Improving blood pressure control in primary care: feasibility and impact of the ImPress intervention

Abstract of a paper presented at he 2015 PHC Research Conference, 29-31 July, Adelaide, Australia

Patient experiences of nurse-facilitated advance care planning in a general practice setting: a qualitative study

Background: Advance care planning (ACP) can offer benefits to patients and their families, especially when delivered in outpatient settings, but uptake remains low. Common barriers for health professionals include a perceived lack of time and adequate training, experience, and confidence in conducting ACP. Patient-reported barriers include a lack of awareness of ACP or discomfort initiating or engaging in discussions about end-of-life. Methods: We aimed to explore patients\u27 perspectives of an ACP intervention designed to address common barriers to uptake in the general practice setting. We provided training and support to doctors and general practice nurses (GPNs) to initiate and lead ACP discussions at their respective practices (2014 to 2015). Following the intervention, we conducted interviews with patients to explore their experience of engaging in ACP in the general practice setting. Thematic analysis was used to inductively code transcripts and identify key themes from semi-structured interviews with patients. Results: Six major themes relating to patient experiences of GPN-facilitated ACP were identified: Working through ideas, therapeutic relationship with nurses, significance of making wishes known, protecting family from burden, autonomy in decision-making, and challenges of family communication. The patients valued the opportunity to speak about issues that are important to them with the GPN who they found to be compassionate and caring. The patients felt that ACP would lead to significant benefits not only to themselves but also for their family. Despite encouragement to involve other family members, most patients attended the ACP discussions alone or as a couple; many did not see the relevance of their family being involved in the discussions. Some patients felt uncomfortable or reluctant in communicating the results of their discussion with their family. Conclusions: With adequate training and support, GPNs are able to initiate and facilitate ACP conversations with patients. Their involvement in ACP can have significant benefits for patients. Psychosocial and relational elements of care are critical to patient satisfaction. Our findings show that some patients may feel uncomfortable or reluctant to communicate the results of their ACP discussions with their family. A future larger study is required to verify the findings of this pilot study

Weight management for patients in general practice tailored to health literacy

Our aim was to develop and evaluate the feasibility and impact of a PHC approach to weight management tailored to the level of health literacy of obese patients. There were three key activities undertaken in this regard: 1) a literature review; 2) a pilot study; and 3) a weight management trial called “Better Management of Weight in General Practice” (BMWGP). In this report we describe the three activities and use the BMWGP baseline data to explore three issues. First, we look at the effectiveness of a screening tool to identify patients with low health literacy in general practice. Second, we describe the association between health literacy and a range of factors, behavioural intentions, lifestyle behaviours and quality of life to better understand the link between health literacy and health in a population of patients with obesity attending general practices. Third, we identify the groups most likely to experience weight stigma and how stigma relates to health literacy.The research reported in this paper is a project of the Australian Primary Health Care Research Institute which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research Evaluation and Development Strategy

Barriers and outcomes of an evidence-based approach to diagnosis and management of chronic obstructive pulmonary disease (COPD) in Australia: a qualitative study

Background. Chronic obstructive pulmonary disease (COPD) is commonly managed in primary care but there is poor awareness of evidence-based guidelines and the quality and interpretation of spirometry is suboptimal. Objectives. The aims of this qualitative study were to explore how an intervention involving case finding and management of COPD was implemented, and the extent to which the GPs and practice nurses (PNs) worked in partnership to diagnose and manage COPD. Methods. Semi-structured interviews with PNs (n = 7), GPs (n = 4) and patients (n = 26) who had participated in the Primary care EarLy Intervention for Copd mANagement (PELICAN) study. The Theoretical Domains Framework was used to guide the coding and analysis of the interviews with PN and GPs. The patient interviews were analysed thematically. Results. PNs developed technical skills and understood the requirements for good-quality spirometry. However, many lacked confidence in its interpretation and felt this was not part of their professional role. This was reflected in responses from the GPs. Once COPD was diagnosed, the GPs tended to manage the patients with the PNs less involved. This was in contrast with PNs’ active role in managing patients with other chronic diseases such as diabetes. The extent to which the GPs and PNs worked in partnership to manage COPD varied. Conclusions. PNs improved their skills and confidence in performing spirometry. Beliefs about their professional role, identity and confidence influenced the extent to which PNs were involved in interpretation of the spirometry results and managing the patient in partnership with the GP

A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams : Study Protocol

Background: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. Design: A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD. The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities. The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups. Discussion: This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care

Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: views of general practitioners and practice nurses

