General medicine

Our democratic processes have moved on — so must our science In April 2007, Victoria became the first Australian state to enact legislation (the Infertility Treatment Amendment Bill 2007) that followed the passage by federal Parliament in December 2006 of the Prohibition of Human Cloning for Reproduction and the Regulation of Human Embryo Research Amendment Act 2006 (Cwlth). This Act gave effect to most of the recommendations of the Legislation Review Committee, chaired by the late John S Lockhart, which reported in December 2005. The Lockhart Committee engaged in wide community consultation and considered expert advice from many sources before making its recommendations on what was inevitably an issue arousing passionate public debate. Similar intense debate had crossed party lines in both federal and Victorian Parliaments, but with a “conscience vote” in both houses in each instance (allowing members to vote as they personally wished rather than along set political party lines), legislation was passed containing major provisions for strict regulation of all aspects of research involving human embryonic material and the strict prohibition of human cloning for reproductive purposes — with draconian penalties for transgression. Many other prohibitions set out in the previous Research Involving Human Embryos Act 2002 (Cwlth) have been firmly retained. Similar legislation has now passed both houses of the New South Wales Parliament, following vigorous public controversy over the respective roles of the legislature and of the Catholic church on the issue. Corresponding legislation is expected to be considered in other states and territories, as Australia moves to permit further progress in this critical and fast-moving area of scientific development. Legislative protection from both federal and state governments allows greater freedom in the quest to understand disease mechanisms by studying stem cells containing abnormalities underlying genetic disorders, and the development of new approaches to treatment of hitherto unyielding diseases. The new science of regenerative medicine can move ahead in Australia, with the research and technological developments now permitted having great implications for human medicine. A new international system for collaboration in this important field is also emerging.1 Human embryonic stem cell lines were first created in 1998 from blastocysts;2 the techniques used were based on at least a decade of research on mouse embryonic stem cells. The key characteristic of embryonic stem cells, not shared with adult stem cells, is their capacity for long-term or immortalised culture, permitting extended research and growth of the large number of cells necessary for human implantation. The process of somatic cell nuclear transfer allows human embryonic stem cells to contain the nucleus of the recipient cell, so an individual’s immunological constitution will be conferred to the stem cell and its progeny. Technological developments to date have included: Better methods for growth and maintenance of human embryonic stem cells in vitro, including Good Manufacturing Practice (GMP) compliance and industrial scale production; Better methods to more reliably drive embryonic stem cells along particular cell and tissue pathways; Differentiated embryonic stem cell progeny have been used for drug screening and toxicology testing; Demonstration of the medically relevant capabilities of human embryonic stem cells in animal models; and Isolation of new embryonic stem cell lines and creation of collaborative cell banks and networks. Regulatory compliance still presents challenges, as expected of any living-cell therapy. The potential applications to human disease are many, as shown by real advances made recently with human diseases in animal models. Studies transplanting cells derived from human and monkey embryonic stem cells into animal models have shown correction or partial correction of Parkinson’s disease.3,4 Growth of cardiac myocytes derived from human embryonic stem cells has been demonstrated in pigs, with correction of electromechanical function;5 human embryonic stem cell-derived oligodendrocytes have improved spinal cord injuries in rats;6,7 and human embryonic stem cell-derived islet cells have functioned in animals with diabetes.8 However, regenerative medicine in human subjects using transplanted stem cells or their progeny faces three serious technical hurdles: Transplant rejection (and the monitoring of this); Efficient guidance of embryonic stem cells down correct pathways of differentiation using growth factors; and Ensuring cells of such great proliferative potential do not, on rare occasions, develop into cancers. Strongly held views in the community on all aspects of research involving human embryonic stem cells must be acknowledged. Similarly, unrealistically high hopes for rapid advances in developing new treatments for distressing and debilitating diseases fail to grasp the long lead times that inevitably apply; medical practitioners will probably be asked for their advice on such matters. Our democratic processes have moved on — so must our science. It is important to recognise that there will continue to be strict regulatory oversight of all research involving human embryonic stem cells, and regular reviews of progress will be important.

David G Penington AC · Graham F Mitchell AO

Objectives: To examine the effect of the debate on the safety of non-steroidal anti-inflammatory drugs (NSAIDs) on decision making by Australian general practitioners and patients with osteoarthritis (OA), and to explore issues concerning the use of NSAIDs from both prescriber and consumer perspectives.Design and setting: A qualitative study in which five focus groups (three for GPs, and two for patients with OA) were conducted between 15 May and 4 August 2006 in south-western Sydney.Participants: Five advanced general practice registrars, six experienced GPs, and 20 patients with OA aged 54–85 years.Main outcome measures: Key themes and issues identified by content analysis of focus group transcripts.Results: GPs reported adopting a cautious approach to prescribing NSAIDs because of uncertainty about safety and medicolegal concerns. They were sceptical about information provided by the pharmaceutical industry and found the literature about the safety of NSAIDs confusing. Time was identified as a major barrier to adequate discussion with patients, and explaining the risk to patients in a meaningful way was perceived as a challenge. Patients wanted information and sought it from a range of sources, most commonly pharmacists and GPs. Most patients made active decisions about using or not using NSAIDs, with some favouring physical function over safety. Patients were also using other forms of treatment including alternative medicine.Conclusion: Our findings reflect the need to provide clear, unbiased information about NSAIDs to help both GPs and patients negotiate this decision-making dilemma.

Suzi S Mikhail MB Bch, AMC, FRACGP · Nicholas A Zwar MPH, PhD, FRACGP · Sanjyot Vagholkar MB BS, MPH, FRACGP · Sarah M Dennis MSc, PhD · Richard O Day AM, MD, FRACP

Objective: To investigate the prevalence and format of medical morning handover report (MMHR) in Australian hospitals.Design, setting and participants: Questionnaire survey faxed to 76 Australian hospitals accredited for basic physician training by the Royal Australasian College of Physicians (RACP). The survey was conducted in 2005.Main outcome measures: Use of MMHR; structure and format of meetings.Results: 53 of 76 (70%) hospitals responded. However, some data (1.7% of possible responses) were missing or illegible. Prevalence of the use of MMHR in respondent hospitals was 58% (31/53). Analysing the data by RACP accreditation level, 18/24 Level 3 hospitals (75%) conducted MMHR compared with 5/9 Level 2 hospitals (56%) and 7/18 Level 1 hospitals (39%) (odds ratio [OR] for trend, 2.17; 95% CI, 1.12–4.23; P = 0.023). 44 of 53 respondents reported their Rural, Remote and Metropolitan Areas (RRMA) classification. MMHR is less likely to be held in hospitals in regions classified as RRMA 2–4 (8/21 [38%]) than those in capital cities (RRMA 1) (16/23 [70%]) (OR, 0.27; 95% CI, 0.08–0.95; P = 0.042). In 62% of hospitals, MMHR was chaired by a consultant, and at most hospitals (23/31 [74%]), meetings were 15–30 minutes long.Conclusions: In spite of RACP accreditation requirements, the use of MMHR in Australian hospitals accredited for basic physician training is low.

