General medicine

Patient-reported outcomes (PROs) are reports coming directly from patients about how they function or feel in relation to a health condition and its therapy, without interpretation of the patient’s responses by a physician or anyone else1 (Box 1). PROs are increasingly used in clinical research, and their usefulness to inform clinicians’ and patients’ decisions about treatment alternatives is beginning to be understood.3 But results of empirical testing of using PROs in clinical practice have been inconsistent, and ascertaining the circumstances under which PROs are truly helpful beyond research settings remains a challenge. What benefits and harms can we expect from using PRO measures in clinical practice?The potential benefits of using PRO assessments in daily clinical practice include facilitating patient–clinician communication about issues that are important to patients, thereby promoting shared decision making; monitoring disease progression and response to treatment; identifying vulnerable patients; and enabling continuous assessment of quality of care.1,3 These benefits could lead to improvement in outcomes that are important to patients. On the other hand, the use of PROs may interfere with doctor–patient communication and patients may be concerned about who will review or use the information. Even in the absence of harm, the use of PROs would carry an opportunity cost, which is an important consideration given that administering some of the currently available measures is already burdensome, and scarce resources would be consumed in computing and reviewing PRO scores. What is the evidence for using PRO measures in clinical practice?A number of systematic reviews have assessed the impact of measuring PROs in clinical practice. The most recent included 28 randomised controlled trials and the results were consistent with previous reviews: in most trials, the impact of PROs was limited.1 Feedback of PROs to health professionals has, in some studies, had an impact on the process of care, with a less evident impact on health outcomes. In cancer clinics, feedback of PROs to health professionals has been shown to increase the frequency with which doctors discuss issues such as quality of life and symptoms with their patients, without an increase in the visit duration.4,5 In one of these studies, physicians informed by PROs had greater agreement with their patients about how well the patient was functioning.5 A meta-analysis showed that PRO reports of mental health status in a variety of settings resulted in a higher likelihood of diagnostic notations recorded in patients’ medical records.6 There are a number of additional steps that must be taken before changes in the process of care can be translated into changes in outcome (Box 2). For instance, routine provision of feedback to health professionals may not necessarily translate into routine use of the information for all patients. Thus, those who demand evidence of improved patient-important outcomes will not be impressed simply by improvements in process. Moreover, randomised controlled trials on PROs have been highly heterogeneous in setting (primary care; specialised outpatient and inpatient clinics), participants (new and known patients; experienced and more junior clinicians), the intensity and content of the PRO intervention implemented, and diversity of outcomes reported.1 This heterogeneity poses a major challenge in interpreting the evidence and in identifying the clinical contexts and strategies for measuring and reporting PRO results to clinicians that will result in improved patient outcomes. Some additional methodological weaknesses affect these trials. Often, the investigators analysed the data as if they had randomised patients, when in fact they had randomised clinicians or groups of clinicians.1 This error would bias results in favour of the intervention. Some interventions were suboptimal in the degree of training clinicians received in interpreting the results, and in the manner of presentation of results to the clinicians.8 Methodologically stronger trials successfully implementing feasible interventions with clear positive effects are required to provide clear direction for clinicians. What are the challenges for implementing PRO measures in clinical practice?The systematic use of PRO instruments in clinical practice has the potential to bring about significant improvements in a number of relevant areas of health care. But possible barriers to implementation would need to be overcome, including scepticism about the validity and potential utility of PRO data; unfamiliarity with the interpretation of PRO information; a paucity of direct face-to-face instrument comparisons; costs of data collection; and the need for rapid data manipulation and processing. Significant progress has been made in some of these areas. A recent review comparing common medical measurements and their associated error with PRO measurements concluded that the latter were comparable with commonly used outcome data.9 The next step is to convince clinicians that this is the case and that they may reliably benefit from information derived from PROs. Researchers are also finding new, imaginative ways to help clinicians understand the magnitude of treatment impact on quality of life. One useful measure in this regard is the Minimal Important Difference (MID) — the smallest change in instrument score that patients perceive as important.10 For instance, the MID for the Chronic Respiratory Questionnaire is 0.5 on a scale that ranges from 1 to 7. This means that changes smaller than 0.5 should not be considered relevant, regardless of the statistical significance of the comparison. Some authors propose linking PRO scores with expected performance profiles to facilitate interpretation of results.7 The development of standardised tools relying on sound criteria11 is making direct comparison between instruments and their devised purposes easier. These evaluative approaches should facilitate the selection of the most appropriate PRO for each occasion. Also, efforts are being made to develop very brief questionnaires by either shortening existing ones or applying computer-based methods to tailor the content of the instrument to each patient based on the responses provided to each previous item. This approach should reduce the burden of collecting PRO data. Finally, the development of new PROs specifically devised for use in the clinical setting might also help to overcome barriers to successful implementation. Where to from here?PRO instruments used in clinical research can theoretically provide important information to guide decisions about alternative treatments. There are some grounds for optimism that the use of PROs could have a positive impact on clinical practice (specifically in improving diagnosis and recognition of problems and in patient–physician communication), but considerable work is still required before clinicians can invest resources in the process and confidently anticipate benefits for their patients. 1 Examples of patient-reported outcome (PRO) instruments Medical Outcomes Study short-form health surveys (SF-36, SF-12, SF-6D): the most used family of PRO measures EuroQol (EQ-5D): a well known econometric preference-based measure, and one of the shortest instruments available McGill Pain Questionnaire: the most widely cited PRO instrument for measuring pain KIDSCREEN: a specific tool for PRO measurement in children and adolescents Patient Health Questionnaire (PHQ-9): a tool for assessing severity of depression; currently part of the “pay-for-performance” incentives scheme for primary care practitioners in the United Kingdom2 Schedule for the Evaluation of Individual Quality of Life (SEIQoL): an individualised measure, eliciting both the content of the items and the ratings from the respondent 2 Assessing the impact of patient-reported outcomes in clinical practice: a model for feedback on functional assessment* in clinical practice7 * The assessment of a patient’s ability to perform tasks.

Jose M Valderas MD, PhD, MPH · Jordi Alonso MD, PhD · Gordon H Guyatt MD, FRCPC

Objective: To determine the timeliness of access to general practitioner appointments in South Australia.Design and setting: Face-to-face interviews with a random and representative sample of South Australians living in metropolitan Adelaide and country towns with a population of 1000 or more in 2007.Participants: 2507 people aged 15 years and over who had seen a GP in the previous 12 months.Main outcome measures: Waiting times for obtaining an appointment with a GP, patients’ perceptions about appointment waiting times, and waiting times at the GP’s surgery.Results: Most respondents reported that for their last visit with a GP, they were able to be seen on the same day (39%) or within 1 or 2 working days (33%); 20% waited more than 2 working days for their appointment. Nine per cent of respondents (159/1764) reported waiting more than 2 working days because an earlier appointment was not available. Respondents reporting lower levels of household income were more likely to report longer waits for GP appointments. Most respondents (78%) felt that they were able to make a GP appointment as soon as they thought necessary. At the surgery, 46% of respondents were seen within 15 minutes, but 13% waited 45 minutes or longer.Conclusions: In general, access to GPs is timely, and most South Australians reported that for their last GP visit they were able to make an appointment as soon as they thought was necessary.

Richard L Reed MD, MPH · Leigh S Roeger BA(Hons), PhD · Nova Reinfeld-Kirkman BBSc(Hons) · Sara L Howard BHlthSc(Hons), PhD

