Cheffins, Tracy Elizabeth (2013) Responding to local needs: implementing research and evaluation in general practice in North Queensland. Professional Doctorate (Research) thesis, James Cook University.

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Abstract

Following the Australian Government's review of its general practice strategy in 1998, policies were implemented to increase the contribution of general practice to health research, and move general practice towards a population based approach to service delivery.

The Primary Health Care Research Evaluation and Development (PHCRED) program was established to enable all Australian University Departments of General Practice to increase research output and build research capacity in primary health care including general practice. The North Queensland Practice-Based Research Network (NQPBRN) was formed by James Cook University (JCU) in 2007 to implement general practice research and build capacity for research and evaluation in the primary health care sector.

At the same time, the Townsville General Practice Network (TGPN) was promoting population health practice and addressing the increasing burden of chronic conditions. Evaluation of TGPN chronic condition management projects provided an opportunity for further research within general practice, and complemented the work of the NQPBRN.

This thesis is based on research and evaluation projects undertaken simultaneously at the author's two workplaces - the JCU Discipline of General Practice and Rural Medicine where she coordinated the NQPBRN, and TGPN where she advised their population health program on chronic condition management. The projects are therefore grouped into two sections: general practice clinical research projects undertaken within the NQPBRN and chronic condition management evaluations completed at TGPN. While completing the projects, the author also gained a broader understanding of the most appropriate ways to implement and sustain research in general practice settings.

Aims

1. To design, implement and publish original research undertaken within a network of general practices in North Queensland, and through this build research capacity in general practices in the region.

2. To evaluate chronic condition management projects undertaken by the Townsville General Practice Network population health program.

Methods

Part One: Projects completed within the North Queensland Practice-Based Research Network. Three clinical studies were designed and implemented to respond to local needs as identified by the general practitioners (GPs) affiliated with the NQPBRN. Practices were recruited, practice nurses were trained in data collection, and the network coordinator worked closely with practices to ensure projects were completed. Mixed research methods were chosen to suit the clinical questions and the limitations of the general practice setting. The methods used for each study were:

1. GP management of acute otitis externa (AOE) – a descriptive study using medical record audits, prospective data collection including microbiological testing, and a GP survey to explore usual clinical practice. The three components were then compared for validation of outcomes.

2. Evaluation of over 75 years health assessments – a descriptive study based on medical record audits benchmarked against guidelines, and a practice survey of general practitioner and practice nurse attitudes to health assessments.

3. Improving vaccination rates in new parents – this study measured the impact of a practice nurse vaccination intervention, using patient surveys before and after the intervention.

An evaluation of the NQPBRN was performed to assess its progress and inform further development of research studies. The results of the evaluation are included in the discussion and conclusion to Part One.

Part Two: Evaluation of chronic condition management projects at TGPN.

Four evaluations were undertaken of chronic condition management projects implemented by the TGPN population health program. The evaluations applied mixed methods as follows:

1. Evaluation of self-management support training for health professionals - this project used semi-structured interviews to explore the application of self-management support by a cohort of health professionals who underwent training with TGPN. Barriers and enablers of self management support were identified.

2. Evaluation of an integrated health care partnership for chronic condition management – this evaluation was done in partnership with Queensland Health and used hospital avoidance data to assess the impact of multi-disciplinary team care planning for frequent re-admissions with chronic conditions. Semi-structured interviews with the team of health professionals were done to ascertain the benefits of the partnership.

3. Evaluation of a rural chronic condition management program – this extension of the integrated health care partnership to a rural town was evaluated using self-reported patient satisfaction surveys before and after the intervention. Health professionals and patients were interviewed to provide a more detailed understanding of the limitations of the program.

4. Evaluation of a Team Care Arrangement support program – this study was undertaken to assess the impact of an initiative to help practices improve their team care arrangement completion rates. It used practice audits before and after the intervention and semi-structured interviews with practice personnel.

Literature reviews were undertaken to inform the two sections of the thesis. The outcomes of the reviews have been integrated with the NQPBRN evaluation and the author's experience while implementing the projects, to provide a number of conclusions and recommendations for sustainable general practice research and evaluation.

Results

Part One. Projects completed within the North Queensland Practice Based Research Network. 1. Management of acute otitis externa (AOE) by general practitioners in North Queensland. Pseudomonas aeruginosa was the most common causative pathogen of AOE in all participating practices; GPs were able to correctly name the most common causative pathogens; there was variation in the use of oral antibiotics between regions (15.8 to 36.6%); ear syringing was commonly used in managing AOE (51.3%); and most patients (68.9%) required only one GP appointment.

2. Evaluating the use of enhanced primary care health assessments by general practices in North Queensland. Preventive health screening tests were recorded more frequently in patients with a completed health assessment: notably urinalysis, visual acuity and Faecal Occult Blood Test or colonoscopy. Blood pressure was the most frequently recorded test with or without a health assessment. The questionnaires provided useful information on how health assessments are implemented and showed that GPs believed they can provide more information about their patients' conditions.