Matthew J Fassett BInfoSys(Hons) · Terry J Hannan MB BS, FRACP · Iain K Robertson MB BCh, MPH · Steven J Bollipo MB BS, FRACP · Robert G Fassett MB BS, FRACP

To the Editor: In his “Personal perspective” piece, Allen1 reminded us all of how medicine can at times truly be the noblest of professions. Writing to the next of kin after the death of a patient is occasionally a difficult task, but more usually provides an appropriate form of closure, not only to the relationship with the deceased patient, but also to relationships with the person’s partner, family members and friends whom you may have met during the treatment episode and whom you may not see again. Since I began practice as a consultant 20 years ago (a practice that involves a substantial number of patients who require surgery for cancer), I have tried to write to the next of kin or significant other of every patient who has died while under my care. The letter allows me the opportunity to say perhaps how brave the patient had been in the face of adversity or to acknowledge the support the next of kin had provided. A simple expression of condolence and an indication of how much a loved one may be missed seems to be the best way to “sign off”. Such letters are only a small gesture, but I have often been gratified by how much comfort they seem to provide to those who receive them, and in all this time I have never had a response that could even remotely be considered “negative”. In this current day, when practising clinicians appear to have a diminished role in our medical schools, may I suggest that Allen’s article — which I think is a great example of what is meant by the “art of medicine” — be distributed to our universities and colleges to be considered for inclusion in their teaching material and curricula.

Ian T Jones

It is a national disgrace how little is known about the impact of the Divisions after 15 years In this issue of the Journal, Scott and Coote provide an important contribution to a better understanding of one of the more significant Australian health policy changes of the past 20 years: the Divisions of General Practice (→ Wither Divisions of General Practice? An empirical and policy analysis of the impact of Divisions within the Australian health care system).1 Why this article is so significant in policy impact terms is that, according to the Australian Government: The Divisions network is Australia’s largest representative voice for [general practitioners] and provides local support to general practice. Divisions perform a range of activities to improve and address access, integration, chronic disease management, workforce issues and consumer needs.2 This makes the Divisions the third component of the Australian national organised health care system, the other two being the public health/hospital and private insurance sectors. It is therefore a national disgrace how little is known about the impact of the Divisions of General Practice after 15 years of operation. It is in this context that the article by Scott and Coote is so critical. A unique and key feature of the Divisions is that they are GP member owned and operated, regional health care organisations. This private ownership by a medical professional grouping is a unique approach to a national health structure, and is unlikely to be emulated by any other medical or allied health specialty group in the future. The Divisions have been allocated further core funding, as noted in the recent Australian Government budget papers: The Government will provide $243.3 million over three years from 2008–09 to continue funding the Divisions of General Practice network. The objective of the network is to promote the health and wellbeing of Australians by working with general practitioners and other health service providers to improve the quality and accessibility of health care at the local level. The programme also provides an important avenue for the support and delivery of Government programmes.3 Additional funding from various state governments and other sources is now growing more rapidly than the core Australian Government funding. My Division, the Hunter Urban, is a typical Division with more than 10% of local GPs having participated in a leadership role at board level over the 15 years. The Division serves a population of more than 400 000, with over 420 GP members; more than 90% of GPs participate in any divisional service or clinical activity and 80% of GPs were involved in more than five service or clinical activities in 2006. The range of activity is very broad, and encompasses funding from over 10 different sources (both public and private), a budget of more than $10 million (of which Australian Government core funding is about $1.5 million), and services across a significant spectrum of GP activity, including practice infrastructure support.4 However, the burning question for 15 years has been, and continues to be, what do Divisions do and, more importantly, what impact do they have? Are taxpayers receiving value for their investment? What should that value look like and how might it be quantified? The study by Scott and Coote involved “Regression analysis using longitudinal data across Australia”,1 and the first question it raises is why was such a complex tool necessary? A more conventional organisational analysis using targets and benchmarks set by the main funder (the Australian Government) should have been possible, particularly where a cumulative total of $2 billion or more of taxpayer funds have been expended over 15 years. Unfortunately, as the authors have noted, these data simply do not appear to exist — certainly not in readily analysable form. Despite a major review of the Divisions undertaken in 2002–2003,5,6 which made recommendations related to the need for clarity in measuring performance and for a rigorous evaluation process, in 2006–07, the Divisions’ goals for core funding from the Australian Government remain couched in vague terms. In 2006–07, the agreement between the Australian Government and the Divisions, known as the Multi Program Funding Agreement, has a set of overall goals (Australian Government, Agreement plan for the funding period annual plan 07/08). These include: Governance: organisational capability, financial accountability, and governance; Prevention and early intervention: focus on prevention and early intervention; Access: improve access; Integration: encourage integration and multidisciplinary care; Chronic disease: better manage chronic conditions; General practice support: support GPs and general practices within a changing primary care environment; Quality support: support quality and evidence base; Consumer focus: ensure a growing consumer focus; and Workforce: support the recruitment and retention of an appropriate primary care workforce. The only clearly specified funding-dependent target is organisational (organisational accreditation), with few other clearly targeted benchmarks for health or service outcomes. This lack of specificity in targeted outcomes is not unique to Divisions as, for example, an examination of the private health insurance sector (with an annual government subsidy expenditure in 1 year greater than Divisions over 15 years) also demonstrates how widespread the absence of service and health outcome data is. So what does the article by Scott and Coote reveal and, particularly, what does it not reveal? They report that Divisions have a positive effect at the infrastructure and organisational level and, in the absence of any other equivalently rigorous research, this now represents the best evidence we have for some aspects of the utility of Divisions of General Practice in 2002–2004. In an environment where workforce shortage and lack of patient access is a key issue, with improvements in infrastructure being seen as one of the main solutions, then the inference from the article is that Divisions should be increasingly funded to tackle the infrastructure and organisational deficits within general practice. Critical to the analysis of the Divisions, and acknowledged by Scott and Coote, is that “Only a relatively narrow range of Divisions’ outputs and primary care performance was examined, because of a lack of data”.1 This lack of outcome measures clearly is an indictment of the lack of responsibility the government and its agency, the Department of Health and Ageing (DHA), take in monitoring their own performance as administrators of community resources. It represents an accountability deficit at government level. What is puzzling is that, in other DHA-administered program areas, there are clear, simple and effective measures of performance. This does not seem to extend to the Divisions program. Service delivery forms a major part of the activity of many Divisions, particularly in rural areas. For example, under the More Allied Health Services program, rural Divisions are often the major or only suppliers of these services to their rural communities. As another example, in my region, the Hunter Urban Division is the default provider of ambulatory after-hours GP services, with more than 100 000 patient interactions each year delivered by more than 250 GPs and 60 nurses. Service delivery, as acknowledged by Scott and Coote, is the most rapidly growing part of divisional activity, and the relationship between Divisions and service provision needs something better than a “lack of data”, which implies a lack of performance indicators and targeted benchmarks to define its worth. My experience has been that individual Divisions and their peak bodies have been ready, willing and able to set and meet specific targets and it is the Australian Government and its bureaucracy that apparently is struggling with this facet of accountability. So, where to from here? The first step is not more studies using regression analysis or research involving experimental and control groups. Australia has had far too much policy by trials (a phenomenon internationally unique to Australian health policymakers and their bureaucracies). If, as I and many others believe, Divisions are the greatest single, positive, underutilised organisational health resource in our nation, and funding should match their potential for a much larger role in primary care health service delivery, then policymakers and governments need to put this to the test by establishing clear goals, with attached performance measures and targeted benchmarks that are open and transparent to all. We all have a right to see if what appears to be true is based on empirical evidence. It might well set an example for other health policy initiatives, which would have to meet the same challenge: transparent accountability to the Australian community. The article by Scott and Coote is a step in the right direction.

