Glycaemic control of Type 2 diabetes in older patients visiting general practitioners: An examination of electronic medical records to identify risk factors for poor control.

OBJECTIVE: To investigate factors associated with glycaemic control of diabetes in older patients in the general practice setting in metropolitan Melbourne, Australia. METHOD: This retrospective study used the data from 10,257 patients aged ≥ 65 years with Type 2 diabetes from the Melbourne East Monash General Practice Database (MAGNET), 2009-2014. Poor glycaemic control was defined as HbA1c ≥ 9.0%. Univariate and multivariate analyses were conducted to assess the association between risk factors and glycaemic control. RESULTS: Of the total 10,257 patients, 6819 (66.5%) had their HbA1c recorded within a period of 2 years prior to their last GP visit. Between 4% and 6% had HbA1c level ≥ 9.0%. Robust predictors of poor glycaemic control were found to be decreasing age group (OR = 0.77, 95% CI: 0.65-0.90) and prescribed insulin (OR = 2.83, 95% CI: 2.41-3.32). CONCLUSION: One third of older patients with Type 2 diabetes did not have HbA1c recorded in the previous 2 years, despite clinical guidelines recommending at least annual testing. Many older patients had good glycaemic control, however the findings indicate that those aged 65-74 and those prescribed insulin may require special care and management to achieve this.

The willingness of Saudi men with type 2 diabetes to discuss erectile dysfunction with their physicians and the factors that influence this.

OBJECTIVES: The study's objectives were to find out the proportion of Saudi men with type 2 diabetes who have been asked by their physicians about erectile dysfunction (ED) in the last year, to determine the willingness of Saudi men with type 2 diabetes to discuss ED, and to explore the factors that may be related to their willingness to discuss ED with their physicians. METHODS: This study employed a cross-sectional survey design using a quantitative self-administered questionnaire among 309 Saudi men with type 2 diabetes. The study was conducted in hospital-based primary care clinics at King Khalid University Hospital, Riyadh, Saudi Arabia during the period from July to September 2015. RESULTS: The mean age of the patients was 60.2 years with the mean duration of diabetes approximately 12.5 years. Few of the patients (9.7%) had been asked by their physicians about ED within the last year of attending the clinics although most patients (84.8%) were willing to discuss this issue. The presence of ED among the respondents was 89%. Two participants' characteristics were associated with a willingness to discuss ED with the physicians. These characteristics were age above 60 (OR = 0.25, 95% CI: 0.11-0.55), and having severe ED (OR = 0.26, 95% CI: 0.08-0.85). The respondents' main barriers to discussing ED with their physicians were embarrassing the doctor, ED is a personal issue, too old or too sick to address ED issues now, no effective treatment available, and the doctor is too young to discuss ED with. CONCLUSIONS: Most patients who have type 2 diabetes are not asked about ED within the last year of attendance even though most are willing to discuss it with their physicians. Being older and suffering more severe ED will result in being less willing to discuss ED with their doctor. Further research is needed to explore the barriers which prevent physicians from discussing ED with their patients who have diabetes.

General practitioners knowledge and management of whiplash associated disorders and post-traumatic stress disorder: implications for patient care.

