Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials.

RATIONALE: To determine whether spirometry and regular medical review improved quality of life or other outcomes in children and adolescents with asthma. METHODS: We conducted two cluster randomized controlled trials. We recruited 238 asthma patients aged between 7 and 17 years from 56 general practices in South Eastern Australia. Participants were randomized to receive an intervention that included spirometry or usual care. The main outcome measure was asthma related quality of life. RESULTS: Baseline characteristics were well matched between the intervention and control groups. Neither trial found any difference in asthma related quality of life between groups. However because of measurement properties, a formal meta-analysis could not be performed. Nor were there any significant effects of the intervention upon asthma attacks, limitation to usual activities, nocturnal cough, bother during physical activity, worry about asthma, or written asthma action plans. CONCLUSIONS: The findings do not support more widespread use of spirometry for the management of childhood asthma in general practice, unless it is integrated into a complete management model.

Practice nurse involvement in general practice clinical care: policy and funding issues need resolution.

In Australia, primary care-based funding initiatives have been implemented to encourage general practices to employ practice nurses. The aim of this paper is to discuss limitations of the current funding and policy arrangements in enhancing the clinical role of practice nurses in the management of chronic conditions. This paper draws on the results of a real-world economic evaluation, the Primary Care Services Improvement Project (PCSIP). The PCSIP linked routinely collected clinical and resource use data to undertake a risk-adjusted cost-effectiveness analysis of increased practice nurse involvement in clinical-based activities for the management of diabetes and obesity. The findings of the PCSIP suggested that the active involvement of practice nurses in collaborative clinical-based activities is cost-effective, as well as addressing general practice workforce issues. Although primary healthcare organisations (e.g. Medicare Locals) can play a key role in supporting enhanced practice nurse roles, improvements to practice nurse funding models could further encourage more efficient use of an important resource.

Practice nurse involvement in primary care depression management: an observational cost-effectiveness analysis.

BACKGROUND: Most evidence on the effect of collaborative care for depression is derived in the selective environment of randomised controlled trials. In collaborative care, practice nurses may act as case managers. The Primary Care Services Improvement Project (PCSIP) aimed to assess the cost-effectiveness of alternative models of practice nurse involvement in a real world Australian setting. Previous analyses have demonstrated the value of high level practice nurse involvement in the management of diabetes and obesity. This paper reports on their value in the management of depression. METHODS: General practices were assigned to a low or high model of care based on observed levels of practice nurse involvement in clinical-based activities for the management of depression (i.e. percentage of depression patients seen, percentage of consultation time spent on clinical-based activities). Linked, routinely collected data was used to determine patient level depression outcomes (proportion of depression-free days) and health service usage costs. Standardised depression assessment tools were not routinely used, therefore a classification framework to determine the patient's depressive state was developed using proxy measures (e.g. symptoms, medications, referrals, hospitalisations and suicide attempts). Regression analyses of costs and depression outcomes were conducted, using propensity weighting to control for potential confounders. RESULTS: Capacity to determine depressive state using the classification framework was dependent upon the level of detail provided in medical records. While antidepressant medication prescriptions were a strong indicator of depressive state, they could not be relied upon as the sole measure. Propensity score weighted analyses of total depression-related costs and depression outcomes, found that the high level model of care cost more (95% CI: -$314.76 to $584) and resulted in 5% less depression-free days (95% CI: -0.15 to 0.05), compared to the low level model. However, this result was highly uncertain, as shown by the confidence intervals. CONCLUSIONS: Classification of patients' depressive state was feasible, but time consuming, using the classification framework proposed. Further validation of the framework is required. Unlike the analyses of diabetes and obesity management, no significant differences in the proportion of depression-free days or health service costs were found between the alternative levels of practice nurse involvement.

A model-based economic evaluation of improved primary care management of patients with type 2 diabetes in Australia.