Australian-based researchers are participating in an international collaboration to improve general practice research Primary care is where most patients receive most of their health care. It makes a greater contribution to the community’s health than specialty practice.1,2 Yet research in primary care lags far behind that in the specialties; it is a “Cinderella”, criticised for its comparatively small output and its lack of relevance and methodological rigour.3-6 This discordance has focused attention on the need to strengthen primary care research infrastructure and capacity.7,8 In Australia, the federal government responded with the Primary Health Care Research, Evaluation and Development program.9 The Brisbane International Initiative (BII) is another approach with similar — but international — objectives. Wide-ranging and ambitious, it was founded at a Brisbane meeting of leaders in primary care research from eight countries in 2002.10 Its aim is to develop expertise in primary care through promoting capacity and fostering excellence in primary care research. It now operates within the World Organization of Family Doctors (WONCA). Originally a collaboration of 14 university departments of general practice (in North America, the United Kingdom, Europe and Australia), the BII has since expanded and promotes primary care research capacity-building through a range of activities (Box 1). One of these activities is the convening of postdoctoral peer-learning cohorts in a 2-year program of development for research leadership administered at the University of Oxford in the UK. We were among the second (2007) cohort of 12 researchers (Box 2): two of us are Australian (P J M and J S F), and the third (M L v D), originally from the University of Ghent, has since taken up an academic position in Australia. The 2-year program has a flexible overall structure but begins and concludes with meetings at the host institution. The initial meeting for our cohort was held on 3–6 September 2007 at St Hugh’s College, Oxford (Box 3). The meeting had a conventional structure — seminars, talks and workshops — but stood out for the quality of its content. It was designed and seamlessly facilitated by Alison Ward (Research Support Director, Department of Primary Health Care, University of Oxford). Box 4 outlines the material covered and the impressive range of presenters. However, the meeting had a further agenda: the smallness of the group, the cloistered surroundings, and the privileged access to distinguished and influential people in the field of primary care research instilled in us a sense of responsibility; the meeting also introduced us to international peers at a similar career stage and, specifically, gave us an opportunity to plan collaborations. Key lessons from the meetingOur role as research leaders Critically, we explored the difference between leadership and management. Sue Dopson showed us how being a leader is about inspiring and motivating others, exploring new frontiers and crossing boundaries. To influence policy, we need links with policymakers. As primary care research deals with the realities of implementing policies in daily patient care, it should automatically feed back to the settings where policy is designed. Martin Roland outlined the importance of primary care leaders sitting on decision-making committees. He also suggested that we should not ignore links with the media and the wider community. Career paths and the pursuit of researchTrisha Greenhalgh and Paul Glasziou gave us insights into their own careers. Each engaged and intrigued us with stories of careers that were rarely linear, and were most often guided by intuition and an open mind. Greenhalgh spoke of diverging into political advocacy and a triathlon career, all pursued with the energy and passion she continues to bring to primary care research. Glasziou spoke of how a “feeling” for a research idea could drop into the mind over tea or at the photocopy machine, and then evolve into a research question that contributes to the knowledge base of primary care. He keeps a record of many such research ideas in development at any time, refining the questions and ideas through discussions with others and small-scale pilot work. The insights of these speakers suggested that we should be open to students and early-career researchers choosing less-than-conventional options in our efforts to build a creative and thriving primary care culture in the future. Publication — an insider’s viewFiona Godlee gave us a view inside the editorial workings of the BMJ as it struggles with the tensions between publishing high-quality research reports and publishing articles reflecting the world in which clinicians work, and between the needs of multiple audiences (general practitioners and specialists, UK and international). Godlee acknowledged feedback that the BMJ’s balance needs to tip more towards research articles, including primary-care research articles, to support its overarching purpose of helping doctors make better decisions. Outcomes of the meetingThe BII has high aims. A major objective of the week in Oxford was to bring the cohort together and foster collaborations. But was it just a talk fest for a privileged few? The proof is in the pudding. What matters is what we achieve as a group from coming together. Already there are good signs. The 2007 cohort will organise a workshop at the Society for Academic Primary Care conference in Galway, Ireland, in 2008, focusing on developing measures of research output for departments of general practice. The group (led by J S F) has written an article on future directions in primary-care research and submitted it to a peer-reviewed journal. The Australian BII participants are developing other collaborations. These include an article on journal impact factors and their influence on research and researchers (lead author, M L v D).11 P J M has developed a collaboration to study GP referral patterns for transient ischaemic attack and is exchanging ideas with another group member on parallel projects on inappropriate prescribing in older people. Undergraduate students from the University of Aberdeen, Scotland, may be offered the opportunity to complete an elective research term in a collaborating department at the University of Newcastle, Australia. P J M will also make short visits, facilitated by colleagues at Keele University, the University of Sheffield, the University of East Anglia and University College London, to study the organisation and functioning of British research networks of general practices. In addition, the Australian-based BII participants hosted a breakfast meeting at the national General Practice and Primary Health Care Research Conference in Hobart in June to explore the possibility of local Australian postdoctoral peer-learning groups. These may be modelled on the experience of Andrew Farmer (Lecturer in General Practice, University of Oxford) who spoke at the BII meeting of his experience as a member of a Medical Research Council peer-learning group of postdoctoral primary care researchers. Opportunities for othersIt is still quite early in the 2007 cohort’s BII program, but it is proving to be an exciting and potentially productive exercise. We urge Australian postdoctoral (or near to doctoral submission) primary care researchers to consider applying for subsequent cohorts. Applicants must be nominated by their department. If they are selected, the department agrees to become a partner institution of the BII. This involves providing financial support for their participants to complete their BII obligations (except for accommodation and expenses at the Oxford meetings, which are funded by the University of Oxford), and agreeing to host BII participants from partner institutions. We feel strongly that this would prove a sound investment in research capacity-building for the departments involved. 1 Activities of the Brisbane International Initiative Cooperative development of research educational resources Convening of expert groups and think tanks Fellowships and visiting traineeships Support of small, international peer-learning cohorts aimed at postdoctoral primary care researchers 2 Some of the participants at the 2007 meeting Left to right: Chris Del Mar (Visiting Professor of General Practice, University of Oxford), Parker Magin (Senior Lecturer, University of Newcastle), Mieke van Driel (Senior Lecturer and Research Fellow, University of Ghent), Caroline Mitchell (Senior Lecturer, University of Sheffield), John Furler (Senior Research Fellow, University of Melbourne), Umesh Kadam (GP Epidemiologist, Keele University), Barbara Hanratty (Senior Lecturer in Population and Community Health, University of Liverpool), Greta Rait (Senior Clinical Lecturer, Royal Free and University College Medical School), Jennifer Cleland (Clinical Senior Lecturer in Primary Care and Medical Education, University of Aberdeen), and Colin McCowen (MRC Training Fellow, University of Dundee). 3 St Hugh’s College, Oxford, venue of the meeting 4 Program of the 2007 meeting Scene setting. A presentation on the current state of primary care research and the challenges and opportunities facing the group (Chris Del Mar, Dean of Health Sciences and Medicine, Bond University, and Visiting Professor of General Practice, University of Oxford). Skill development for leadership. Seminars on: leadership theory (Sue Dopson, Reader in Organisational Behaviour, University of Oxford); the research–policy nexus (Martin Roland, Director, National Primary Care Research and Development Centre, University of Manchester); and scenario planning for anticipating future strategy and policy in primary care (Sara Ward, Executive Director, James Martin Institute for Science and Civilization, University of Oxford). Skill development for research. Presentations on developing research questions (Paul Glasziou, Professor of Evidence-Based Medicine, University of Oxford) and successfully collaborating in large-scale trials and meta-analyses (Mike Clarke, Director, UK Cochrane Centre). Inspiration. Before- and after-dinner presentations on the career paths of eminent primary care researchers (Paul Glasziou, and Trisha Greenhalgh, Professor of Primary Health Care, University College, London). Inside knowledge. A seminar on the strategic editorial issues facing the British Medical Journal (Fiona Godlee, Editor, BMJ). Networking and bonding. Each participant spoke about their personal research and that of their department. Ample opportunities were provided for discussion and exploring potential collaborations, in organised small groups, in free time and also at nightly in-house dinners.

Parker J Magin PhD, FRACGP · John S Furler PhD, FRACGP · Mieke L van Driel MD, PhD

The Primary Health Care Research, Evaluation and Development (PHCRED) Strategy aims to improve Australia’s output of high-quality research from primary care. We compared publication rates from general practice, medicine and surgery for the period 2000–2007, and found that general practice publications increased since 1990–1999 from 1.0 to 3.0 publications per 1000 general practitioners per year. However, general practice publication rates have plateaued since 2000, and represent only 2%–5% of the equivalent rates for medicine and surgery. This finding suggests that more time and sustained investment in PHCRED are essential to see tangible outputs from funded research in general practice. Since 2000, the Australian Government has invested $110 million in the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy to “improve Australia’s capacity to produce high quality primary health care research”. An evaluation of the PHCRED Strategy in the 2004–05 financial year reported significant progress in achieving this aim.1 Published research is one measure of research capacity. As evaluation of Phase 2 of the Strategy has commenced,1 we considered it timely to measure the publication rate from general practice research, and to compare this with rates of published research from other medical disciplines and with an earlier stocktake of published research from the 1990s.2 MethodsWe repeated the search strategy used in the previous stocktake.2 The United States National Library of Medicine’s PubMed database details the institutional affiliation of the first author in the address field of indexed publications. We used this information to identify publications from three Australian disciplines — general practice, medicine and surgery — published between 1 January 1990 and 31 December 2007. Publications with the terms “comment”, “editorial”, “letter” or “review” in the publication type field were excluded. Average annual publication rates from 2000 to 2007 for each discipline were calculated as the number of publications per 1000 practitioners per year. Poisson regression was used to compare these rates with those in the previous stocktake, to model the raw numbers of general practice publications (using discipline workforce size as the exposure), and to adjust general practice publication rates relative to medicine and surgery publication rates (referenced to 1990). For all models, goodness-of-fit and residual checks were undertaken. All analyses were performed using Stata, version 10.0 (StataCorp, College Station, Tex, USA), and a level of α = 5% was used to define statistical significance. ResultsFrom 2000 to 2007, there were 545 publications from Australian general practice, published in 130 different journals, including eight specific primary care journals. These eight journals together published 223 (41%) of the publications from general practice. For the period 2000–2007, there were 3.0 (95% CI, 2.8–3.3) publications per 1000 general practitioners per year — a significant increase from the previously reported level of one publication per 1000 GPs per year for the period 1990–1999,2 but still less than 5% of the rate for surgeons during 2000–2007, and about 2% of that of physicians (Box). From 1990 to 2007, the number of publications from each discipline increased. After adjusting for changes in publication rates for medicine and surgery, general practice publication rates increased significantly between 1990 and 2000, but plateaued between 2000 and 2007. No evidence was found to doubt the adequacy of any of the Poisson regression models. DiscussionThe annual general practice research publication rate has trebled since the PHCRED Strategy was introduced, but remains very low compared with medicine and surgery, and is incommensurate with the level of clinical activity in general practice. Despite considerable investment in building research capacity in general practice, its level of research output continues to be much lower than that of other disciplines. This can be partly explained by the very small number of GPs on government salaries (2%) compared with physicians and surgeons (56% and 26%, respectively).3 GPs working in a fee-for-service environment lose revenue if they take time away from direct patient care, which is a disincentive for conducting research. This is not the case for their salaried colleagues, for whom research is often an expected component of their work. Could this be replicated in general practice? Two components of the PHCRED Strategy (the Research Capacity Building Initiative and the Researcher Development Program) have largely focused on training novice researchers (from all fields within the extensive primary care workforce) and funding small, short-term projects that are unlikely to produce many publications. In contrast, the PHCRED Fellowships, Scholarships, and investigator- and priority-driven clinical research project grants are long-term investments with lengthy timelines for completion and publication of outcomes. Our inability to identify any real increase in the number of general practice publications suggests the level of investment is insufficient and more time is needed to see funded activity translate into tangible research output. As with the earlier stocktake,2 our approach has important limitations. The search strategy was not specific to research articles, it did not identify publications by general practice researchers whose institutional affiliation does not include the words “general practice”, and it identified only first authors, ignoring general practice researchers collaborating with other disciplines and those outside Australia. Additionally, current and accurate workforce data are not available, requiring us to use different sources to estimate workforce sizes. Nevertheless, our approach is quick, easily replicable and produces an indicative comparison of general practice research productivity over time and with other disciplines. The large disparity we found in relative publication rates is unlikely to disappear with a more rigorous assessment. Importantly, although research productivity is an indicator of research capacity, it is not the only indicator, and it does not provide information on the quality of research. The PHCRED Strategy should not be assessed solely on the number of publications produced, but also on other indicators of research capacity, including the number of research grants applied for and funded, evidence of research participation, and involvement in research training. Sustained and targeted investment is needed to develop a sustainable primary care research workforce, if general practice is to provide high-quality, evidence-based care to fulfil its role as the cornerstone of the Australian health care system. Relative publication rates of Australian general practitioners, physicians and surgeons, identified in PubMed search, 2000–2007 Number (%) of publications Approximate size of workforce Proportion of total medical workforce (N = 60 252)* Publications per 1000 practitioners per year (95% CI)† GPs 545 (3%) 22 600* 38% 3.0 (2.8–3.3) Physicians 11 487 (72%) 9 000‡ 15% 159.5 (156.6–162.5) Surgeons 3 849 (24%) 7 100§ 12% 67.8 (65.6–69.9) * Source: Australian Institute of Health and Welfare, http://www.aihw.gov.au/publications/hwl/mlf05/mlf05-xx-all-employed-practitioners.xls (accessed Feb 2008). † 95% confidence intervals calculated using exact Poisson distribution. ‡ Source: Royal Australasian College of Physicians (total of all Fellows of the RACP, including those from New Zealand), http://www.racp.edu.au/index.cfm?objectid=3F6EF93E-2A57-5487-D7CE8B12AD671563 (accessed Apr 2008). § Source: Royal Australasian College of Surgeons (total of all Fellows and trainees of the RACS, including those from New Zealand), http://www.surgeons.org/AM/Template.cfm?Section=Who_We_Are (accessed Apr 2008).