Arn Sprogis MB BS, FRACGP, GradDipClinEpid

The time has come to review and reflect on where these reforms are meant to be leading There is now a plethora of new Medicare Benefits Scheme (MBS) item numbers encompassing chronic disease management, diabetes annual cycle of care, asthma cycle of care, 45-year-old health check, health assessments for older people and refugees, general practitioner mental health care, pregnancy support counselling service, and domiciliary medication management reviews. The availability of these item numbers would appear to be logical, as they are linked to important national policy initiatives such as the National Chronic Disease Strategy,1 Australian Better Health Initiative,2 and the National Mental Health Strategy.3 However, of increasing concern is that, with each budget cycle, another layer of new MBS item numbers is added. There is little clarification of what the final end point of these reforms will be. If the goal is a strong, robust and integrated primary care system4 that will deliver improved outcomes for these patient groups, then using the rather crude tool of successive new MBS item numbers alone is unpredictable5 and is likely to provide only part of the solution. There is a paucity of published evidence that the new MBS item numbers have improved patient care. Some improvements in patients with diabetes have been noted,6,7 and smaller studies have found positive changes in referrals to allied health professionals due to the use of care plans.8 In a review of information technology and health, Georgeff cited evidence that “less than 14% of patients with chronic disease are placed on care plans” and less than 1% are followed to see if patients adhere to these plans.9 In this issue of the Journal, Hickie and McGorry query the geographical distribution of the uptake of the mental health items, the out-of-pocket expenses for patients referred, and the possible absence of focus on the highest risk groups (→ Increased access to evidence-based primary mental health care: will the implementation match the rhetoric?).10 They suggest that the uptake is in groups who were already accessing psychological support services.10 Another study found further evidence regarding the lack of equity in use of health assessments.11 It is an indictment of the health bureaucracy that no systematic evaluation has been established to formally assess the effect of these new MBS items. Earlier evaluations for the original enhanced primary care item numbers12 and asthma Service Incentive Payment (SIP) item number13 have resulted in constructive innovations. If the overall aim is an integrated general practice that can manage the burgeoning number of patients with these conditions, then it is important to gather evidence to support this hypothesis. Over the period from July 2005 to June 2006, the number of health assessments claimed for was 285 861; care plans and case conferences, 1 234 703; GP diabetes, asthma and mental health items, 249 620; and the use of psychological strategies, 30 261.14 This is about 2% of the 90 million patient consultations completed over this period. Yet we do not know the patient impact and cost-effectiveness of these activities. GPs are voting with their feet and continuing to focus on the core of general practice — the consultation. Red tape, GP workforce shortages and the paucity of trained allied health professionals have been regularly cited as causing the lack of uptake of these items.15 Jurisdictional differences between state, territory and federal governments also continue to surface as key barriers for evidence-based health policy. Also in this issue of the Journal, Harris and Zwar outline concerns with chronic illness (→ Care of patients with chronic disease: the challenge for general practice),16 arguing that these new chronic disease items are only part of a fully functional chronic disease model. The complete model would include:17 clinical information systems that measure quality of care; actively implemented decision support and guidelines; ongoing information management and data exchange; integrated chronic condition self-management programs; appropriate finance systems; practice-based teams; and community and consumer linkages. The only elements being fully supported by the new MBS items are the final two. The principal policy response seems to be to add new MBS item numbers and then hope that Australian general practice can adapt and deliver the required outcomes. There are no regular programs to consult on or support the development of the other elements. The way forwardThe time has come to halt this approach to the MBS and review and reflect on where these reforms are meant to be leading. We need a better system. Following are some of the elements this system should include. Developing an articulated vision for general practice and primary careThe reforms1-3 that underpin these new MBS items require more than item numbers. A vision that is accepted by all groups, with agreed goals, effective leadership and alignment across all governments and local non-government providers, is vital if these reforms are to deliver the desired outcomes. Methods of increased accountability that foster quality and accessibility for all groupsModels that “reward practices for delivering clinical and organisational quality”, such as in the United Kingdom,18 need exploring. Since 2004, general practices in the UK have been given the opportunity to receive extra funding for achieving a range of specific standards in clinical areas (eg, stroke, diabetes, and asthma), practice organisation (eg, information for patients), patient experience, and additional services.18 In a similar way, Australian general practices should be financially rewarded with extra payments for reaching agreed practice-based targets for health assessments, diabetes SIP, and GP chronic disease items. This model would need to be supported by ongoing practice-based audits, which could be implemented by the Divisions of General Practice. Supporting longer consultationsA debate is required about whether a financial model that rewards GPs for spending more time with the patients would achieve as much as the plethora of new item numbers.19 Improving the infrastructure to foster the use of shared e-health recordsIt has been calculated that $1.5 billion could be saved by “improved knowledge sharing and care plan management”.9 Providing financial incentives to all GPs and allied health providers to foster the use of shared records with the electronic delivery of referrals and discharge summaries is a logical initial first step.9 Improving the flexibility of delivery of chronic disease programsFunding self-management programs,20 and allowing other allied health groups to instigate multidisciplinary care plans and establish the primary care teams in partnership with general practice are other options. The health priorities that underpin the MBS item evolution will not disappear. They will only increase and we have a pressing need to find solutions that will provide sustainable and acceptable solutions. But the time to gather evidence for effectiveness and efficacy is long overdue.