BACKGROUND: There are few studies investigating the economic value of the Australian practice nurse workforce on the management of chronic conditions. This is particularly important in Australia, where the government needs evidence to inform decisions on whether to maintain or redirect current financial incentives that encourage practices to recruit practice nurses. OBJECTIVE: The objective of this study was to estimate the lifetime costs and quality-adjusted life-years (QALYs) associated with two models of practice nurse involvement in clinical-based activities (high and low level) in the management of type 2 diabetes within the primary care setting. METHODS: A previously validated state transition model (the United Kingdom Prospective Diabetes Study Outcomes Model) was adapted, which uses baseline prognostic factors (e.g. gender, haemoglobin A1c [HbA1c]) to predict the risk of occurrence of diabetes-related complications (e.g. stroke). The model was populated by data from Australian and UK observational studies. Costs and utility values associated with complications were summed over patients' lifetimes to estimate costs and QALY gains from the perspective of the health care system. All costs were expressed in 2011 Australian dollars (AU$). The base-case analysis assumed a 40-year time horizon with an annual discount rate of 5 %. RESULTS: Relative to low-level involvement of practice nurses in the provision of clinical-based activities, the high-level model was associated with lower mean lifetime costs of management of complications (-AU$8,738; 95 % confidence interval [CI] -AU$12,522 to -AU$4,954), and a greater average gain in QALYs (0.3; 95 % CI 0.2-0.4). A range of sensitivity analyses were performed, in which the high-level model was dominant in all cases. CONCLUSION: Our results suggest that the high-level model is a dominant management strategy over the low-level model in all modelled scenarios. These findings indicate the need for effective primary care-based incentives to encourage general practices not only to employ practice nurses, but to better integrate them into the provision of clinical services.

Microbiological contamination of spirometers - an exploratory study in general practice.

BACKGROUND: Spirometry is an important tool when diagnosing chronic respiratory conditions in general practice. However, the equipment may harbour pathogenic micro-organisms and cross-transmission of aerolised pathogens could occur if hygiene measures are insufficient. METHODS: We assessed microbiological contamination in 16 spirometers from a convenience sample of South Australian general practices. Results We found potentially relevant microbiological contamination in three spirometers: two Pseudomonas spp.; one coagulase negative Staphylococcus sp. and one Alcaligenes sp. Although the three practices concerned all reported to have a written spirometer cleaning protocol in place, the frequency of spirometer disinfection did not match the manufacturers' DISCUSSION: Despite the small size of our study sample, we found potentially relevant microbiological contamination in 3 out of 16 spirometers from metropolitan general practices. The potential hazard of spirometers as reservoirs of microorganisms stresses the need for stricter attention to hygiene measures for spirometer maintenance in general practices.

Does spirometry training in general practice improve quality and outcomes of asthma care?

OBJECTIVE: Clinical asthma guidelines recommend spirometry for asthma diagnosis, but there is inconsistent evidence about benefits to patients in using it for ongoing management. Our aim was to determine whether training in the use of spirometry for management of asthma provided better health outcomes and improved the quality of care in the primary care setting. DESIGN: Pragmatic, cluster randomized controlled trial. SETTING: General practices in two states of Australia. PARTICIPANTS: Forty practices and 397 adults with asthma. INTERVENTION: The staff of 26 intervention practices received comprehensive spirometry training. Fourteen control practices provided usual care. MAIN OUTCOME MEASURES: Primary outcome measures were quality of life, self-reported asthma symptoms and lung function. Secondary measures related to the process of care (e.g. performance of spirometry, preparation of a written asthma action plan) and patient and general practitioner rating of the acceptability and usefulness of spirometry. RESULTS: There were no statistically significant differences between the groups at 12 months for quality of life (mean difference = -0.23; 95% CI: -0.44, -0.01), days off work (rate ratio = 1.52; 95% CI: 0.91, 2.54), exacerbations (rate ratio = 1.09; 95% CI: 0.85, 1.41), asthma on waking (rate ratio = 1.21; 95% CI: 0.79, 1.85), nocturnal asthma (rate ratio = 0.98; 95% CI: 0.63, 1.51) and post-bronchodilator FEV(1)/FVC ratio (mean difference = -0.01, 95% CI: -0.03, 0.02). There was no improvement in the quality of care provided. CONCLUSIONS: Training in spirometry did not result in any measurable improvement in the use of spirometry, quality of management of asthma or patient outcomes in primary care.

A tool to measure whether business management capacity in general practice impacts on the quality of chronic illness care.

Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

Systematic care for asthma in Australian general practice: a randomised controlled trial.

OBJECTIVE: To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma. DESIGN AND SETTING: Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group. PARTICIPANTS: 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids. MAIN OUTCOME MEASURES: Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months. RESULTS: Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0-3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators. CONCLUSION: We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12605000091606.

Spirometry and impulse oscillometry (IOS) for detection of respiratory abnormalities in metropolitan firefighters.

BACKGROUND AND OBJECTIVE: As firefighters are at increased risk of adverse health effects, periodic examination of their respiratory health is important. The objective of this study was to establish whether the use of impulse oscillometry (IOS) reveals respiratory abnormalities in metropolitan firefighters that go undetected during routine respiratory health screening by spirometry and assessment of respiratory symptoms. METHODS: This was a cross-sectional analysis of spirometry, IOS and questionnaire data from 488 male firefighters. Abnormal spirometry was defined as FEV(1), FEV(1)/FVC and/or FEF(50) below the lower limit of normal. Abnormal IOS was defined as resistance at 5 Hz (R5), frequency dependence of resistance (DeltaR5-R20) and/or reactance area (AX) above the upper limit of normal. Respiratory symptoms, smoking history, exposures and medical history were assessed. Data were analysed using logistic and linear regression models. RESULTS: The mean age of the firefighters was 43.8 (SD 8.4) years. There were 123 (25%) former smokers and 50 (10%) current smokers. Abnormal spirometry was detected in 12%, abnormal IOS in 9% and respiratory symptoms in 20% of firefighters. Current smoking was associated with all IOS parameters (OR for R5 = 3.1, OR for DeltaR5-R20 = 7.7, OR for AX = 4.3), and with FEF(50) (OR = 9.1), chronic productive cough (OR = 4.0) and breathlessness (OR = 5.4) (P < 0.05 for all). Exposure during firefighting duties was associated with chronic productive cough (OR = 2.6), but not with spirometry or IOS parameters. Interaction terms in the linear regression models indicated associations between smoking and DeltaR5-R20, and also between smoking and AX, in the lowest and second lowest quartiles of spirometry parameters. CONCLUSIONS: Application of IOS for the assessment of respiratory health in firefighters identified airways dysfunction in some individuals, even when spirometry values were within the normal range and there were no respiratory symptoms.

Lung function and health status in metropolitan fire-fighters compared to general population controls.

PURPOSE: To assess health status of South Australian (SA) metropolitan fire-fighters in terms of lung function and health-related quality of life, compare these with general population controls, and explore associations between fire-fighters' self-reported occupational exposure and health status. METHODS: The study was a cross-sectional comparison of (respiratory) health indices between 501 fire-fighters and 1,324 general population controls taken from the North West Adelaide Health Study (NWAHS). All were men aged 21 to 61. Measurements included spirometry (i.e., forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), mid-expiratory flow (FEF(25-75)) and the Short Form 36 (SF-36) health-related quality of life questionnaire. RESULTS: Health status in the fire-fighters was generally better than in NWAHS controls. Mean % predicted FEV(1) and FVC were 103.4% [SD 12.1] versus 89.5% [13.7] and 110.0% [11.6] versus 88.5% [12.5] (both p < 0.001 in linear regression analysis, adjusted for age, smoking, BMI, and FEV(1) % predicted). FEV(1)/FVC and FEF(25-75) were significantly lower in the fire-fighters (p < 0.003). A total of 93 (18.6%) fire-fighters and 82 (6.2%) controls had an FEV(1)/FVC < 70% (p < 0.001). The SF-36 Mental Health scale was the only scale on which fire-fighters had a lower mean score (p = 0.009), but none of the SF-36 scales showed clinically meaningful differences between the cohorts. Fire-fighters exposed > 6 h/week to dust, smoke, and fire showed lower FEV(1), FEV(1) % predicted, and FVC values compared to those who were less exposed (p < 0.05). CONCLUSIONS: Male metropolitan fire-fighters showed better general health, better lung health, and similar mental health compared to general population controls. The high rate of fire-fighters with FEV(1)/FVC values below the recommended cut-point for airflow obstruction illustrates the inappropriateness of this clinical cut-point for use in populations preselected on their physical fitness. The observed dose-effect relationship between self-reported occupational exposure and fire-fighters' lung function warrants further investigation.

