Infant gastro-oesophageal reflux disease (GORD): Australian GP attitudes and practices.

AIM: The aim of this study was to evaluate the attitudes and practices of Australian general practitioners (GPs) regarding infant gastro-oesophageal reflux disease (GORD) diagnosis and management. METHODS: A national cross-sectional survey, involving a random sample of currently practising Australian GPs (n = 2319) was undertaken between July and September 2011. GPs attitudes and management of infant GORD were surveyed via an online and paper-based 41-item questionnaire. RESULTS: In total, 400 responses were analysed (17.24% response rate). The majority of GPs employed empirical trials of acid-suppression medication and/or lifestyle modifications to diagnose infant GORD. GPs frequently recommended dietary modification despite the belief that they were only moderately effective at best. In addition, GPs frequently prescribed acid-suppression medication, despite concerns regarding their safety in the infant population. Other GP concerns included the lack of clinical guidelines and education for GPs about infant GORD, as well as the level of evidence available for the safety and efficacy of diagnostic tests and treatments. CONCLUSION: Despite the important role Australian GPs play in the diagnosis and management of infant GORD, high-level evidence-based guidelines for GPs are lacking. Consequently, GPs engage in diagnostic and management practices despite their concerns regarding the safety and effectiveness.

GPs, families and children's perceptions of childhood obesity.

BACKGROUND: Childhood obesity has a high risk of becoming a chronic disease requiring life-long weight management. Evidence based guidelines were developed and distributed to GPs throughout Australia by the NHMRC, but current application falls short. Measuring height and weight, and calculating BMI for children appears to be rare. Some general practitioners (GPs) perceive significant barriers to managing this patient cohort, and patients report not having confidence in their GPs. AIM: To explore perceptions and experiences of treating childhood obesity of (i) GPs, (ii) families involved in a childhood obesity study in general practiceâ?? and (iii) families not involved in the project, but who had concerns about childhood obesity. METHODOLOGY: Supported by the literature, a semi-structured schedule was developed to address the aims. Ten GPs and eight families involved, and four families previously not involved in the project participated in interviews in 2009. All family interviews were audio-taped and transcribed verbatim. Data were thematically analyzed. FINDINGS: Five themes emerged: (1) raising the topic, (2) frustrations experienced by GPs and families, (3) support available for GPs to provide to families and/or anticipated by families, (4) successes from involvement in the project and (5) sustaining improvements â?? the GPsâ?? and family's perspectives. DISCUSSION AND CONCLUSION: All acknowledged that childhood obesity is a sensitive issue with both GPs and parents preferring the other to raise the topic. GPs reported successes in practice and patient management such as improved patient records. For families, the GPs dedication and support were major factors sought.

Adapting lung cancer symptom investigation and referral guidelines for general practitioners in Australia: reflections on the utility of the ADAPTE framework.

RATIONALE: The ADAPTE framework was established to enhance efficiency in guideline development and to facilitate adaptation of high-quality clinical practice guidelines for a local context. It offers guideline developers a systematic methodology for guideline adaptation; however, the feasibility and usability of the process has not been widely evaluated. AIM: A pragmatic approach was undertaken throughout the evaluation of the ADATPE process throughout the development of a guide for general practitioners in Australia regarding the initial investigation of symptoms of lung cancer. At each step of the framework all members of the project team leading the development process reflected on the steps outlined in the ADAPTE. The reflections were collated into a lesson-learned log and analysed following completion of the project. RESULTS: Several opportunities for improvement were identified to improve usability and practicability of the ADAPTE framework. These items were both specific, in response to using steps and tools, and general issues concerned with the overall ADAPTE framework. Key challenges to using ADAPTE, highlighted in this study, were the lack of clarity about efficiency of the guideline adaptation process, level of assumed knowledge and expertise, and requirement of resources. In response to these challenges, modifications to the ADAPTE have been recommended. CONCLUSION: The ADAPTE framework offers an attractive alternative to de novo guideline synthesis in circumstances where high-quality, compatible guidelines already exist. Pending further evaluation, the modifications identified in this study may be applied to future versions of ADAPTE to improve usability and feasibility of the framework.