BACKGROUND: In Australia, general practitioners (GPs) see around two-thirds of people injured in road traffic crashes. Road traffic crash injuries are commonly associated with diverse physical and psychological symptoms that may be difficult to diagnose and manage. Clinical guidelines have been developed to assist in delivering quality, consistent care, however the extent to which GPs knowledge and practice in diagnosing and managing road traffic crash injuries concords with the guidelines is unknown. This study aimed to explore Australian GPs knowledge, attitudes and practices regarding the diagnosis and management of road traffic crash injuries, specifically whiplash associated disorders (WAD) and post-traumatic stress disorder (PTSD). METHOD: A cross-sectional survey of 423 GPs across Australia conducted between July and December 2014. We developed a questionnaire to assess their knowledge of WAD and PTSD, confidence in diagnosing and managing WAD and PTSD, frequency of referral to health providers, barriers to referral, and attitudes towards further education and training. Factor analysis, Spearman's correlation, and multiple ordered logistic regressions were performed. RESULTS: Overall, GPs have good level knowledge of WAD and PTSD; only 9.6 % (95 % CI: 7.1 %, 12.8 %) and 23.9 % (95 % CI: 20.8 %, 28.2 %) of them were deemed to have lower level knowledge of WAD and PTSD respectively. Key knowledge gaps included imaging indicators for WAD and indicators for psychological referral for PTSD. GPs who were male, with more years of experience, working in the urban area and with higher knowledge level of WAD were more confident in diagnosing and managing WAD. Only GPs PTSD knowledge level predicted confidence in diagnosing and managing PTSD. GPs most commonly referred to physiotherapists and least commonly to vocational rehabilitation providers. Barriers to referral included out-of-pocket costs incurred by patients and long waiting times. Most GPs felt positive towards further education on road traffic crash injury management. CONCLUSION: This study has enhanced understanding of the knowledge skills and attitudes of GPs towards road traffic crash injury care in Australia, and has identified areas for further education and training. If delivered, this training has the potential to reduce unnecessary imaging for WAD and optimise the early referral of patients at risk of delayed recovery following a road traffic crash.

Minimally disruptive medicine is needed for patients with multimorbidity: time to develop computerised medical record systems to meet this requirement.

BACKGROUND: Minimally disruptive medicine (MDM) is proposed as a method for more appropriately managing people with multiple chronic disease. Much clinical management is currently single disease focussed, with people with multimorbidity being managed according to multiple single disease guidelines. Current initiatives to improve care include education about individual conditions and creating an environment where multiple guidelines might be simultaneously supported. The patient-centred medical home (PCMH) is an example of the latter. However, educational programmes and PCMH may increase the burden on patients. PROBLEM: The cumulative workload for patients in managing the impact of multiple disease-specific guidelines is only relatively recently recognised. There is an intellectual vacuum as to how best to manage multimorbidity and how informatics might support implementing MDM. There is currently no alternative to multiple single-condition- specific guidelines and a lack of certainty, should the treatment burden need to be reduced, as to which guideline might be 'dropped'. ACTION: The best information about multimorbidity is recorded in primary care computerised medical record (CMR) systems and in an increasing number of integrated care organisations. CMR systems have the potential to flag individuals who might be in greatest need. However, CMR systems may also provide insights into whether there are ameliorating factors that might make it easier for them to be resilient to the burden of care. Data from such CMR systems might be used to develop the evidence base about how to better manage multimorbidity. CONCLUSIONS: There is potential for these information systems to help reduce the management burden on patients and clinicians. However, substantial investment in research-driven CMR development is needed if we are to achieve this.

How general practitioners manage mental illness in culturally and linguistically diverse patients: an exploratory study.

BACKGROUND: General practitioners (GPs) see a range of mental illnesses and a diversity of patients, including patients from culturally and linguistically diverse (CALD) backgrounds. The aim of this study was to understand the barriers and facilitators GPs encounter when managing mental illness in CALD patients. METHODS: Semi-structured interviews with 10 Melbourne GPs were undertaken between May and July 2013. Data were analysed thematically. RESULTS: GP barriers included difficulties in recognising initial symptoms, communicating the diagnosis and using interpreter services. Facilitators included cultural concordance between the GP and patient, practice-based initiatives targeting CALD patients, and areas of further education for GPs and CALD patients. DISCUSSION: Cultural concordance between GPs and CALD patients is likely to be effective in facilitating management of mental illness. Further research is needed on interpreter use and scaling up practice-based initiatives to improve service delivery. At a population level, GPs thought it necessary to improve mental health literacy in CALD communities.

Refugee experiences of general practice in countries of resettlement: a literature review.