Chronic Care Team Profile: a brief tool to measure the structure and function of chronic care teams in general practice.

AIM: At a time when workforce shortages in general practices are leading to greater role substitution and skill-mix diversification, and the demand on general practices for chronic disease care is increasing, the structure and function of the general practice team is taking on heightened importance. To assist general practices and the organizations supporting them to assess the effectiveness of their chronic care teamworking, we developed an interview tool, the Chronic Care Team Profile (CCTP), to measure the structure and function of teams in general practice. This paper describes its properties and potential use. METHOD: An initial pool of items was derived from guidelines of best-practice for chronic disease care and performance standards for general practices. The items covered staffing, skill-mix, job descriptions and roles, training, protocols and procedures within the practice. The 41-item pool was factor analysed, retained items were measured for internal consistency and the reduced instrument's face, content and construct validity were evaluated. RESULTS: A three-factor solution corresponding to non-general practitioner staff roles in chronic care, administrative functions and management structures provided the best fit to the data and explained 45% of the variance in the CCTP. Further analyses suggested that the CCTP is reliable, valid and has some utility. DISCUSSION: The CCTP measures aspects of the structure and function of general practices which are independent of team processes. It is associated with the job satisfaction of general practice staff and the quality of care provided to patients with chronic illnesses. As such, the CCTP offers a simple and useful tool for general practices to assess their teamworking in chronic disease care.

Management of asthma in Australian general practice: care is still not in line with clinical practice guidelines.

OBJECTIVE AND BACKGROUND: We investigated the quality of primary care asthma management in a sample of Australian general practices. METHODS: 247 general practitioners (GPs) from 97 practices completed a structured interview about management of asthma, diabetes and hypertension/heart disease. A further structured interview with the senior practice principal and practice manager was used to collect information about practice capacity for chronic disease management. RESULTS: Just under half of GPs (47%) had access to an asthma register and the majority (76%) had access to spirometry in their practice. In terms of routine management of asthma, 12% of GPs reported using spirometry routinely, 13% routinely reviewed written asthma action plans, 27% routinely provided education about trigger factors, 30% routinely reviewed inhaler technique, 24% routinely assessed asthma severity, and 29% routinely assessed physical activity. Practice characteristics such as practice size (p=1.0) and locality (rural/metropolitan) (p=0.7) did not predict quality of asthma management nor did indicators of practice capacity including Business maturity, IT/IM maturity, Multidisciplinary teamwork, and Clinical linkages. CONCLUSION: Gaps remain in the provision of evidence-based care for patients with asthma in general practice. Markers of practice capacity measured here were not associated with guideline-based respiratory care within practices.

Validation of an instrument to measure inter-organisational linkages in general practice.

PURPOSE: Linkages between general medical practices and external services are important for high quality chronic disease care. The purpose of this research is to describe the development, evaluation and use of a brief tool that measures the comprehensiveness and quality of a general practice's linkages with external providers for the management of patients with chronic disease. In this study, clinical linkages are defined as the communication, support, and referral arrangements between services for the care and assistance of patients with chronic disease. METHODS: An interview to measure surgery-level (rather than individual clinician-level) clinical linkages was developed, piloted, reviewed, and evaluated with 97 Australian general practices. Two validated survey instruments were posted to patients, and a survey of locally available services was developed and posted to participating Divisions of General Practice (support organisations). Hypotheses regarding internal validity, association with local services, and patient satisfaction were tested using factor analysis, logistic regression and multilevel regression models. RESULTS: The resulting General Practice Clinical Linkages Interview (GP-CLI) is a nine-item tool with three underlying factors: referral and advice linkages, shared care and care planning linkages, and community access and awareness linkages. Local availability of chronic disease services has no affect on the comprehensiveness of services with which practices link, however, comprehensiveness of clinical linkages has an association with patient assessment of access, receptionist services, and of continuity of care in their general practice. CONCLUSIONS: The GP-CLI may be useful to researchers examining comparable health care systems for measuring the comprehensiveness and quality of linkages at a general practice-level with related services, possessing both internal and external validity. The tool can be used with large samples exploring the impact, outcomes, and facilitators of high quality clinical linkages in general practice.

