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Parkinson's disease poses challenges for timely diagnosis and specialist care, particularly in rural areas. This paper aims to assist general practitioners (GPs) who wish to collaborate with their patient with probable Parkinson's disease to improve access to appropriate medication when there might be a delay in obtaining a confirmatory diagnosis from a Parkinson's disease specialist. The feasibility and rationale for commencing levodopa as well as an approach to initiating and monitoring its response are discussed. The importance of educating patients and caregivers, encouraging exercise and building a multidisciplinary team to optimise care is also discussed. The literature supports early levodopa initiation in probable Parkinson's disease to improve a patient's quality of life. The presented approach offers GPs effective management strategies that enhance patient care and mitigate the risks of delayed treatment.

Background There is international interest in whether improved primary care, in particular for patients with chronic or complex conditions, can lead to decreased use of health resources and whether financial incentives help achieve this goal. This trial (EQuIP-GP) will investigate whether a funding model based upon targeted, continuous quality incentive payments for Australian general practices increases relational continuity of care, and lessens health-service utilisation, for high-risk patients and children. Methods We will use a mixed methods approach incorporating a two-arm pragmatic cluster randomised control trial with nested qualitative case studies. We aim to recruit 36 general practices from Practice-Based Research Networks (PBRN) covering urban and regional areas of Australia, randomised into intervention and control groups. Control practices will provide usual care while intervention practices will be supported to implement a new service model incorporating incentives for relational continuity and timely access to appointments. Patients will comprise three groups: older (over 65 years); 18–65 years with chronic and/or complex conditions; and those aged less than 16 years with increased risk of hospitalisation. The funding model includes financial incentives to general practitioners (GPs) for providing longer consultations, same day access and timely follow-up after hospitalisation to enrolled patients. The payments are proportional to expected health system savings associated with improved quality of GP care. An outreach facilitator will work with practices to help incorporate the incentive model into usual work. The main outcome measure is relational continuity of care (Primary Care Assessment Tool short-form survey), with secondary outcomes including health-related quality of life and health service use (hospitalisations, emergency presentations, GP and specialist services in the community, medicine prescriptions and targeted pathology and imaging ordering). Outcomes will be initially evaluated over a period of 12 months, with ongoing data collection for 5 years. Discussion The trial will provide robust evidence on a novel approach to providing continuous incentives for improving quality of general practice care, which can be compared to block payment incentives awarded at target quality levels of pay-for-performance, both within Australia and also internationally. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12618000105246 . Registered on 23 January 2018.

Objective: Appropriate use of oral anticoagulants (OACs) reduces the risk of stroke in patients with atrial fibrillation (AF). The study characterized the prescribing of OACs in people with AF in the Australian primary care setting over 10 years. Design: Retrospective population study. Setting and Participants: We performed 10 sequential cross-sectional analyses of patients with a recorded diagnosis of AF between 2009 and 2018 using national general practice data. The proportion of patients with AF who were prescribed an OAC based on their stroke risk was examined. Primary and secondary outcomes: The primary outcome was the proportion of high stroke risk patients who were prescribed an OAC over a decade. The secondary outcome was variation in OAC prescribing among general practices. Results: The sample size of patients with AF ranged from 9,874 in 2009 to 41,751 in 2018. The proportion who were prescribed an OAC increased from 39.5% (95% CI 38.6–40.5%) in 2009 to 52.0% (95% CI 51.5–52.4%) in 2018 ( p for trend < 0.001). During this time, the proportion of patients with AF and high stroke risk who were prescribed an OAC rose from 41.7% (95% CI 40.7–42.8%) to 55.2% (95% CI 54.7–55.8%; p for trend < 0.001) with the direct-acting oral anticoagulants accounting for over three-quarters of usage by 2018. There was substantial variation in OAC prescribing between general practices. In 2018, the proportion of moderate to high stroke risk patients who were prescribed an OAC was 38.6% (95% CI 37.2–40.1%) in the lowest practice site quintiles and 65.6% (95% CI 64.5–66.7%) in the highest practice site quintiles. Conclusions: Over the 10 years, OAC prescribing in high stroke risk patients with AF increased by one-third. There was considerable variation in OAC prescribing between general practices.

