Delayed prescribing of antibiotics for acute respiratory infections by GP registrars: a qualitative study

Background: Antibiotic prescribing for acute self-limiting respiratory tract infections (ARTIs) in Australia is higher than international benchmarks. Antibiotics have little or no efficacy in these conditions, and unnecessary use contributes to antibiotic resistance. Delayed prescribing has been shown to reduce antibiotic use. GP registrars are at a career-stage when long-term prescribing patterns are being established. Aim: To explore experiences, perceptions and attitudes of GP registrars and supervisors to delayed antibiotic prescribing for ARTIs. Design and setting: A qualitative study of Australian GP registrars and supervisors using a thematic analysis approach. Method: GP registrars and supervisors were recruited across three Australian states/territories, using maximum variation sampling. Telephone interviews explored participants’ experience and perceptions of delayed prescribing of antibiotics in ARTIs. Data collection and analysis were concurrent and iterative. Results: A total of 12 registrars and 10 supervisors were interviewed. Key themes included the use of delayed prescribing as a safety-net in cases of diagnostic uncertainty or when clinical review was logistically difficult. Delayed prescribing was viewed as a method of educating and empowering patients, and building trust and the doctor–patient relationship. Conversely, it was also seen as a loss of control over management decisions. Supervisors, more so than registrars, appreciated the psychosocial complexity of ARTI consultations and the importance of delayed antibiotic prescribing in this context. Conclusion: Better awareness and understanding by GP registrars of the evidence for delayed antibiotic prescription may be a means of reducing antibiotic prescribing. Understanding both registrar and supervisor usage, uncertainties and attitudes should inform educational approaches on this topic

Immediate and delayed antibiotic prescribing strategies used by Australian early-career GP: A cross-sectional analysis

BACKGROUND: Antibiotics are overused for non-pneumonia acute respiratory tract infections (ARTIs). AIM: To establish prevalence and explore associations of delayed and immediate antibiotic prescribing strategies of Australian early-career GPs (specialist GP vocational trainees, also known as GP registrars) for non-pneumonia ARTIs. DESIGN AND SETTING: Cross-sectional analysis of data collected between September 2016 and December 2017 from the Registrar Clinical Encounters in Training cohort (ReCEnT) study, an ongoing cohort study of GP registrars’ in-practice clinical experiences in four Australian states and territories. METHOD: Multinomial logistic regression with outcome antibiotic prescribing (no prescribing, immediate prescribing, and delayed prescribing). RESULTS: Of 7156 new ARTI diagnoses, no antibiotics were prescribed for 4892 (68%); antibiotics were prescribed for immediate use for 1614 diagnoses (23%) and delayed antibiotics were used for 650 diagnoses (9%). Delayed prescribing was used in 22% of otitis media, 16% of sinusitis, 13% of sore throat, 11% of acute bronchitis/bronchiolitis, and 5% of upper respiratory tract infection (URTI) diagnoses. Delayed prescribing was used for 29% of all prescriptions written. Delayed prescribing and immediate prescribing were associated with markers of clinical concern. Delayed prescribing was associated with longer duration of consultation and with fewer diagnoses/problems dealt with in the consultation. CONCLUSION: Australian early-career GPs use no prescribing for ARTIs substantially more than established GPs; however, except where URTIs are concerned, they still prescribe antibiotics in excess of validated benchmarks. Australian early-career GPs may use delayed prescribing more often than European established GPs, and may use it to manage diagnostic uncertainty and, possibly, conflicting influences on prescribing behaviour. The use of delayed prescribing may enable a transition to an environment of more-rational antibiotic prescribing for ARTIs

Changing the antibiotic prescribing of general practice registrars: The ChAP study protocol for a prospective controlled study of a multimodal educational intervention

