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The Research Enterprise

General practice research in Australia, 1980-1999

Alison M Ward, Derrick G Lopez and Max Kamien
Med J Aust 2000; 173 (11): 608-611.

The Research Enterprise

General practice research in Australia, 1980-1999

Alison M Ward, Derrick G Lopez and Max Kamien

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MJA 2000; 173: 608-611
For editorial comment, see Van Der Weyden

Abstract - Methods - Results - Summary and conclusions - Acknowledgements - References - Authors' details

- - More articles on General practice and primary care


   

Abstract

  • There has been a nearly fivefold increase in the amount of Australian general practice research published in 1990-1999 compared with the previous decade.
  • The university departments of general practice and other university departments have been responsible for most of the research.
  • GPs were involved in at least 60% of all of the research reviewed. Half of the research was found to be clinically pertinent to the front-line GP.
  • The National Health Priority areas, introduced in 1994, were poorly represented, but it is probably too soon for this research to be published. There has also been little research on rural general practice.
  • This review provides a starting point for classifying general practice and primary healthcare research in the future.

In Australia, the general practice research effort, begun by a few enthusiastic general practitioners (GPs) in the early 1970s, now extends to academic programs involving GPs and social scientists with an interest in general practice. The inception of academic departments of general practice resulted in a gradual professionalisation and an increase in research.1

In 1991-92 the research effort received an extra boost through the General Practice Evaluation Program (GPEP) of the Commonwealth Department of Health, which aimed to develop data on the dynamics of general practice in Australia and to improve standards and quality assurance. In April this year, the Department announced a new funding initiative -- a national strategy for Primary Health Care Research, Evaluation and Development.2

In the light of these developments, we reviewed and analysed Australian general practice research published in the past 20 years to provide a baseline for future research initiatives.


Methods

Data sources
We conducted literature searches in March and April 2000 to identify all Australian articles relating to general practice research published since 1980. Letters and editorials were excluded. The search strategies, search terms and outcomes are shown in Box 1.

Study selection

  • We restricted the review to the two decades 1980-1989 and 1990-1999; and

  • We used a similar definition of general practice research to that used by Starfield for primary care research; that is, even if the problem being examined is a problem seen in general practice, it is not necessarily general practice research unless the context of the research is general practice.3

We identified general practice research published in the past two decades by scanning the abstracts of the 2242 articles retrieved by our search (those articles without abstracts [about 28%] were viewed in full). Scanning identified 663 general practice research articles. The remainder were discussion papers, or not general practice research.

Classification categories
We classified each article and the research reported according to nine variables:

  • Country of publication;

  • Journal;

  • Affiliation of authors: Determining affiliation was complicated by the name changes of departments of general practice. We compiled lists of department names and of academic GPs to help identify who was doing the research.

  • Type of research: Searches of the Australian and overseas literature failed to find a comprehensive classification system for type of general practice research.3,4-6 We extended the classification categories used by the National Information Service (NIS) for the GPEP grants, giving 13 categories of general practice research.

  • Research methodology: The research methods used were difficult to classify.7,8 The usual method categories for public health research do not include some methods used in general practice. We used the public health categories (see Box 6) as a starting point and expanded on these.

  • International Classification of Primary Care (ICPC);9

  • National Health Priority areas; 10,11

  • Rural health;

  • Other areas of concern (eg, Aboriginal or Torres Strait Islanders; aged or adolescent populations).

Data analysis
One of us (A M W) coded all articles and trained a research officer to check the coding. A test-retest reliability check on 41 articles showed an average reliability across the classification variables of 92% (98% for affiliation, 83% for type of research, 83% for methodology, 95% for ICPC category, 98% for National Health Priority areas, 98% for areas of concern, 90% for rural research). The classified data were analysed using SPSS.12


Results

Number and location of publications (Boxes 2 and 3)

Publications of Australian general practice research increased markedly in the second decade, with 82% published since 1990. As expected, most were published in Australia, but the proportion published overseas has increased from 17.1% in 1980-1989 to 31.7% in 1990-1999, with a marked increase in publications in England in the second decade.

Over half of the research has been published in two journals -- Australian Family Physician (31%) and The Medical Journal of Australia (21%). The proportion published in Australian Family Physician almost halved in the second decade, with publications increasing across a range of other journals.

Authors and affiliation (Box 4)

The States with two or more universities with departments of general practice produced most research, with the amount from New South Wales (37%) being more than double that from any other State. Victoria was second with 18%, followed by Queensland (12%) and South Australia (12%).