Deborah A Askew PhD · Philip J Schluter BSc(Hons), MSc, PhD · Jane M Gunn MB BS, FRACGP, PhD

Defining the ideal generalist medical practitioner is essential to effective primary care It is 30 years since 3000 delegates from 134 governments, 67 international organisations and many non-government organisations gathered in Alma-Ata, Kazakhstan, to agree upon a declaration about how primary health care could achieve “health for all by 2000”.1 The conference was convened by the World Health Organization and the United Nations Children’s Fund (UNICEF) in response to the growing inequality among large sections of the world’s population. The conference was influenced by global political and social change in the preceding decades and a strong desire to move away from medical dominance and elitism,2 to focus on developing countries rather than dominant Western nations, and to propose a model of health as a tool for economic development.1 The leadership of WHO Director-General Halfdan Mahler (1973–1988) was crucial to the direction of the declaration, as he had been impressed by developments in China, India, Africa and Latin America that provided health care via local community-controlled services using lay participation, and he envisioned such programs addressing health inequalities across the world.3 The resulting Declaration of Alma-Ata consisted of 10 sections (Box 1). Anniversaries often prompt reflection, and as the Alma-Ata Declaration reaches its 30th birthday, it is clear that implementing the Declaration has been more difficult than creating the vision.4-7 Many commentators argue that the Alma-Ata experiment failed;5 others say it has never been tried.8 Some highlight the influence of the Declaration on policy agendas in developing countries (eg, Mozambique, Nicaragua) and on the development of community health workers.4 However, many programs that evolved were disease-focused, and critics would say that the community health workers, rather than being agents of change, became civil servants.8 So what is the relevance of a WHO declaration made 30 years ago to the Australian health care system? Some may see the Declaration as applying mainly to developing countries, but on reflection there is much we can gain from considering it in our own context. As a population, we desire health for all, and yet we continue to see health inequities. The rise in chronic disease and the ageing population means that multiple morbidities are the most common reasons for presentation to primary care,9-12 yet Australia, like many countries, continues to focus on single-disease-led health care linked to relative disease burden, often via treatment guidelines.13 This approach encourages specialisation, leads to fragmentation of health care, and affects our ability to deliver the goal of “health for all”. The fragmentation in so many health initiatives goes against the spirit of the Declaration. Perhaps governments, the health professions and wider society did not fully understand or truly value the kind of health care proposed. The Declaration called for a dramatically different approach to health and health care, but it failed to articulate the attributes required of the health care workers. The essential role and inclusion of primary medical care in the conceptualisation of primary health care was poorly articulated. Perhaps the desire to reject medical dominance, combined with a poor understanding of primary care,14-17 explains why there was no definition of what a “suitably trained physician”1,18 would need to be like to deliver the ambitious goals. Even though there was increasing focus on the need for a team of professionals to provide primary health care,19,20 there was little systematic gathering of evidence to inform the roles and values of various team members. What kind of physician could contribute to achieving the Alma-Ata vision?We propose that a generalist primary care medical practitioner is a vital component of primary health care. Australia has a well trained general practitioner workforce, yet most GPs continue to practise mostly reactive, consultation-based medicine with little time for planning, monitoring, teamwork, community involvement, and networking or integration activities. As a nation, we face a medical workforce crisis in that general practice struggles to attract and maintain high-quality graduates. The policy response is to shift the work of GPs to non-medically qualified practitioners and assistants. Interestingly, there has been little public involvement in debate of this issue. Our recent review, commissioned in 2007 by the Australian Primary Health Care Research Institute (APHCRI), provides, for the first time, a conceptual model of a primary care generalist based on a systematic narrative review of the literature (Box 2). A full description of the review methods and findings is available from the APHCRI website.21 The generalist ideal encapsulated in our model can bridge the inclusive vision of who should be involved in promoting health for all, with the much more narrowly and often specialty-focused health care found in many countries, such as the United States. The type of generalist role proposed is sophisticated and requires interpretive skills, a broad approach, excellent networks and supports. We conceptualise generalists as exhibiting compassion, tolerance, trust, empathy and respect (virtues). They reflect carefully on each clinical interaction, recognise its complexity, and acknowledge their prejudices (eg, towards obesity, unsafe sex practices, single parenthood, substance misuse, poverty, violence, religion). By acknowledging and dealing with their feelings (being reflexive), generalists can begin to fully engage with each patient. The generalists spend time gathering information from the biopsychosocial and cultural domains, rather than focusing solely on physical symptoms and signs. Each interaction requires biotechnical expertise, and the generalist needs to use the best available evidence to manage health. This is likely to be facilitated by access to independent evidence-based guidelines and reliable information systems. The generalist knows how to access appropriate technology to achieve health (this will range from familiarity with accessing online evidence to knowing how to access a magnetic resonance imaging scan to being aware of how to get patients from a remote area to a district hospital during the rainy season). In addition, the generalist will exhibit a high index of suspicion for medical, psychological and social “complications” and awareness of the complex interaction of morbidities and social factors. A fundamental role of the generalist is to balance the biotechnical with the biographical. The generalist must know and understand how each life story and social context are constantly influencing and being influenced by physical and emotional health. To achieve the balance between the biotechnical and biographical aspects of each interaction, the generalist must have the skills to reach a mutual understanding of the priorities and challenges that individual patients face when managing their health. The ideal generalist would be easily accessible and knowledgeable about other services to arrange appropriate and timely referral. The generalist would balance individual needs against those of the population, and consider the whole person and what they know about each to provide comprehensive care, dealing with areas such as sexual health with as much knowledge, interest and respect as diabetes. They will be comfortable working with both mental and physical health problems (flexible), and able to negotiate a plan for health care that suits each person (patient centred). This might be as simple as ensuring that single parents can get appointments that suit their work schedule and childcare requirements. The generalists would work in a system that allows them to ensure that each person receives all the health care they need regardless of their ability to pay for it, and the generalists would have the potential to guard against fragmentation in the delivery of care. Such a generalist embodies the medical practitioner role for primary health care that has the potential to deliver health for all. Like the Declaration, it is an ideal, but striving towards this goal is likely to have far-reaching health benefits. Generalism and the Alma-Ata DeclarationThe generalists’ character, reflexive and interpretive ways of being, biographical ways of knowing, and accessible, longitudinal, contextual approach place them at the crux of the social, economic and community sectors that are the focus of the Alma-Ata Declaration. The generalists’ biotechnical focus is the link to medicine, but also a way of bridging the gap between medicine and the personal, social and cultural circumstances of individual patients. This vision of generalism responds to the Alma-Ata Declaration and can inform primary care practice in developed or developing countries. There is a strong synergy between the Declaration and the conceptual model of generalism, especially around the importance of incorporating biopsychosocial aspects in the delivery of health care and the focus on first contact, locally accessible health promotion, prevention, cure and rehabilitation (section VII of the Declaration). The virtuous character in our model is in keeping with the spirit of social justice required in the Declaration (section V). The community focus of the generalist is critical to integrating the social and economic sectors into the promotion of health (section I), to bringing health care as close as possible to where people live and work (section VI), and to getting the kind of work done that the Declaration called for (section VII). The promise of generalismWe have identified a conceptual model of generalism that could underpin a new primary health care approach, building on the bold vision of the Alma-Ata Declaration. We have argued that a major limitation of the Declaration was its failure to consider the kind of physician and the health care relationships needed to deliver health for all. Having control over resources, participating in health care and ensuring communities are equipped and empowered to deal with their health needs are important ideals. But someone must integrate health care within a relationship context, continue that care, and support promotion of health, prevention, diagnosis and treatment. Health for individuals, let alone health for all, cannot happen without access to health care practitioners able to promote health, prevent disease, diagnose, treat, and follow up. This will require more than one health professional, but acknowledgement of the important central role of the generalist is missing from the Declaration. Few studies have explored whether generalist approaches to primary care are cost-effective. No randomised trial of generalism has ever been conducted, nor is it ever likely to be undertaken. But there is observational evidence that generalist primary health care contributes to achieving the goals of Alma-Ata.22 The potential pitfalls in achieving generalismGeneralism alone is not the answer. The issues of sustainability, war, terrorism, well planned cities, public transport, affordable housing, secure employment, quality childcare and education are just as important to health as the common physical and emotional health problems that consume most of the health dollars. The generalist offers a bridge between the biomedical and the social, but within limits. To truly realise the potential that generalism offers will require that generalists work closely with others with an expanded view of health and health care. In Australia, this would require us to reconsider the way GPs work and the infrastructure support required to enable them to undertake preventive, curative and rehabilitative health care as a core component of the primary care team. If this is made possible, generalists may find themselves not only providing physical and mental health care, but playing a role in a team that focuses on keeping individuals in their community safe from harm, finding them work for a living wage, advocating for a child-friendly environment, changing the gaming laws, or introducing a cervical cancer vaccination program. The generalist is a part of the wider health care and social system and the generalist role is inherently adaptable to local needs and grounded in local relationships. To avoid the pitfalls of fragmentation in health care and interprofessional rivalry that may stand in the way of achieving generalism and the ideals of Alma-Ata, this role will increasingly need to pay attention to the broad partnerships called for in the Declaration. ConclusionCritics may argue that our literature-based model encompasses an ideal that is impossible to achieve. But, much like the Declaration, if it is not an aspiration, it will never be achieved. One major challenge remains — whether the community as a whole will value the concepts of generalism and the Declaration made at Alma-Ata 30 years ago over the more seductive promise of specialism and high-tech, high-cost intervention. If health for all is the goal, governments, health care professions and individuals need to carefully consider the central role of generalism and the components set down at Alma-Ata, and will need to invest in making sure that they can happen. 1 Summary of the Declaration of Alma-Ata1 The 1978 Declaration of Alma-Ata formally adopted primary health care as the means for providing a comprehensive, universal, equitable and affordable health care service for all countries. Consisting of 10 sections, in summary it declares: I: health as the state of complete physical, mental and social wellbeing; II: the unacceptability of health inequalities, especially between developed and developing countries; III: the necessity of economic and social development for health; IV: the right and duty for lay participation in planning and implementing health care; V: the responsibility of governments for providing primary health care and for measuring health and social wellbeing; VI: the role of primary health care as the local, universally available, essential, first point of contact with the health system, based on practical, scientifically sound and socially acceptable methods and technology at a cost the community and country can afford; VII: the essential elements of primary health care (culturally relevant; addresses the main health problems; provides preventive, curative and rehabilitative care; provides health education; includes a multisectoral approach; community participation; integrated functional referral systems; consists of physicians, nurses, midwives, auxiliaries, and community workers trained to work as a health team); VIII: the need for government policies on primary health care; IX: the need for international cooperation for health; and X: the need for better use of the world’s resources and a policy for peace and disarmament. 2 A conceptual model: essential dimensions of a primary care generalist medical practitioner Ways of being (ontological frame) Virtuous character: holds ethical character traits of compassion, tolerance, trust, empathy and respect. Reflexive: interdependent; reflects on judgements and biases; lifelong learner. Interpretive: uses processes of interpretation to understand patients, with an emphasis on the contextual factors; use of multiple health systems languages; active listener; autonomous decisionmaker; has good communication skills. Ways of knowing (epistemological frame) Biotechnical: uses scientific and rational evidence; high index of suspicion; biomedically driven; technically focused; uses advanced information systems. Biographical: concentrates on lived experience and life story; family, carers, community and social knowledge all provide evidence. Ways of doing (theoretical frame) Access: accessible; first-contact point; gatekeeper; provides referral. Approach: balances individual versus population needs; consultation-based; holistic; comprehensive; flexible; adaptable; acts across clinical boundaries; provides early diagnosis; interdisciplinary team approach; negotiates and coordinates services; integrates knowledge; promotes health through education; prevents disease; is culturally sensitive; provides patient-centred care; minimises service inequities; reduces service fragmentation. Time: provides continuity of care over whole of life cycle. Context: community-based; uncertain; complex; deals with undifferentiated multiple problems of patients; acute and chronic care.