BACKGROUND: Refugees and asylum seekers often struggle to use general practice services in resettlement countries. AIM: To describe and analyse the literature on the experiences of refugees and asylum seekers using general practice services in countries of resettlement. DESIGN AND SETTING: Literature review using systematic search and narrative data extraction and synthesis methodologies. International, peer-reviewed literature published in English language between 1990 and 2013. METHOD: Embase, Ovid MEDLINE, PsycINFO, CSA Sociological Abstracts, and CINAHL databases were searched using the terms: refugee, asylum seeker, experience, perception, doctor, physician, and general practitioner. Titles, abstracts and full texts were reviewed and were critically appraised. Narrative themes describing the refugee or asylum seeker's personal experiences of general practice services were identified, coded, and analysed. RESULTS: From 8722 papers, 85 were fully reviewed and 23 included. These represented the experiences of approximately 864 individuals using general practice services across 11 countries. Common narrative themes that emerged were: difficulties accessing general practice services, language barriers, poor doctor-patient relationships, and problems with the cultural acceptability of medical care. CONCLUSION: The difficulties refugees and asylum seekers experience accessing and using general practice services could be addressed by providing practical support for patients to register, make appointments, and attend services, and through using interpreters. Clinicians should look beyond refugee stereotypes to focus on the needs and expectations of the individual. They should provide clear explanations about unfamiliar clinical processes and treatments while offering timely management.

Online continuing medical education (CME) for GPs: does it work? A systematic review.

BACKGROUND: Numerous studies have assessed the effectiveness of online continuing medical education (CME) designed to improve healthcare professionals' care of patients. The effects of online educational interventions targeted at general practitioners (GP), however, have not been systematically reviewed. METHODS: A computer search was conducted through seven databases for studies assessing changes in GPs' knowledge and practice, or patient outcomes following an online educational intervention. RESULTS: Eleven studies met the eligibility criteria. Most studies (8/11, 72.7%) found a significant improvement in at least one of the following outcomes: satisfaction, knowledge or practice change. There was little evidence for the impact of online CME on patient outcomes. Variability in study design, characteristics of online and outcome measures limited conclusions on the effects of online CME. DISCUSSION: Online CME could improve GP satisfaction, knowledge and practices but there are very few well-designed studies that focus on this delivery method of GP education.

Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews.

OBJECTIVES: To investigate whether General Practice Management Plans (GPMPs), Team Care Arrangements (TCAs) and reviews of these improve the management and outcomes of patients with diabetes when supported by cdmNet, a web-based chronic disease management system; and to investigate adherence to the annual cycle of care (ACOC), as recommended in diabetes guidelines. DESIGN, PARTICIPANTS AND SETTING: A before-and-after study to analyse prospectively collected data on 577 patients with type 1 or 2 diabetes mellitus who were managed with a GPMP created using cdmNet between June 2008 and November 2012. MAIN OUTCOME MEASURES: Completion of the clinical tests in the ACOC (process outcome) and values of six of these clinical measurements (clinical outcomes). RESULTS: Significant improvements were seen after creation of a GPMP in the proportion of ACOC clinical tests completed (57.9% v 74.8%, P < 0.001), total cholesterol level (P < 0.01), low-density lipoprotein (LDL) cholesterol level (P < 0.001) and body mass index (BMI) (P < 0.01). Patients using GPMPs and TCAs also improved their glycated haemoglobin (HbA1c) level (P < 0.05). Patients followed up with irregular reviews had significant improvements in the proportion of ACOC clinical tests completed (59.2% v 77.6%, P < 0.001), total cholesterol level (P < 0.05), and BMI (P < 0.01), but patients with regular reviews had greater improvements in the proportion of ACOC clinical tests completed (58.9% v 85.0%, P < 0.001), HbA(1c) level (57.7 v 53.0 mmol/mol, P < 0.05), total cholesterol level (4.8 v 4.5 mmol/L, P < 0.05), LDL cholesterol level (2.8 v 2.4 mmol/L, P < 0.01) and diastolic blood pressure (76.0 v 74.0 mmHg, P < 0.05). CONCLUSION: There were significant improvements in process and clinical outcomes for patients on a GPMP or a GPMP and TCA, particularly when these were followed up by regular reviews. Patients using cdmNet were four times more likely to have their GPMP or TCA followed up through regular reviews than the national average.

Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial.

INTRODUCTION: This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. METHODS: General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. RESULTS: 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. CONCLUSIONS: The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN012606000098538.

Care planning and adherence to diabetes process guidelines: medicare data analysis.

OBJECTIVE: To test the association, in patients with a diagnosis of diabetes I and II, between having or not having a care plan, (i.e. General Practice Management Plans (GPMPs),Team Care Arrangements (TCAs)), and having the recommended number of biochemical checks according to the diabetes Annual Cycle of Care guideline. The checks comprised HbA1c, HDL cholesterol and urinary microalbumin. METHODS: Chi-square analysis of retrospective group data obtained from the Medicare database (from 'billing' patterns only). RESULTS: The creation of GPMPs was associated with general practitioners (GPs) requesting checks for HbA1c (59.7%), HDL cholesterol (36.9%) and microalbumin (50.8%) for diabetes patients in accordance with guideline recommendations. Although the introduction of multidisciplinary care via a TCA was associated with an increase in the frequency of HbA1c checks (61.3%) in accordance with the guidelines, there was a reduction in the number of HDL cholesterol (23.7%) and microalbumin (36.8%) checks. The group with no care plans had the lowest association with HbA1c (47.8%), HDL cholesterol (19.7%) and microalbumin (29.3%) checks that met guideline requirements for diabetes. CONCLUSIONS: The use of GPMPs showed strong association with increased testing of process measures that met guideline requirements for diabetes. Further research is needed to understand the value and benefits of TCAs in promoting adherence to diabetes guidelines.

Fitness to drive - GP perspectives of assessing older and functionally impaired patients.

BACKGROUND: General practitioners have expressed concern about their ability to assess patients' driving fitness. This study explores GP perspectives regarding assessing fitness to drive in older and functionally impaired patients. METHODS: We held face-to-face interviews with seven metropolitan GPs and a focus group with nine rural GPs. Data were analysed using thematic analysis. RESULTS: General practitioners were unsure whether they or driving authorities should have responsibility for assessing patients' fitness to drive; recognised that driving is important for maintaining independence; described referral to an occupational therapist as useful, and expressed concern about the lack of access to alternative forms of transport and also about privacy issues. Opinion was divided about the merits of the VicRoads Medical Report Form and the usefulness of the Austroads guide. DISCUSSION: This qualitative study suggests that some GPs may find assessing fitness to drive to be challenging and problematic in general practice. Further resources and education could assist these GPs to increase their confidence and competence in assessing a patient's fitness to drive.

The CDM-Net Project: The Development, Implementation and Evaluation of a Broadband-Based Network for Managing Chronic Disease.

Background. In Australia most chronic disease management is funded by Medicare Australia through General Practitioner Management Plans (GPMPs) and Team Care Arrangements (TCAs). Identified barriers may be reduced effectively using a broadband-based network known as the Chronic Disease Management Service (CDMS). Aims. To measure the uptake and adherence to CDMS, test CDMS, and assess the adherence of health providers and patients to GPMPs and TCAs generated through CDMS. Methods. A single cohort before and after study. Results. GPMPs and TCAs increased. There was no change to prescribed medicines or psychological quality of life. Attendance at allied health professionals increased, but decreased at pharmacies. Overall satisfaction with CDMS was high among GPs, allied health professionals, and patients. Conclusion. This study demonstrates proof of concept, but replication or continuation of the study is desirable to enable the impact of CDMS on diabetes outcomes to be determined.

Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework.

BACKGROUND: There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. METHODS: The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? RESULTS: A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. CONCLUSIONS: We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process.

Web based diabetes care planning - sociotechnical barriers to implementation in general practice.