Job satisfaction of staff and the team environment in Australian general practice.

OBJECTIVE: To study the work satisfaction of general practice staff, the differences between types of staff, and the individual and organisational factors associated with work satisfaction. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional multipractice study based on a self-completed job satisfaction survey of 626 practice staff in 96 general practices in Australia between 16 December 2003 and 8 October 2004. MAIN OUTCOME MEASURES: Job satisfaction scores for all staff and for general practitioners alone; relationship between job satisfaction and the team climate, practice size, particular jobs within practices, demographic characteristics of participants, and geographical location of practices. RESULTS: The response rate was 65%. Job satisfaction was high, with a mean score of 5.66 (95% CI, 5.60-5.72). Multilevel analysis showed that all general practice staff were highly satisfied if they worked in a practice with a good team climate. Practice managers reported the highest satisfaction with their work. Practice size and individual characteristics such as the sex of the participant were unrelated to job satisfaction. GPs tended to have lower satisfaction than other staff in relation to income, recognition for good work and hours of work. Rural GPs were more satisfied. CONCLUSIONS: Most general practice staff are satisfied with their work. Facilitating teamwork may be a key strategy for both recruitment and retention of the general practice workforce, especially staff who are not GPs.

Quality of chronic disease care in general practice: the development and validation of a provider interview tool.

BACKGROUND: This article describes the development and psychometric evaluation of an interview instrument to assess provider-reported quality of general practice care for patients with diabetes, cardiovascular disease and asthma--the Australian General Practice Clinical Care Interview (GPCCI). METHODS: We administered the GPCCI to 28 general practitioners (family physicians) in 10 general practices. We conducted an item analysis and assessed the internal consistency of the instrument. We next assessed the quality of care recorded in the medical records of 462 of the general practitioners' patients with Type 2 diabetes, ischaemic heart disease/hypertension and/or moderate to severe asthma. This was then compared with results of the GPCCI for each general practice. RESULTS: Good internal consistency was found for the overall GPCCI (Cronbach's alpha = 0.75). As far as the separate sub-scales were concerned, diabetes had good internal consistency (0.76) but the internal consistency of the heart disease and asthma subscales was not strong (0.49 and 0.16 respectively). There was high inter-rater reliability of the adjusted scores of data extracted from patients' medical notes for each of the three conditions. Correlations of the overall GPCCI and patients' medical notes audit, combined across the three conditions and aggregated to practice level, showed that a strong relationship (r = 0.84, p = 0.003) existed between the two indices of clinical care. CONCLUSION: This study suggests that the GPCCI has good internal consistency and concurrent validity with patients' medical records in Australian general practice and warrants further evaluation of its properties, validity and utility.

Organisational capacity and chronic disease care: an Australian general practice perspective.

Although we are rapidly improving our understanding of how to manage patients with chronic illness in Australian general practice, many patients are still receiving suboptimal care. General practices have limited organisational capacity to provide the structured care that is required for managing chronic conditions: regular monitoring, decision support, patient recall, supporting patient self management, team work, and information management. This requires a shift away from episodic, acute models. Overseas research has shown that areas such as team work, clinical information systems, decision support, linkages and leadership are also important in managing chronic illness, but we do not know which of these are most important in Australia.

Chronic disease management in Australia: evidence and policy mismatch, with asthma as an example.

All Western countries are developing and implementing new models for managing asthma. In Australia, the Asthma 3+ Visit Plan was implemented in 2001-2002, with the aim of establishing a structured approach in general practice for people with moderate and severe asthma, within a fee-for-service system. Evidence is emerging that the uptake across general practice has been poor, with approximately 5% of eligible people being enrolled. The reasons for the poor uptake include such factors as an inability to identify people with asthma, general practitioners being too busy with other clinical priorities, and the lack of interest and understanding of the need for a structured approach for this disease. This mismatch between evidence and policy development needs to be rectified, if sustainable models of chronic disease care are to be firmly established in general practice.