Background: Australian General Practitioners (GPs) are generous prescribers of antibiotics, prompting concerns including increasing antimicrobial resistance in the community. Recent data show that GPs in vocational training have prescribing patterns comparable with the high prescribing rate of their established GP supervisors. Evidence-based guidelines consistently advise that antibiotics are not indicated for uncomplicated upper respiratory tract infections (URTI) and are rarely indicated for acute bronchitis. A number of interventions have been trialled to promote rational antibiotic prescribing by established GPs (with variable effectiveness), but the impact of such interventions in a training setting is unclear. We hypothesise that intervening while early-career GPs are still developing their practice patterns and prescribing habits will result in better adherence to evidence-based guidelines as manifested by lower antibiotic prescribing rates for URTIs and acute bronchitis. Methods/design: The intervention consists of two online modules, a face-to-face workshop for GP trainees, a face-to-face workshop for their supervisors and encouragement for the trainee-supervisor dyad to include a case-based discussion of evidence-based antibiotic prescribing in their weekly one-on-one teaching meetings. We will use a non-randomised, non-equivalent control group design to assess the impact on antibiotic prescribing for acute upper respiratory infections and acute bronchitis by GP trainees in vocational training. Discussion: Early-career GPs who are still developing their clinical practice and prescribing habits are an underutilized target-group for interventions to curb the growth of antimicrobial resistance in the community. Interventions that are embedded into existing training programs or are linked to continuing professional development have potential to increase the impact of existing interventions at limited additional cost. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12614001209684 (registered 17/11/2014)

Prevalence and associations of general practitioners’ ordering of “non-symptomatic” prostate-specific antigen tests: A cross-sectional analysis

Aims: Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of “non-symptomatic” PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars). Methods: A cross-sectional analysis from the ReCEnT cohort study of registrars’ consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an “asymptomatic” PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors. Results: A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69\ua0years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test). Conclusion: GP registrars frequently order “asymptomatic” PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted

General practice training in regional and rural Australia: a cross‐sectional analysis of the Registrar Clinical Encounters in Training study

Objective: We aimed to investigate registrar, practice and consultation characteristics associated with varying degrees of GP registrars' practice rurality.Design: A cross-sectional analysis of 12 rounds of data collection (2010-2015) from the longitudinal Registrar Clinical Encounters in Training study, an ongoing, cohort study of Australian GP registrars. The principal analysis used was a generalised ordered logistic regression.Setting/Participants: GP registrars in training practices within five of 17 GP regional training providers in five Australian states.Main outcome measure: Degree of rurality of the practice in which the registrar undertook training terms was calculated from the practice postcode using the Australian Standard Classification-Remoteness Area classification.Results: A total of 1161 registrars contributed data for 166 998 patient consultations (response rate 95.5%). Of these, 56.9% were in major city practices (ASGC-RA1), 25.7% were in inner-regional practices (ASGC-RA2) and 17.4% were in outer-regional/rural practices (ASGC-RA3-5). Several statistically significant associations (P = < .001) were found within regional/rural practices (ASGC-RA2-5), when compared with major city practices (ASGC-RA1). These included registrar characteristics such as being in Term 1, being medically trained overseas, and having worked at the practice previously; patient characteristics such as the patient being an existing patient, being older and being Aboriginal or Torres Strait Islander; and consultation characteristics such as performance of procedures.Conclusion: Our findings suggest that registrars are undertaking rural practice early in their GP training and are being exposed to a rich and challenging mix of clinical and educational practice

General practitioner trainees' in-consultation generation of clinical questions for later answering: prevalence and associations