BACKGROUND: This research explored the sociotechnical barriers in the implementation of web based diabetes care plans in general practice from the perspective of implementing stakeholders. METHODS: A qualitative case study design was use to explore the sociotechnical barriers. Twenty-one stakeholders were purposely recruited and interviewed. RESULTS: Technological barriers included rudimentary IT applications in general practice; standardisation and interoperability issues; and 'bugs' in the system. The role of practice managers as gatekeepers influenced the uptake of the technology. General practitioners were noted to be time poor, while practice nurses preferred to stick with paper based ways of doing care plans. The relationship between allied health professionals and GPs also influenced the adoption process. DISCUSSION: Implementers had significant insight into the sociotechnical barriers to diabetes web based care planning in general practice. Future research should examine the roles of the stakeholders involved in determining standards and the interoperability of systems.

Data extraction and feedback - does this lead to change in patient care?

BACKGROUND Computers enable general practitioners to collate clinical data within their practices. The improvements that this can make to clinical care remain the subject of enquiry. OBJECTIVE Does the analysis of clinical data for the purpose of instigating quality improvement strategies in general practice, with support from a local division of general practice, lead to positive changes in measures of care after 12 months? DISCUSSION This study demonstrated that, in this setting, the collection and analysis of clinical data, with support from a division of general practice, led to modest increases in the recording of information rather than improvements in clinical outcomes.

Electronic care plans and medicolegal liability.

BACKGROUND: Government policy encourages the use of care plans in general practice, and developments in information technology have the potential to facilitate their use via a shared electronic care plan. Sharing a comprehensive set of patient data raises privacy issues and questions about the nature and extent of potential liability. METHODS: A round table discussion was held with participants purposively selected for expertise in their fields. RESULTS: Consensus stressed the privacy dangers inherent in the creation of a shared electronic care plan accessible by multiple treating professionals and a private sector intermediary information technology provider, and the difficulties in ensuring appropriate informed consent is provided by patients. DISCUSSION: As the use of shared electronic care plans increases in Australia, new legal and ethical issues may emerge which need to be understood and addressed if general practitioners and other healthcare team members are to be able to participate with confidence.

The usefulness of a clinical 'scorecard' in managing patients with sore throat in general practice.

OBJECTIVE: To evaluate the usefulness of a clinical scorecard in managing sore throat in general practice. DESIGN: Validation study of scorecard for sore throat with a throat swab culture used as the 'gold standard'. SETTING: A solo family practice in rural New South Wales, AustraliaParticipants: Patients attending with sore throat. METHODS: Patients from the age of 5 years and above presenting with the main symptom of a sore throat, and who have not had any antibiotic treatment in the previous two weeks, were invited to participate in the study. The doctor completed a scorecard for each patient participating and took a throat swab for culture. Adult patients (> 16 yrs) were asked to complete a patient satisfaction questionnaire, while guardians accompanying children (5 yr to < 16 yrs old) were asked to complete a similar, guardian questionnaire. MAIN OUTCOME MEASURES: 1. Ability of a new scorecard to differentiate between bacterial and non-bacterial sore throat.2. Patients' trust in the scorecard. RESULTS: The scorecard has a sensitivity of 93.33%, a specificity of 63.16%, a positive predictive value of 50% and a negative predictive value of 96%. The sensitivity is better than other sore throat scorecards that have been published but with a slightly lower specificity.There was a high level of patient trust in the scorecard was (85.8% agreement). Patients also trusted their doctor's judgement based on the scorecard (90.6% agreement). CONCLUSIONS: As the scorecard has a high sensitivity but only a moderate specificity, this means that it is more reliable for negative results, i.e. when the result suggests a viral infection. When the result favours a bacterial sore throat, then a high sensitivity can mean that there are a number of false positives. GPs can be confident in withholding antibiotics when the scorecard indicates a viral infection.

Identification of features of electronic prescribing systems to support quality and safety in primary care using a modified Delphi process.

