Gaps and barriers in the control of blood glucose in people with type 2 diabetes

Background: Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature. Methods: An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online. Results: Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed. Conclusion: Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section

General practitioners knowledge and management of whiplash associated disorders and post-traumatic stress disorder: Implications for patient care

© 2016 The Author(s). Background: In Australia, general practitioners (GPs) see around two-thirds of people injured in road traffic crashes. Road traffic crash injuries are commonly associated with diverse physical and psychological symptoms that may be difficult to diagnose and manage. Clinical guidelines have been developed to assist in delivering quality, consistent care, however the extent to which GPs knowledge and practice in diagnosing and managing road traffic crash injuries concords with the guidelines is unknown. This study aimed to explore Australian GPs knowledge, attitudes and practices regarding the diagnosis and management of road traffic crash injuries, specifically whiplash associated disorders (WAD) and post-traumatic stress disorder (PTSD). Method: A cross-sectional survey of 423 GPs across Australia conducted between July and December 2014. We developed a questionnaire to assess their knowledge of WAD and PTSD, confidence in diagnosing and managing WAD and PTSD, frequency of referral to health providers, barriers to referral, and attitudes towards further education and training. Factor analysis, Spearman's correlation, and multiple ordered logistic regressions were performed. Results: Overall, GPs have good level knowledge of WAD and PTSD; only 9.6 % (95 % CI: 7.1 %, 12.8 %) and 23.9 % (95 % CI: 20.8 %, 28.2 %) of them were deemed to have lower level knowledge of WAD and PTSD respectively. Key knowledge gaps included imaging indicators for WAD and indicators for psychological referral for PTSD. GPs who were male, with more years of experience, working in the urban area and with higher knowledge level of WAD were more confident in diagnosing and managing WAD. Only GPs PTSD knowledge level predicted confidence in diagnosing and managing PTSD. GPs most commonly referred to physiotherapists and least commonly to vocational rehabilitation providers. Barriers to referral included out-of-pocket costs incurred by patients and long waiting times. Most GPs felt positive towards further education on road traffic crash injury management. Conclusion: This study has enhanced understanding of the knowledge skills and attitudes of GPs towards road traffic crash injury care in Australia, and has identified areas for further education and training. If delivered, this training has the potential to reduce unnecessary imaging for WAD and optimise the early referral of patients at risk of delayed recovery following a road traffic crash

Education of rural and remote general practitioners (GPs) in Australia on type 2 diabetes: impact of online continuing medical education on GPs’ knowledge, attitudes and practices and barriers to online learning

