Undertaking general practice quality improvement to improve cancer screening - a thematic analysis of provider experiences

Background: Cancer is a major cause of illness and death, and its incidence and mortality can be reduced through effective screening. In order to improve below target screening rates in one region of Australia, the local Primary Health Network supported local general practices to implement a range of quality improvement initiatives. Methods: We used a qualitative approach and interviewed 18 general practice staff and five Primary Health Network staff and contractors to understand their experiences with these quality improvement initiatives. Results: In a thematic analysis, we identified four key themes related to program set-up and implementation; patient and community education and promotion; engaging patients and communities in screening; and general practice enhancement. Program roles were clear and understood, and the program received strong oversight and support. Practice staff felt supported and motivated. Information Technology was a challenge for many practices often requiring tailored assistance. Education provided by practices facilitated patient empowerment but practice staff noted difficulties engaging patients in screening. Practices were enhanced though strong leadership and teamwork and practice learning activities. Conclusions: The tailored evidence-based quality improvement initiatives were considered effective in supporting general practices to increase their cancer screening. Key facilitators reported by participants included use of Plan-Do-Study-Act cycles, enhanced data entry and audit capacity, effective recall and reminder systems and maintaining staff motivation

Drivers to obesity : a study of the association between time spent commuting daily and obesity in the Nepean Blue Mountains area

Obesity has become a public health challenge in every country on this planet, with a substantial contribution to global mortality and morbidity. Studies of the built environment have shown some promise in understanding the drivers of this obesity pandemic. This paper contributes to this knowledge, by focusing on one aspect of the urban environment and asking whether there is an association between commuting and obesity in residents of the Nepean Blue Mountains area on the fringes of Sydney. This is a cross-sectional study with obesity being the dependent variable, and commuting the independent variable, where 45 min or less was defined as local and distant commute was more than 45 min. In the sample of 158 respondents, the risk of obesity was twice as likely in the distant commuters than in the local commuters (OR 2.04, 95% CI 1.051 to 3.962, p = 0.034). Investigation of possible mediators of this association was limited by sample size; however, mode of transport was found to be a significant mediator. The results support the design of cities to provide health supporting environments for all residents, including equitable access to employment at a reasonable distance and effective public transport

Integrating health care in Australia : a qualitative evaluation

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses. We aimed to investigate the WSICP’s effectiveness through a qualitative evaluation focused on the 10 WSICP strategies. The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research

Developing indicators and measures of high-quality for Australian general practice

Background: Rising health costs and health inequity are major challenges in Australia, as internationally. Strong primary health care is well evidenced to address these challenges. Primary Health Networks (PHNs) work with general practices to collect data and support quality improvement; however, there is no consensus regarding what defines high quality. This paper describes the development of an evidence-based suite of indicators and measures of high-quality general practice for the Australian context. Methods: We reviewed the literature to develop a suitable framework and revise quality assurance measures currently in use, then reviewed these in three workshops with general practitioners, practice managers, nurses, consumers and PHN staff in western Sydney. We used a descriptive qualitative research approach to analyse the data. Results: A total of 125 evidence-based indicators were agreed to be relevant, and 80 were deemed both relevant and feasible. These were arranged across a framework based on the Quadruple Aim, and include structure, process and outcome measures. Conclusions: The agreed suite of indicators and measures will be further validated in collaboration with PHNs across Australia. This work has the potential to inform health systems innovation both nationally and internationally

Is a good death possible in Australian critical and acute settings? : physician experiences with end-of-life care

Background: In Australia approximately 70% of all deaths are institutionalised but over 15% of deaths occur in intensive care settings where the ability to provide a "good death" is particularly inhibited. Yet, there is a growing trend for death and dying to be managed in the ICU and physicians are increasingly challenged to meet the new expectations of their specialty. This study examined the unexplored interface between specialised Australian palliative and intensive care and the factors influencing a physician's ability to manage deaths well. Method. A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care. Results: Physicians negotiated multiple influences when managing dying patients and their families in the ICU. The way they understood and experienced end-of-life care practices was affected by cultural, institutional and professional considerations, and personal values and beliefs. Interpersonal and intrapsychic aspects highlighted the emotional and psychological relationship physicians have with patients and others. Many physicians were also unaware of what their cross-disciplinary colleagues could or could not do; poor professional recognition and collaboration, and ineffective care goal transition impaired their ability to assist good deaths. Experience was subject to the efficacy of physicians in negotiating complex bedside dynamics. Conclusions: Regardless of specialty, all physicians identified the problematic nature of providing expert palliation in critical and acute settings. Strategies for integrating specialised palliative and intensive care were offered with corresponding directions for future research and clinical development

The Nepean Blue Mountains Partners in Recovery Evaluation

This report presents an evaluation of the Nepean Blue Mountains Partners in Recovery program funded by the Nepean Blue Mountains Medicare Local and carried out by researchers from the Department of General Practice at the University of Western Sydney

Afterhours telehealth in Australian residential aged care facilities : a mixed methods evaluation