Justin J Beilby FRACGP, DRCOG, DA

Increasing the number of “special interest” GPs may exacerbate the current GP shortage According to the Royal Australian College of General Practitioners (RACGP): In the provision of primary care, much undifferentiated illness is seen; the general practitioner often deals with problem complexes rather than with established diseases. The general practitioner must be able to make a total assessment of the person’s condition without subjecting a person to unnecessary investigations, procedures and other treatment.1 In this paradigm, a condition such as chest pain may have its roots in the physical, social and/or psychological domains, and a robust general practice system is crucial to managing these complex clinical interactions. A GP is well placed to determine the relative contributions of these causes and to effectively manage the interface between primary care and the hospital. Starfield and colleagues have long argued this case, and few have offered a cogent counterargument.2 However, in the United Kingdom, and now in Australia, a formal system of GPs with special interests (GPwSIs) — that is, GPs having a subspecialisation within general practice — is touted as the answer to the growing demand for specialist services in this issue of the Journal (page 111)3 and elsewhere.4 There is clear evidence of the value of subspecialisation in some areas of general practice — for instance, in Indigenous health, palliative care, drug and alcohol services, and HIV management.5 The case for expanding these roles to include yet more “special interests” is that the policy will “develop careers through offering additional interest, personal development and heightened self-esteem”.6 This may be a persuasive argument for increasing the attractiveness of general practice, where there is a growing manpower crisis and an urgent need for enthusiastic new recruits. However, this approach is also associated with a call for more “locums” to make up for manpower shortages in general practice and the deskilling of the GP pool in some clinical areas. Thus, diverting the GP workforce will compound shortages in “core general practice”. A key driving force behind the promotion of GPwSIs in the UK was the perceived need to reduce “inappropriate” referrals and hospital admissions, thereby improving the efficiency of health resource utilisation. However, referral processes in general practice are frequently complex and multifactorial, and are unlikely to respond to this approach.7,8 GPs may also be reluctant to refer to colleagues whom they perceive as generalists with much the same level of skill as their own.9 In other words, GPwSIs may offer an additional service rather than an alternative to specialist services. If GPwSIs were to reduce the workload for specialists, their impact on primary care could be unhelpful or even detrimental. In a recent UK patient survey, it emerged that patients foresaw difficulty making appointments with their chosen GP in circumstances where a special-interest GP was working at the practice.10 In the Australian context, it may be difficult to predict the likely impact, given that general practice is a privatised business. However, if such difficulties with access were mirrored here, the resulting loss of continuity of care could diminish the key value of the GP as defined by the RACGP. This is of special concern given the growing burden of chronic disease in an ageing population. Indeed, many patients are still receiving suboptimal care for chronic disease.11 Furthermore, with the increasing policy emphasis on prevention, screening and surveillance, many patients will need more access to GPs. To achieve the long-term benefits of these policy directions, we need to protect the principle of equal access for all. Patients in the UK, where the GPwSIs concept has been widely embraced, are impressed by the speed of access and personal aspects of the service, but not necessarily by its quality. In the UK, GPs-in-training have been reported to be naive about the potential complexities of accreditation and governance required for the roles of GPwSIs. If GPwSIs are to become a feature of the primary care landscape in Australia, appropriate training and accreditation will be critical to prevent them being regarded as a cheaper, second-class service. Another danger with facilitating growth in the number of GPwSIs is the possibility that it will interfere with the fabric of primary care — namely, an accessible, generalised, integrated and coordinated approach to patient management. Furthermore, we should not underestimate the financial incentive to dabble in lucrative specialist procedures in a largely unregulated health care system in which many GPs feel undervalued. Indeed, a more appropriate remunerative structure, especially for cognitive (as opposed to procedural) practice, may well serve to change perceptions of what is attractive and rewarding. Thus, promoting GPwSIs in Australia may serve only to redistribute scarce GP resources while running the risk of exacerbating GP workforce shortages. This, in turn, will require more GP training positions to be established, a decision that is not under the control of the profession. Balancing the increasing role of GPwSIs in Australian general practice will require careful workforce modelling and planning.

Moyez Jiwa MD, FRACGP, MRCGP · Hooi C Ee MB BS, PhD, FRACP · Justin J Beilby MD, MPH, FRACGP