Jane M Gunn PhD, FRACGP, DRANZCOG · Victoria J Palmer PhD, BA(Hons) · Lucio Naccarella PhD · Renata Kokanovic PhD, BSociol · Catherine J Pope PhD, BA(Hons) · Judith Lathlean DPhil, MA, BSc(Econ) · Kurt C Stange MD, PhD

New medical graduates expect to work in an environment that allows scope for flexibility and change across a career in medicine. Recruitment to general practice is adversely affected by its perceived limited scope of practice. Training in procedural and hospital skills is not difficult to access for general practice trainees, but complex and inconsistent credentialling criteria and protectionist attitudes among some specialist colleges mean that many skilled general practitioners are unable to utilise the full range of their skills in clinical practice. The discipline of emergency medicine is also experiencing difficulty in recruiting trainees. The employment of skilled GPs in emergency departments (including metropolitan departments) could improve vocational satisfaction for GPs and emergency physicians, and possibly also improve patient outcomes and flow through the emergency department.

Simon M Willcock PhD, FRACGP, DipRACOG

Addiction medicine deals with problems arising from the use of psychoactive substances, and encompasses the disciplines of general practice and primary care, psychiatry, psychology, internal medicine, public health, pharmacology and sociology. Addiction is a chronic, relapsing illness that is difficult to cure. There are now effective, evidence-based interventions for the prevention and treatment of substance misuse disorders. Harm minimisation and treatment are more cost-effective than policing and supply-reduction methods of responding to substance misuse.

Brian R McAvoy MD, FAChAM, FRNZCGP

If the female perspective is missing, how can true feminisation of the medical workforce occur? Much has been written about the feminisation of the medical workforce. However, this usually refers to the increasing numbers of women entering medicine, rather than to an adaptation of medical theories and practices to incorporate a female perspective. Women and men work differently, and these behavioural differences are attracting attention as the workforce debate brings women’s contribution to medicine, and their place in general practice,1 under an intense spotlight. A number of studies have demonstrated the gendered nature of communication and practice styles,2-6 health care delivery7 and patient care.8 Some have raised the question of whether female work styles contribute to the workforce problem9 — work styles that are often assumed to represent inherent female behavioural attributes.10 The tension generated by increasing numbers of women within a predominantly male-driven medical ethos can be examined using two conceptual models — the “Medusa effect” and the “Mother Teresa effect”. These are used to demonstrate how gender-based stereotyping, plus entrenched assumptions and concepts about gendered behaviour, may be affecting the interpretation of practice styles11 and underpinning the workforce debate. We argue that there is an urgent need to re-think the gendered nature of medicine in order to allow us to explore innovative solutions to the problem of the current workforce shortage in general practice. Exploring female attributes: what is acceptable behaviour? The Mother Teresa effect exemplifies the virtuous in female behaviour. It is based on the famous Roman Catholic nun who worked in the slums of Calcutta, India, for much of the 20th century. Her universally admired behavioural qualities included selflessness; a commitment to vocation above ambition or a personal life; chastity; a willingness to care for the bereft and the destitute; and subservience to a greater authority. Although these behavioural traits are not exclusively female, they do embody socially accepted female behavioural attributes. Medusa, on the other hand, is a mythical goddess whose fate is emblematic of transgressing the boundaries of acceptable female behaviour and highlights the complexities of gender relationships. Medusa emerges in the dawn of history, in many guises and in many civilisations. Her name means sovereign female wisdom, and she possessed powers of foresight, but Medusa paid a gruesome price for her wisdom and her power. Mythology has it that Medusa, a beautiful maiden, so enraged Athena after coupling with Poseidon in Athena’s temple that Athena turned Medusa into a hideous sight, and then assisted the hero Perseus to pursue the pregnant Medusa and behead her. The symbolism of Medusa hints at retribution if female knowledge, wisdom, sexuality and independence overpower the more acceptable female virtues of nurturing and caring. Female behaviour, women doctors and general practiceAn interplay between the Mother Teresa effect and the Medusa effect echoes the complexity of the female presence in medicine across several professional domains, including the doctor–patient relationship (and local care), the societal delivery of health care, and the medical profession itself.12 The doctor–patient relationshipWomen’s presence in medicine has been good for patient care. Studies from Western countries about gender differences in the consultation have produced similar findings — women have an inclusive and democratic style of communication13 that helps foster “collaborative relationships” with patients.12 Women tend to be “information giving”, use a more participatory decision-making model14 and appear less motivated by financial rewards.15 They deal with more complaints, are more patient-centred in their approach, and provide more preventive health care.2,16 These attributes, which could be grouped or labelled as consistent with the Mother Teresa effect, are valued by patients, appear to produce good patient outcomes,17 and have helped shift medical teaching away from a doctor-centred agenda to a patient-centred one.18 On the other hand, in relation to health care delivery, women’s work patterns are seen by some to limit patients’ access to medical services as well as being a contributory cause of workforce shortages. Although acknowledging that “empathy and communication are important”,1 quantitative studies also demonstrate that women work about 13.8 hours less per week than men, tend to work part-time, have longer consultations, and provide less institutional care, emergency services or procedural services.10 However, simply assuming that quantitative studies are evidence of female doctors’ inefficiency or “inability to live with risk”,1 or are a consequence of female doctors preferred working styles7 may confuse cause and effect. Numbers merely describe gendered work patterns — they do not and cannot explain them. Seeking such an explanation may help clarify solutions for some of our workforce problems. Attributing the cause to “women’s behaviour” and in doing so ignoring any other possible factors could reflect an underlying attitude related to the Medusa effect. The importance of these other factors, such as the patient’s gender, the sex match of the doctor–patient duo or the patient’s prior health status,5,19 was highlighted in an Australian study by Britt and colleagues, who established that some of the associations attributed to gendered work styles disappeared after controlling for the influence of age, experience, other practitioners’ characteristics, and patient mix.20 Similarly, a cross-sectional European study into consultation length found that 55% of the variance was due to factors at the patient level and that “the age and sex of the doctor had no impact on the duration of the consultation”.21 Societal delivery of health careThe missing ingredient in contemporary discussions of the effect of women in medicine is the role of sex socialisation, a powerful force for both women and men. The traditions of Western medicine have been forged in a male-centric work model. In this model, vocational commitment is demonstrated by long hours of work and dedication to the profession.18 This could be seen as the male version of the Mother Teresa effect, except that it is predicated on a personal life that is provided by a full-time “invisible” other. That invisible other is traditionally female. It would seem that little has changed. Many female medical students still see their gender as a disadvantage for their careers and expect that they will be required to sacrifice their professional lives to have a personal life, even if they are in a dual career relationship.22 This persistence of “gendered schemas” within the medical profession means that “men are consistently over-rated and women under-rated” in relation to competence and performance.23 Invisible barriers such as the classic glass ceiling24,25 — or other hidden forms of the Medusa effect — may often stymie women’s attempts at assertiveness or leadership. Overcoming the constraints of such a “discriminatory environment”18 may be having an adverse effect on female doctors’ health and wellbeing,26 especially if the effects of gendered behavioural expectations are not given a place at the “workforce patterns” discussion table. In any debate that draws on quantitative data, women are likely to “fall foul” for biological reasons. In a male-centric environment, periods of peak career building coincide with the time of establishing a family. Both are time hungry, and gendered socialising still sees women expected to take the prime responsibility for both children and domestic requirements.27 Gjerberg, from the Norway Work Research Institute, has pointed out that any discussion of medical workforce patterns that does not factor this expectation in ignores the fact that, while women work shorter hours in paid work, compared with their male colleagues, they work longer hours in total.28 The medical profession Women are here to stay, and we believe that trying to dance to the Henry Higgins refrain of “why can’t a woman be more like a man?” will not help us find workable and practical solutions to help shape the profession’s future. Women now account for about 37% of the Australian general practice workforce overall and half the workforce among general practitioners younger than 45 years. These trends appear set to continue, as two-thirds of all GP registrars younger than 35 years are female.29 As the medical workforce races toward a gender balance, to what extent is the female perspective influencing major decision making within the profession? Evidence suggests this is limited, as gender still appears to have a filtering effect in terms of leadership roles, choice of specialty, and academic advancement for women within the profession.30 Embracing gendered health careIf the female perspective is absent from medical decision making, how is it possible for true feminisation of the medical workforce to occur? Real feminisation implies an adaptation of medicine’s epistemology to include a female perspective and female ways of knowing, which are then expressed ontologically through its workforce. If the female voice is missing, so is the female perspective. As the number of female doctors continues to grow, their perspective is vital for finding workable and realistic solutions that meet society’s needs and expectations for adequate health care. An obsessive focus on women’s behaviour, whether it be on the Mother Teresa or the Medusa traits, in a gender “blame game” is unlikely to accomplish this perspective. As Australian researchers Joyce and colleagues have said, it is indeed “time for a new approach to workforce planning”.31 Are we mature enough then, as a profession, to explore assumptions about gendered social and professional roles and responsibilities? In laying these bare, are we ready to truly “feminise” the medical workforce and embrace new possibilities in workplace patterns that do not sacrifice ourselves, our children, our personal relationships or our responsibilities to our community to provide medical care? The implications for medical education, clinical practice and health care policy will be considerable (for some examples, see Box). A tall order certainly, but in the spirit of the recent Australia 2020 Summit, a think tank is urgently needed that has the gendered basis of medicine firmly at its centre, with a vision focused on the need for medical theory and practice to be inclusive of all the factors that are currently moulding medical workforce styles and health care delivery. Placing gendered workplace solutions on the agenda — some suggestions Medical education All students applying for medicine should be able to attend information sessions about the personal and social expectations of being a doctor. Medical students need to understand how sex socialisation and sexual stereotyping can affect self-expectations, patient expectations and society’s expectations of being a doctor. Vocational educational perspectives could address how the gender of the doctor (and the gender of the patient) can sculpt clinical practice. Clinical practice Alternative models of health care delivery could be explored, such as including childcare subsidies in practice incentive payments. This could, for example, help support practices to provide childcare facilities on site to enable doctors to have access to their children, while their patients have access to the doctors. Job-sharing rosters could address peak times for both practice and families; split (rather than continuous) shifts may help to better match supply and demand. Enhanced electronic communication could ensure appropriate patient handover and follow up. Health care policy There should be a decreased reliance on “proxy” workforce measures such as consultation times (if not controlled for patient gender, conditions managed, and health promotion). Patient health outcomes should be included in workforce modelling. The new opportunity provided by the GP Super Clinics could be used to trial gender-friendly workplace models of health care.