Universities were responsible for 58% of the research, with hospitals accounting for 12% and the Royal Australian College of General Practitioners (RACGP) 7%. The "other" category included health departments, and the Divisions of General Practice (the latter published less than 1%). The number of articles without a recorded affiliation decreased over the decades (the "institution" field was added to MEDLINE in 1988), but, as many of the early articles had no abstracts and were viewed in full, we were often able to identify the first author's affiliation.

The contribution made by GPs to research not conducted in general practice academic departments was assessed by searching for GPs among the co-authors; 39% of the research in other academic departments had GPs as co-authors. We also found that 36% of the research conducted in hospitals and other organisations (eg, health departments) had GPs as co-authors. Overall, GPs were involved as authors in at least 64% of all research in general practice. This has implications for discussions about research conducted by GPs as opposed to research conducted on GPs.

Type of research (Box 5)

Twenty-seven per cent of research was in the category "GP behaviour, views and opinions". This includes screening, health prevention and promotion, prescribing, counselling and many other general practice activities. The number of GP behaviour studies increased in the second decade. Next most common was studies into education and training -- both undergraduate and postgraduate training.

The "encounter" category included studies such as the Australian Morbidity and Treatment Survey (AMTS), clinical epidemiology studies, clinical presentation studies and Health Insurance Commission (HIC) data analyses. Very little research was found in workforce, finance or evidence-based medicine. The "other" category included studies evaluating national health promotion campaigns, and studies that could not be classified elsewhere.

Methodologies used (Box 6)

Two-thirds of the research was observational, nearly a quarter involved some form of intervention, and little qualitative research was published. There was an increase in both interventional and observational studies over the decades. Forty-one per cent of the studies were purely descriptive, many of these being surveys of GPs' views. Only 5% were randomised controlled trials. Many of the evaluation studies were evaluations of educational or training programs for GPs.

Research topics (Box 7)

ICPC categories: The psychological category was the most frequently studied (13%); over a quarter of these studies were on smoking behaviour. Most of the "female genital" studies were cervical or breast screening studies and 62% of the "respiratory" studies were on asthma.

In over half of the studies, no specific ICPC category applied; 22% of these were education and training studies. However, at least half the research topics focused on a clinical area, indicating their pertinence for practising GPs.

The main differences between the two decades were increases in cervical, breast and skin cancer studies, and in respiratory studies.

National Health Priority (NHP) areas: Nearly two-thirds of the research did not focus on NHP areas. Research into cancer control accounted for 15%, and the proportion doubled over the two decades, followed by mental health (10%). Studies on asthma, cardiovascular disease and diabetes combined accounted for less than 10% of all the research.

Other areas of concern: Only 5% of studies dealt with Aboriginal and Torres Strait Islanders, and aged or adolescent populations.

Rural research: We found very little research on rural populations. The amount of rural research has remained constant (16%) over these two decades. The bulk is conducted by academic departments (56%), followed by hospitals (14%) and the RACGP (6%).



Summary and conclusions

This is the first rigorous review of general practice research in Australia. It has demonstrated a marked increase in the amount of research conducted in the past decade. The university departments of general practice have been responsible for most of the research, and GPs were involved in at least 60% of all of the publications reviewed. Half of all the research was found to be clinically pertinent to the front-line GP.

The National Health Priority areas were poorly covered in the reviewed articles, but, as these were only formulated in 1994, there has been insufficient time to conduct the research and get it published. There has also been little research in rural general practice; most was conducted by university departments, although not always the general practice departments. The paucity of research on rural populations may be due partly to the fact that many rural studies were not focused specifically on general practice and not listed under "Family practice" in MEDLINE. In addition, the Australian Journal of Rural Health was not indexed in MEDLINE until 1995, which may account for the small number of general practice publications identified in this journal.

The limitations of our review are that only one database was searched (MEDLINE) and several journals relevant to general practice research (eg, Education for General Practice) are not indexed in MEDLINE. By checking the curricula vitae of three prominent researchers in Australian general practice, we know that we missed some publications. This is because of inconsistencies in department names in the institution field and omission of the terms "family practice" or "physicians, family" in the medical subject headings (MeSH) field.

We encountered difficulties in developing a comprehensive classification system for type of general practice research. We wanted the codes to be useful to both policy makers and providers, but the final categories were still broad. We will continue to refine this coding system in the future.

This review did not examine quality of the research, an area which has presented problems for previous researchers.8 However, the proportion of randomised controlled trials was small, mirroring the findings of a review of general practice research in the United Kingdom in the mid-1990s.5

The 11 university departments of general practice in Australia are relatively small, with an average of three full-time equivalent core academic positions each. Most staff have large teaching loads and little time to pursue research activities. The marked increase in research being conducted by these departments over the last decade shows a commitment to research, despite the problems of finding time and adequately trained staff.