Background: The aged care system in Australia is under pressure. Residential aged care facilities (RACFs) and general practitioners (GPs) have difficulty providing the care needed by their residents, particularly after hours. Many residents are given ambulance support and transferred to hospital emergency departments (EDs) for care that could be provided at RACFs. The MyEmergencyDoctor (MED) service was commissioned in a 12-month program (February 2020-February 2021) using ED physicians to provide afterhours telehealth care in six RACFs. Methods: Using the NASSS framework, we synthesised descriptive analyses of statistical data from the MED service, RACFs and the ambulance service and a thematic analysis of interview data collected from GPs, RACF and MED service staff, and family members of residents. Results: Most calls to MED (179/209) were resolved with in-house treatment thereby reducing ambulance usage and hospital admissions. Interviews further revealed that MED enabled timely care for residents who were unwell but did not need hospital transfer. Technology, training, and rapid access to MED assisted RACF staff and complemented usual GP care. MED potentially reduced GP burnout. Refresher training was considered important especially in RACFs with high staff turnover, as was greater afterhours access to medications. Conclusions: The afterhours telehealth model provided in-house care and reduced ambulance transfers, and GPs and RACF staff generally felt supported. The service was easy to use and fostered good communications with GPs and RACF staff. Some GPs preferred to provide their own care, commenting on the need for a good understanding of patient and family needs and of the local context. Other stakeholders suggested this model could be extended to palliative care settings and to normal business hours when GPs were unavailable. The reduced ambulance and hospital use suggested benefits to wider health systems, however policies and funding that remunerate GPs, support community-based care and provide additional staffing in RACFs are needed to sustain afterhours telehealth in RACFs. Use of the NASSS (non-adoption, abandonment, scale-up, spread, and sustainability) Framework provided a valuable explanatory lens for our analyses

Partners in Recovery : an early phase evaluation of an Australian mental health initiative using program logic and thematic analysis

Background: Mental illness is a leading cause of illness and disability and around 75% of people suffering mental illness do not have access to adequate care. In Australia, nearly half the population experiences mental illness at some point in their life. The Australian Government developed a National program called Partners in Recovery (PIR) to support those with severe and persistent mental illness. The program was implemented through 48 consortia across Australia. One of these was led by the Nepean Blue Mountains Medicare Local who adapted the program according to its specific local needs. Methods: We conducted an early evaluation of the PIR program in Nepean Blue Mountains (NBMPIR) using a program logic model (PLM) to frame the evaluation and complemented this with an additional thematic analysis. Participants (n = 73) included clients and carers, program management and staff of the Consortium and other partners and agencies, and clinical, allied health, and other service providers. Our PLM utilised multiple data sources that included document review, open and closed survey questions, and semi-structured interviews. Quantitative data received a descriptive analysis and qualitative data was analysed both in alignment with the PLM framework and inductively. Results: We aligned our results to PLM domains of inputs, activities, outputs, outcomes and impacts. The NBMPIR consortium implemented a recovery approach and provided greater access to services by enhancing healthcare provider partnerships. Our thematic analysis further described five key themes of collaboration; communication; functioning of PIR; structural/organisational challenges; and understanding of PIR approaches. Facilitators and barriers to the NBMPIR program centred on the alignment of vision and purpose; building an efficient system; getting the message out and sharing information; understanding roles and support and training of staff; building capacity and systems change; addressing service gaps; and engaging peers. Conclusions: Our study provided helpful insights into the coordinated management of complex mental illness. The NBMPIR’s focus on partnerships and governance, service coordination, and systems change has relevance for others engaged in this work. This PLM effectively mapped the program, including its processes and resources, and is a useful framework providing a baseline for future evaluations

Evaluation of Nepean Blue Mountains Primary Health Network (NBMPHN) Cancer Screening Program

Cancer is a leading cause of death globally and is also the leading cause of disease burden in Australia, thus it has a significant social and economic impact on individuals, families and the community. National screening programs in Australia aim to detect breast, bowel and cervical cancer. Screening is free to all individuals in particular target groups, defined by age and gender, however barriers to engaging in cancer screening are common. The aim of the Nepean Blue Mountains Primary Health Network (NBMPHN) Cancer Screening Program is to work with primary health care providers and the local community to raise cancer screening rates across its four local government areas by targeting specific population groups where breast, cervical and bowel cancer screening participation rates are lower than NSW state averages. Commissioned and jointly funded by Wentworth Healthcare Limited and the Cancer Institute NSW, we conducted a qualitative study aimed at evaluating the implementation of the NBMPHN Cancer Screening Program. Thematic analysis of the interview data is included in Appendix A of the report

Evidence still insufficient that advance care documentation leads to engagement of healthcare professionals in end-of-life discussions : a systematic review

Background: Administration of non-beneficial life-sustaining treatments in terminal elderly patients still occurs due to lack of knowledge of patient’s wishes or delayed physician–family communications on preference. Aim: To determine whether advance care documentation encourages healthcare professional’s timely engagement in end-of-life discussions. Design: Systematic review of the English language articles published from January 2000 to April 2015. Data sources: EMBASE, MEDLINE, EBM REVIEWS, PsycINFO, CINAHL and Cochrane Library and manual searches of reference lists. Results: A total of 24 eligible articles from 10 countries including 23,914 subjects met the inclusion criteria, mostly using qualitative or mixed methods, with the exception of two cohort studies. The influence of advance care documentation on initiation of end-of-life discussions was predominantly based on perceptions, attitudes, beliefs and personal experience rather than on standard replicable measures of effectiveness in triggering the discussion. While health professionals reported positive perceptions of the use of advance care documentations (18/24 studies), actual evidence of their engagement in end-of-life discussions or confidence gained from accessing previously formulated wishes in advance care documentations was not generally available. Conclusion: Perceived effectiveness of advance care documentation in encouraging end-of-life discussions appears to be high but is mostly derived from low-level evidence studies. This may indicate a willingness and openness of patients, surrogates and staff toperceive advance directives as an instrument to improve communication, rather than actual evidence of timeliness or effectiveness from suitably designed studies. The assumption that advance care documentations will lead to higher physicians’ confidence or engagement in communicating with patients/families could not be objectively demonstrated in this review