Background: The benefit of exercise in the prevention and management of type 2 diabetes (T2D) has a strong evidence base, so it is important to ensure exercise is part of every patient's management plan. Objective: This article reviews the evidence for exercise in T2D and the factors affecting a patient's willingness to commence and sustain enough exercise to gain benefit. The article offers tips about how to safely and effectively prescribe the 'medicine' of exercise for all, even the frailest patients; who to stabilise before an exercise program should begin; and how to use the skills of an accredited exercise physiologist (AEP) to deliver the best 'prescription' possible. Discussion: General practitioners and their teams, along with other healthcare providers such as AEPs, can increase the amount of exercise medicine a patient receives. This is the case for those at risk of developing T2D, those with T2D and those with the many comorbidities associated with T2D.

Background Chronic kidney disease (CKD) affects drug elimination and patients with CKD require appropriate adjustment of renally cleared medications to ensure safe and effective pharmacotherapy. The main objective of this study was to determine the extent of potentially inappropriate prescribing (PIP; defined as the use of a contraindicated medication or inappropriately high dose according to the kidney function) of renally-cleared medications commonly prescribed in Australian primary care, based on two measures of kidney function. A secondary aim was to assess agreement between the two measures. Methods Retrospective analysis of routinely collected de-identified Australian general practice patient data (NPS MedicineWise MedicineInsight from January 1, 2013, to June 1, 2016; collected from 329 general practices). All adults (aged ≥18 years) with CKD presenting to general practices across Australia were included in the analysis. Patients were considered to have CKD if they had two or more estimated glomerular filtration rate (eGFR) recorded values < 60 mL/min/1.73m 2 , and/or two urinary albumin/creatinine ratios ≥3.5 mg/mmol in females (≥2.5 mg/mmol in males) at least 90 days apart. PIP was assessed for 49 commonly prescribed medications using the Cockcroft-Gault (CG) equation/eGFR as per the instructions in the Australian Medicines Handbook. Results A total of 48,731 patients met the Kidney Health Australia (KHA) definition for CKD and had prescriptions recorded within 90 days of measuring serum creatinine (SCr)/estimated glomerular filtration rate (eGFR). Overall, 28,729 patients were prescribed one or more of the 49 medications of interest. Approximately 35% ( n  = 9926) of these patients had at least one PIP based on either the Cockcroft-Gault (CG) equation or eGFR (CKD-EPI; CKD-Epidemiology Collaboration Equation). There was good agreement between CG and eGFR while determining the appropriateness of medications, with approximately 97% of the medications classified as appropriate by eGFR also being considered appropriate by the CG equation. Conclusion This study highlights that PIP commonly occurs in primary care patients with CKD and the need for further research to understand why and how this can be minimised. The findings also show that the eGFR provides clinicians a potential alternative to the CG formula when estimating kidney function to guide drug appropriateness and dosing.

In the original publication of this article [1], the first name of the 3rd author is wrong.

Background: Guidelines on lipid disorders are constantly evolving. General practitioners regularly face critical decisions about the best treatment strategies for individual patients. Cardiovascular disease (CVD) is common, with most morbidity and mortality due to atherosclerosis. Raised low-density lipoprotein cholesterol (LDL-C) is the most atherogenic component - lowering it lowers the risk of future cardiovascular events. Objective: The aim of this article is to provide an evidence-informed summary of national guidelines and recent research to help clinicians reduce the risk of atherosclerotic CVD and improve health service delivery through improved lipid management strategies. Discussion: Elevated plasma lipids, especially LDL-C, increase the likelihood of a CVD event over time. Knowledge of family and personal histories plus other risk factors for CVD should alert clinicians to the need for treatment. The greater the overall burden of combined risk factors, the greater the lifetime risk. This update provides new information that informs future approaches for improving lipid management in Australian general practice.

Background: Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. Methods: A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. Results: Ten patients (60% male, median age = 78.5 years) completed interviews. Patients’ passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients’ overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. Conclusion: Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.