Background. As well as generating patient-specific questions, patient consultations are a rich source of questions relating to clinicians' need to acquire or maintain wider clinical knowledge. This is especially so for GP trainees. Objectives. To establish the prevalence and associations of GP trainees' generation of 'learning goals' (LGs: questions generated during clinical consultations for intended post-consultation answering). Also, to characterize the type of learning goals generated. Methods. A cross-sectional analysis (2010-15) of an ongoing cohort study of Australian GP trainees' consultations. Once each 6-month training term, trainees record detailed data of 60 consecutive consultations. The primary outcome was generation of an LG. Analysis was at the level of individual problem/diagnosis managed. The secondary outcome was the problems/diagnoses to which the LGs related. Results. One thousand one hundred and twenty-four trainees contributed data for 154 746 consultations including 222 307 problems/diagnoses. LGs were generated for 16.6% [95% confidence intervals (CI) = 16.4-16.7] of problems/diagnoses, in 22.1% (95% CI = 21.9-22.3%) of consultations. Associations of LGs included patient factors: younger age and having seen the trainee previously; trainee factors: earlier training stage, being overseas-trained and the trainee's training organization; consultation factors: longer duration, addressing a chronic disease, referring the patient, organizing follow-up, organizing investigations and accessing in-consultation information. LGs were commonly generated for skin (12.9% of all learning goals), musculoskeletal (12.7%) and respiratory (8.7%) problems. LGs were generated for 31.8% of male genital, 27.0% of neurological and 23.3% of eye problems. Conclusion. Australian GP trainees frequently generate questions in-consultation to be pursued post-consultation. Prevalence, 'complexity' and familiarity of clinical topic area influenced LG generation.Funding: 2014 General Practice Education and Training (GPET) research grant (D14/11354); General Practice Training Valley to Coast, the Victorian Metropolitan Alliance, General Practice Training Tasmania, Tropical Medicine Training and Adelaide to Outback GP Training Program that were funded by the Australian Government (to ReCEnT project 2010–15); Australian Department of Health (commissioned research grant and supported by GP Synergy Regional Training Organisation) (to ReCEnT project from 2016)

Early career GPs, mental health training and clinical complexity: a cross-sectional analysis

Patients with mental health conditions commonly present in General Practice. Mental health curricula are broad. We do not know that trainees are exposed to the learning they require. This study aimed to establish the prevalence, characteristics and associations of GP trainees' management of mental health problems. This paper presents a cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing multisite cohort study of Australian GP trainees (registrars) documenting their clinical experiences over 60 consecutive consultations. Univariate and multivariable logistic regression analyses were conducted with outcome of the problem/diagnosis being a mental health condition. 1659 trainees provided data on 218,325 consultations and 340,453 problems/diagnoses. Mental health conditions were associated with patients being male, of Aboriginal or Torres Strait Islander or English-speaking background. Trainee characteristics were being more senior and having trained in Australia. Practice characteristics included being in low socioeconomic areas. Trainees sought less help for mental health concerns than they did for other problems. While early-career GPs see a broad range of mental health conditions, they may benefit from training to manage patients from cross-cultural contexts. They may also need support to generate appropriate learning goals and seek assistance if they are to continue to deepen competence

Changes in pathology test ordering by early career general practitioners: a longitudinal study

To assess the number of pathology tests ordered by general practice registrars during their first 18-24 months of clinical general practice.Longitudinal analysis of ten rounds of data collection (2010-2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%.Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms.876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8-15%; P < 0.001) per training term.Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns

General practitioner trainees' in-consultation generation of clinical questions for later answering: prevalence and associations

Background. As well as generating patient-specific questions, patient consultations are a rich source of questions relating to clinicians' need to acquire or maintain wider clinical knowledge. This is especially so for GP trainees

Temporal trends in, and associations of, early-career general practitioner prescriptions of second-line Type 2 Diabetes medications, 2010-2018.

IntroductionSecond-line pharmacotherapy for Type 2 Diabetes Mellitus ('diabetes') is necessary for optimal glycaemic control and preventing longer-term complications. We aimed to describe temporal trends in, and associations of, Australian general practitioner (GP) registrars' prescription, and initiation, of 'new' second-line oral agents (dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists) compared to sulphonylureas.Materials and methodsA longitudinal analysis (2010-2018) of data from the Registrar Clinical Encounters in Training project. Analysis included any diabetes problem/diagnosis that involved prescription of sulphonylureas or 'new' oral agents. Simple and multiple logistic regression models were fitted within the generalised estimating equations framework.Results2333 registrars recorded 6064 diabetes problems/diagnoses (1.4%). 835 problems/diagnoses involved sulphonylurea or 'new' medication prescription. Of these, 61.0% [95% CI:57.4-64.4] involved 'new' medication prescription. 230 problems/diagnoses involved sulphonylurea or 'new' medication initiation, with 77% [95%CI:70.8-82.1] involving a 'new' medication. There was a significant 52% per year increase in prescribing (OR = 1.52[95% CI:1.38-1.68],pConclusionRegistrar uptake of 'new' oral agents compared to sulphonylureas has increased rapidly