improving general practitioner satisfaction, knowledge, practices and/or patient outcomes. Evidence to support the effectiveness of education is partial and weak. To determine effective strategies for general practitioner education related to Type 2 diabetes, further well designed studies, accompanied by valid and reliable evaluation methods, are needed.

Management of type 2 diabetes: Australian rural and remote general practitioners' knowledge, attitudes, and practices.

BACKGROUND: The gap between current and evidence-based best practice management of chronic diseases in Australian general practice is widely acknowledged. This study seeks to explore some of the factors underpinning this gap in relation to type 2 diabetes management in rural and remote general practice settings. METHODS: A cross-sectional survey of 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations between 10 000 and 30 000. RESULTS: A total of 209 completed surveys were returned for an overall response rate of 24.5%. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2%). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge around the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (n=87, (45.5%)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medical management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties. CONCLUSIONS: This national survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, GPs revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through continuing professional development. GP preferences for continuing medical education and information may inform future activities, to specifically address the needs of GPs in rural and remote locations.

Comparison of plain vertebral X-ray and dual-energy X-ray absorptiometry for the identification of older women for fracture prevention in primary care.

BACKGROUND: Recently, the dual-energy X-ray absorptiometry (DXA) diagnostic cut-off (T-score) for Australian Pharmaceutical Benefits Scheme (PBS) supported primary fracture prevention therapy with alendronate for older women (>70 years) has been changed from -3.0 to -2.5. AIM: To examine the impact of the expanded criteria for PBS-supported fracture prevention therapy in older women on case finding and cost. METHODS: One thousand, nine hundred and eighty-three women, median age 76 years, not previously known to have low bone mineral density by DXA or a vertebral fracture underwent DXA scanning and a thoracolumbar X-ray. A woman was considered eligible for fracture prevention therapy if she had a T-score ≤-2.5 at the femoral neck and/or the lumbar vertebrae (two to four) or at least one vertebral fracture of ≥20% deformity. RESULTS: Seven hundred and forty-six women (37.6%) met the new criteria as a case for PBS-subsidised fracture prevention therapy. Four hundred and thirty-one (21.7%) had a T-score ≤-2.5 on DXA compared with 10.6% (n = 210) with a T-score ≤-3.0. Four hundred and eighty-three (24.4%) had at least one vertebral fracture. Only 8.5% (n = 168) had both a T-score ≤-2.5 and a prevalent vertebral fracture. The cost per case found by DXA equated to $460 compared with $398 for screening by thoracolumbar X-ray. CONCLUSIONS: The use of either DXA or X-ray will identify approximately two-thirds of women aged 70 years and over who would be eligible for fracture prevention. The use of X-ray would identify a marginally larger number of women and at lower financial cost but involve substantially greater radiation exposure.

An examination of Australian general practitioners' knowledge, attitudes and practices in relation to sleep disorders.

BACKGROUND: Sleep disorders represent an under-recognised public health problem and are reported to be under-diagnosed in general practices. AIMS: To examine general practitioners' (GPs) attitude, knowledge and practice behaviour and identify barriers to detection, diagnosis and treatment of sleep disorders encountered in the Australian primary care setting. METHOD: Using mixed methods, quantitative data from the Dartmouth Sleep Knowledge Questionnaire (DSKQ) were analysed using MS Excel 2007. Qualitative data were obtained from one focus group and eight interviews. Data were thematically analysed. RESULTS: 15 GPs participated; seven in a focus group and eight in interviews. Scores from DSKQ suggest gaps in GPs' knowledge. Qualitative analysis revealed that patients frequently presented with sleep disorders underpinned by mental health disorders. GPs agreed that prescribing pharmacological interventions was undesirable and behavioural interventions were preferred. Barriers included limited training for GPs, lack of resources, patient expectations and willingness to engage in lifestyle changes, and consultation time constraints. DISCUSSION: Greater flexibility to investigate sleep related problems within the standard consultation and improved access to educational activities could assist GPs. Patient factors, such as adherence to management strategies, are paramount to successful management of sleep disorders; however, these obstacles to clinical practice may be difficult to overcome. CONCLUSION: Providing education for GPs about sleep disorders, greater flexibility within consultations may improve patient care and patient engagement in management strategies may assist, yet a critical success factor in disease management includes patient engagement in management strategies.