To further encourage a research culture in general practice in Australia, the General Practice Strategy Review made several recommendations in 1998, including strengthening the research environment in academic departments of general practice, developing and supporting multidisciplinary career pathways in general practice research, and involving consumers and Divisions of General Practice.13 The success of the recently announced national strategy for Primary Health Care Research, Evaluation and Development1 in implementing the recommendations of the General Practice Strategy Review will, in part, be demonstrated by an increase in the quality, quantity and relevance of general practice research in Australia over the next decade.

This overview of general practice research takes stock of where we are now and provides a starting point for classifying general practice and primary healthcare research in the future.



Acknowledgements

We would like to thank Sandra Pullman, of the University of Western Australia medical library, for performing the literature searches.



References

  1. Lawson KA, Chew M, Van Der Weyden MB. The rise and rise of academic general practice in Australia. Med J Aust 1999; 171: 643-648.
  2. General Practice Branch, Department of Health and Aged Care. General practice in Australia: 2000. Canberra: The Department, May 2000: p 377.
  3. Starfield B. A framework for primary care research. J Fam Pract 1996; 42: 181-185.
  4. Silagy CA, Schattner P, Baxter RG. Current status of general practice research in Australia. Med J Aust 1992; 157: 108-113.
  5. Thomas T, Fahey T, Somerset M. The content and methodology of research papers published in three United Kingdom primary care journals. Br J Gen Pract 1998; 48: 1229-1232.
  6. Jones R. Primary care research: ends and means. Fam Pract 2000; 17: 1-4.
  7. Dawson-Saunders B, Trapp RG. Basic and clinical biostatistics. Connecticut: Appleton & Lange, 1990.
  8. Meijman FJ, de Melker RA. The extent of inter- and intrareviewer agreement on the classification and assessment of designs of single-practice research. Fam Pract 1995; 12: 93-97.
  9. Lamberts H, Wood M, editors. International classification of primary care. New York: Oxford University Press; 1989.
  10. National Health Priorities. In: Wood T, editor. Australia's health 1998. The sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare, 1998: 75.
  11. Better Health Outcomes for Australians. Canberra: AGPS; 1994.
  12. SPSS [computer program], version 8.0. Chicago, Ill: SPSS Inc, 1997.
  13. General Practice Strategy Review Group. General practice, changing the future through partnerships. Department of Health and Family Services. Canberra: The Department, 1998.

(Received 27 Sep, accepted 9 Nov, 2000)



Authors' details

Department of General Practice, University of Western Australia, Perth, WA.
Alison M Ward, BPsych, PhD, Senior Research Fellow.
Derrick G Lopez, BSc, MMedSci, Research Officer.
Max Kamien, MD, FRACGP, FRACP, Professor and Head of Department.

Reprints: Dr A M Ward, Department of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010.
alison.wardATuwa.edu.au


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1: Australian general practice research -- main search strategies, search terms and outcomes

 

MEDLINE (via Ovid Technologies)

1. General practice research by Australian researchers

The terms (physicians, family or family practice) in the medical subject headings (MeSH) field combined with the terms (australia$) or (tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field; and

2. Research conducted by GPs regardless of the topic

The terms (australia$) or (tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field combined with the names of all the academic departments of general practice ((family or general) and (physician$ or practi$)) in the institution field.

Outcome 881 articles
3. General practice research published in Australia whether or not by GPs

The terms (physicians, family or family practice) in the text field combined with (australia$) in the country-of-publication field.

Outcome 834 articles
4. Research from departments possibly missed because of name changes

The terms (australia$ or tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field combined with ((community or primary) and (health or medicine or practice)) in the institution field.

Outcome 480 articles
5. Additional searches, including using additional department names in the institution field; and the names of all heads of departments of general practice, and all professors of general practice in the author field.
Outcome 47 articles
Australasian Medical Index (AMI) (publications not catalogued in MEDLINE)

Using the terms (family practice or physicians, family) in the MeSH field, we identified a further 991 possible articles. Many of these were in non-refereed journals, were duplicates of the MEDLINE articles or were only marginally relevant to general practice research. Because their short truncated titles and abstracts made it impossible to classify the type of research being reported they were not included. We estimate this meant possibly another 100-200 references were missed.

