Factors affecting the embedding of integrated primary-secondary care into a health district.

With the aging population, the tide of chronic disease is rising with attendant increases in health service need. Integrated care and patient-centred approaches, which established partnerships between a regional Hospital and health service (HHS), the local primary health network and local general practitioners (GPs), were identified as exemplars of an approach needed to support growing community health needs. This paper summarises the findings from a process evaluation of four GP-specialist care integration programs with the aim of identifying recommendations for embedding integrated GP-specialist care into routine practice within the HHS. The process evaluation of the integration programs drew on input from a multidisciplinary expert advisory group and data collected through face-to-face semi-structured interviews with key stakeholders, as well as surveys of participating GPs and patients. Overarching findings were identified and grouped under six themes: interdisciplinary teamwork; communication and information exchange; the use of shared care guidelines or pathways; training and education; access and accessibility; and funding. Within each theme, key challenges and enablers emerged. The findings of this study highlight benefits and challenges associated with the establishment of integrated care between primary and secondary care providers, leading to the development of key recommendations for routine integration.

Why do people with chronic disease not contact consumer health organisations? A survey of general practice patients.

UNLABELLED: Aim Consumer health organisations (CHOs) are non-profit or voluntary sector organisations that promote and represent the interests of patients and carers affected by particular conditions. The purpose of this study was to examine, among patients with chronic disease, what differentiates those who contact CHOs from those who do not and what stops people from making contact. BACKGROUND: CHOs can enhance people's capacity to manage chronic disease by providing information, education and psychosocial support, but are under-utilised. Little is known about barriers to access. METHODS: Data were from a baseline telephone survey conducted as part of a randomised trial of an intervention to improve access to CHOs. Participants constituted a consecutive sample of 276 adults with diagnosed chronic disease recruited via 18 general practitioners in Brisbane, Australia. Quantitative survey items examined participants' use and perceptions of CHOs and a single open-ended question explored barriers to CHO use. Multiple logistic regression and thematic analysis were used. Findings Overall, 39% of participants had ever contacted a CHO for their health and 28% had contacted a CHO specifically focussed on their diagnosed chronic condition. Diabetes, poorer self-reported physical health and greater health system contact were significantly associated with CHO contact. The view that 'my doctor does it all' was prevalent and, together with a belief that their health problems were 'not serious enough', was the primary reason patients did not make contact. CONCLUSION: Attitudinal and system-related barriers limit use of CHOs by those for whom they are designed. Developing referral pathways to CHOs and promoting awareness about what they offer is needed to improve access.

Are care plans suitable for the management of multiple conditions?

BACKGROUND: Care plans have been part of the primary care landscape in Australia for almost two decades. With an increasing number of patients presenting with multiple chronic conditions, it is timely to consider whether care plans meet the needs of patients and clinicians. OBJECTIVES: To review and benchmark existing care plan templates that include recommendations for comorbid conditions, against four key criteria: (i) patient preferences, (ii) setting priorities, (iii) identifying conflicts and synergies between conditions, and (iv) setting dates for reviewing the care plan. DESIGN: Document analysis of Australian care plan templates published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. RESULTS: Sixteen templates were reviewed. All of the care plan templates addressed patient preference, but this was not done comprehensively. Only three templates included setting priorities. None assisted in identifying conflicts and synergies between conditions. Fifteen templates included setting a date for reviewing the care plan. CONCLUSIONS: Care plans are a well-used tool in primary care practice, but their current format perpetuates a single-disease approach to care, which works contrary to their intended purpose. Restructuring care plans to incorporate shared decision-making and attention to patient preferences may assist in shifting the focus back to the patient and their care needs.

Incorporating patient preferences in the management of multiple long-term conditions: is this a role for clinical practice guidelines?

BACKGROUND: Clinical practice guidelines provide an evidence-based approach to managing single chronic conditions, but their applicability to multiple conditions has been actively debated. Incorporating patient-preference recommendations and involving consumers in guideline development may enhance their applicability, but further understanding is needed. OBJECTIVES: To assess guidelines that include recommendations for comorbid conditions to determine the extent to which they incorporate patient-preference recommendations; use consumer-engagement processes during development, and, if so, whether these processes produce more patient-preference recommendations; and meet standard quality criteria, particularly in relation to stakeholder involvement. DESIGN: A review of Australian guidelines published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Document analysis of guidelines examined the presence of patient-preference recommendations and the consumer-engagement processes used. The Appraisal of Guidelines for Research and Evaluation instrument was used to assess guideline quality. RESULTS: Thirteen guidelines were reviewed. Twelve included at least one core patient-preference recommendation. Ten used consumer-engagement processes, including participation in development groups (seven guidelines) and reviewing drafts (ten guidelines). More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Overall quality of guidelines was mixed, particularly in relation to stakeholder involvement. CONCLUSIONS: Guidelines do incorporate some patient-preference recommendations, but more explicit acknowledgement is required. Consumer-engagement processes used during guideline development have the potential to assist in identifying patient preferences, but further research is needed. Clarification of the consumer role and investment in consumer training may strengthen these processes.

Relative Performance of Frequency Weighting W(h) and Candidates for Alternative Frequency Weightings for Predicting the Occurrence of Hand-transmitted Vibration-induced Injuries.

Exposure to hand-transmitted vibration is usually assessed according to International Standard ISO 5349-1:2001 using the frequency weighting W(h). This paper compares eight frequency weightings that might be used to supplement or replace W(h). The comparison is based on a data from two databases, one containing over 7200 measured hand-arm vibration (HAV) spectra from a wide range of industrial machines the other recording exposure history and injury for workers referred to the Health and Safety Laboratory. Acceleration spectra from the machinery database are analysed to give weighted values for the alternative frequency weightings. These weighted values are compared and then used to estimate a set of alternative lifetime vibration dose values for subjects in the referral database. Statistical comparison of these lifetime dose values against assessments of hand-arm vibration syndrome (HAVS) and sensorineural HAVS prevalence suggests that values based the two weightings W(h) and W(h50lp) (the W(h) weighing low-pass filtered at 50 Hz) provide the strongest indicators for developing these injuries. For vascular HAVS there was no clear evidence to advocate any individual frequency weighting. For all injury categories the strongest relationships were for the first power of acceleration magnitude.

Investigating referral pathways from primary care to consumer health organisations.

While chronic disease places an increasing burden on Australia's primary care system it is unrealistic to expect GPs to meet the range of support needs experienced by patients managing chronic conditions. Consumer health organisations (CHO) have the potential to augment clinical care by providing a variety of supportive services; however, they are underutilised by patients and GPs. This qualitative study investigates GPs' knowledge and perceptions of CHO and their contributions to chronic disease care. The study involved semi-structured interviews with 10 GPs. Overall, participants demonstrated clear understanding of the role of CHO in chronic disease management, but a critical finding was the way GPs' view of their own chronic care role appears to influence referral practices. GPs operating in a traditional role were less likely to refer to CHO than those who had adopted a chronic care approach. A second key finding related to GPs' views of Diabetes Australia. All GPs identified this organisation as an important referral point, providing some reassurance that CHO can be integrated into the primary care sector. Further research is needed to determine how the 'definite advantages' associated with Diabetes Australia can be used to extend GP referral and enhance the health system's integration of other CHO.