Revenue effects of practice nurse-led care for chronic diseases.

OBJECTIVE: To determine the economic feasibility in Australian general practices of using a practice nurse (PN)-led care model of chronic disease management. METHODS: A cost-analysis of item numbers from the Medicare Benefit Schedule (MBS) was performed in three Australian general practices, one urban, one regional and one rural. Patients (n =254; >18 years of age) with chronic conditions (type 2 diabetes, hypertension, ischaemic heart disease) but without unstable or major health problems were randomised into usual general practitioner (GP) or PN-led care for management of their condition over a period of 12 months. After the 12-month intervention, total MBS item charges were evaluated for patients managed for their stable chronic condition by usual GP or PN-led care. Zero-skewness log transformation was applied to cost data and log-linear regression analysis was undertaken. RESULTS: There was an estimated A$129 mean increase in total MBS item charges over a 1-year period (controlled for age, self-reported quality of life and geographic location of practice) associated with PN-led care. The frequency of GP and PN visits varied markedly according to the chronic disease. CONCLUSIONS: Medicare reimbursements provided sufficient funding for general practices to employ PNs within limits of workloads before the new Practice Nurse Incentive Program was introduced in July 2012.

The relationship between resilience and personality traits in doctors: implications for enhancing well being.

Objective. The health and well being of medical doctors is vital to their longevity and safe practice. The concept of resilience is recognised as a key component of well being and is an important factor in medical training to help doctors learn to cope with challenge, stress, and adversity. This study examined the relationship of resilience to personality traits and resilience in doctors in order to identify the key traits that promote or impair resilience. Methods. A cross sectional cohort of 479 family practitioners in practice across Australia was studied. The Temperament and Character Inventory measured levels of the seven basic dimensions of personality and the Resilience Scale provided an overall measure of resilience. The associations between resilience and personality were examined by Pearson product-moment correlation coefficients, controlling for age and gender (α = 0.05 with an accompanying 95% confidence level) and multiple regression analyses. Results. Strong to medium positive correlations were found between Resilience and Self-directedness (r = .614, p < .01), Persistence (r = .498, p < .01), and Cooperativeness (r = .363, p < .01) and negative with Harm Avoidance (r = .-555, p < .01). Individual differences in personality explained 39% of the variance in resilience [F(7, 460) = 38.40, p < .001]. The three traits which contributed significantly to this variance were Self-directedness (ß = .33, p < .001), Persistence (ß = .22, p < .001) and Harm Avoidance (ß = .19, p < .001). Conclusion. Resilience was associated with a personality trait pattern that is mature, responsible, optimistic, persevering, and cooperative. Findings support the inclusion of resilience as a component of optimal functioning and well being in doctors. Strategies for enhancing resilience should consider the key traits that drive or impair it.

Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice.

The Australian government's commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model's feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients' stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded.

A decade of Australian Rural Clinical School graduates--where are they and why?

INTRODUCTION: The Australian Rural Clinical School (RCS) initiative has been addressing the rural medical workforce shortage at the medical education level for over a decade. A major expectation of this initiative is that it will improve rural medical workforce recruitment and subsequent retention through a rurally based undergraduate clinical training experience. The longitudinal nature of these workforce initiatives means that definitive evidence of its impact on the shortage of rural doctors is yet to be provided; however, to date cross-sectional studies are accumulating a measure of efficacy for these initiatives by monitoring early career factors such as internship location choice and speciality choice of RCS graduates. This article reports on a study in one RCS that is monitoring the impact of rural undergraduate clinical training on trends in workforce participation patterns of its graduates as long as 9 years in the workforce. Career location and speciality choice are reported as well as perspectives on early career intentions and the reality of making career and life decisions as a doctor in the medical workforce. METHODS: A longitudinal mixed methods sequential explanatory design employed a quantitative data collection phase followed by a qualitative phase with the merging of data sources during the interpretation and analysis. In 2007 a database was established that maintained the contact details of all former graduates since 2002. Every 2 years graduates are invited to participate in a survey and provide an update on the influences on their current career intentions/decisions. The qualitative sample was recruited through a survey question asking for interest in participating in an interview. RESULTS: The whole-sample survey results showed that out of a 64% (N = 115) response rate, 40% of respondents were currently working in non-urban locations. The majority (

Predictors of government subsidized pharmaceutical use in patients with diabetes or cardiovascular disease in a primary care setting: evidence from a prospective randomized trial.