BACKGROUND: Electronic prescribing is increasingly being used in primary care and in hospitals. Studies on the effects of e-prescribing systems have found evidence for both benefit and harm. The aim of this study was to identify features of e-prescribing software systems that support patient safety and quality of care and that are useful to the clinician and the patient, with a focus on improving the quality use of medicines. METHODS: Software features were identified by a literature review, key informants and an expert group. A modified Delphi process was used with a 12-member multidisciplinary expert group to reach consensus on the expected impact of the features in four domains: patient safety, quality of care, usefulness to the clinician and usefulness to the patient. The setting was electronic prescribing in general practice in Australia. RESULTS: A list of 114 software features was developed. Most of the features relate to the recording and use of patient data, the medication selection process, prescribing decision support, monitoring drug therapy and clinical reports. The expert group rated 78 of the features (68%) as likely to have a high positive impact in at least one domain, 36 features (32%) as medium impact, and none as low or negative impact. Twenty seven features were rated as high positive impact across 3 or 4 domains including patient safety and quality of care. Ten features were considered "aspirational" because of a lack of agreed standards and/or suitable knowledge bases. CONCLUSIONS: This study defines features of e-prescribing software systems that are expected to support safety and quality, especially in relation to prescribing and use of medicines in general practice. The features could be used to develop software standards, and could be adapted if necessary for use in other settings and countries.

GP registrar well-being: a cross-sectional survey.

OBJECTIVES: To investigate the major stressors affecting GP registrars, how those at risk can be best identified and the most useful methods of managing or reducing their stress. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional postal questionnaire of all GP registrars in one large regional training provider's catchment area. MAIN OUTCOME MEASURES: The Depression, Anxiety and Stress Scale (DASS), a specifically developed Registrar Stressor Scale consisting of five subscales of potential stressors, plus closed questions on how to identify and manage stress in GP registrars. RESULTS: Survey response rate of 51% (102/199). Rural difficulties followed by achieving a work/life balance were the principal stressors. Ten percent of registrars were mildly or moderately depressed or anxious (DASS) and 7% mild to moderately anxious (DASS). Registrars preferred informal means of identifying those under stress (a buddy system and talks with their supervisors); similarly, they preferred to manage stress by discussions with family and friends, debriefing with peers and colleagues, or undertaking sport and leisure activities. CONCLUSIONS: This study supports research which confirms that poor psychological well-being is an important issue for a significant minority of GP trainees. Regional training providers should ensure that they facilitate formal and informal strategies to identify those at risk and assist them to cope with their stress.

Clinical data extraction and feedback in general practice: a case study from Australian primary care.

BACKGROUND: Quality improvement in general practice has increasingly focused on the analysis of its clinical databases to guide its improvement strategies. However, general practitioners (GPs) need to be motivated to extract and review their clinical data, and they need skills to do so. This study examines the initial experience of 15 practices in undertaking clinical data extraction and management and the support they were given by their local division of general practice. OBJECTIVES: To explore the uptake of data extraction tools in general practice and understand how divisions of general practice can assist with their uptake. METHOD: This study was conducted within a single division of general practice within the south-eastern suburbs of metropolitan Melbourne, Australia. Self-selected practices were offered a data extraction program ('tool') free of charge, with ongoing division support. Practice representatives, either GPs, practice nurses or other practice staff members, were given instructions on how to extract data using the data extraction tool. This was followed by discussion with division staff regarding which clinical areas might be focused on. Division staff systematically recorded information about the experience of the practices and collated their clinical data. RESULTS: Fifteen practices, representing 69 GPs, participated. The practices chose from the following areas to work on as quality improvement activities: improving data entry; inactivating patient files for those who no longer attended the practice; correcting demographic information; diabetes and coronary heart disease management. The recording of data, according to the extraction tool, was found to be incomplete. For example, one-third of the patients who had HbA1cs recorded were on target, i.e. <7%, but nearly half the patients with diabetes did not have HbA1cs recorded at all. About half the patients with coronary heart disease were not reported as taking aspirin and one-third were not on a statin. Nearly half the patients who had attended their practice in the previous 30 months did not have smoking status recorded. CONCLUSION: While data extraction programs provide GPs with useful tools for examining their clinical databases and identifying clinical practice issues which could be improved, external support, such as that provided by divisions, is helpful. Technical barriers, such as the failure of extraction tools to recognise some data and the failure to comprehensively enter data, are impediments, but in spite of these considerable interest exists in the use of clinical data to improve practice.