An Australian GP’s pilgrimage to Rome to sound the voice of primary care Rather than finishing paperwork after a busy Monday in a Katoomba general practice, I (A W K) found myself sitting (jet-lagged) in a marble auditorium in Rome within the Istituto Superiore di Sanità (Institute of Public Health; Box 1) with about 200 other conference participants from the United States, Australia, and more than 22 different European Union (EU) and non-EU member states. We were waiting for an announcement by the Honourable Livia Turco, the Italian Minister of Health. An article I co-authored, which was published in the Journal in July 2006,1 had led to an invitation to participate in the 2-day International Rare Disease Conference (IRDC) and the subsequent 3-and-a-half-day NEPHIRD (Network of Public Health Institutions on Rare Disease) conference organised by Dr Domenica Taruscio, Director of the Centro Nazionale Malattie Rare (National Centre for Rare Diseases) in Rome, together held from 18–23 September 2006. The Ministry of Health announcement confirmed the Italian Government’s commitment to rare diseases and to orphan drugs research and development. The IRDC proceeded with an overview of initiatives in rare diseases in Italy and some of the more than 22 countries represented. The NEPHIRD involved morning presentations and afternoon small-group work, with the first day devoted to prevention and epidemiology, and the second to diagnosis and treatment. The third day dealt with the social aspects of rare diseases and, on the final morning, we heard plenary sessions on specific rare diseases such neurofibromatosis, Prader–Willi syndrome, myasthenia gravis, Cornelia de Lange syndrome and Rett syndrome. Plenary presenters were significant people in the field of rare diseases from Europe and the US, including Dr Kerstin Westermark, Chair of the Committee for Orphan Medicinal Products of the European Medicines Agency, Dr Ségolène Aymé, the Chair of the European Rare Disease Task Force, and Dr Marlene Haffner, Director of the Office of Orphan Products Development, which is part of the US Food and Drug Administration. The patient voiceAs the week unfolded, a striking theme was the presence of patients. Patients and carers dealing with Ehlers–Danlos syndrome, cystic fibrosis, narcolepsy, multiple endocrine cancers, Sjögren syndrome, chronic fatigue syndrome, fibromyalgia, fibrodysplasia ossificans, muscular dystrophy, cyclical vomiting, neurofibromatosis, and many others disorders, participated in and presented sessions. Specific sessions were devoted to patient groups to allow them to present the problems they face. In one moving contribution, Claudio Buttarelli, President of the neurofibromatosis support group Ananas (Italian for pineapple — rough on the outside but sweet on the inside), described the impact of this rare and misunderstood disease on every aspect of his life from socialisation in his teenage years through to the limitations imposed by nerve palsies on playing soccer with his children. Such sessions kept presentations on genetic research, new compounds, and public health initiatives grounded in the everyday experience of patients. However, the presence of patients should have been no surprise, as patient voices were instrumental in bringing the problem of rare diseases to the attention of governments. In the 1980s in the US, a peak patient group, the National Organization for Rare Disorders (NORD),2 was established to lobby for funding and research that no single rare disease could attract (Box 2). Eurordis (the European Organisation for Rare Diseases) fulfils a similar function. Notably, there is no peak patient body for rare diseases in Australia. Different storiesThe USDr Stephen Groft, Director of the Office of Rare Diseases (ORD) of the US National Institutes of Health,4 spoke at both conferences, describing ORD and some of its activities. ORD was set up in 1993 to stimulate and coordinate research on rare diseases and to support research to respond to the needs of patients with rare diseases. ORD supports a grants program to establish a network for research on rare diseases; grants are provided for such activities as the training of rare diseases researchers and programs to stimulate clinical research on rare diseases. Of particular interest to Australians because of its online accessibility is an information centre aimed at the public, researchers, and health care providers (http://rarediseases.info.nih.gov/asp/resources/rardis_info.asp). ORD also supports a national scientific conferences program to stimulate research and regional workshops to help patient support groups obtain assistance through the National Institutes of Health. EuropeIn April 1999, the EU Parliament set forth Decision No. 1295/1999/EC, adopting a program of community action on rare diseases within the framework for action in the field of public health (1999–2003). Many projects were funded under this program, and important initiatives that continued in the 2003–2008 European public health program5 include ORPHANET, a database for the general public on rare diseases (http://www.orpha.net/consor/cgi-bin/home.php?Lng=GB), and EUROCAT (http://www.eurocat.ulster.ac.uk/), which surveys more than one million births per year in 19 countries to provide epidemiological information on congenital abnormalities. We heard about innovative Italian initiatives, including the national network for the prevention, surveillance, diagnosis and therapy of rare diseases made up of certified centres expressly identified by the regions (decentralised administrative units) and the National Registry of Rare Diseases. This registry is established at the Centro Nazionale Malattie Rare,6,7 led by Dr Domenica Taruscio. The centre carries out a wide range of activities including genetic research into rare diseases, quality assurance of genetic testing, primary prevention projects, maintenance of the rare disease registry, dissemination of information, development of guidelines, involvement and coordination of EU projects such as NEPHIRD, qualitative research on patients’ quality of life, narrative medicine, and training of health professionals. Lessons for an Australian GPA need for coordinated activityThe relative lack of coordinated activity in rare disease in Australia compared with the US and Europe is striking — we believe there is a need for a peak patient group (such as NORD or Eurordis) in Australia to lobby for patients with rare diseases. Australia’s small population (with consequent small numbers of patients with any given rare disease) and geographic dispersal presents particular challenges in connecting patients with rare diseases with each other and with expert care. Presentations at the rare diseases conference covered a number of potentially useful strategies for connecting and empowering patients. Of particular note is Ågrenska in Sweden,8 which organises week-long camps at which families and patients with similar problems receive intensive education and establish connections with each other, and hear about specialist services. Ågrenska has been able to demonstrate better outcomes and cost savings through its strategy.8 Europe is establishing networks of excellence in which researchers and institutions with expertise in particular diseases are linked. We wonder whether Australian patients and clinicians with interests in particular diseases could join these networks, perhaps even participating in e-medicine consultations. The role of primary careThe specialists and scientist researchers at the conferences expressed frustration about the supposedly “low” level of skills of their primary care colleagues in identifying the rare disease in which they were expert. One specialist exclaimed that some GPs had never even heard of neurofibromatosis type 1. Some sessions at the conference presented this as an equity issue — surely, a patient with Prader–Willi syndrome has as much right to prompt diagnosis and evidence-based treatment as a patient with type 2 diabetes? The natural reaction is to call for more education of primary care clinicians in individual rare diseases. However, we do not think it would be realistic or even wise for GPs to use their time learning all the details of the 6000 identified rare diseases.4 We do believe that primary care has a neglected but important role in rare diseases. To date, progress in rare diseases has been driven by patients through their specialist clinicians and through public health institutions. Primary care clinicians provide a key link between patients in our community and the very specialised services those with rare diseases require. The Australian proposal of a generic model of general practice care1 was presented and discussed at the IRDC. One important and simple strategy identified during the week was careful monitoring of infant development as a generic strategy to screen for many rare congenital diseases. A voice from the perspective of primary care seemed to be quite strange to this very specialised community. In the main, they welcomed the general practice contribution and were excited by the possibilities of adding a primary care perspective to the rare disease agenda. Patients at the conference in particular confirmed the need to continue to develop the role of primary care clinicians in rare disease. Future connectionsThe pursuit of an idea (the common problem of rare disease in general practice) through to publication in the Medical Journal of Australia has led to a number of connections which have been professionally stimulating, satisfying and helpful. One of them was the IRDC in Rome 2006, which highlighted the international agenda on rare diseases. This conference has stimulated one Australian GP (A W K) to think further about and conduct more research into the role of GPs in rare disease. Policymakers, other clinicians, and patient groups in Australia also have the opportunity to reflect on the way forward. In particular, a funded initiative to establish a peak patient body for rare diseases seems long overdue. 1 The Istituto Superiore di Sanità (Institute of Public Health), conference venue, Rome 2 Rare disease facts Rare diseases are life-threatening or chronically debilitating diseases that have such a low prevalence (not more than 5 per 10 000) that specially combined efforts are needed to prevent morbidity and perinatal or early mortality, and to address quality-of-life and equity issues. There are approximately 6000 defined rare diseases. It is estimated that up to 6%–10% of the community have a rare disease.2 Patients with rare diseases have common experiences — including delayed diagnosis, wrong diagnosis, inappropriate surgery, lack of access to evidence-based care, and social consequences — because their diseases are rare.3 Orphan drugs are pharmaceuticals developed to treat diseases that affect relatively few people.

