Identifying risk factors for developing obesity: a record linkage longitudinal study in metropolitan Sydney using the 45 and Up Study.

BACKGROUND: Primary care clinicians have key responsibilities in obesity prevention and weight management. AIMS: We aimed to identify risk factors for developing obesity among people aged ≥45 years. METHODS: We conducted a record linkage longitudinal study of residents of metropolitan Sydney, Australia using data from the: (1) 45 and Up Study at baseline (2005-2009) and first follow-up (2012-2015); (2) Medicare claims; (3) Pharmaceutical Benefits Scheme; and (4) deaths registry. We examined risk factors for developing obesity (body mass index [BMI]: 30-40) at follow-up, separately for people within the: (1) healthy weight range (BMI 18.5-<25) and (2) overweight range (BMI 25-<30) at baseline. Covariates included demographics, modifiable behaviours, health status, allied health use, and medication use. Crude and adjusted relative risks were estimated using Poisson regression modelling. RESULTS: At follow-up, 1.1% (180/16,205) of those in the healthy weight range group, and 12.7% (1,939/15,266) of those in the overweight range group developed obesity. In both groups, the following were associated with developing obesity: current smoking at baseline, physical functioning limitations, and allied health service use through team care planning, while any alcohol consumption and adequate physical activity were found to be associated with a lower risk of developing obesity. In the healthy weight group, high psychological distress and the use of antiepileptics were associated with developing obesity. In the overweight group, female sex and full-time work were associated with developing obesity, while older age was found to be associated with a lower risk of developing obesity. CONCLUSIONS: These findings may inform the targeting of preventive interventions for obesity in clinical practice and broader public health programs.

Early intervention to prevent weight gain requires a targeted multidisciplinary team-based approach to improve diet, increase physical activity, and change behaviour. However, the capacity to provide this within primary care is limited and there is little funding for consultations with allied health professionals. There is a need to identify priority at-risk groups to help primary care clinicians target interventions to those in most need. We have identified, using a longitudinal study of residents of metropolitan Sydney, key characteristics of older adults who are at risk of gaining weight and developing obesity, including risk behaviours (smoking and physical inactivity), and chronic conditions or their treatment (physical function, psychological distress, and use of anti-epileptic medications). These findings may help alert clinicians to the need for preventive interventions in selected cases, as well as informing the targeting of public health programs.

A review of skin cancer primary prevention activities in primary care settings.

OBJECTIVES: Skin cancer is highly preventable through primary prevention activities such as avoiding ultraviolet radiation exposure during peak times and regular use of sun protection. General practitioners (GPs) and primary care nurses have key responsibilities in promoting sustained primary prevention behaviour. We aimed to review the evidence on skin cancer primary prevention activities in primary care settings, including evidence on feasibility, effectiveness, barriers and enablers. STUDY TYPE: Rapid review and narrative synthesis. METHODS: We searched published literature from January 2011 to October 2022 in Embase, Medline, PsychInfo, Scopus, Cochrane Central and CINAHL. The search was limited to skin cancer primary prevention activities within primary care settings, for studies or programs conducted in Australia or countries with comparable health systems. Analysis of barriers and enablers was informed by an implementation science framework. RESULTS: A total of 31 peer-reviewed journal articles were included in the review. We identified four main primary prevention activities: education and training programs for GPs; behavioural counselling on prevention; the use of novel risk assessment tools and provision of risk-tailored prevention strategies; and new technologies to support early detection that have accompanying primary prevention advice. Enablers to delivering skin cancer primary prevention in primary care included pairing preventive activities with early detection activities, and access to patient resources and programs that fit with existing workflows and systems. Barriers included unclear requirements for skin cancer prevention counselling, competing demands within the consultation and limited access to primary care services, especially in regional and remote areas. CONCLUSIONS: These findings highlight potential opportunities for improving skin cancer prevention activities in primary care. Ensuring ease of program delivery, integration with early detection and availability of resources such as risk assessment tools are enablers to encourage and increase uptake of primary prevention behaviours in primary care, for both practitioners and patients.

