A proof of concept study to identify familial hypercholesterolaemia in primary care

This study examines the feasibility (acceptability, usefulness, convenience and cost) of using a new method of detecting hypercholesterolaemia through GP clinics. If the condition is found following a fasting pathology test, close relatives will also be checked. This family tracing will identify new patients with the condition as they stand to benefit most from early treatment. The proposed new approach will allow the condition to be managThe 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

Multimorbidity in patients enrolled in a community-based methadone maintenance treatment programme delivered through primary care

Background: Multimorbidity, the co-existence of two or more (2+) long-term conditions in an individual, is common among problem drug abusers. Objective: To delineate the patterns, multimorbidity prevalence, and disease severity in patients enrolled in a community-based primary care methadone maintenance treatment (MMT) programme. Design: This was a retrospective cohort study (n=274). The comparator group consisted of mainstream primary care patients. Electronic medical record assessment was performed using the Cumulative Illness Rating Scale. Results: Prevalence of multimorbidity across 2+ domains was significantly higher within the MMT sample at 88.7% (243/274) than the comparator sample at 51.8% (142/274), p<0.001. MMT patients were seven times more likely to have multimorbidity across 2+ domains compared with mainstream patients (OR 7.29, 95% confidence interval 4.68–11.34; p<0.001). Prevalence of multimorbidity was consistently high across all age groups in the MMT cohort (range 87.8–100%), while there was a positive correlation with age in the comparator cohort (r=0.29, p<0.001). Respiratory, psychiatric, and hepatic–pancreatic domains were the three most common domains with multimorbidity. Overall, MMT patients (mean±SD, 1.97±0.43) demonstrated significantly higher disease severity than mainstream patients (mean±SD, 1.18±0.78), p<0.001. Prevalence of moderate disease severity observed in the <45-year MMT age group was 50% higher than the ≥45-year comparator age group. Conclusions: Prevalence of multimorbidity and disease severity in MMT patients was greater than in the age- and sex-matched comparators. Patients with a history of drug abuse require co-ordinated care for treatment of their addiction, and to manage and prevent chronic illnesses. Community-based programmes delivered through primary care help fulfil this need.Journal of Comorbidity 2014;4(1):46–5

Practice nurses and research: The Fremantle Primary Prevention Study

The Primary Health Care Research Evaluation and Development strategy provides financial support for the development of early to mid career researchers through its Research Capacity Building Initiative and Research Development Program. Practice nurses can provide valuable contributions to research practices undertaking research projects. This article documents the experiences of three practice nurses involved in an independently funded cardiovascular research project and how the experience helped to enhance their role in their general practice. The combination of general practitioner and practice nurse working together is an important component of primary care research. The development of research skills is an exciting option for practice nurses wishing to expand and develop their careers. ISSN: 0300-849

Opportunistic Screening in General Practice for Chlamydia Trachomatis in Young Men

Study Objective: There is little information available regarding the prevalence of Chlamydia Trachomatis in young men in the general population. The community based rate of infection is estimated to be 4.6%, but this is thought to reflect an over-representation of high-risk groups. The aims of this study were to1) estimate the rate of Chlamydia infection in young men attending general practitioners in the Perth metropolitan area, 2) assess behavioural factors associated having the disease and 3) assess GP management of patients testing positive. Methodology: Sexually active men (15-29 years) were recruited from 8 general practices in Perth, Western Australia. Participants were required to complete a questionnaire concerning their sexual orientation, history, behaviours and genital symptoms and provide a urine sample for PCR testing for Chlamydia. If a participant returned a positive PCR result, the treating doctor was contacted by a researcher 2 weeks following the test to assess patient follow up. Results: 401 men were recruited. 373 had urine results available. Of these 3.8% (95% CI, 2.1-6.2) returned a positive PCR result for Chlamydia Trachomatis. There were no remarkable differences between the sexual practices and behaviours of positive and negative participants, although we cannot exclude sampling bias given the small number of positive participants. All patients were followed up by their treating doctor once results were received. Despite the small number of positive participants, there was little relationship between self reported sexual behaviour or symptoms and incidence of Chlamydia in young men. Details of these findings will be provided at presentation. Conclusion: Given the asymptomatic nature, it may be appropriate to offer screening for at risk individuals, thereby moving towards curbing the increasing infection rate for this disease