Andrew W Knight FRACGP, MMedSci(Clin Epid) · Domenica Taruscio MD

Objective: To understand how multidisciplinary care plans are being used in the management of patients with diabetes, and to explore the role of collaboration in care planning.Design: Grounded theory interview study.Setting: Primary care, June 2005 to October 2006.Participants: Thirty-eight people from three New South Wales Divisions of General Practice: 19 general practitioners, eight diabetes-related allied health providers, two endocrinologists, and nine adults with type 2 diabetes. Sampling was purposeful then theoretical.Results: GPs use care plans to organise clinical care and help patients access allied health providers. Written plans are used to educate patients about their care and to motivate change. GPs rarely discuss care plans with other providers, and providers are unlikely to change their approach to patients on the basis of care plans. Patients do not expect to participate in care planning.Conclusions: Care planning may increase evidence-based multidisciplinary care for patients with diabetes, but it rarely results in genuine collaboration between providers and patients. This suggests a difference may exist between Australian policymakers’ and providers’ definitions of patients with complex needs. Care plans could facilitate patient self-management by including more personalised information. Further research is needed to clarify which patients would benefit from a truly collaborative approach to their care.

Timothy D Shortus MB BS, MPH, FRACGP · Suzanne H McKenzie MMSc(ClinEpid), GradCertULT, FRACGP · Lynn A Kemp BHSc, PhD · Judith G Proudfoot BEd, MA, PhD · Mark F Harris MD, DRACOG, FRACGP

Objective: To identify trends associated with health website recommendations by selected general practitioners to their patients.Design and setting: Quantitative data collection using a prepaid postal survey, consisting of 17 questions, mailed to 250 of 410 GPs (61%) on the Gold Coast, Queensland. The survey was conducted between 9 October and 11 December 2006.Main outcome measures: GPs’ website recommendations to patients; associated GP demographic variables (age, sex and years of practice).Results: 59% (64/108) of participating GPs recommend health websites to their patients during consultations. Male GPs (63%, 45/72), those aged 41–50 years (55%, 35/64), and those practising for < 10 years (60%, 12/20) are more inclined to recommend a health website to a patient. The majority of GPs (69%, 44/64) reported that they most often recommended websites to patients 26–45 years old. 53% of GPs (34/64) recommended websites to 1%–20% of their male patients, while 47% (30/64) recommended websites to 21%–40% of their female patients. A greater proportion of participating female GPs (47%, 17/36) do not recommend health websites, compared with male GPs (38%, 27/72).Conclusions: More than half the surveyed GPs actively recommend websites to their patients, with a GP’s sex, age and years of experience influencing his or her recommendation decisions. Web-based continuing medical education courses or programs in medical schools may help doctors develop the skills necessary for the delivery of effective e-health care.

Wayne T Usher MHealthSci

An innovative team approach and integration of care across sectors, including general practices, community health services, allied health professionals and hospitals, can deliver high-quality comprehensive care in disadvantaged areas while providing teaching and research opportunities and community service. Academic general practice departments are committed to supporting and evaluating such models. A governance infrastructure that encourages strong partnerships across health care sectors is essential. With broad health partnership support, bulk-billing is viable in an Australian general practice team model providing health care to the disadvantaged.

Claire L Jackson MPH, GradCMt, FRACGP · John E Marley MD, MB ChB, FRACGP

Objectives: To describe the patients seen and the clinical activity undertaken by general practitioners during encounters at residential aged-care facilities (RACFs), and to ascertain how these differ from all GP encounters in Australia as a whole.Design and participants: A secondary analysis of encounter data from the Bettering the Evaluation and Care of Health (BEACH) study, April 2004 to March 2006, comparing RACF consultations (identified by Medicare item numbers) with all BEACH study encounters in Australia. Participants were a random sample of GPs who had claimed at least 375 general practice Medicare items in the 3 months prior to the study.Main outcome measures: Differences in the characteristics of GPs and patients at RACF consultations, morbidities managed, and treatments provided to patients.Results: Over the study period there were 2310 RACF encounters out of a total of 197 000 BEACH encounters; 360/1970 GPs (18.4%) recorded at least one RACF consultation. GPs aged ≥ 45 years were more likely to record at least one RACF consultation than those aged < 45 years. Patients were predominantly women (70.7%), and 83.4% were aged ≥ 75 years. At RACF consultations, problems managed significantly more often included chronic problems, as well as psychological, neurological, urological, circulatory, eye and musculoskeletal problems. Dementia was the most common problem managed, at 33 times the usual management rate in everyday practice. Significantly fewer medications, non-pharmacological treatments, referrals, pathology and imaging tests were recorded at RACF consultations.Conclusion: GP encounters at RACFs involve the management of chronic and complex conditions, including some not frequently seen in everyday general practice. The provision of additional education and resources where required may assist with workforce shortages in this setting.

Julie O’Halloran BAppSc(HIM)(Hons) · Helena Britt BA, PhD · Lisa Valenti BEc

We conducted a literature review to assess the current status of general practitioner services in residential aged-care facilities (RACFs) in Australia and the impact of recent initiatives to enhance access by RACF residents to these services. Of 400 publications identified, 22 were selected as relevant to our study. We also analysed publicly available statistical data on GP services in RACFs. Recent initiatives to improve quality of care and facilitate access to GP services for RACF residents include the Aged Care GP Panels Initiative, the Enhanced Primary Care program, and an expanded role of palliative care. Despite these initiatives, many GPs still find RACF services unappealing due to a perceived poor level of remuneration for the effort involved. Further improvements in access to and quality of GP services to RACFs may require new models of care delivery and financing.

Svetla Gadzhanova PhD · Richard Reed MD, MPH

There is clear evidence that coordinated systems of medical and psychological care (“collaborative care”) are superior to single-provider-based treatment regimens. Although other general practice-based mental health schemes promoted collaborative care, the new Medicare Benefits Schedule payments revert largely to individual-provider service systems and fee-for-service rebates. Such systems have previously resulted in high out-of-pocket expenses, poor geographical and socioeconomic distribution of specialist services, and proliferation of individual-provider-based treatments rather than collaborative care. The new arrangements for broad access to psychological therapies should provide the financial basis for major structural reform. Unless this reform is closely monitored for equity of access, degree of out-of-pocket expenses, extent of development of evidence-based collaborative care structures, and impact on young people in the early phases of mental illness, we may waste this opportunity. The responsibility for achieving the best outcome does not lie only with governments. To date, the professions have not placed enough emphasis on systematically adopting evidence-based forms of collaborative care.