Lyn E Clearihan MB BS, MD, FRACGP, GradDipFM, MFM(Clin) · Jan Y Coles MB BS, PhD, MMed(Women’s Health), DCH, GCHPE

Cervical cancer screening needs to take into account a partially vaccinated population and new technologies A national, well funded and organised program of screening using the conventional Pap smear has significantly reduced the incidence of and mortality from cervical cancer in Australia.1 While the program has been in place, there has been a great increase in knowledge of the pathogenesis of cervical cancer, with certain oncogenic subtypes of human papillomavirus (HPV) shown to be a necessary cause for development of this disease.2 In addition, a national program of vaccination against two of the 15 oncogenic viruses began in April 2007, and tests to detect HPV are now available. Furthermore, research showing that new technologies for screening cervical samples are superior to conventional cytology has also been published.3,4 How is the cervical screening program responding to the presence of a partially vaccinated population and these newly available tests? When the Pharmaceutical Benefits Advisory Committee assessed the value of funding HPV vaccination, it noted that the current cumulative lifetime risk of cervical cancer in Australia’s screened population is 0.78% — a substantial reduction from the estimated 2.4% risk in an unscreened population, reflecting the success of the screening program. With continued screening, this risk was predicted to further decrease to 0.38% following vaccination of 12-year-old girls, 0.43% for 14-year-old girls and 0.59% for 26-year-old women.5 The Committee further commented that there would be cost savings if vaccination were to completely replace cervical screening, but the cervical cancer lifetime risk would increase to 1.173%.5 The recommendation therefore is that screening must continue after vaccination. The screening interval and screening test for vaccinated women should be different to those for unvaccinated women and should be determined by population-based research over the next 5–10 years, as the vaccinated cohort reaches maturity. A national HPV vaccination register is being established, which will be critical for determining the appropriate screening regimen. HPV testing is already recommended and funded as a “test of cure” for follow-up of high-grade cervical disease after treatment. The Digene HPV test is used in Australia and detects any one of 13 high-risk HPV subtypes but does not identify the specific subtypes. Although some individual HPV subtyping assays are available, these are expensive and not widely used, and no serological tests for HPV are available in routine practice. Use of the HPV test is therefore limited but, given its importance, should its use be expanded for screening and management of cervical disease? There has been much discussion overseas about replacing cervical cytology tests with HPV testing for primary screening.6 Currently, there is no justification for this as HPV testing is highly sensitive but not specific. It has a limited role in women under the age of 30 years, as large studies have shown that about 25% of women in this age group test positive for the oncogenic viruses.7 The great majority of these women clear the virus naturally, usually via a cell-mediated immune response or, less often, through an antibody response. Such infected women may not show any sign of disease. It is when the virus persists that women are at greater risk of both high-grade cervical intraepithelial disease and invasive cancer. HPV testing is also not recommended before vaccination8 in women who request it but are already sexually active as the decision to proceed with vaccination will not be altered by the results of the test. HPV testing may have a greater role in the management of indeterminate abnormalities detected by cervical cytology tests. Data from large United States studies are fairly compelling in assigning a true risk of significant disease based on cervical cytology and HPV testing. The latter is more accurate than colposcopy in determining the significance of low-grade squamous intraepithelial lesions detected by cervical cytology. So-called “reflex” HPV testing in women with these findings is recommended in the US.9 Another major question for cervical cancer screening in the short term is whether image-guided liquid-based cytology samples should be used as the preferred screening test. The use of liquid-based cytology in this country has long been controversial.10 However, there is now good evidence that one of the techniques — the ThinPrep Imaging System (Hologic, Marlborough, Mass, USA) — is superior to conventional cytology.4 This technique decreases the number of unsatisfactory samples and detects more true abnormalities. There are also substantial laboratory efficiencies when using this technology, which could potentially overcome the chronic shortage of trained scientists. The increased sensitivity might allow the screening interval to be lengthened. This technique also provides a sample for HPV and other microbiological testing, and is ideal for a vaccinated population in which the number of screen-detected abnormalities will decrease. Although Australia has an enviable record in the control of cervical cancer, new knowledge and associated technologies should be incorporated into screening and management of cervical disease, as they offer real benefits. Both HPV testing and ThinPrep imaging are more expensive than conventional cytology, but they could be cost-effective if used appropriately in conjunction with a comprehensive review of the cervical screening program.

Annabelle Farnsworth FRCPA, FIAC, DipCytopath(RCPA)

Girl stuff. Your full-on guide to the teen years. Kaz Cooke. Melbourne: Penguin, 2007 (554 pp). ISBN 978 0 670 02887 0. Kaz Cooke seems to have explored every nook and cranny in a teenage girl’s mind in this colourful, accessible tome. Divided into four parts: body, head, heart and “info to go,” she covers a vast range of issues from puberty, friends, and stress, to money matters and job hunting. Girl stuff understands where adolescents are coming from — useful for those of us working with them! The minutiae of pubertal development (vaginal secretions, nipple colour, tampon traumas ...) may never come to our attention in the consulting room, but can cause hours of angst for many a young woman. How to negotiate relationships is more important to the sexually experimenting adolescent than the risk of invisible sexually transmissible infections. Cooke learned about the concerns of teenage girls via a web-based survey that received over 4000 responses, and hundreds of these quotes appear throughout. The more medical issues (puberty, acne, eating disorders, and depression, just to name a few) have been well researched, and there is an impressive list of adolescent health experts among the acknowledgements. The book is heavily sprinkled with Kaz Cooke’s delightful humour as well as her great cartoon illustrations. I would have liked more integration of cross-cultural issues. In the otherwise excellent chapter on families, there is no mention of the cultural differences that shape families. An overt statement about how beliefs about sex and gender may be culturally determined and that not everyone will be part of the dominant culture would be preferable to the passing reference to how religion and culture influence people’s beliefs about sex. Adolescent substages progress rapidly, and by the time most adolescent girls are faced with sexual decision making, they may have worked out puberty. Conversely, the chapters on sex and drugs may not seem appropriate for a very young adolescent preoccupied with buying her first bra. It has been handy having three adolescent girls at home, one in each substage, to test this out. The book is so full of common sense and practical information including statements such as “don’t read this chapter if you’re not ready”, that I had no qualms myself. I wish it had been around when I was a teenager.

Melissa S L Kang

Primary care has the lead role in reducing the burden of common mental disorders in Australia. This supplement adds to the evidence base needed to achieve it

Harvey A Whiteford MPH, FRANZCP, FAFPHM

Objectives: To assess the characteristics of people with common mental health problems who are recognised by their general practitioner, and those who are not.Design: Two different case-finding techniques (brief self-report and structured diagnostic interview) were compared with GPs’ independent assessments of patients’ presentations as psychological and/or medical.Setting and participants: 371 patients in general practices in metropolitan Sydney and rural New South Wales, with follow-up telephone interview as soon as possible after the GP visit. The study was conducted from 2001 to 2003.Main outcome measures: Overall rates of disorder, measured by the 12-item Somatic and Psychological HEalth REport (SPHERE-12), and anxiety, depression and somatisation diagnostic categories of the Composite International Diagnostic Interview – Auto; rates of disability, assessed by the 12-item Short-Form (SF-12) General Health Survey’s mental (MCS) and physical component scales; GP ratings of patients’ psychological problems, and intended treatments.Results: The SPHERE-12 showed the highest rate of case detection and greater agreement with GP assessments of psychological reasons for presentation. Patients who presented with somatic symptoms alone were most likely to be overlooked by GPs: none of the 57 patients identified by SPHERE-12 with a somatic disorder were identified by GPs as psychological presentations. Specificity for the SPHERE-12 psychological scale changed from 72% to 93%, and from 84% to 96% for the combined psychological and somatic scale, when the criterion of an SF-12 MCS score ≤ 40 was added.Conclusion: Low rates of recognition of psychological problems by GPs, and infrequent treatment for those presenting with somatic symptoms, indicate a need for building GPs skills in the assessment and management of somatisation. The SPHERE-12 may be a useful screening tool for primary care if followed by further questioning and other methods to assess diagnosis and severity to target appropriate treatment.

Kay A Wilhelm MD, FRANZCP · Adam W Finch MPsychol · Tracey A Davenport BA(Hons), eMBA · Ian B Hickie MD, FRANZCP

Objectives: To report the baseline characteristics of the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) study cohort and discuss the implications for depression care in general practice.Design: A prospective longitudinal study beginning in January 2005.Participants and setting: Adult patients with depressive symptoms identified via screening with the Center for Epidemiologic Studies Depression Scale (CES-D ≥ 16) in 30 randomly selected Victorian general practices.Main outcome measure: Depression status on the Patient Health Questionnaire (PHQ).Results: 789 patients form the cohort (71% women). At baseline, 47% were married, 21% lived alone, 36% received a pension or benefit, 15% were unable to work, 23% reported hazardous drinking, 32% were smokers, 39% used antidepressants and 19% used sedatives. 27% satisfied criteria for current major depressive syndrome (MDS) on the PHQ, while 52% had “persistent” depressive symptoms, and 22% had “transient” depressive symptoms, lasting at most a few weeks. Of those satisfying criteria for MDS, 49% were also classified with an anxiety syndrome, 40% reported childhood sexual abuse, 57% reported childhood physical abuse, 42% had at some time been afraid of their partner, and 72% reported a chronic physical condition; 84% were receiving mental health care (either taking antidepressants or seeing a health practitioner specifically for mental health care) compared with 66% of those with persistent depressive symptoms and 57% with transient depressive symptoms.Conclusion: This method of screening for depressive symptoms in general practice identifies a group of patients with substantial multiple comorbidities — psychiatric, physical and social problems coexist with depressive symptoms, raising challenges for the management of depression in general practice.