Utility of survivorship care plans: A mixed-method study exploring general practitioners' and cancer specialists' views.

PURPOSE: Survivorship care plans (SCP) are recommended as integral to survivorship care but are not routinely provided in many centers. We explore whether SCP from the Sydney Cancer Survivorship Centre (SCSC) clinic was received by general practitioners (GP) and cancer specialists, and their views on SCP. METHODS: A mixed-method study comprising a quality assurance audit, a questionnaire of GP practices and GP, and semi-structured interviews of cancer specialists who referred patients to the SCSC clinic between 2019-2020. Descriptive statistics were used for quantitative data and content analysis for qualitative data. RESULTS: The audit found 153/190 (80.5%) SCSC attendees had SCP uploaded to hospital medical records. The response rate from GP practices was 41%; among the 55 responding practices, 38 (69%) did not receive the SCP. The response rate from GP was 19%; among the 29 responding GP, 25 (86%) indicated the SCP was worthwhile, especially follow-up plans and multidisciplinary team recommendations. Analysis of 14 cancer specialist interviews identified themes of 1) awareness of SCP; 2) access: SCP difficult to locate; 3) process: access and distribution require improvement; 4) systemic issues; 5) content and layout: more concise and better readability required; 6) value: mainly for GP and survivors; 7) use of SCP: limited; 8) recommendations: improve delivery process, enhance layout/content, more stakeholder input, more tailored information. CONCLUSION: Although response rates from GP were low, those responding perceived SCP to be useful. Cancer specialists believed SCP were more valuable for GP and survivors. Process issues, especially SCP delivery, need to be improved.

"We're trained to trust our patients": a qualitative study on the general practitioners' trust in patients for colorectal cancer shared care.

BACKGROUND: In a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making, and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. However, few empirical studies have explored physicians' trust in patients and its implications for shared care models. AIM: To explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs' willingness to engage in new models of care, such as colorectal cancer shared care. METHODS: GP participants were recruited through professional networks for semi-structured interviews. Transcripts were integrity checked, coded inductively, and themes developed iteratively. RESULTS: Twenty-five interviews were analysed. Some GPs view trust as a responsibility of the physician and have a high propensity for trusting patients. For other GPs, trust in patients is developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients with whom they have a developed, trusting relationship. CONCLUSIONS: Trust plays a significant role in the patient's access to shared care. The implementation of shared care should consider the relational dynamics between the patient and health care providers.

In a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. Trust is key to this partnership. However, few studies have explored the physicians' trust in patients and its implications for shared care models. This study aims to explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs' willingness to engage in new models of care, such as colorectal cancer shared care. After analysing 25 interview transcripts with GPs, we found some GPs view trust as a responsibility of the physicians, while in others, trust in patients developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients whom they have a developed, trusting relationship. Trust plays a significant role in the patient's access to shared care. The rollout of shared care should consider the relational dynamics between the patient and health care providers.

Demystifying human research ethics committee applications.

BACKGROUND: The National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research and updated Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research provide guidance for primary care researchers. OBJECTIVE: This paper describes a step-by-step approach to ethics applications for research projects in primary care for new or inexperienced researchers, or those new to primary care research. DISCUSSION: Domains that may enhance ethics applications include increased consumer involvement; comprehensive literature reviews; evidence of researcher training in ethical research and clinical trials; the use of online platforms for participant information, consent processes and surveys; and consideration of the risks of genomic research or research in subpopulations. This paper discusses steps required when preparing ethics applications to ensure the community, clinicians and researchers are protected.

Ethical considerations regarding the use of pooled data from electronic health records in general practice.