Management of Chronic Heart Failure in Primary Care: What Evidence do we have for Heart Failure with Preserved Systolic Function?

Chronic Heart Failure (CHF) is a debilitating illness commonly encountered in primary care. Its prevalence in developing countries is rising as a result of an ageing population, and an escalating epidemic of hypertension, type 2 diabetes and coronary heart disease. CHF can be specifically diagnosed as Heart Failure with Reduced Systolic Function (HF-RSF) or Heart Failure with Preserved Systolic Function (HF-PSF). This paper illustrates a common presentation of HF-PSF in primary care; and critically appraises the evidence in support of its diagnosis, prognosis and management. Regardless of the specific diagnosis, long term management of CHF is intricate as it involves a complex interplay between medical, psychosocial, and behavioural factors. Hence, there is a pressing need for a multidisciplinary team management of CHF in primary care, and this usually takes place within the broader context of an integrated chronic disease management programme. Primary care physicians are ideally suited to lead multidisciplinary teams to ensure better co-ordination, continuity and quality of care is delivered for patients with chronic conditions across time and settings. Given the rising epidemic of cardiovascular risk factors in the Malaysian population, preventive strategies at the primary care level are likely to offer the greatest promise for reducing the growing burden of CHF.

Evaluation of an internet-based psychological intervention for the treatment of erectile dysfunction.

Recent research on the treatment of erectile dysfunction (ED) has focused on medical interventions, in particular oral medications. The current study examined the effectiveness of an internet-based psychological intervention for this condition. In total, 31 men (12 in treatment group, 19 in control group) completed the program. The results demonstrated that men who completed the program reported improved erectile functioning and sexual relationship satisfaction and quality. The implications of these findings for the treatment of ED are discussed.

Training program in the field of addiction medicine - an experience of learning while abroad.

This paper illustrates the training program in the field of Addiction Medicine designed for primary care doctors by the Department of General Practice, School of Primary Care at Monash University in Melbourne. The nine month program was based around coursework, field visits and clinical observations. There were five modules that were completed and passed, twenty six Continuous Medical Education sessions attended, twenty nine field visits on Drug & Alcohol services, forty seven clinical visits and a total of three hundred and sixty clinical observations made. The comprehensive training program has benefited the first author in several ways to improve the Drugs & Alcohol services in Malaysia.

Impact of Master of Family Medicine degree by distance learning on general practitioners' career options.

INTRODUCTION: This study investigated the impact of a Master of Family Medicine degree (via distance education) on GPs' career options, and in particular, whether they were more likely to adopt university positions after the course. A secondary aim was to examine whether those who undertook a research project as part of their Masters took up different career options than Masters graduates who undertook a more clinically orientated course. METHODS: A questionnaire survey was posted to all 192 graduates of the Master of Family Medicine degree. Approximately one fifth of these resided overseas, with the majority in Hong Kong. RESULTS: The response rate was 68%. Graduates stated that they benefited from the course, particularly in the areas of clinical knowledge and improvement in 'academic' skills. Changes in careers, with increases in non-clinical appointments, did occur after the course for both the Research and Clinical Masters graduates. DISCUSSION: Responses to the survey indicated that graduates benefited in completing the course and changes in their career direction following graduation. However, whether the Masters course provided new skills to enable career change, or the GPs were in the process of change anyway, cannot be determined with certainty. Further studies, including interviews, are required to establish the impact of a distance education higher degree. CONCLUSION: The research output of general practice remains behind that of its specialist colleagues. Higher degrees for GPs might encourage them to undertake more academic pursuits, but the precise relationship still remains uncertain.

Complementary medicine use among people living with HIV/AIDS in Victoria, Australia: practices, attitudes and perceptions.

There is limited evidence suggesting the underlying reasons for the use of complementary and alternative medicines (CAMs) by people with HIV/AIDS, or individual attitudes and beliefs about the use of CAMs. Using focus groups and a survey with 151 individuals attending the HIV Clinics at The Alfred Hospital, Melbourne, we aimed to provide insights into factors that influence the use of CAMs among people living with HIV/AIDS. Roughly half (49%) of the participants had used CAMs to manage their HIV/AIDs. Users of CAMs utilized a wide range of treatments in managing their condition, but costs of the CAMs meant that users were not necessarily able to use them as much as they might have liked. Use of CAMs was based on a desire to find something beneficial rather than on being dissatisfied with conventional medicine. Further research is needed into (a) the effects of CAMs and (b) the enhancement of communication and collaboration between patients, doctors and complementary medicine practitioners.