Ian B Hickie MD, FRANZCP · Patrick D McGorry MD BS, PhD, FRANZCP

General practice can provide good quality care for a range of high-prevalence chronic diseases, at the same time providing continuity of care and management of comorbidity. Although the quality of care for patients with chronic disease is improving in general practice, about half of patient care does not meet optimal standards. Factors contributing to the gap between optimal and current practice include the method of financing, the availability of other disciplines to participate in team care, limited engagement with self-management education, and lack of information and decision support systems. National initiatives and incentives have enhanced planned and systematic care in general practice, and some programs have been introduced to improve access to allied health care. The number and complexity of programs, and lack of integration between them are a significant administrative burden for general practice, and the financial incentives are small compared to overseas programs. A better integrated and more comprehensive strategy is required to achieve widespread and sustained improvements in the quality of care for people with chronic disease in general practice.

Mark F Harris FRACGP, MD · Nicholas A Zwar FRACGP, PhD

Almost 60% of general practices now employ at least one practice nurse. Australian Government initiatives to support the expansion of practice nursing are not consistently based on strong evidence about effectiveness, outcomes or efficiencies. Reviews from other countries suggest that practice nurses can achieve good health outcomes, but there is little information about the Australian practice-nurse workforce, funding models to support their work, scope of their practice, or its outcomes. Australian practice nursing lacks a career structure and an education framework to advance nurses’ skills and knowledge. To maximise the contribution of nurses in primary care, a more systematic approach is needed, with a stronger evidence base for policy to support effective outcomes.

Helen Keleher PhD · Catherine M Joyce BA(Hons), MPsych, PhD · Rhian Parker BScEcon(Hons), MSc, PhD · Leon Piterman MRCP, FRACGP, MAFOM

General practitioners face the challenge of developing a career path and credentialling pathway for doctors working in special interest areas to ensure safe practice and to develop a professional profile for these groups. Breast physicians are one example. They care for women with benign and malignant breast disease and work in multidisciplinary teams in hospitals, clinics, private practice, and the breast screening program. The training and credentialling of breast physicians has recently been formalised by the Australasian Society of Breast Physicians with the introduction of a training program and fellowship in breast medicine.

Meagan E Brennan FRACGP, FASBP · Andrew J Spillane MD, FRACS

Cancer is the leading cause of death among Australians, causing 28% of all deaths. The average general practitioner will only encounter about four new patients each year with a potentially fatal cancer. A GP’s cancer-related workload mostly involves prevention, and dealing with patients with suspicious symptoms or concerns about possible cancer, or who may be at increased risk due to family history or lifestyle factors. GPs cover the full spectrum of cancer care from prevention to palliation, including providing psychosocial support to patients and their families and carers. GPs have a key role in early diagnosis and referral, follow-up and detection of recurrence, and survivorship. There is a developing role for GPs in cancer policy and research.

Brian R McAvoy MD, FRCP, FRACGP

Violence is a serious public health issue and the medical profession has a role to play in tackling this issue. Occupational violence is a significant problem in Australian general practice. Doctors need training to recognise and manage patients at risk of becoming perpetrators or victims of violent behaviour, both to protect themselves and to reduce violence in the wider community. A national taskforce on violence in medical practice should be established to monitor, evaluate, prevent, and reduce medical workplace violence. A national summit of all medical groups should be held to examine the increasing violence in Australian society as a public health issue. Australia’s medical practitioners are in a strong position to advocate for better mental health, drug and alcohol, and family support services to manage patients at risk of violent behaviour.

Leanne Rowe AM, MB BS, MD, FRACGP · Michael R Kidd MB BS, MD, FRACGP

There is increasing demand to provide clinical and teaching experiences in the general practice setting. Vertical integration in teaching and learning, whereby teaching and learning roles are shared across all learner stages, has the potential to decrease time demands and stress on general practitioners, to provide teaching skills and experience to GP registrars, and to improve the learning experience for medical students, and may also help meet the increased demand for teaching in general practice. We consider potential advantages and barriers to vertical integration of teaching in general practice, and provide results of focus group discussions with general practice principals and registrars about vertical integration. We recommend further research into the feasibility of using vertical integration to enhance the capacity to teach medical students in general practice.

Marie-Louise B Dick MPH, FRACGP · David B King FRACGP, MPH · Geoffrey K Mitchell FRACGP, FAChPM, PhD · Glynn D Kelly FACPsychMed, FRACGP, GradCertHigherEd · John F Buckley FRACGP, DipRACOG · Susan J Garside BEd(Hons), GradCertEd

There’s a lot of it about: acute respiratory infections in primary care Graham Worrall. Oxford: Radcliffe Publishing, 2006 (136 pp). ISBN 1 84619 084 3. Although there appears to have been a decline in attendance to general practitioners in Australia for acute respiratory infections (ARIs), they still account for close to 10% of the GP’s workload. The evidence base for their management has never been better defined and yet, given recent research and prescribing patterns, many GPs either find it difficult to, or do not, apply this evidence in practice. Worrall does not waste any time on trying to distinguish between upper and lower respiratory tract infections but discusses each condition in a separate chapter, starting with “The common cold” and ending with “Bronchiolitis”. Each chapter is a concise summary of the available literature and, despite now being an academic in Canada after many years as a GP in the United Kingdom, he limits the number of references he uses. However, as succinct as he may be in conveying the evidence in the text, it will be the summary boxes “Epidemiology and aetiology”, “Clinical course and diagnosis” and “Treatment” that many readers will be drawn to. This is a pity because a real understanding of the topic can only be drawn from the studies themselves and a discussion of their strengths and weaknesses; something the author does very well. The chapter on croup demonstrates this; summary boxes provide simple treatment details, but the text highlights the need for primary care-based randomised controlled trials to determine the best form of management for mild and moderate croup in the community. The final three chapters highlight the importance of clinical assessment and the lack of decision rules for the majority of ARIs, the relentless battle between bacteria and antibiotics and the potential role inappropriate prescribing of antibiotics in the community has had on emerging bacterial resistance, and finally, evidence-based strategies that GPs can use to change their own and their patients’ behaviour for the better (eg, delayed prescribing to reduce antibiotic use being one of the simplest and best). This textbook offers established GPs an opportunity to revisit and improve their current management of ARIs, and general practice registrars a chance to get it right from the start.