Background: The gap between current and evidence-based management of type 2 diabetes is widely acknowledged in Australia. Therefore, there is a need to find effective strategies to encourage GP awareness and uptake of evidence-based diabetes guidelines. A well-developed and evaluated web-based education strategy is considered to be an appropriate method for practising GPs in rural and remote areas to undertake continuing medical education. This PhD research forms one part of an NHMRC project entitled “The effectiveness of continuing medical education and feedback in altering diabetes outcomes at a population level-A RCT”. Aims: 1) to examine the current knowledge, attitudes and practices of Australian rural and remote GPs regarding type 2 diabetes management, 2) to test the impact of an online education intervention on GPs’ learning outcomes, and 3) to identify barriers to GPs undertaking and completing the online educational intervention and online learning in general. Methods: The research design consisted of seven complementary studies: three systematic reviews of the literature; a cross-sectional national survey; a quasi-experimental study; and a mixed methods study comprising a short cross-sectional survey and semi-structured telephone interviews. The systematic literature reviews were conducted applying systematic approaches to the literature search, study selection and data extraction. The first systematic review (Study 1) aimed to assess evidence in the literature for the effectiveness of type 2 diabetes educational interventions specifically targeting practising GPs, and where possible, those practising in rural and remote locations. The second systematic review (Study 2) aimed to assess evidence in the literature for the effectiveness of online continuing medical education (CME) specifically targeting GPs. The third systematic review (Study 3) aimed to examine barriers to GPs undertaking and completing online CME. A national cross-sectional survey (Study 4) was conducted with 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations of between 10,000 and 30,000. A quasi-experimental design (Study 5) was used to compare the knowledge, attitudes and reported changes in practice of GPs who completed an online diabetes active learning module (ALM). The module has been offered by the main NHMRC project to 146 rural and remote GPs in the 11 intervention towns of NSW and QLD which have populations of 10,000 to 30,000. A mixed methods study, involving a short cross-sectional survey (Study 6) and semi-structured interviews (Study 7), were then used to identify enabling and inhibiting factors in undertaking and completing the online ALM. Findings: The national cross-sectional survey (Study 4) revealed that 209 completed surveys were returned, yielding an overall response rate of 24.5 %. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2 %). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge of the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (N = 87, (45.5 %)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medication management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties. The quasi-experimental study (Study 5) failed to demonstrate the effect of the online ALM on learning outcomes due to inadequate responses to generate statistical inferences. Findings from the systematic review (Study 2) indicated that online CME has the capacity to improve GP satisfaction, knowledge and practice. However, there are very few well-designed studies that focus on this delivery method for GP education. A systematic review (Study 1) also showed that few studies have examined the effectiveness of GP type 2 diabetes education. Evidence to support their effectiveness in improving GP satisfaction, knowledge, practices and/or patient outcomes is partial and weak. GPs reported reasons for non-participation in the online diabetes CME (Study 6) that correspond with the findings from the systematic reviews (Study 3). Barriers to GP online learning were grouped into four main domains: 1) structure, 2) learners, 3) facilitator and 4) the online program itself. However, GPs rarely reported difficulties inhibiting their completion of the online ALM (Study 6 and Study 7). Contribution of the research: This research adds new knowledge to the field of general practice education in Australia and internationally. The research addresses some of the widespread challenges of CME evaluation: there are currently few well-designed studies focusing on (1) GP CME in general; (2) GP diabetes CME (Study 1); (3) GP online CME (Study 2). The research also provides new insights into the current knowledge, attitudes and practices of Australian rural and remote GPs regarding their type 2 diabetes management. This may further assist CME providers and policy-makers in developing and providing education that addresses GPs’ needs. Conclusions and Recommendations: The national cross-sectional survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, the GP respondents revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through CME. Online CME has the capacity to improve GP satisfaction, knowledge and practices, but there are very few well-designed studies that focus on this delivery method for GP education. In order to overcome challenges identified in this research, improvements are needed in planning, developing and selecting the topics of education that are needed for GPs. Based on the doctoral research findings, the following recommendations are made: First, in order to provide CME programs for GPs or health care professionals, the learning needs should be clearly identified prior to program implementation. CME providers need to tailor education programs that specifically focus on and address current GP needs. Second, there is a noticeable absence of research focussing on diabetes CME, specifically for GPs practising in rural and remote areas. The use of multiple combined education techniques showed mixed effects. Future studies may need to examine specific combinations of educational techniques and delivery methods tailored to specific desired outcomes for rural and remote GPs. Third, in order to provide online learning activities for GPs, providers who develop the learning programs need to take into account barriers to undertaking and completing online CME. The number of studies examining GP online education is very limited. Therefore, further research is warranted specifically targeting GPs. In addition, future research should focus on clarifying when to use online CME for GP education and how online teaching technologies can be used most effectively. Fourth, future studies need to examine strategies to improve GPs’ participation in CME programs, and in research evaluating these programs

Management of type 2 diabetes: Australian rural and remote general practitioners’ knowledge, attitudes, and practice

Background: The gap between current and evidence-based best practice management of chronic diseases in Australian general practice is widely acknowledged. This study seeks to explore some of the factors underpinning this gap in relation to type 2 diabetes management in rural and remote general practice settings. Methods: A cross sectional survey of 854 general practitioners (GPs) currently practicing in rural and remote Australian communities with populations between 10,000 and 30,000. Results: 209 completed surveys were returned for an overall response rate of 24.5%. GPs reported on their education preferences, knowledge, attitudes, and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2%). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge around the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (n=87, (45.5%)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medical management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges, and health system-related difficulties. Conclusion: This national survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, GPs revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through continuing professional development. GP preferences for continuing medical education and information may inform future activities, to specifically address the needs of GPs in rural and remote locations

The perspectives of learners at a public medical school on the evaluation of an online learning management system for degree and non-degree courses