OBJECTIVES: This study uses data from a prospective randomized controlled trial to estimate predictors of pharmaceutical expenditure in diabetes (DM) or cardiovascular disease (CVD) patients. Identifying drivers of pharmaceutical use and the extent to which they are modifiable may inform cost-effective policy-making. METHODS: The trial followed 260 patients aged >18 years (mean 68) from three general practices for 12 months. Patients had type 2 diabetes (90 patients) or cardiovascular disease (170 patients). Costs for pharmaceuticals prescribed on the Pharmaceutical Benefits Scheme (PBS) were obtained retrospectively at 12 months. Sociodemographic data and health-related quality-of-life (QoL) were recorded from questionnaires. Clinical measures (including body mass index (BMI), blood pressure, high and low density lipoprotein (LDL), and HbA1c) were also collected. RESULTS: Mean pharmaceutical costs for DM patients (AU$4119) was greater than CVD patients (AU$2424). The largest contributor to costs in both groups was pharmaceuticals used for management of conditions other than CVD or DM. QoL (EQ5D) and BMI were significant predictors of costs in both groups. A history of cardiac events, HbA1c, age, and unemployment were significant predictors of costs in the DM group. A diagnosis of heart failure, frequency of hospital admissions, and LDL levels were significant predictors of costs in the CVD group. Roughly one third of total variation of costs can be explained by the regressors in both models. LIMITATIONS: Generalizability will be limited as data was derived from a trial and the study was not powered for this post-hoc analysis. Missing data imputation and self-reporting bias may also impact on results. CONCLUSIONS: Factors such as QoL BMI, HbA1c levels, and a history of cardiac events are significant predictors of costs. The results suggest there may be a place for interventions that improve quality-of-life and concurrently reduce pharmaceutical costs in patients with CVD or DM.

Present and past carers' health: some considerations.

We sought to examine the mental and physical health and health-related quality of life of current and past carers compared to non-carers, using two instruments--the Short Form-12 (SF-12) and the EuroQol 5-dimension (EQ-5D). A total of 249 participants (34 current carers, 14 previous carers, 197 non-carers, 4 non-respondents) completed a baseline self-report survey at randomization into the larger study. Previous carers demonstrated moderate to severe anxiety or depressive symptoms measured with the EQ-5D (P < 0.001), reported on the SF-12 that they accomplished less because of emotional problems (P = 0.01) and more likely to have 'felt down' (P = 0.01) and used more health-care services than current or non-carers. Current carers tended towards a higher level of emotional problems and limitations to mobility than non-carers. This study indicates major differences in the well-being of these three cohorts. Health practitioners should pay particular attention to the mental health and health related quality of life of previous carers.

A nurse led model of chronic disease care - an interim report.

BACKGROUND: Chronic condition management in general practice is projected to account for 50% of all consultations by 2051. General practices under present workforce conditions will be unable to meet this demand. Nurse led collaborative care models of chronic disease management have been successful overseas and are proposed as one solution. OBJECTIVE: This article provides an interim report on a prospective randomised trial to investigate the acceptability, cost effectiveness and feasibility of a nurse led model of care for chronic conditions in Australian general practice. METHOD: A qualitative study focused on the impact of this model of care through the perceptions of practice staff from one urban and one regional practice in Queensland, and one Victorian rural practice. DISCUSSION: Primary benefits of the collaborative care model focused on increased efficiency and communication between practice staff and patients. The increased degree of patient self responsibility was noted by all and highlights the motivational aspect of chronic disease management.