Managing chronic disease--patients' views and attitudes to using a broadband based service.

BACKGROUND: The uptake of chronic disease management initiatives among general practitioners remains low. cdmNet is a broadband based service used to assist registered care providers in developing GP management plans, team care arrangements, reviews and home medicines review for patients with a chronic disease. This study examined patients' views and attitudes of managing chronic disease using cdmNet. METHODS: Cross-sectional survey consisting of an anonymous questionnaire was completed by patients whose chronic diseases were managed using the broadband based service. RESULTS: Significant correlation was found between GPs' use of this broadband based service, and patients' perception that using a broadband based service will improve their control of chronic disease (p<0.001). Patients who felt confident their personal information would be kept private were also significantly more likely to recommend cdmNet (p<0.001). DISCUSSION: Patients who feel that technology may contribute to improving the management of their chronic disease and have an understanding of privacy are more likely to have positive views and attitudes toward using a broadband based service.

Severely obese people with diabetes experience impaired emotional well-being associated with socioeconomic disadvantage: results from diabetes MILES - Australia.

AIM: To examine the emotional well-being of severely obese Australians with type 2 diabetes, along with markers of social and economic disadvantage, using the Diabetes MILES - Australia dataset. METHODS: Diabetes MILES - Australia was a national survey of 3338 adults with diabetes that focused on psychosocial issues; 1795 had type 2 diabetes and reported BMI. We extracted data regarding depression (PHQ-9), anxiety (GAD-7), obesity- and diabetes-related comorbidities, and demographics. The severely obese group (SOG) (BMI ≥ 35; median BMI=41.6) constituted 530 (30%) of the type 2 diabetes respondents and was matched with 530 controls (CG) (BMI<35; median BMI=28.2). Within- and between-group trends were examined. RESULTS: The SOG had higher depression scores (median (IQR) 6.0 (3-12)) than CG (5.0 (2-10)); p<0.001, and were more likely to report moderate-severe depressive symptoms (37% versus 27%; p<0.001). The groups did not differ on anxiety. The SOG, compared with the CG, were more likely to live alone (21% versus 17%), receive a disability pension (21% versus 15%), earn ≤$40.000/year (51% versus 41%; all p<0.05), and were less likely to be employed (46% versus 53%), university or higher educated (17% versus 26%), or have health insurance (50% versus 60%; all p ≤ 0.01). Moderate-severe depression was positively associated with cumulative stressors of severe obesity, socioeconomic disadvantage, and obesity- and diabetes-related comorbidity. CONCLUSIONS: Severely obese people living with type 2 diabetes have cumulative stressors related to health, disability, demographic and socioeconomic factors, and impaired emotional well-being.

Solid versus liquid-satiety study in well-adjusted lap-band patients.

BACKGROUND: Patients following laparoscopic adjustable gastric banding (LAGB) are generally advised to avoid liquid calories, opt for solids and refrain from drinking with meals as this is believed to prolong satiety. The role of food consistency and satiety following LAGB is largely uninvestigated. The purpose of the study was to: (1) determine if food consistency impacts on post meal satiety in participants with well-adjusted LAGB and (2) compare the level of satiety achieved after consuming a solid versus a liquid meal between groups. METHODS: Twenty intervention (well-adjusted LAGB) and 20 control participants were recruited. All participants consumed three iso-caloric breakfasts that were randomised for nine mornings. Participants were asked to rate their satiety on visual analogue scales (VAS) at set times after the test meal. Areas under the curve (AUC) VAS scores were compared within and between groups. RESULTS: Solids (bars) with or without water provided greater satiety than the liquids (shakes) for both groups. Drinking water with the bar did influence satiety in the intervention group. For the intervention group (LAGB), AUC VAS values for the bar with water were 77.4 ± 11.2* and 72.4 ± 16.7* for the controls. CONCLUSION: Solid meals are more satisfying in both LAGB and non-LAGB individuals. However, a solid meal with accompanying water did not alter meal satiety.

Difficult-to-treat-depression: what do general practitioners think?