ABSTRACTBackground There has been a rapid development and adoption of online learning in medical education. However, it is difficult to adopt the currently available online learning management systems (LMS). This study aimed to examine learners’ perspectives on the evaluation of online LMS.Methods An online LMS was developed based on the evidence-based guidelines. Two cross-sectional studies were conducted. A short survey was conducted with 716 learners registered on the LMS to obtain their perspectives on the online participation. A satisfaction survey was conducted with 255 learners enrolled in the courses taught solely online. Data from the LMS monitoring system was used to report the uptake of online courses. Data were analyzed using descriptive statistics.Results Participants reported that the major factor influencing LMS uptake was the ability to be accessed anytime and anywhere (n = 556, 77.7%). The participants had good experience in using the LMS and were satisfied with it (n = 255, mean = 4.53, SD = 0.62). For online degree courses, the course had a high completion rate of 90% provided that a mark was assigned for course attendance. For non-degree courses, irrespective of whether they were free, paid, exam-based, or participation only, the completion rate was considered low (range 4.3–36.7%).Conclusion Under a limited budget, a medical school in a low- to middle-income country could develop an effective online LMS to meet learners’ needs. Our newly developed online LMS is relevant, accepted and to the satisfaction of the learners. Medical schools in the same context are encouraged to develop their own online LMS that serve and support learning in both degree and non-degree courses

Expanded practice in rural community pharmacy in Australia: pharmacists’ perspectives

Background: Pharmacists internationally have successfully expanded their role to provide service delivery to remote rural communities. Aim: This study evaluated Australian rural community pharmacists’ perspectives of expanded services, to identify priorities, areas of concern, enablers and barriers to their implementation. Method: A self‐administered questionnaire was distributed to rural and remote Australian (all states and territories) pharmacists between September and December 2019; respondents were asked to rank health issues and the expanded pharmacy services that could potentially address these issues in their communities. Questions were also included to evaluate health service accessibility, skills/knowledge, workspace limitations, time and support for the implementation of these services. Potential associations between demographic factors and responses were also assessed. Results: Of the 92 returned responses analysed, the top three heath concerns were: Mental health, Cardiovascular disease and Diabetes. Depression screening/referral, diabetes management and vaccinations were the top three areas rated for expanded services. There was agreement (90%; 83/92) that pharmacists had the skills and knowledge for implementation, while time and space were reported as barriers for 50% (46/92) and 25% (23/92) of pharmacists, respectively. The majority of the pharmacists (80%; 74/92) felt services were not easily accessible, and all (92/92, 100%) agreed that service provision would improve community health outcomes. Conclusion: Rural pharmacists were supportive of the delivery of expanded pharmacy services, describing improved health outcomes and increased access to health services as potential benefits. Successful implementation of these expanded services would require both an understanding of pharmacist resources available and local community health needs

Poor uptake of an online intervention in a cluster randomised controlled trial of online diabetes education for rural general practitioners

Background: In Australia, rural and remote communities have high rates of diabetes-related death and hospitalisation. General practitioners (GPs) play a major role in diabetes detection and management. Education of GPs could optimise diabetes management and improve patient outcomes at a population level. The study aimed to describe the uptake of a continuing medical education intervention for rural GPs and its impact on the viability of a cluster randomised controlled trial of the effects of continuing medical education on whole-town diabetes monitoring and control. Method: Trial design: the cluster randomised controlled trial involved towns as the unit of allocation and analysis with outcomes assessed by de-identified pathology data (not reported here). The intervention programme consisted of an online active learning module, direct electronic access to specialist advice and performance feedback. Multiple rounds of invitation were used to engage GPs with the online intervention content. Evidence-based strategies (e.g. pre-notification, rewards, incentives) were incorporated into the invitations to enrol in the programme. Recruitment to the programme was electronically monitored through the hosting software package during the study intervention period. Results: Eleven matched pairs of towns were included in the study. There were 146 GPs in the 11 intervention towns, of whom 34 (23.3%) enrolled in the programme, and 8 (5.5%) completed the online learning module. No town had more than 10% of the resident GPs complete the learning module. There were no contacts made by GPs regarding requests for specialist advice. Consequently, the trial was discontinued. Conclusion: There is an ongoing need to engage primary care physicians in improving diabetes monitoring and management in rural areas. Online training options, while notionally attractive and accessible, are not likely to have high levels of uptake, even when evidence-based recruitment strategies are implemented