Jane M Gunn PhD, FRACGP, MB BS · Gail P Gilchrist PhD, GradDipAlc · Patty Chondros MSc(Stats), GradDipEpi · Melina Ramp MSc(AppStats), GradDipPsych, BA(SocSci) · Kelsey L Hegarty PhD, FRACGP, MB BS · Grant A Blashki MB BS, MD, FRACGP · Dimity C Pond PhD, FRACGP, MB BS · Mike Kyrios PhD, MPsych, PgradDipEduPsych · Helen E Herrman MD, FAFPHM, FRANZCP

Objective: To evaluate the diagnosis of patients with somatisation disorders in primary care, and the effectiveness of coordinated care and evidence-based care planning on psychiatric symptoms and quality of life for these patients.Design, setting and participants: This was a project of the SA HealthPlus Coordinated Care Trial, comprising a randomised controlled trial of 124 subjects recruited by general practitioners in southern Adelaide. Eligible patients had a GP diagnosis of somatisation, including unexplained physical symptoms as part of anxiety, chronic pain or somatoform disorders. Diagnoses were checked using the Composite International Diagnostic Interview (CIDI). The study was conducted from December 1997 to December 1999.Intervention: A care plan including treatment for depression and anxiety disorders, a containment strategy for somatisation, and service coordinator-assisted self-management. Control patients received standard treatment.Main outcome measures: Psychiatric symptoms; quality of life; medication use; and depression, anxiety and hostility scores.Results: Compared with CIDI diagnoses, mood disorders in patients were underdiagnosed by GPs (64 v 31), particularly major depression (46 v 1). At 12 months, the intervention group showed reductions in depression (P = 0.002), guilt (P = 0.006) and anxiety (state, P = 0.043; trait, P = 0.001). Compared with the control group, physical role functioning improved for the intervention group (P = 0.006), and their medication use decreased by 8.9%.Conclusions: Conservative management, treatment of depression, and case management by service coordinators is effective in managing somatising patients in primary care. GPs require training in the diagnosis of depression and how to say “no” to patients with unexplained physical symptoms who request further unnecessary investigations or referrals.

Rene G Pols FRANZCP, FAFPHM, FFPMANZCA · Malcolm W Battersby PhD, FRANZCP, FAChAM

Objectives: To determine the effectiveness of “Keeping the blues away” (KBA), a manualised depression relapse prevention program for general practice, in reducing the relapse of depression compared with usual care (with the aim of halving the relapse rate), and in reducing depression severity and improving the process of care.Design and setting: A cluster randomised controlled trial conducted in 2004–2005 in South Australian general practices.Participants: 43 general practitioners from 23 urban and rural practices recruited 110 patients with depression (age range, 18–75 years).Intervention: GP training manual or patient manual and relaxation CD; 20 hours of training on depression, the study protocol, assessment tools and skills.Main outcome measures: Relative risk (RR) of depression relapse; depression severity and quality of life scores.Results: There were no significant differences in relapse rates between the groups (χ21 = 1.51; P = 0.23), although there was a non-significant tendency for relapse to be reduced in the KBA group (RR = 0.77; 95% CI, 0.50–2.05). Older patients (≥ 50 years) in the KBA group showed a significantly lower probability of relapse than those in the control group (P = 0.018). There was a decrease in depression scores in both groups. KBA participants had more severe depression at baseline, and the reduction in severity in those with symptoms for > 6 months was nearly significant (P = 0.06). KBA was positively received by GPs and patients.Conclusions: Although this pilot study of a small sample did not achieve its primary outcome of reducing depression relapse by 50%, KBA was found to be a promising program for older patients and for those with more severe or persistent symptoms.

Catherine A Howell BM BS, FRACGP, MHSM · Deborah A Turnbull BA(Hons), MPsych(Clin), PhD · Justin J Beilby MB BS, MD, FRACGP · Charlotte A Marshall BA(Hons), MPsych(Clin), MAPS · Nancy Briggs BSc, MA(Psych), PhD · Wendy L Newbury RN

Who owns our health? Medical professionalism, law and leadership beyond the age of the market state. Thomas Faunce. Sydney: UNSW Press, 2007 (xi + 298 pp). ISBN 978 086840 821 7. Global warming, unsustainable global demands for fossil fuel as China and India come on line, threats to biodiversity, obesity, 1.1 billion people in extreme poverty, wars and rumours of wars — it’s enough to make you sick. How, in a world like this, can we find the strength to be a doctor? Faced with this mess, you might choose to retreat into silence, keep your own council, look after your family and plan for retirement. Not prepared to retreat or be silent, Thomas Faunce — doctor, lawyer, philosopher and ethicist at the Australian National University — writes passionately in pursuit of a future for medical professionalism. He is deeply worried about how market fundamentalism has come to dominate everything, including politics, and explores what might be a satisfactory foundational ethic, or basic moral commitment, for tomorrow’s doctor. He considers the market state will not last, but in the meantime, we need to keep the flame of professionalism alight. Of the market state, which Faunce finds so objectionable, he writes: Governments are controlled by the will not of the people, but of . . . corporate executives [who] espouse . . . socially and environmentally damaging, profit-laden values . . . creating a world where . . . individualistic consumers grow increasingly apathetic about the erosion of their rights and responsibilities as citizens. Faunce sees the progressive privatisation of health care as a manifestation of the growing dominance in politics, without a popular mandate, of the private health insurance funds, large pharmaceutical and device manufacturers, and those seeking to make huge profits on behalf of shareholders from the care of the sick. Here is market fundamentalism on full display. After extended excursions into philosophy and ethics, and multiple literary allusions, Faunce proposes that the foundational value — the base plate — for medical practice should be “loyalty to the relief of patient suffering”. He does not think that medicine should primarily be promoting communal welfare, nor promoting and maintaining health. These are worthy actions, but they lack the voltage to power the engine of dedicated medical practice. If we cut medicine off from a strong connection to individual human suffering, then we cut it off at the knees. The relief of patient suffering, Faunce argues, is a strong moral force that generates action that is externally and publicly focused. There are many good things that come from being a doctor, such as status, job satisfaction and money, that motivate us, but none of these internally directed, individualistic ambitions provides all the strength for medical practice that responds to the need of individual patients who come seeking help. This requires us to put suffering patients always ahead of ourselves. A primary moral commitment to the relief of patient suffering then allows us, Faunce argues, to build a structure of other ethical action that constitutes truly professional practice.

Stephen R Leeder

Patients’ simple vital signs are a highly reliable predictor of life-threatening clinical events At a time when hospital staff are becoming increasingly dependent on new technologies, the review by Cretikos et al1 entitled “Respiratory rate: the neglected vital sign” is refreshing. It is a timely reminder that understanding, documenting and acting on changes in patients’ simple vital signs are of fundamental importance to clinical outcomes. An abnormal respiratory rate (high or low) is known to be a highly reliable predictor of life-threatening clinical events. However, daily documentation of this simple number in many hospitals is remarkably poor. More controversial is the question of how best to develop systems that use changes in vital signs to trigger clinicians to respond rapidly and effectively. In recent years, many Australian hospitals have embraced medical emergency teams (METs) as the answer.2 METs enable rapid, skilled medical responses to changes in patients’ vital signs, aiming to intervene and reverse patients’ downhill slides towards intensive care unit (ICU) admission, cardiac arrest, or death. Call criteria for the MET (changes in respiratory rate, pulse rate, blood pressure, and coma score) have been carefully researched and are highly predictive of adverse events. METs are resource-intensive and are usually comprised of an intensive care registrar, a medical registrar and skilled nursing staff. They provide resuscitation skills at short notice in busy hospitals, where the primary medical teams may be busy, inexperienced, under-resourced or slow to respond. Australian studies based on single centres with historical controls,3,4 and on a single-centre before-and-after study,5 have reported that the introduction of METs was associated with reductions in key adverse events. Although before-and-after studies cannot separate the effect of an intervention from other factors that may have changed over time, studies like these were used to justify the enthusiasm and funding needed for the Medical Early Response Intervention and Therapy (MERIT) study investigators, with the Australian and New Zealand Intensive Care Society’s Clinical Trials Group, to conduct the world’s first large multicentre randomised controlled trial of MET introduction versus usual care.6 In clinical trial terms, the results of the MERIT study were clearly negative. There was no difference between intervention and control hospitals for either a composite endpoint (incorporating cardiac arrest, unexpected death or unexpected ICU admission) or for the same key study outcomes analysed separately. Adverse events decreased in both the intervention and control hospitals during the study period (as they had also done in the previous single-centre studies3-5), suggesting that factors other than the introduction of METs were improving key endpoints in both intervention and control hospitals during the study period. The MERIT study also found that introducing METs markedly increased the number of calls to hospital emergency teams and increased the early designation of suitable patients with “do not resuscitate” (DNR) orders. Total hospital deaths (unexpected plus expected [DNR] deaths) were marginally higher in MET hospitals than in non-MET hospitals during the study period. The MERIT study was remarkable in that it involved 23 Australian hospitals and over 36 000 patients, used a vigorous education process, and changed established systems in 12 hospitals.6 In order to account for its negative findings, the study has been criticised for inadequate power, for inadequate calling of the MET in the MET centres, and for a Hawthorn effect likely in the unblinded study design. It has also been said that changes after MET introduction may take longer to mature than was allowed for in the study design. These criticisms have validity, but it is also highly likely that the results of the unique MERIT trial were essentially correct. METs do not provide a single solution to the complex problem of clinician management of clinical instability in hospital patients. However, they do enhance appropriate designation of patients with resuscitation status, and they do encourage education, documentation and attention to patients’ key vital signs. Supporting this view is the recent experience of a hospital in Victoria that has focused, for the past 10 years, on using the MET system to improve management of clinically unstable ward patients.7 Cardiac arrest rates fell before and after the introduction of a formal and informal education process and a MET in this hospital, but then continued to decrease annually for each of the following 5 years (to extremely low rates). This was despite the fact that the MET was unchanged over the 10-year period. It appeared that the most important parts of a MET system are not the MET at all, but rather the audit, educational programs and DNR designations associated with it. The article by Cretikos et al and the MERIT trial results inform us that understanding, education, documentation, rapid clinical response to abnormal vital signs, and early designation of patients with an appropriate resuscitation status really do matter. To improve our hospitals we need mechanisms for simple, real-time communication of abnormal vital signs to hospital clinicians, so that timely management can occur across all acute hospital beds. Communication systems that do this, and also report, audit, and provide staff education and training, exist now, and may enable improved clinical management of unstable in-hospital patients. METs are a simplistic “bandaid” response to a complex problem in our hospitals. They are not the best response. Instead we need better education, focused on those critical vital signs. We need earlier appropriate DNR designation, and we need to test real-time emergency information systems. The evidence is that patient outcomes can be improved.