OBJECTIVE: To understand the perspectives of a group of general practitioners regarding management of patients with difficult-to-treat depression (DTTD). DESIGN, SETTING AND PARTICIPANTS: A qualitative approach using a focus group and semi-structured telephone interviews conducted in 2011 with 10 GPs from urban and rural Victoria. Five main topics were explored: (1) understanding of DTTD; (2) understanding of other terms used to describe DTTD; (3) experiences of diagnosing DTTD; (4) experiences of managing DTTD; and (5) management options. RESULTS: The participants had generally poor recognition of diagnostic terms, and questioned their relevance. Participants felt that management guidelines were not always helpful. Access to psychiatrists was often difficult, and non-pharmacological or complementary treatments were considered to have a role in management. Environmental and cultural factors, social isolation and cost of treatment have an impact on patient adherence, and the participants felt that the professional-patient relationship is important in ensuring comprehensive care. CONCLUSIONS: Despite extensive experience and knowledge of their patients, there were gaps in GPs' appraisal of the literature and about specific resources available. The GPs had little interest in the nuances of classifications; instead, their focus was on their patient and what to do in practical terms regarding optimal management.

Computer assisted chronic disease management: does it work? A pilot study using mixed methods.

Background. Key factors for the effective chronic disease management (CDM) include the availability of practical and effective computer tools and continuing professional development/education. This study tested the effectiveness of a computer assisted chronic disease management tool, a broadband-based service known as cdmNet in increasing the development of care plans for patients with chronic disease in general practice. Methodology. Mixed methods are the breakthrough series methodology (workshops and plan-do-study-act cycles) and semistructured interviews. Results. Throughout the intervention period a pattern emerged suggesting GPs use of cdmNet initially increased, then plateaued practice nurses' and practice managers' roles expanded as they became more involved in using cdmNet. Seven main messages emerged from the GP interviews. Discussion. The overall use of cdmNet by participating GPs varied from "no change" to "significant change and developing many the GPMPs (general practice management plans) using cdmNet." The variation may be due to several factors, not the least, allowing GPs adequate time to familiarise themselves with the software and recognising the benefit of the team approach. Conclusion. The breakthrough series methodology facilitated upskilling GPs' management of patients diagnosed with a chronic disease and learning how to use the broadband-based service cdmNet.

The Attitudes and Practices of General Practitioners about the Use of Chaperones in Melbourne, Australia.

Introduction. To consider the use of medical chaperones during certain clinical examinations is important whether one practises as a specialist, nurse, medical student, or generalist. Chaperones have been used by doctors conducting intimate examinations for many years but their true extent remains largely unknown. Until recently, there was no national guidance in Australia. Aim. To explore the attitudes and practices of general practitioners (GP) regarding their use of chaperones in urban Melbourne, Australia. Method. Qualitative two focus groups involving seventeen GPs from two locations. Discussions were audio-taped, transcribed verbatim and analysed. Results. Common themes and subthemes emerged which were grouped into three main areas: (a) practitioner-related, (b) patient-related and (c) practice related. Discussion. This is the first study from an Australian primary care perspective to gauge the attitudes and experiences of GPs on their use of chaperones. It will provide vital information to inform the next step of extending this research to a national GP audience. From an international perspective, this study provides an excellent template for other primary care clinicians to conduct research in this important field of doctor-patient relationship.

General practice research--does gender affect the decision to participate?

BACKGROUND: Recruitment of general practitioners for research in Australia is problematic. We aimed to explore general practice demographics and recent research experience for effects on research attitudes and enablers and inhibitors of research participation. METHODS: A survey was developed and distributed to GPs via two divisions of general practice in Melbourne, Victoria. RESULTS: Seven hundred and fifty-six questionnaires were mailed and 215 (28%) returned; 50% of respondents were women and 51% of all GPs had previously participated in general practice research. Gender differences were found in factors affecting the decision to participate. Women were significantly more concerned about out-of-hours commitment (p<0.001), paperwork volume (p<0.001), recruitment criteria (p=0.009) and research methodology complexity (p=0.016). They were more likely to want to work as a general practice group (p=0.007) and to be inhibited by having to present results to peers (OR 2.4, 95% CI: 1.5-3.8). CONCLUSION: Research challenges, reduced interest in research participation and feminisation of the workforce have major implications for the future of research in general practice. Systemic changes are needed to address these issues.