BACKGROUND: It is important that research conducted in general practice is ethical and technically robust. Electronic health records (EHRs) have high potential to contribute to research and policy that benefits both individual patients and the broader community. General practitioners are increasingly approached to make EHRs available for research, but they also have ethical and legal obligations to ensure personal information remains confidential and is handled safely. OBJECTIVE: The aim of this article is to discuss the ethical considerations associated with the pooling of general practice EHRs for research. DISCUSSION: There are associated benefits and potential risks to patients and practices when using pooled EHR data for research. Careful consideration and judgement are required to ensure ethical requirements are met, with particular attention to informed consent, data quality and confidentiality.

Assessing suitability for long-term colorectal cancer shared care: a scenario-based qualitative study.

BACKGROUND: Shared care is the preferred model for long-term survivorship care by cancer survivors, general practitioners and specialists. However, survivorship care remains specialist-led. A risk-stratified approach has been proposed to select suitable patients for long-term shared care after survivors have completed adjuvant cancer treatment. This study aims to use patient scenarios to explore views on patient suitability for long-term colorectal cancer shared care across the risk spectrum from survivors, general practitioners and specialists. METHODS: Participants completed a brief questionnaire assessing demographics and clinical issues before a semi-structured in-depth interview. The interviews focused on the participant's view on suitability for long term cancer shared care, challenges and facilitators in delivering it and resources that would be helpful. We conducted thematic analysis using an inductive approach to discover new concepts and themes. RESULTS: Interviews were conducted with 10 cancer survivors, 6 general practitioners and 9 cancer specialists. The main themes that emerged were patient-centredness, team resilience underlined by mutual trust and stronger system supports by way of cancer-specific training, survivorship care protocols, shared information systems, care coordination and navigational supports. CONCLUSIONS: Decisions on the appropriateness of this model for patients need to be made collaboratively with cancer survivors, considering their trust and relationship with their general practitioners and the support they need. Further research on improving mutual trust and operationalising support systems would assist in the integration of shared survivorship care.

GP attitudes to and expectations for providing personal genomic risk information to the public: a qualitative study.

BACKGROUND: As part of a pilot randomised controlled trial examining the impact of personal melanoma genomic risk information on behavioural and psychosocial outcomes, GPs were sent a booklet containing their patient's genomic risk of melanoma. AIM: Using this booklet as an example of genomic risk information that might be offered on a population-level in the future, this study explored GP attitudes towards communicating genomic risk information and resources needed to support this process. DESIGN & SETTING: Semi-structured interviews were conducted with 22 Australian GPs. METHOD: The interviews were recorded and transcribed, and data were analysed thematically. RESULTS: GPs in this sample believed that communicating genomic risk may become a responsibility within primary care and they recommended a shared decisionmaking approach to guide the testing process. Factors were identified that may influence how and when GPs communicate genomic risk information. GPs view genomics-based risk as one of many disease risk factors and feel that this type of information could be applied in practice in the context of overall risk assessment for diseases for which prevention and early detection strategies are available. They believe it is important to ensure that patients understand their genomic risk and do not experience long-term adverse psychological responses. GPs desire clinical practice guidelines that specify recommendations for genomic risk assessment and patient management, point-of-care resources, and risk prediction tools that include genomic and traditional risk factors. CONCLUSION: These findings will inform the development of resources for preparing GPs to manage and implement genomic risk information in practice.

Personalized melanoma risk assessments and tailored prevention advice: a pragmatic randomized controlled trial in Australian general practice.