Multimorbidity in a marginalised, street-health Australian population: a retrospective cohort study

OBJECTIVES: Demographic and presentation profile of patients using an innovative mobile outreach clinic compared with mainstream practice. DESIGN: Retrospective cohort study. SETTING: Primary care mobile street health clinic and mainstream practice in Western Australia. PARTICIPANTS: 2587 street health and 4583 mainstream patients. MAIN OUTCOME MEASURES: Prevalence and patterns of chronic diseases in anatomical domains across the entire age spectrum of patients and disease severity burden using Cumulative Illness Rating Scale (CIRS). RESULTS: Multimorbidity (2+ CIRS domains) prevalence was significantly higher in the street health cohort (46.3%, 1199/2587) than age-sex-adjusted mainstream estimate (43.1%, 2000/4583), p=0.011. Multimorbidity prevalence was significantly higher in street health patients(37.7%, 615/1649) compared with age-sex-adjusted mainstream patients (33%, 977/2961), p=0.003 but significantly lower if 65+ years (62%, 114/184 vs 90.7%, 322/355, p CONCLUSIONS: Age-sex-adjusted multimorbidity prevalence and disease severity is higher in the street health cohort. Earlier onset (23-34 years) multimorbidity is found in the street health cohort but prevalence is lower in 65+ years than in mainstream patients. Multimorbidity prevalence is higher for Aboriginal patients of all ages

Early primary care physician contact and health service utilisation in a large sample of recently released ex-prisoners in Australia: prospective cohort study

Objective To describe the association between ex-prisoner primary care physician contact within 1 month of prison release and health service utilisation in the 6 months following release. Design A cohort from the Passports study with a mean follow-up of 219 (±44) days post release. Associations were assessed using a multivariate Andersen-Gill model, controlling for a range of other factors. Setting Face-to-face, baseline interviews were conducted in a sample of prisoners within 6 weeks of expected release from seven prisons in Queensland, Australia, from 2008 to 2010, with telephone follow-up interviews 1, 3 and 6 months post release. Participants From an original population-based sample of 1325 sentenced adult (≥18 years) prisoners, 478 participants were excluded due to not being released from prison during follow-up (n=7, 0.5%), loss to follow-up (n=257, 19.4%), or lacking exposure data (n=214, 16.2%). A total of 847 (63.9%) participants were included in the analyses. Exposure Primary care physician contact within 1 month of follow-up as a dichotomous measure. Main outcome measures Adjusted time-to-event hazard rates for hospital, mental health, alcohol and other drug and subsequent primary care physician service utilisations assessed as multiple failure time-interval data. Results Primary care physician contact prevalence within 1 month of follow-up was 46.5%. One-month primary care physician contact was positively associated with hospital (adjusted HR (AHR)=2.07; 95% CI 1.39 to 3.09), mental health (AHR=1.65; 95% CI 1.24 to 2.19), alcohol and other drug (AHR=1.48; 95% CI 1.15 to 1.90) and subsequent primary care physician service utilisation (AHR=1.47; 95% CI 1.26 to 1.72) over 6 months of follow-up. Conclusions Engagement with primary care physician services soon after prison release increases health service utilisation during the critical community transition period for ex-prisoners. Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12608000232336)