D James Cooper MD, FRACP, FJFICM · Michael D Buist MD, FRACP, FJFICM

Premature ejaculation (PE) is ejaculation occurring without control, on or shortly after vaginal penetration and before the subject wishes it, causing marked distress or interpersonal difficulties. PE is the most common male sexual complaint. Primary (lifelong) PE has a physiological basis. Therapy should involve the man and his partner. The primary aims of therapy are for the man to regain a sense of control over his ejaculation time and for him and his partner to feel satisfaction with sexual intercourse. The most effective therapies for primary PE are certain selective serotonin reuptake inhibitors, given on a daily basis or “on demand” before sexual activity. Topical anaesthetics have also been shown to be effective. The most common cause of secondary PE is declining erectile function. The approach to treating secondary PE is to treat the underlying condition.

Neil R Palmer MB BS DObstRCOG · Bronwyn G A Stuckey BA, MB BS, FRACP

Marshall and Ruedy’s On call: principles and protocols. Mike Cadogan, Anthony F T Brown, Antonio Celenza. Sydney: Saunders Elsevier, 2007 (xvi + 576 pp). ISBN 978 0 7295 3803 9. Being on call can be a daunting experience. You are called to a patient you don’t know who has become unwell. They might have developed a severe headache, be short of breath or have chest pain. What are you going to do? When should you call for more experienced help? On call principles and protocols attempts to systematically answer such questions. Based on the book of the same name by Canadian authors Shane Marshall and John Ruedy, it differs in its arrangement, separating interpretation of common investigations and procedures, with a brief formulary to separate sections. For the common problems encountered, the authors detail what questions to ask over the phone and what initial instructions to give. Conditions under which the patient should be given immediate priority are listed. Assessment and management of life-threatening problems are dealt with first, followed by a more complete discussion, including when to call for more experienced help. Interestingly, the authors are all emergency physicians who have probably not been on call for ward patients for many years, but all have experience in medical education and the principles of assessing the emergency patient are not dissimilar. Some hospitals have their own handbooks dealing with hospital emergencies but the approach taken in this text is more systematic and comprehensive. One omission is a discussion of common surgical problems, such as management of diabetes peri-operatively and postoperative analgesia. Guidelines given for managing patients on aniticoagulation therapy, a common on-call problem, are restricted to over-anticoagulation and do not provide detail on heparin and warfarin prescribing. These omissions aside, the style and content of On call principles and protocols is well laid out and the book fills a niche for doctors practising hospital medicine. With a recommended retail price of $60 the book represents value for money.

Robert P Dowsett

Objective: To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients.Design: Observational time and motion study.Setting: 400-bed teaching hospital in Sydney.Participants: 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006.Main outcome measures: Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions.Results: The greatest proportions of doctors’ time were in professional communication (33%; 95% CI, 29%–38%); social activities, such as non-work communication and meal breaks (17%; 95% CI, 13%–21%), and indirect care, such as planning care (17%; 95% CI, 15%–19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%–57%), while 24% (95% CI, 23%–25%) were undertaken alone and 15% (95% CI, 15%–16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care.Conclusions: Two-thirds of doctors’ time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns’ previously reported dissatisfaction with their level of administrative work and documentation.

Johanna I Westbrook BAppSc, MHA, PhD · Amanda Ampt RN, MHIM · Leanne Kearney RN · Marilyn I Rob MA, CStat, PhD

Objective: To report on the sentiments of the Australian health and medical research (HMR) workforce on issues related to employment and funding opportunities.Design, setting and participants: In August 2006, the Australian Society for Medical Research (ASMR) invited all of its members to participate in an online survey. The survey took the form of a structured questionnaire that focused on career aspirations, career development and training opportunities, attitudes toward moving overseas to work, and employment conditions for medical researchers.Main outcome measures: Researchers’ views on career opportunities, funding opportunities, salary and quality of the working environment; impact of these views on retaining a skilled medical research workforce in Australia.Results: Of the 1258 ASMR members, 379 responded (30% response rate). Ninety-six per cent of respondents were currently based in Australia; 70% had a PhD or equivalent; and 58% were women. Most respondents worked at hospital research centres (37%), independent research institutes (28%) or university departments (24%). Sixty-nine per cent had funding from the National Health and Medical Research Council, with the remainder funded by other sources. Over the previous 5 years, 6% of respondents had left active research and 73% had considered leaving. Factors influencing decisions about whether to leave HMR included shortage of funding (91%), lack of career development opportunities (78%) and poor financial rewards (72%). Fifty-seven per cent of respondents were directly supported by grants or fellowships, with only 16% not reliant on grants for their continuing employment; 62% believed that funding had increased over the previous 5 years, yet only 30% perceived an increase in employment opportunities in HMR. Among the respondents, twice as many men as women held postgraduate qualifications and earned ≥ $100 000 a year.Conclusions: Employment insecurity and lack of funding are a cause of considerable anxiety among Australian health and medical researchers. This may have important implications for the recruitment and retention of researchers.

Maria Kavallaris PhD · Sarah J Meachem PhD · Mark D Hulett PhD · Catherine M West · Rachael E Pitt BA(Hons), DEdPsych · Jennifer J Chesters BSocSc(Hons) · Warren S Laffan BAppSc, QPMR · Paul R Boreham BEcon(Hons), PhD · Levon M Khachigian BSc(Hons), PhD

The APHCRI projects in this supplement have strengthened capacity and increased policy-relevant knowledge, but primary health care researchers and policymakers need to work much more closely together if evidence is to contribute to decision making