BACKGROUND: Personalized risk assessments using prediction models that incorporate several melanoma risk factors may promote melanoma-prevention behaviours. OBJECTIVES: To evaluate the effect on short-term melanoma-prevention behaviours of web-based, real-time, model-generated personalized melanoma risk information and tailored prevention advice, and its feasibility and clinician acceptability. METHODS: Between February and April 2016, in an open randomized controlled trial across four general medical practices in New South Wales, Australia, 272 patients were randomly allocated to receive (i) real-time model-generated personalized melanoma risk assessment and tailored melanoma-prevention advice or (ii) generic melanoma-prevention advice. We measured self-reported melanoma-prevention behaviours at baseline and 6 weeks and the intervention's feasibility and acceptability. RESULTS: Follow-up questionnaires were completed by 185 patients at 6 weeks: 174 assessed as average risk and 11 as high or very high risk. There were no statistically significant differences between intervention and control patients in sun protection, sun exposure or early diagnosis behaviours. When stratified by melanoma risk, average risk patients in the intervention group appeared to show greater sun protection at 6 weeks (mean difference = 0.23, on a scale of 1-5; 95% confidence interval: 0.01 to 0.45; P = 0.04) than patients in the control group; the P value for interaction between intervention and risk category was 0.10. There was favourable feedback from patients and general practitioners. CONCLUSIONS: Web-based delivery in general practice of real-time, model-generated personalized melanoma risk prediction and tailored melanoma-prevention advice is feasible and acceptable. An apparent increase in sun protection behaviour in average risk patients warrants further evaluation in different risk groups.

The experiences of smoking cessation among patients with chronic obstructive pulmonary disease in Australian general practice: a qualitative descriptive study.

BACKGROUND: It is important to understand the experiences surrounding smoking cessation among patients with chronic obstructive pulmonary disease (COPD) to improve the likely success of future smoking cessation programs. OBJECTIVE: To explore the personal experiences surrounding smoking cessation among general practice patients with COPD. METHODS: A purposive sample of 33 general practice patients with COPD, 28 ex-smokers and 5 smokers, participated in the semi-structured telephone interviews. Thematic analysis was conducted using a predominantly deductive approach guided by the Behaviour Change Wheel framework. RESULTS: Three inter-related themes were generated: the motivation, opportunities and capabilities among the participants to quit and maintain smoking cessation. Most quit attempts occurred without explanation or prior planning, though some attempts were motivated by the participants' family, peers or GP. Internet-based smoking cessation support programs led by general practices and involving the practice nurse were perceived as opportunities to engage in quit attempts. Most participants, both ex-smokers and smokers, demonstrated capacity to engage in multiple quit attempts. However, for many smokers, boredom, mood disturbances, the strong sense of identity as a smoker, peer reinforcement, irritability, cravings, hunger and weight gain limited capability to maintain smoking cessation. CONCLUSIONS: Patients with COPD have motivation to quit and have demonstrated capacity to engage in multiple quit attempts. GPs and other primary care practitioners need to recognize the patients' spontaneity around quit attempts and to meet the needs of the individual patient by being ready to offer support for each attempt once the patient has made their decision to quit.

Development and External Validation of a Melanoma Risk Prediction Model Based on Self-assessed Risk Factors.

IMPORTANCE: Identifying individuals at high risk of melanoma can optimize primary and secondary prevention strategies. OBJECTIVE: To develop and externally validate a risk prediction model for incident first-primary cutaneous melanoma using self-assessed risk factors. DESIGN, SETTING, AND PARTICIPANTS: We used unconditional logistic regression to develop a multivariable risk prediction model. Relative risk estimates from the model were combined with Australian melanoma incidence and competing mortality rates to obtain absolute risk estimates. A risk prediction model was developed using the Australian Melanoma Family Study (629 cases and 535 controls) and externally validated using 4 independent population-based studies: the Western Australia Melanoma Study (511 case-control pairs), Leeds Melanoma Case-Control Study (960 cases and 513 controls), Epigene-QSkin Study (44 544, of which 766 with melanoma), and Swedish Women's Lifestyle and Health Cohort Study (49 259 women, of which 273 had melanoma). MAIN OUTCOMES AND MEASURES: We validated model performance internally and externally by assessing discrimination using the area under the receiver operating curve (AUC). Additionally, using the Swedish Women's Lifestyle and Health Cohort Study, we assessed model calibration and clinical usefulness. RESULTS: The risk prediction model included hair color, nevus density, first-degree family history of melanoma, previous nonmelanoma skin cancer, and lifetime sunbed use. On internal validation, the AUC was 0.70 (95% CI, 0.67-0.73). On external validation, the AUC was 0.66 (95% CI, 0.63-0.69) in the Western Australia Melanoma Study, 0.67 (95% CI, 0.65-0.70) in the Leeds Melanoma Case-Control Study, 0.64 (95% CI, 0.62-0.66) in the Epigene-QSkin Study, and 0.63 (95% CI, 0.60-0.67) in the Swedish Women's Lifestyle and Health Cohort Study. Model calibration showed close agreement between predicted and observed numbers of incident melanomas across all deciles of predicted risk. In the external validation setting, there was higher net benefit when using the risk prediction model to classify individuals as high risk compared with classifying all individuals as high risk. CONCLUSIONS AND RELEVANCE: The melanoma risk prediction model performs well and may be useful in prevention interventions reliant on a risk assessment using self-assessed risk factors.