Nigel P Stocks

General practice psychiatry Grant Blashki, Fiona Judd, Leon Piterman, editors. Sydney: McGraw-Hill, 2006 (xii + 388 pp). ISBN 007471351 5. Who might have anticipated that a book dealing with psychiatry in general practice has, as its second chapter, “GP self-care”? Or that the first third of the text includes chapters on cross-cultural and Indigenous issues, consumers’ and carers’ views of general practice psychiatry, and mental health and the law, among others? What I like about this book is that it challenges conventional priorities and paradigms and offers new, unforeseen material, while retaining obligatory examination of the various psychiatric illnesses — depression, anxiety, substance misuse, psychoses, and others — encountered in general practice. The need for general practitioners to be skilled in the assessment and management of mental health problems is unarguable. Among other reasons, these problems are very common in the community (and far too common to be seen exclusively by mental health professionals), and many sufferers choose to seek help from a GP, certainly in the first instance. In this book’s pages, the reader will find much practical advice: there is information about assessment techniques, useful rating scales, psychological treatments and pharmacotherapy (in some detail), and strategies for difficult behaviours (eg, for the persistently angry patient or for when a staff member is a target of anger). The style is engaging, with regular use of case studies (often revisited later in a chapter), “key facts”, other lists (oddly, referred to as figures) and tables. The editors and assembled authors have a strong reputation in this field. It is noteworthy that each chapter was co-developed by a GP, so the utility for general practice was always in the contributors’ minds. General practice psychiatry is an ambitious book — at once attempting to be thought-provoking and to provide the “good oil” — but the editors and authors appear to have pulled it off. It is very good value for money.

Garry J Walter

What seems to be the trouble? Stories in illness and healthcare Trisha Greenhalgh. Oxford: Radcliffe Publishing, 2006 (viii + 112 pp). ISBN 1 84619 122 X. In What seems to be the trouble? Trisha Greenhalgh, Professor of Primary Care at University College London, takes a narrative approach to narrative. A story, she says, can explain an illness, help to diagnose an illness, illuminate the dark corners of a complex illness and generate new meaning, or help to shape an illness. Her book is not just about individuals. There are stories about systems, too. A chapter on “Stories and organisations” begins with a comment in a hospital visitors’ book. After describing the delays in treatment for his dying father, the writer said, “I am shocked and amazed that you consider the management of my father’s case and the administration of his treatment to be of a good standard”. In the same chapter, a consultant obstetrician tells the story of a teenage girl who froze to death in the grounds of a hospital after being discharged late in the afternoon, following a miscarriage, “Apparently no one — or at least no one on duty at the time — had known that this unfortunate young woman did not have a home to go back to”. The obstetrician was one of a group of health professionals who were opposing an attempt by the National Institute for Clinical Excellence to delete such stories and adopt a more evidence-based approach in their report writing. Facts and figures, the group agreed, are not enough — stories have emotional traction, and emotions drive change. A chapter on “Stories and research” provides a small dose of narrative theory and some narrative research methods. It’s a bit unnerving to see J K Rowling (author of the Harry Potter childrens’ books) on the same page as Martha Nussbaum (the American philosopher), or to skip from Aristotle to Derrida and Foucault in a book of fewer than 100 pages, but the author has the deft touch of a skilled raconteur. In these and the other chapters on illness, healing, learning and ethics, medical readers will gain practical insights and a better understanding of the narrative approach.

J Jill Gordon

Is it me or my hormones? Understanding midlife change. 2nd ed. Margaret Smith, Patricia Michalka. Sydney: Finch Publishing, 2006 (278 pp). ISBN 187645174 2. We’ve all seen them in our practices: anxious women, bewildered or even frightened by the signs of the menopause transition. Perhaps they’re carrying the burden of family folklore; perhaps they’ve somehow managed to insulate themselves — even through pregnancy and childbirth — from a proper understanding of their own bodies; perhaps they’re shocked by these intimations of mortality. Hot flushes, night sweats and mood swings may have taken them by surprise. The loss of sexual desire or the experience of discomfort during intercourse may be evoking confused responses, ranging from self-doubt (“Am I still an attractive woman?”), to worry about the state of the relationship with their partner. For some women, patient listening and an assessment of their physical state (including, in appropriate cases, hormone therapy) may provide all the reassurance they need. For others, though, something more comprehensive is called for. For women who need detailed information — physical, emotional, sexual, social and even spiritual — about the menopause transition, this book is a godsend. Margaret Smith, a gynaecologist specialising in the menopause, and Patricia Michalka, a psychotherapist, have distilled their combined wisdom into a book that addresses one of the most fundamental questions raised by menopausal women: “Is it me or my hormones?” In a genuinely holistic approach, the authors explore the many symptoms and issues that sometimes confuse menopausal women to the point of despair. The case-study approach is handled warmly and with compassion: worried women will find it easy to identify with the stories in this book. We all know that the “one size fits all” approach flies in the face of common sense and our experience of the uniqueness of each patient’s situation. Is it me or my hormones? emphasises the need to take an individual approach, and to recognise that symptoms are rarely a sign of only one thing.

Sheila O’Neill

Objective: To investigate the effectiveness of an educational Quality Use of Medicines program, delivered at the level of general practice, on medicines use, falls and quality of life in people aged ≥ 65 years.Design: Cluster randomised controlled trial conducted in 2002.Setting: General practices in the Hunter Region, New South Wales, Australia.Participants: Twenty general practitioners recruited 849 patients to participate in the study.Intervention: Education (academic detailing, provision of prescribing information and feedback); medication risk assessment; facilitation of medication review; financial incentives.Main outcome measures: Primary measures: a composite score reflecting use of benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs) and thiazide diuretics; secondary measures: use of medication reviews, occurrence of falls, quality of life (as assessed by SF-12 and EQ-5D survey scores.Results: Compared with the control group, participants in the intervention group had increased odds of having an improved medication use composite score (odds ratio [OR], 1.86; 95% CI, 1.21–2.85) at 4-month follow-up but not at 12 months. At 4-month follow-up, the intervention group had reduced odds of using NSAIDs (OR, 0.62; 95% CI, 0.39–0.99) and showed a non-significant reduction in use of benzodiazepines (OR, 0.51; 95% CI, 0.20–1.30) and thiazide diuretics (OR, 0.70; 95% CI, 0.48–1.01). Changes in drug use were not significant at 12-month follow-up. At 12 months, intervention-group participants had lower adjusted ORs (AORs) for having a fall (AOR, 0.61; 95% CI, 0.41–0.91), injury (AOR, 0.56; 95% CI, 0.32–0.96), and injury requiring medical attention (AOR, 0.46; 95% CI, 0.30–0.70). Quality-of-life scores were unaffected by the intervention.Conclusion: Education and systems for medication review conducted by GPs can be used to improve use of medicines. These interventions are associated with a reduction in falls among older people, without adverse effects on quality of life.

Sabrina W Pit MSc, PhD · Julie E Byles BMed, PhD · David A Henry MB ChB, FRCP · Lucy Holt BPharm · Vibeke Hansen BA(Psych)(Hons) · Deborah A Bowman BA