Self-monitoring of blood glucose among diabetes patients attending government health clinics.

The aims of this study were (i) to determine the prevalence of self-monitoring of blood glucose (SMBG) among Type 2 diabetes patients attending government health clinics and (ii) to ascertain the factors influencing SMBG. Five hundred and fifty-six Type 2 diabetes patients from two government health clinics in Selangor and Negeri Sembilan were interviewed using a structured questionnaire. The total subjects of the study were 556 patients. Eighty-five patients (15.3%) of patients; performed SMBG. However, 170 subjects were included in the statistical analysis, 85 patients who were not self-monitoring were randomly selected and was compared with 85 patients who were self-monitoring. Among those who performed SMBG, the majority (83.5%) monitored less than once per day and only 16.5% monitored at least once a day. One-third of patients adjusted their medications based on their SMBG results. The higher patient's level of education (p= 0.024, CI 1.29 - 35.3); the higher total family income (p= 0.041, CI 1.26 - 4.79); the longer duration of diabetes (p<0.01, CI 2.22 - 7.29); and treatment regime which includes insulin (p< 0.001, CI 2.05 -9.24) were significant predictors of SMBG practice. Although SMBG is recognised to be useful and effective in achieving diabetes control, this study has found that only a minority of patients with diabetes performed SMBG. Hence healthcare personnel must increase awareness on the importance of SMBG and strongly promote the practice among diabetic patients.

Part II. General practitioner-specialist referral process.

This is the second of two articles that explore the general practitioner (GP)-specialist relationship. In this article, we explore the nature of the referral process, beginning with referrals frequently made by GPs in Australia and reasons for referral to specialists. In Australia, GPs commonly refer patients to specialists, particularly orthopaedic surgeons, ophthalmologists, surgeons and gynaecologists for a variety of reasons, including diagnosis or investigation, treatment and reassurance (reassurance for themselves as well as reassurance for the patient). GPs will choose a specialist after considering a variety of factors, such as the specialist's medical skill, their previous experience with the specialist, the quality of communication between them, office location and patient preferences. The referral is generally made by telephone or by letter, the latter of which is known to vary significantly in content and quality. The specialist, GP and patient expectations of the referral and the consultation process are also described. Specialists expect the GP to provide information about the problem to be addressed and adequate patient history, GPs expect a clear response regarding diagnosis and management as well as justification for the course of action, and patients expect clear communication and explanation of the diagnosis, treatment and follow-up requirements. When these expectations remain unmet, GPs, specialists and patients end up dissatisfied with the referral process.

Part I. General practitioner-specialist relationship.

This article is the first of a two-part series that seeks to explore the relationship and interaction between general practitioners (GPs) and medical specialists. A historical account of the medical profession is given, beginning from the tripartite division (i.e. the physicians, surgeons or barbers and the apothecaries), the Apothecaries Act of 1815, and the Medical Act of 1858. An account is also given of factors that exacerbated the division and friction between GPs and specialists, and how general practice developed in Australia. The role of the GP is stated as the provision of primary care, preventive care, patient-centred care, continuing care, comprehensive care, and community-based care to individuals and their families. The role of the specialists on the other hand is that of a consultant to advise GPs who carry on the management after the patient leaves the specialist. The dynamics of the GP-specialist relationship are discussed in relation to power, interdependence, morale, public image, education and training, and support from the Colleges, and we conclude by discussing the importance of collaboration between professions.

Depressive disorders in elderly Chinese patients in Macau: a comparison of general practitioners' consultations with a depression screening scale.