First Australian experiences with an oral volume restriction device to change eating behaviors and assist with weight loss.

Eating behaviors impact satiety and caloric intake so should be considered in any weight-loss program. A novel custom-made oral device has been designed to be worn in the upper palate while eating in order to slow eating-rate and aid weight loss. The aim of this study was to assess the device's potential impact on weight-loss and gain first impressions among overweight/obese Australians. Twenty participants (M: 6, F: 14, mean age 36 years, BMI 27-33 kg/m(2)) were enrolled in a 4-month open-label trial. Each received a device and nutritionist-delivered diet plan. Weight, compliance, and acceptability were assessed fortnightly. Anthropometry, biochemical and clinical outcomes were measured at baseline and 16 weeks. Sixteen participants completed the study. Mean weight-loss was 4.9 ± 0.9 kg, or 5.2 ± 0.9% initial bodyweight (P < 0.001, n = 20, intention-to-treat). There were no significant adverse events (AEs), but 65% of participants required device adjustment by the dentist. Compliance (defined as >5 uses/week) was achieved by 80% of participants and correlated positively with weight-loss (R = 0.68, P = 0.001). All reported that the device was comfortable and reduced bite-size, promoted chewing and slowed eating-rate. Most observed either no change, or increased satiety, despite reduced meal sizes. For most, speech difficulties discouraged device use in social settings. All reported greater awareness of food choices, portion sizes and eating-rate. Subjective control of dietary behaviors, measured by the Three Factor Eating Questionnaire (TFEQ), improved significantly. The device should be explored as an adjunct to dietary composition change in weight-management programs, to assist patients to modify eating behaviors and achieve successful weight-loss.

Barriers to recruitment of professionals into a general practice childhood obesity program.

Recruiting general practitioners to take part in research in primary care is important and challenging. This paper describes the process, barriers and achievements experienced by a research team whilst recruiting Divisions and general practitioners (GPs)/practices into a project related to management of obesity in children, which used Breakthrough Series methodology in the intervention arm. The research team chose to recruit GPs through Divisions of General Practice, because of the existing positive relationship between the research team and the Divisions, and the Divisions' positive relationships with the GPs/practices in their area. The project aimed to recruit four Divisions of General Practice, who in turn would recruit a total of 24 GPs/practices. Four Divisions (two rural, two metropolitan) were recruited initially, but the two rural Divisions withdrew before the project commenced and were replaced by two metropolitan Divisions. As Divisions were unable to recruit sufficient GPs/practices, two additional strategies were used, but despite all efforts, only 17 practices were recruited. Reflection on recruitment failure focussed on reasons from the perspective of Divisions, GPs, other projects using the Breakthrough Series methodology with a chronic disease focus and other projects conducted in Australia where the focus was childhood obesity. The results showed that even Divisions who were enthusiastic about joining a project may be unable to recruit sufficient GPs and practices, for reasons including staff changeover and GP reluctance. Caution is suggested when setting recruitment targets where the condition is sensitive, is not the presenting problem, is not routinely tackled in general practice, involves minors, where treatment is perceived to be of doubtful effectiveness, or where major government policies may need to be considered.

Bipolar disorder in general practice: challenges and opportunities.