Total 2242 articles

$ = wild card (ie, search finds all words beginning with the letters before the $ sign).
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2: Country of publication -- number (%) of publications

Country 1980-1989 (n = 117) 1990-1999 ( n = 546)

Australia
England
United States
Europe (excluding England)
Canada
Unknown

97 (82.9%)
16 (13.7%)
3 (2.6%)
1 (0.9%)
0
0

373 (68.3%)
126 (23.1%)
35 (6.4%)
9 (1.6%)
1(1.6%)
2 (0.4%)

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3: Top five journals publishing Australian general practice research -- number (%) of publications
Journal 1980-1989 Journal 1990-1999

Aust Fam Physician
Med J Aust
Fam Pract
Aust N Z J Psychiatry
Community Health Stud*
59 (50.4%)
30 (25.6%)
9 (7.7%)
4 (3.4%)
2 (1.7%)
Aust Fam Physician
Med J Aust
Aust N Z J Public Health*
Fam Pract
Aust J Rural Health †
145 (26.6%)
112 (20.5%)
44 (8.1%)
36 (6.6%)
21 (3.8%)

* Community Health Stud became Aust N Z J Public Health in 1996. †Not indexed in MEDLINE until 1995.

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4: Affiliation of first author -- number (%) of publications
Afiliation 1980-1989 (n = 117) 1990-1999 (n = 546)

University department of general practice
Other university departments
Other (eg, health department)
Hospital
RACGP
Unknown
35 (29.9%)
17 (14.5%)
19 (16.2%)
12 (10.3%)
6 (5.1%)
28 (23.9%)
205 (37.5%)
131 (24.0%)
89 (16.3%)
65 (11.9%)
38 (7.0%)
18 (3.3%)
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5: Type of research -- number (%) of publications
Type of research 1980-1989 (n = 117) 1990-1999 (n = 546)

Encounter and clinical epidemiology studies
GP behaviour, views, opinions
Education and training
Patient behaviour, views, opinions, compliance
GP and patient behaviour
Workforce
Organisation of general practice
Health services interface
Research methodology
Finance
Ethical/legal/professional
Evidence-based medicine
Other
28 (23.9%)
27 (23.1%)
15 (12.8%)
15 (12.8%)
10 (8.5%)
7 (6.0%)
5 (4.3%)
4 (3.4%)
2 (1.7%)
1 (0.9%)
0
0
2 (2.6%)
66 (12.1%)
153 (2.80%)
81 (14.8%)
34 (6.2%)
62 (11.4%)
14 (2.6%)
31 (5.7%)
51 (9.3%)
20 (3.7%)
7 (1.3%)
5 (0.9%)
3 (0.5%)
19 (3.5%)
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6: Methodology used -- number (%) of publications
Methodology 1980-1989 (n = 117) 1990-1999 (n = 546)

Intervention
Evaluation of a service
Randomised controlled trial
Other controlled trial
15 (12.8%)
3 (2.6%)
1 (0.9%)
102 (18.7%)
28 (5.1%)
6 (1.1%)
Observation
Descriptive without analytical component
Cross-sectional quantitative or qualitative
Observational over time
Cohort
46 (39.3%)
19 (16.2%)
1 (0.9%)
1 (0.9%)
224 (41.0%)
112 (20.5%)
26 (4.8%)
9 (1.6%)
Reviews
Systematic review
Meta-analysis alone
2 (1.7%)
0
11 (0.2%)
1 (0.2%)
Other
None of the above
29 (24.8%) 27 (4.9%)
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7: International Classification of Primary Care categories -- number (%) of publications*
ICPC category 1980-1989 (n = 117) 1990-1999 (n = 546)

Psychological
Female genital (pap smears, mammogram)
Respiratory
Pregnancy, child bearing, family planning
Skin
Circulatory
Endocrine, metabolic, nutritional
Digestive
General and unspecified
Male gential (eg, prostate screening)
No ICPC category applied
20 (17.1%)
3 (2.6%)
1 (0.9%)
5 (4.3%)
1 (0.9%)
5 (4.3%)
4 (3.4%)
2 (1.7%)
3 (2.6%)
1 (0.9%)
69 (59.0%)
65 (11.9%)
37 (6.8%)
36 (6.6%)
20 (3.7%)
22 (4.0%)
17 (3.1%)
16 (2.9%)
12 (2.2%)
8 (1.5%)
8 (1.5%)
282 (51.6%)

* Categories with fewer than 1% of articles (musculoskeletal; neurological; social problems; blood-forming organs; immune mechanisms; eye; urological; ear; hearing) are not listed.
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Alison M Ward
Derrick G Lopez
Max Kamien