OBJECTIVE: The objectives of this study were to identify the prevalence of depressive symptomatology in an elderly population using a screening scale; to assess general practitioner (GP) recognition of depression; to determine patient reasons for consultation; and to relate depression to social and demographic factors. METHOD: An analytical cross-sectional study was carried out on a systematic sample of elderly Chinese patients currently resident in Macau, who presented to general practices in December 1997. Data collected included patient demographics, economic and social supports, patient depressive status assessed using the Hospital Anxiety and Depression scale (HAD), reason for attendance, and the reason for the consultation. Clinical records were analysed in order to collect GP-registered morbidity and recent relevant management. RESULTS: Data were collected from 386 elderly Chinese patients of 31 GPs (97% patient response rate). Patients presented with somatic symptoms rather than psychological issues. Using HAD cut-off score of >8, 47% of the population studied were depressed; with a HAD subscale score >11, 26.2% were depressed. Depression was detected more often in women (59%) and being female was associated with depressive status (p = 0.010). Age (greater than 75 years) was also associated with being depressed, as was not having someone to talk to (p = 0.037), and being from low social class (p = 0.050). Not having someone willing to listen to their problems, difficulties and worries, was significantly related to depression (p = 0.041). There were no referrals or antidepressive medications detected in the clinical charts. CONCLUSION: Participants' characteristics such as being over 75 years of age, being female and socially isolated were related to depression. General practitioners can play an important role in the early detection and management of psychological disorders. Although studies on a sample of Chinese patients in Macau cannot be generalized to Chinese populations elsewhere, awareness of somatic presentation of psychological illness is crucial in detecting depression in this and possibly other Chinese populations.

Medico-legal knowledge of general practitioners: disjunctions, errors and uncertainties.

This article discusses a survey of Victorian general practitioners which investigated doctors' legal knowledge, the impact of law on clinical practice, doctors' current medico-legal information sources and their legal education needs and preferences. Knowledge of legal standards was investigated in relation to three areas: disclosure of risk; ownership of, and access to, medical records; and proxy decision-making. Additionally, the impact of statutory reform in relation to proxy decision-making was explored. Further, doctors' past experience of medico-legal education, current sources of medico-legal information and preferences concerning future medico-legal information were explored. Results indicated that overall, respondents had a very inadequate understanding of relevant law and that relevant statutory standards have had little impact on clinical practice. Professional bulletins and journals were identified as major current legal information sources, whilst printed materials, seminars and conferences were preferred sources of legal information. The authors conclude that there is a significant disjunction between legal standards and doctors' awareness of those standards, thereby creating a significant source of liability for doctors. Results highlight an urgent need to develop legal education programs for general practitioners based on doctors' identified needs and preferences.

A comparative study of venlafaxine with a focused education and psychotherapy program versus venlafaxine alone in the treatment of depression in general practice.

The efficacy of a focused education and psychotherapy program (FEPP) plus antidepressant was compared with that of usual psychosocial treatment and antidepressant in a general practice setting. The FEPP comprised interpersonal counselling (IPC) delivered in a modified way to suit the general practice setting, together with patient education and selected cognitive behavioural techniques. All patients were treated with venlafaxine-XR. Thirty-one patients entered the study, three withdrawing before completion of the 12 week trial. Both treatments produced a statistically significant reduction in BDI and POMS scores from baseline, with greater improvement evident in the FEPP plus antidepressant group. Copyright 2001 John Wiley & Sons, Ltd.

Chinese attitudes to institutional care of their aged. A study of members from the Chung Wah Association, Western Australia.

OBJECTIVE: To examine Chinese attitudes to institutional care of their aged and to identify the factors that influence these attitudes. METHOD: A cross sectional survey of 815 randomly selected members of the Chung Wah Association, Western Australia was undertaken in 1997 using a mailed self administered questionnaire. The survey instrument was developed through a literature review, interviews and pilot testings and consisted of categorical and noncategorical items. The data were analysed using the SAS (V 6.12) software package. Factor analysis, logistic regression and Chi-square analysis were used on the data. The statistical significance level was set at p < or = 0.05. RESULTS: A total of 431 (53%) completed responses were received. The study showed that 86% of the respondents agreed that the disabled elderly should be institutionalised. Age contributed mainly to the respondents' attitudes to institutionalising the disabled elderly, while the respondents' sex, education, occupation, country of origin and length of residence in Australia did not. Social responsibilities together with the health factors of the elderly had important effects on these attitudes. About 55% of respondents agreed that their Chinese culture influenced their attitude. Only 21% of the respondents agreed that the nondisabled elderly should be institutionalised, 54% disagreed, while 24% remained neutral. Respondents who were likely to institutionalise their disabled elderly were also unlikely to live with their children when they became disabled. A majority of respondents were in favour of government funding of institutions and care givers of the elderly. CONCLUSION: The study provided several important observations and information for health planners and general practitioners to identify the aged at risk of institutionalisation and make arrangements for community support for effected families so that the aged can be encouraged to remain with their families.