Feasibility of a GP delivered skin cancer prevention intervention in Australia.

BACKGROUND: Despite years of public education, sun-related behaviours are difficult to change and a recent survey showed low levels of sun protection. In this study we evaluated the feasibility and acceptability of an opportunistic skin cancer prevention intervention in general practice. METHODS: We used a controlled pre-and-post intervention design. Participants (n = 100) were recruited sequentially from patients attending two general practices in Sydney, Australia, from November to December 2010. Participants in the intervention practice (n = 50) received general practitioner delivered sun protection advice after completing a skin cancer risk assessment tool, and a sun protection pamphlet, in addition to routine care, at a single attendance. The skin cancer risk assessment tool provided three levels of risk. The general practitioner (GP) reinforced the level of risk and discussed sun protection. Participants in the control practice (n = 50) received routine care. We measured feasibility by patients' and GPs' participation in the intervention and time taken, and acceptability by intervention participants and GPs ratings of the intervention. We measured reported sun-related knowledge, attitudes and behaviour between the two groups at 1 and 13 months. RESULTS: The intervention was found to be feasible within existing primary care team arrangements. Participation at baseline was 81% (108/134), and repeated participation was 88% (88/100) at 1 month and 70% (70/100) at 13 months. Participants and practitioners found the intervention acceptable. At 1 month, sun-related knowledge had increased in both patient groups, with a greater increase in the intervention group (adjusted mean difference 0.48, p = 0.034). There were no differences between groups in sun-related knowledge, attitudes and behaviour at 13 months. CONCLUSIONS: A brief opportunistic skin cancer prevention intervention in general practice is feasible and acceptable. Further research in this setting with a more intensive intervention would be justified.

Risk prediction models for incident primary cutaneous melanoma: a systematic review.

IMPORTANCE: Currently, there is no comprehensive assessment of melanoma risk prediction models. OBJECTIVE: To systematically review published studies reporting multivariable risk prediction models for incident primary cutaneous melanoma for adults. EVIDENCE REVIEW: EMBASE, MEDLINE, PREMEDLINE, and Cochrane databases were searched to April 30, 2013. Eligible studies were hand searched and citation tracked. Two independent reviewers extracted information. FINDINGS: Nineteen studies reporting 28 melanoma prediction models were included. The number of predictors in the final models ranged from 2 to 13; the most common were nevi, skin type, freckle density, age, hair color, and sunburn history. There was limited reporting and substantial variation among the studies in model development and performance. Discrimination (the ability of the model to differentiate between patients with and without melanoma) was reported in 9 studies and ranged from fair to very good (area under the receiver operating characteristic curve, 0.62-0.86). Few studies assessed internal or external validity of the models or their use in clinical and public health practice. Of the published melanoma risk prediction models, the risk prediction tool developed by Fears and colleagues, which was designed for the US population, appears to be the most clinically useful and may also assist in identifying high-risk groups for melanoma prevention strategies. CONCLUSIONS AND RELEVANCE: Few melanoma risk prediction models have been comprehensively developed and assessed. More external validation and prospective evaluation will help translate melanoma risk prediction models into useful tools for clinical and public health practice.