Knowledge and attitudes of men to prostate cancer

Objective: To ascertain the current level of understanding about prostate cancer (PCa), including treatment options and potential side effects of treatment, among older men. Design and Setting: Questionnaires administered by general practitioners (GPs) in 5 general practices in the Perth metropolitan and regional areas of Western Australia. Participants: Convenience sample of men aged 40-80 years (n=503) with or without prostate cancer presenting for routine consultations. Main outcome measures: Knowledge and attitudes of men to prostate cancer Results: Eighty percent of men did not know the function of the prostate and 48% failed to identify PCa as the most common internal cancer in men. Thirty-five percent had no knowledge of the treatments for PCa and 53% had no knowledge of the side effects of treatments. Asked how they would arrive at a decision about treatment, 70% stated they would ask the GP/specialist for all their options and then decide themselves. Conclusion: This study confirms a deficit in knowledge of the disease among men in the at risk age group. Lack of knowledge encompassed areas which could delay diagnosis and hence treatment. Overall the population preferred some GP/specialist involvement in treatment decision making

Familial hypercholesterolaemia: challenges in primary care

Familial hypercholesterolaemia remains largely unrecognised and undertreated in Australian primary care. A new approach involving increased awareness, early detection, lifelong treatment and cascade testing of relatives is essential to improve outcomes of patients with this disorder. Key Points Familial hypercholesterolaemia (FH) is a relatively common inherited disorder of high cholesterol levels. FH can lead to atherosclerosis, premature coronary artery disease and early death if left untreated. Cascade testing of relatives of patients with FH is cost- effective and necessary as one in two will have the condition. Innovations in primary care can improve FH detection in the community. An integrated approach to FH detection involving GPs, specialists and pathology laboratories is recommended. Primary care teams are well positioned to provide a sustainable approach to FH diagnosis and management but greater awareness of this condition is needed

Challenges in the care of familial hypercholesterolemia: a community care perspective

Familial hyperchoelsterolaemia (FH) remains under-diagnosed and under-treated in the community setting. Earlier evidence suggested prevalence of 1:500 worldwide but newer evidence suggests it is more common. Less than 15% of FH patients are ever diagnosed with children and young adults rarely tested despite having most to gain given their lifetime exposure. Increasing awareness among primary care teams is critical to improve detection profile for FH. Cascade testing in the community setting needs a sustainable approach to be developed to facilitate family tracing of index cases. The use of the Dutch Lipid Clinic Network Criteria score to facilitate a phenotypic diagnosis is the preferred approach adopted in Australia and eliminates the need to undertake genetic testing for all suspected FH cases

Detection and management of familial hypercholesterolaemia in primary care in Australia: protocol for a pragmatic cluster intervention study with pre-post intervention comparisons

Introduction: Familial hypercholesterolaemia (FH), an autosomal dominant disorder of lipid metabolism, results in accelerated onset of atherosclerosis if left untreated. Lifelong treatment with diet, lifestyle modifications and statins enable a normal lifespan for most patients. Early diagnosis is critical. This protocol trials a primary care-based model of care (MoC) to improve detection and management of FH. Methods and analysis: Pragmatic cluster intervention study with pre-post intervention comparisons in Australian general practices. At study baseline, current FH detection practice is assessed. Medical records over 2 years are electronically scanned using a data extraction tool (TARB-Ex) to identify patients at increased risk. High-risk patients are clinically reviewed to provide definitive, phenotypic diagnosis using Dutch Lipid Clinic Network Criteria. Once an index family member with FH is identified, the primary care team undertake cascade testing of first-degree relatives to identify other patients with FH. Management guidance based on disease complexity is provided to the primary care team. Study follow-up to 12 months with TARB-Ex rerun to identify total number of new FH cases diagnosed over study period (via TARB-Ex, cascade testing and new cases presenting). At study conclusion, patient and clinical staff perceptions of enablers/barriers and suggested improvements to the approach will be examined. Resources at each stage will be traced to determine the economic implications of implementing the MoC and costed from health system perspective. Primary outcomes: increase in number of index cases clinically identified; reduction in low-density lipoprotein cholesterol of treated cases. Secondary outcomes: increase in the number of family cases detected/contacted; cost implications of the MoC. Ethics and dissemination: Study approval by The University of Notre Dame Australia Human Research Ethics Committee Protocol ID: 0 16 067F. Registration: Australian New Zealand Clinical Trials Registry ID: 12616000630415. Information will be disseminated via research seminars, conference presentations, journal articles, media releases and community forums