Nicholas B Mays FFPH

The Australian Primary Health Care Research Institute (APHCRI) is part of the Primary Health Care Research Evaluation and Development (PHCRED) strategy.1 The Institute was the most recent element of the PHCRED strategy to be established, beginning research activities following the appointment of the Research Advisory Board (RAB) in November 2003. APHCRI’s mission is to “provide national leadership in improving the quality and effectiveness of primary health care through the conduct of high quality priority-driven research and the support and promotion of best practice”.2 APHCRI has a specific focus on the links between primary health care evidence and policy. Its activities not only fund research programs, but also seek to build capacity within the research community and policy community to facilitate the adoption of evidence into policy. There are two important interdependent features in the APHCRI model adopted to fulfil this mission. Firstly, it is a “virtual” institute operating a “hub and spoke” model. The Institute comprises staff based at the Australian National University (the “hub”) and, within different streams of research activities, multiple “spokes” undertaking commissioned programs of research. Secondly, the Institute has a specific pool of funds to commission research — it both funds research and undertakes research. The Institute’s RAB sets the research priorities, oversees the independent assessment of applications for funding and determines the successful spokes. Groups compete to be commissioned within a particular stream of research, but, once successful, collaborate as part of the virtual institute. In this article, we provide an overview of the approach APHCRI has taken to bring research evidence to bear on policy formation. We also reflect on lessons learned through the process of conducting our fourth research stream. Linkage and exchange, APHCRI styleInfluencing policy with research evidence is not a simple “linear” proposition. Health policy draws on many information inputs apart from research evidence, including political realities.3 APHCRI has adapted the Canadian Health Services Research Foundation “linkage and exchange” approach4 in order to make its research products more useful to policymakers. APHCRI links together four groups of participants to exchange knowledge from their different perspectives. These are: Policymakers and decisionmakers in both the federal and state/territory spheres; Providers of primary health care services and the various organisations with which they are associated; Researchers; and Users of primary health care services, and the various organisations with which they are associated. Members of these four groups serve on the RAB. APHCRI’s research priorities are iterated with policy advisers and the RAB to ensure they are relevant to policy. Expert review committees, convened to assess applications within the different streams, include members with expertise across these groups. The assessment criteria for applications within streams reflect the emphasis on policy and provider expertise in addition to more usual academic criteria. Stream 4APHCRI organises its research programs in “streams”. Each stream has a particular focus and may have several spokes or individuals working within it (the numbers of the streams denote the chronological order in which they were announced). The Institute’s Stream 4 program (with $1.8 million funding in total) further sharpened the linkage and exchange focus. It aimed to increase both the capacity of researchers to respond to policy priorities and the capacity of policy advisers to utilise research evidence. A list of policy-relevant topics, approved by the RAB, was identified in consultation with the Australian Government Department of Health and Ageing. A total of 12 spokes were commissioned to address these topics, using a common methodology to address two broad questions: What do we know about the topic?; and What are the possible options for the Australian context? The first question focuses the systematic review that is synthesised by the research team. The second question requires the researchers to use the results of the review to develop evidence-based recommendations for ways forward for Australia’s primary health care system. The policy options include consideration of funding arrangements (existing and alternative), delivery arrangements and governance arrangements reflecting system-level perspectives. An overview of the steps, timelines and major activities that comprised Stream 4 is presented in the Box. Within this supplement, we summarise key findings from each spoke on the topics as follows: Chronic disease management (Cranston et al,6 Dennis et al7); Integration, coordination and multidisciplinary care (Jackson et al,8 Mitchell et al,9 Powell Davies et al10); Innovative models for comprehensive primary health care delivery (McDonald et al,11 Naccarella et al,12 Humphreys et al13); Innovative models for the management of mental health in primary health care settings (Griffiths and Christensen14); Children and young Australians, health promotion and prevention (McDonald et al,15 Hearn et al16); and Workforce (focus on competency-based training) (Glasgow et al17). Systematic review and interactions between policy advisers and researchersThe disparate nature of much of the published literature required careful consideration of the appropriate methods for systematically reviewing and synthesising such evidence. Stream 4 drew heavily on the Journal of Health Services Research and Policy supplement, “Synthesizing evidence for management and policy-making”,18 to underpin its approaches, particularly the narrative synthesis approach of Mays and colleagues.19 Additional funding was provided to Stream 4 participants to allow their engagement in structured meetings in Canberra on four separate occasions during the 12 months of the program. These served five main purposes: Facilitating agreement on methodological issues (eg, common approaches to searching for primary health care literature or economic literature, assignment of quality criteria to diverse literature, “stopping” rules to allow a decision to be made that enough material has been obtained); Minimising duplication of effort through sharing of material and, where more than one spoke was working on a topic, agreeing on how the work of one spoke would complement the work of others on that topic; Facilitating interactions with policy advisers to provide provisional results to them and to test emerging options for their policy relevance; Allowing access to international experts to ensure a high standard of review (eg, Nicholas Mays, Professor of Health Policy at the London School of Hygiene and Tropical Medicine, delivered a workshop on systematic review methods); and Ensuring that progress against stated milestones was achieved so that the results were delivered in a timely fashion. Presentation of resultsThe research teams were asked to present their results (preliminary and final) in different ways through the program. The intent was twofold — addressing the concern of policymakers that research results are often not delivered in a timely fashion, and presenting the final reports in a manner that was easily accessible. The structured research components in Canberra allowed presentation of early results, as did the meetings between the individual spokes and their reference groups and interactions with key stakeholders. Throughout this interaction, the independent nature of the process was maintained by careful attention to the scientific method involved in synthesis and critical internal and external review. The final reports were prepared for web-based presentation using the “1:3:25” approach,5 with one page summarising the key take-home messages, three pages providing an overview, and the longer report containing all the information, including full references and appendices where appropriate. What have we learned?Most spokes found the systematic review process very demanding. A number of participants had experience with the Cochrane approach to systematic reviews, but did not find this suitable for the kind of literature being surveyed. The volume of potential literature identified in the searches was very large, and making decisions about when to stop searching and how to adjudicate the relevance and weight that should be given to retrieved material was a challenge throughout the process. The result for most spokes was a greater proportion of the 12 months being spent on the review process than had been anticipated at the outset, with a relatively lesser proportion of time iterating potential options with key stakeholders. Researchers are accustomed to writing for research audiences. Most spokes found the production of the one- and three-page summaries of the options for non-research audiences challenging. Researchers tended to default into research writing mode — for example, qualifying statements in the summary documents to convey the sense of uncertainty around them rather than stating the implications for policy less ambiguously. While policy advisers played a significant role in priority setting for the research program, participation by policy advisers in the structured sessions in Canberra was more variable. Senior policy advisers usually had unanticipated demands being made on their time and thus were unable to attend. More junior policy advisers were hesitant to offer critical comments from a policy perspective on the material being discussed, and had to balance the commitment of being present for the full day against the other requirements of their roles. Engagement with senior policy advisers was more successful when the separate spokes arranged to meet with individuals outside the structured sessions. Locating the material on the Internet has made it easily accessible to Australian audiences and, to some extent, international audiences. The number of hits suggested the resources have been useful, and, interestingly, it seems the full reports are most often visited rather than the one- or three-page summaries. Anecdotal accounts suggest that the recent Australian Government intervention in the Northern Territory has resulted in much use being made of the reports by McDonald et al15 and Humphreys et al,13 although this can not be corroborated through analysis of APHCRI website activity. Anticipating future policy challenges in an explicit and timely fashion allows for a repository of relevant research information to be developed.20 What has followed Stream 4?Because of the largely positive experiences associated with the conduct of Stream 4, the RAB has continued to support the development of the linkage and exchange approach. Stream 6 is repeating the Stream 4 process, with a single focus on addressing the primary health care workforce shortage. Stream 7 provided opportunities for researchers involved in Stream 4 to compete for new linkage and exchange travelling fellowships, allowing Australian primary health care researchers to visit world-renowned international academic primary health care institutions in relevant comparator countries and consider their Stream 4 work in the context of these international settings. On their return, they will provide written reports of their findings and participate in a briefing to policy advisers in Canberra. What has been the impact of Stream 4?Improving the quality and effectiveness of primary health care requires the adoption of evidence into policy and practice. Has APHCRI’s research been taken up in policy? As Nutley et al report,21 direct or instrumental use of research findings to shape policy is unusual. Research evidence is only one source of information that policymakers draw upon. APHCRI does not expect to demonstrate direct links between its research programs and subsequent policy. However, it does expect to contribute to the policy processes through use of its research to assist with conceptualisation of issues and to mobilise support for key reforms. Conceptual use is illustrated by the provision of succinct summaries of relevant information or provision of new ways of framing issues or gaining further insights into the strengths and weaknesses of different options — all illustrated in the articles of this supplement. APHCRI’s Stream 4 program has contributed to debate and raised public discussion of crucial issues confronting Australia’s health system. An example of this is the contribution APHCRI’s Stream 4 program and related activities have made to mobilising support for discussion of the health system reforms necessary to meet the challenges posed by chronic disease. ConclusionAPHCRI’s development of the linkage and exchange approach through its Streams 4, 6 and 7 has been positively received by the primary health care research community. The RAB will continue to develop and implement refinements to this approach, with a view to enhancing the uptake of evidence in policy. Steps, timelines and major activities within Stream 4, Australian Primary Health Care Research Institute (APHCRI) Steps and timeline Major activity focus Setting priority research topics through iteration with Department of Health and Ageing then decision by RAB (Mar–Apr 2005) Clarifying national policy relevance and prioritising issues Call for responses addressing selection criteria (May 2005) Publication of opportunity in national press, through established email networks and on APHCRI website Optional information workshop for potential applicants (Jul 2005) Overview of APHCRI and Stream 4, with workshop presentation freely accessible on the Internet Assessment of responses by the ERC against selection criteria, with recommendations to the RAB (Aug 2005) Independent assessment of all applications initially, then meeting of the ERC to arrive at consensus scores and recommendations to the RAB Decision making by the RAB and commissioning of spokes (Aug 2005) Further discussion of applications, and identification of any issues needing clarification before announcement of decisions First research program component meeting in Canberra (Sep 2005) Discussion of overall program Identification and management of potential commonalities/synergies between spokes Development of shared approach to: systematically identifying relevant black literature; classifying studies; assessing strength of evidence; and synthesising results Research activities Scoping literature Refining questions Establishment of reference groups and stakeholder lists Second research program component meeting in Canberra (Oct 2005) Further specifying research questions Discussing initial mapping exercise Selecting studies Re-running the searches Research activities In-depth searches Discussions with reference groups and stakeholders Additional research program component meeting in Canberra (Jan 2006) Master class in systematic review methods with Nicholas Mays, Professor of Health Policy at the London School of Hygiene and Tropical Medicine Third research program component meeting in Canberra (May 2006) Key findings against key questions Report on key stakeholders engaged thus far and to be engaged Key learnings from the review process to date 1:3:25* report approach Research activities Formatting draft reports into a 1:3:25* template and development of options Fourth research program component meeting in Canberra (Sep 2006) Technical problems with template discussed Provisional options presented and commented on by participants 1:3:25* reports finalised and submitted to APHCRI (Oct–Nov 2006) Editing Standardising presentations Iterating with authors to ensure sense not changed 1:3:25* reports published on APHCRI website (Nov 2006) ERC = Expert Review Committee. RAB = Research Advisory Board. * The 1:3:25 approach uses one page to summarise the key take-home messages, three pages to provide an overview, and a longer report to give all the information, including full references and appendices where appropriate.5

Nicholas J Glasgow MD, FRACGP · John E Marley MD, FRCP(Edin), FRACGP · Linda J Kristjanson RN, MN, PhD · Janette A Donovan BA, GradDipPubHealth · Sally J Hall RN, GradCertClinMan · Mark F Harris DRACOG, FRACGP, MD · David M Lyle MB BS, PhD, FAFPHM · Elizabeth J Kerr BA(Off Mgt), GradDipAET · Frith Rayner BA, GradDipJournalism

Objective: To review the literature for any promising strategies for the primary care management of mild-to-moderate asthma and chronic obstructive pulmonary disease (COPD) in adults.Methods: Using “MeSH” terms for COPD, asthma and primary health care, we conducted an extensive literature search for relevant meta-analyses, systematic reviews, narrative reviews, reports and individual studies. Grey literature was also included. We chose a narrative review approach because of substantial heterogeneity of study designs in the literature.Results: 1119 articles of potential relevance were retained, of which 246 were included in our review. There was insufficient evidence to determine whether general practitioners with a special interest (GPwSI) in respiratory care improved the diagnosis and management of mild-to-moderate COPD. An asthma service involving GPwSI increased respiratory drug costs but reduced the costs for less specific drugs. No clear benefit has been shown for practice nurse-run asthma clinics in primary care compared with usual care in altering asthma morbidity, quality of life, lung function or medication use. Evidence to determine the effectiveness of practice nurse-run COPD clinics could not be found. Self-management education, GP review and action plans may produce short-term benefits for asthma patients, particularly those with moderate-to-severe disease, but the evidence for a similar approach to patients with mild-to-moderate COPD is equivocal. There has been poor uptake of respiratory clinical guidelines relevant to primary care — partly because most guidelines are based on moderate-to-severe disease. Spirometry programs in primary care are useful for differential diagnosis of asthma and COPD. Spirometry may alter the management of mild asthma, but there is a lack of evidence that it alters the management of COPD in primary care.Conclusion: The role of primary health care in management of mild-to-moderate asthma and COPD requires further investigation using randomised controlled trials.

Josephine M Cranston BSc(Hons) · Alan J Crockett PSM, MPH, PhD · John R Moss MSocSci, MB BS, FCHSE · Robert W Pegram BSc, MB BS, MHSM · Nigel P Stocks MB BS, MD, FRACGP

Objectives: To review the effectiveness of chronic disease management interventions for physical health problems in the primary care setting, and to identify policy options for implementing successful interventions in Australian primary care.Methods: We conducted a systematic review with qualitative data synthesis, using the Chronic Care Model as a framework for analysis between January 1990 and February 2006. Interventions were classified according to which elements were addressed: community resources, health care organisation, self-management support, delivery system design, decision support and/or clinical information systems. Our major findings were discussed with policymakers and key stakeholders in relation to current and emerging health policy in Australia.Results: The interventions most likely to be effective in the context of Australian primary care were engaging primary care in self-management support through education and training for general practitioners and practice nurses, and including self-management support in care plans linked to multidisciplinary team support. The current Practice Incentives Payment and Service Incentives Payment programs could be improved and simplified to encourage guideline-based chronic disease management, integrating incentives so that individual patients are not managed as if they had a series of separate chronic diseases. The use of chronic disease registers should be extended across a range of chronic illnesses and used to facilitate audit for quality improvement. Training should focus on clear roles and responsibilities of the team members.Conclusion: The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence. Consultation with stakeholders and policymakers is valuable in shaping policy options to support the implementation of the National Chronic Disease Strategy in primary care.

Sarah M Dennis MSc, PhD · Nicholas Zwar FRACGP, PhD · Rhonda Griffiths MSc, PhD · Martin Roland DM, FMedSci · Iqbal Hasan MB BS, MPH · Gawaine Powell Davies MHP · Mark Harris FRACGP, MD