Background. Support in primary care can assist smokers to quit successfully, but there are barriers to general practitioners (GPs) providing this support routinely. Practice nurses (PNs) may be able to effectively take on this role. Objectives. The aim of this study was to perform a process evaluation of a PN-led smoking cessation intervention being tested in a randomized controlled trial in Australian general practice. Methods. Process evaluation was conducted by means of semi-structured telephone interviews with GPs and PNs allocated in the intervention arm (Quit with PN) of the Quit in General Practice trial. Interviews focussed on nurse training, content and implementation of the intervention. Results. Twenty-two PNs and 15 GPs participated in the interviews. The Quit with PN intervention was viewed positively. Most PNs were satisfied with the training and the materials provided. Some challenges in managing patient data and follow-up were identified. Conclusion. The Quit with PN intervention was acceptable to participating PNs and GPs. Issues to be addressed in the planning and wider implementation of future trials of nurse-led intervention in general practice include providing ongoing mentoring support, integration into practice management systems and strategies to promote greater collaboration in GPs and PN teams in general practice. The ongoing feasibility of the intervention was impacted by the funding model supporting PN employment and the competing demands on the PNs time

Feasibility and acceptability of a nurse-led hypertension management intervention in general practice

Background: Hypertension is the most frequently seen condition in Australian general practice. Despite the availability of effective therapies, many hypertensive individuals struggle to maintain adequate blood pressure control and are at increased risk of cardiovascular disease and premature morbidity. As such there is an urgent need for research to identify evidence based strategies to improve hypertension management in general practice. General Practice Nurses (GPNs) are conceptually ideally placed to support consumers to receive best practice care and achieve behavioural change. However, their specific role in managing hypertension is unclear. The purpose of this paper is to evaluate the acceptability and feasibility of a GPN-led intervention to manage hypertension in Australian general practice. Methods: Individuals with uncontrolled hypertension were identified from electronic medical records. GPNs provided 4 face-to-face appointments and 2 telephone support calls to deliver the intervention.Qualitative evaluation of the interventions’ feasibility and acceptability was achieved through semi-structured interviews with 6 GPs, 7 GPNs and 12 consumers. Findings: Thematic analysis revealed 5 themes, namely; pre-intervention training, GP/GPN roles, time and workload, acceptability and feasibility. Most GPNs appreciated the pre-intervention training, however the need for additional motivational interviewing education was identified. Consumers were satisfied with the intervention valuing the GPN as a ‘coach’, although they valued ongoing GP input. Issues relating to lack of time and competing work priorities were identified as barriers to successfully delivering the intervention, however, the intervention was perceived to be feasible and acceptable in practice. Conclusion: Despite the demonstrated acceptability and feasibility of the intervention, the ongoing sustainability of the model rests largely upon overcoming the organisational, educational and professional barriers that constrain the GPN’s role. Findings demonstrate great potential for GPNs to significantly contribute to improved health outcomes and play a more active role in hypertension management. This role could be optimised with the development of motivational interviewing skills, enhanced GP/GPN collaborative practice and increased opportunity for consumer follow up

Improving blood pressure control in general practice : a pilot study of the ImPress intervention

Background and objectives Patients with hypertension and at high absolute cardiovascular disease risk are a priority group for improved blood pressure control. This study examined the impact of an intervention, primarily delivered by the general practice nurse, to identify, recall and manage patients with uncontrolled hypertension who are at high risk of cardiovascular disease. Methods A before-and-after pilot study with a six-month follow-up period was conducted in eight general practices in Sydney, Australia. Results From 507 patients identified, 82 (16.2%) attended an assessment visit, were eligible and provided baseline data. Of these, 55 (67.1%) completed the six-month follow-up. The mean decrease in blood pressure was 14.5 mmHg systolic and 7 mmHg diastolic. Significant decreases were also found in mean weight (1.3 kg), body mass index (0.5 kg/m2) and waist circumference (1.9 cm). Adherence to blood pressure treatment, as measured by the Hill-Bone scale, significantly improved (P = 0.01) Discussion The results of this study justify further investigation in a randomised trial. If effective, the approach could alter the way hypertension care is organised and delivered in Australian general practice

Do Multidisciplinary care plans result in better care for patients with type 2 diabetes?

BACKGROUND: Since the introduction of the Enhanced Primary Care package, care plans have become part of Australian general practice. Previous research has focused on barriers to the uptake of care plans. This study examined the effect of multidisciplinary care plans on provision and outcome of care for patients with type 2 diabetes. METHODS: A retrospective before/after medical record audit design was chosen. Subjects of the study were general practitioners practising in Southwest Sydney (New South Wales) and their diabetic patients who had written care plans. Outcome measures were frequency and results of glycosylated haemoglobin, blood pressure, foot, serum lipids, weight, and microalbumin checks. RESULTS: The medical records of 230 patients were audited. Following the care plan, adherence to diabetes guidelines increased. Metabolic control and cardiovascular risk factors improved for patients who had multidisciplinary care implemented. DISCUSSION: Whether the improved diabetes care shown here is attributed to improved teamwork and/or coordination of care needs further research