General practitioners are involved in the continuing care and shared care of patients with chronic mental illness, including bipolar disorder. Psychiatrists are particularly reliant on GPs to monitor and treat comorbidities as well as the psychiatric condition itself. Management of chronic mental illness is compromised by a number of factors, including problems with diagnosis, physical comorbidity, erratic attendance and poor compliance with treatment. Diagnosis of bipolar disorder is often delayed, and differential diagnoses to be considered include unipolar depression, anxiety disorder, drug and alcohol dependence, personality disorder, attention deficit hyperactivity disorder, and general medical and central nervous system diseases. New Medicare items have been introduced under the Better Access to Mental Health Care initiative. However, uptake for patients with chronic psychiatric illness, including bipolar disorder, is low. Patients with bipolar disorder may be prone to a range of comorbid psychological, social and physical problems, and GPs need to be vigilant to detect and manage comorbidity and social problems as part of the overall plan. This includes assistance with certification for sickness and unemployment benefits. GPs may become involved during crises affecting patients and this may pose significant problems for GPs who need to provide ongoing care following patient discharge from hospital. Despite these difficulties, opportunities exist for GPs to play a vital and ongoing role in the management of patients with bipolar disorder.

Effectiveness of IT-based diabetes management interventions: a review of the literature.

BACKGROUND: Information technology (IT) is increasingly being used in general practice to manage health care including type 2 diabetes. However, there is conflicting evidence about whether IT improves diabetes outcomes. This review of the literature about IT-based diabetes management interventions explores whether methodological issues such as sample characteristics, outcome measures, and mechanisms causing change in the outcome measures could explain some of the inconsistent findings evident in IT-based diabetes management studies. METHODS: Databases were searched using terms related to IT and diabetes management. Articles eligible for review evaluated an IT-based diabetes management intervention in general practice and were published between 1999 and 2009 inclusive in English. Studies that did not include outcome measures were excluded. RESULTS: Four hundred and twenty-five articles were identified, sixteen met the inclusion criteria: eleven GP focussed and five patient focused interventions were evaluated. Nine were RCTs, five non-randomised control trials, and two single-sample before and after designs. Important sample characteristics such as diabetes type, familiarity with IT, and baseline diabetes knowledge were not addressed in any of the studies reviewed. All studies used HbA1c as a primary outcome measure, and nine reported a significant improvement in mean HbA1c over the study period; only two studies reported the HbA1c assay method. Five studies measured diabetes medications and two measured psychological outcomes. Patient lifestyle variables were not included in any of the studies reviewed. IT was the intervention method considered to effect changes in the outcome measures. Only two studies mentioned alternative possible causal mechanisms. CONCLUSION: Several limitations could affect the outcomes of IT-based diabetes management interventions to an unknown degree. These limitations make it difficult to attribute changes solely to such interventions.

Childhood obesity, BMI calculators, and medical software--time for an upgrade?

National Health and Medical Research Council (NHMRC) guidelines for the management of childhood obesity recommend active screening of children aged 2-18 years, and intervention for those with a body mass index (BMI) (kg/m2) above the 85th percentile for age and gender. However, guidelines and BMI for age percentile charts are not well utilised in the general practice setting. In addition, there is a tendency for clinicians and parents to visually underestimate body mass in children.

Quality and consistency of clinical practice guidelines for diagnosis and management of osteoarthritis of the hip and knee: a descriptive overview of published guidelines.

OBJECTIVE: To present a descriptive overview of the quality and recommendations of clinical practice guidelines (CPGs) on diagnosis or management of osteoarthritis (OA) of the hip and/or knee. DATA SOURCES: CPGs were identified from several research databases (MEDLINE, EMBASE and The Cochrane Library) and guideline-specific databases from 1966 to August 2005. GUIDELINE RETRIEVAL: Thirty-four relevant CPGs were identified. DATA EXTRACTION: Recommendations were extracted from CPGs and categorised into: assessment and diagnosis, pharmacological management, nonpharmacological management, complementary/alternative therapy, or surgery. The quality of the CPGs were assessed by two appraisers using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. DATA SYNTHESIS: Most recommendations for aspects of diagnosis and treatment of OA of the hip and/or knee were consistent among the CPGs included in this study. However, quality varied considerably, with few CPGs being "strongly recommended" according to the AGREE quality appraisal instrument. CONCLUSIONS: Given the number of CPGs available relevant to OA, and the consistency of recommendations within them, and considering the time and resources required for CPG development, future efforts to guide management of OA of the hip and/or knee may be better directed towards adapting existing CPGs to the local context, implementing practices known to be effective, and facilitating research to answer important questions where there is little evidence.