Occupational sun exposure and risk of melanoma according to anatomical site.

Although sunburn and intermittent sun exposures are associated with increased melanoma risk, most studies have found null or inverse associations between occupational (more continuous pattern) sun exposure and melanoma risk. The association of melanoma with occupational sun exposure may differ according to anatomical site, with some studies finding a positive association with melanoma on the head and neck. We examined the association between occupational sun exposure (self-reported weekday sun exposure) and melanoma risk according to anatomical site, using data from two multicentre population-based case-control studies: the Australian Melanoma Family Study (588 cases, 472 controls) and the Genes, Environment and Melanoma study (GEM; 1079 cases, 2,181 controls). Unconditional logistic regression was used to estimate odds ratios (OR) and their 95% confidence intervals, adjusting for potential confounders. Occupational sun exposure was not positively associated with melanoma risk overall or at different body sites in both studies. The GEM study found inverse associations between occupational sun exposure and melanoma on the head and neck [OR for highest vs. lowest quartile: 0.56, 95% confidence intervals (CI) 0.36-0.86, ptrend 0.02], and between the proportion of total sun exposure occurring on weekdays and melanoma on the upper limbs (OR for highest vs. lowest quartile: 0.66, 95% CI 0.42-1.02, ptrend 0.03). Our results suggest that occupational sun exposure does not increase risk of melanoma, even of melanomas situated on the head and neck. This finding seemed not to be due to negative confounding of occupational sun exposure by weekend sun.

MC1R genotype as a predictor of early-onset melanoma, compared with self-reported and physician-measured traditional risk factors: an Australian case-control-family study.

BACKGROUND: Melanocortin-1 receptor (MC1R) gene variants are very common and are associated with melanoma risk, but their contribution to melanoma risk prediction compared with traditional risk factors is unknown. We aimed to 1) evaluate the separate and incremental contribution of MC1R genotype to prediction of early-onset melanoma, and compare this with the contributions of physician-measured and self-reported traditional risk factors, and 2) develop risk prediction models that include MC1R, and externally validate these models using an independent dataset from a genetically similar melanoma population. METHODS: Using data from an Australian population-based, case-control-family study, we included 413 case and 263 control participants with sequenced MC1R genotype, clinical skin examination and detailed questionnaire. We used unconditional logistic regression to estimate predicted probabilities of melanoma. Results were externally validated using data from a similar study in England. RESULTS: When added to a base multivariate model containing only demographic factors, MC1R genotype improved the area under the receiver operating characteristic curve (AUC) by 6% (from 0.67 to 0.73; P < 0.001) and improved the quartile classification by a net 26% of participants. In a more extensive multivariate model, the factors that contributed significantly to the AUC were MC1R genotype, number of nevi and previous non-melanoma skin cancer; the AUC was 0.78 (95% CI 0.75-0.82) for the model with self-reported nevi and 0.83 (95% CI 0.80-0.86) for the model with physician-counted nevi. Factors that did not further contribute were sun and sunbed exposure and pigmentation characteristics. Adding MC1R to a model containing pigmentation characteristics and other self-reported risk factors increased the AUC by 2.1% (P = 0.01) and improved the quartile classification by a net 10% (95% CI 1-18%, P = 0.03). CONCLUSIONS: Although MC1R genotype is strongly associated with skin and hair phenotype, it was a better predictor of early-onset melanoma than was pigmentation characteristics. Physician-measured nevi and previous non-melanoma skin cancer were also strong predictors. There might be modest benefit to measuring MC1R genotype for risk prediction even if information about traditional self-reported or clinically measured pigmentation characteristics and nevi is already available.