Future Health Today (FHT) is a program integrated with electronic medical record (EMR) systems in general practice and comprises (1) a practice dashboard to identify people at risk of, or with, chronic disease who may benefit from intervention; (2) active clinical decision support (CDS) at the point of care; and (3) quality improvement activities. One module within FHT aims to facilitate cardiovascular disease (CVD) risk reduction in people with chronic kidney disease (CKD) through the recommendation of angiotensin-converting enzyme inhibitor inhibitors (ACEI), angiotensin receptor blockers (ARB), or statins according to Australian guidelines (defined as appropriate pharmacological therapy). This study aimed to determine if the FHT program increases the proportion of general practice patients with CKD receiving appropriate pharmacological therapy (statins alone, ACEI or ARB alone, or both) to reduce CVD risk at 12 months postrandomization compared with active control (primary outcome). General practices recruited through practice-based research networks in Victoria and Tasmania were randomly allocated 1:1 to the FHT CKD module or active control. The intervention was delivered to practices between October 4, 2021, and September 30, 2022. Data extracted from EMRs for eligible patients identified at baseline were used to evaluate the trial outcomes at the completion of the intervention period. The primary analysis used an intention-to-treat approach. The intervention effect for the primary outcome was estimated with a marginal logistic model using generalized estimating equations with robust SE. Overall, of the 734 eligible patients from 19 intervention practices and 715 from 21 control practices, 82 (11.2%) and 70 (9.8%), respectively, had received appropriate pharmacological therapy (statins alone, ACEI or ARB alone, or both) at 12 months postintervention to reduce CVD risk, with an estimated between-trial group difference (Diff) of 2.0% (95% CI -1.6% to 5.7%) and odds ratio of 1.24 (95% CI 0.85 to 1.81; P=.26). Of the 470 intervention patients and 425 control patients that received a recommendation for statins, 61 (13%) and 38 (9%) were prescribed statins at follow-up (Diff 4.3%, 95% CI 0 to 8.6%; odds ratio 1.55, 95% CI 1.02 to 2.35; P=.04). There was no statistical evidence to support between-group differences in other secondary outcomes and general practice health care use. FHT harnesses the data stored within EMRs to translate guidelines into practice through quality improvement activities and active clinical decision support. In this instance, it did not result in a difference in prescribing or clinical outcomes except for small changes in statin prescribing. This may relate to COVID-19-related disruptions, technical implementation challenges, and recruiting higher performing practices to the trial. A separate process evaluation will further explore factors impacting implementation and engagement with FHT. ACTRN12620000993998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380119.

Background Antimicrobial resistance is a worldwide problem caused by the inappropriate use of antibiotics. In Australia, antibiotics are frequently prescribed in general practice (primary care) settings for acute respiratory infections (ARIs) despite these infections most commonly being caused by viruses. The Optimal Implementation of Antimicrobial Stewardship in General Practice (OptimasGP) study aims to provide implementation support for effective antimicrobial stewardship (AMS) interventions for ARIs. The current study will examine if a redesigned workflow, and an AMS Toolbox containing AMS resources, is an acceptable way to access AMS interventions and clinical data collected in general practice settings. Methods A mixed-methods approach will be applied using a single-arm, pragmatic exploratory study. Data will be collected for a period of 3 months. Data collection from general practice settings in New South Wales, Australia, will involve the participation of 4 to 6 practices, 12 general practitioners (GPs), and 6 to 8 practice staff. We also aim to recruit 50–100 patients to complete surveys and 12 patients to participate in focus group discussions. Participating GPs and practice staff will be provided with an online AMS Toolbox to facilitate access to AMS resources. Two hours of online training and a reminder card will also be provided. The AMS Toolbox will contain AMS resources for shared decision-making, clinical decision support (including point-of-care testing), and delayed antibiotic prescribing in patients with ARIs. The primary outcome of the study will be the acceptability of the AMS Toolbox to GPs, practice staff, and patients. Secondary outcomes will include recruitment and completion rates, qualitative findings from the focus group discussions, resource use and antibiotic prescription rates, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMS). Discussion AMS interventions are needed to help reduce inappropriate antibiotic prescribing for ARIs in general practice settings. The findings of this study will inform a hybrid type 3 implementation trial. Trial registration Registered prospectively with the Australian and New Zealand Clinical Trial Registry (ACTRN12624001011572) on 20 August 2024.