3. Are new parents fully vaccinated? An evaluation of a general practice parent vaccination intervention.

Vaccination histories were taken from 117 new parents and recommendations made by a clinician. Catch-up vaccination was recommended for 66.1% (117/177) of parents, and 53% (62/117) complied, resulting in an improvement in up-to-date vaccination status from 33.9% (60/177) to 68.9% (122/177; p<0.0001).

Part Two: Evaluation of chronic condition management projects at TGPN.

1. Self-management support capacity (SMS) of providers of chronic condition primary care. All interviewees rated their understanding of the principles of SMS as moderate or better. In relation to how much they use the principles in their practice, several (5 of 14) said minimally or not at all. The tools they were most likely to use were SMART goals (8 of 14) and decision balance (5 of 14). Core skills used included problem solving (11 of 14), reflective listening (13 of 14), open-ended questions (12 of 14), identifying readiness to change (12 of 14) and goal setting (10 of 14). The most important barriers to implementing SMS were current funding models for health care, lack of space, and staff not interested in change. The most highly rated enabling strategies were more training for general practitioners and practice nurses; the lowest rated strategy was more training for receptionists.

2. A health care partnership for managing chronic conditions: a case study of integrated primary health care. The evaluation identified positive outcomes from the involvement of a GP liaison team in a Queensland Health chronic condition management team. Better understanding of the Medicare system and improved communication with general practitioners were reported. However, there were some barriers to integration between public and private health care, most notably the current funding models. Wide consultation before implementing new programs was recommended. 3. Extending the Reach - Integrated chronic condition management in rural Queensland. Eighteen clients participated in this case conferencing project between hospital and general practice staff. An evaluation showed that clients were generally positive about the case conferencing, reporting greater confidence in managing their condition. Providers expressed diverse opinions of the value of self-management.

4. Evaluation of a team care arrangement (TCA) support program. Completion rates of TCAs were audited in four general practices. They were 38.75% for the first audit and 40% for the second. One practice increased its completion rate from 30% to 60% while another practice showed a decrease from 40% to 25%. The more successful practice targeted a specific group of patients, gave them more choice of allied health practitioners, and provided clients with more detailed descriptions of the TCA process. Most practices stated that failure to complete TCAs was due to GPs and patients having different goals in the management of their chronic conditions.

Conclusion Implementing research and evaluation within general practice requires a commitment from the whole practice team, but delegation of the research tasks to a practice nurse is most effective in maintaining high quality research outcomes. Training and mentoring through practice visits and regular contact is essential. Ideally the research questions should arise through local need and discussion with the practice team. Methods used in practice based research need to be feasible and appropriate to the clinical question, and relevant to the clinical context of general practice.

Successful implementation of CCM programs in general practice requires involvement of the whole practice team and collaboration across sectors. Divisions of General Practice (and now Medicare Locals) can play an important role in supporting this collaboration and evaluating the impact of programs.

Well-maintained disease registers within practice information systems are a fundamental requirement for effective population health strategies, research and evaluation. Patient empowerment through self-management support and patient–centred care planning are highly desirable components of CCM.

The following recommendations are made to support research and evaluation in general practice settings:

• To engage clinicians in practice based research and evaluation, one should ask clinically relevant questions and include reflection on clinical practice in the methodology.

• Clinicians should make a major contribution to the selection of their research questions and topics.

• Financial, academic and infrastructure support is essential for sustainable practice-based research, particularly to undertake time-consuming tasks such as ethics applications, grant applications, analysis and publication of results.

• Practice based workshops for training and timely dissemination of results are important in maintaining motivation of clinicians to do research.

• Face-to-face practice visits from academic researchers and program staff are an important component of coordinating and sustaining a clinical research and evaluation network.

• Research champions who emerge from clinical practice should be generously supported.

Item ID:	31132
Item Type:	Thesis (Professional Doctorate (Research))
Keywords:	general practice; North Queensland Practice-Based Research Network (NQPBRN); population health; primary health care; research studies; Townsville General Practice Network (TGPN)
Related URLs:	http://researchonline.jcu.edu.au/8735/ http://researchonline.jcu.edu.au/11985/ http://researchonline.jcu.edu.au/18134/ http://researchonline.jcu.edu.au/19336/
Copyright Information:	Copyright © 2013 Tracy Elizabeth Cheffins
Additional Information:	Publications arising from this thesis are available from the Related URLs field. The publications are: Chapter 2. Cheffins, Tracy, Heal, Clare, Rudolphy, Steven, Evans, Rebecca, and Veitch, Craig (2009) Acute otitis externa: management by GPs in North Queensland. Australian Family Physician, 38 (4). pp. 262-266. Chapter 3. Cheffins, Tracy, Spillman, Margaret, Heal, Clare, Kimber, Debbie, Brittain, Maureen, and Lees, Michele (2010) Evaluating the use of Enhanced Primary Care Health Assessments by general practices in north Queensland. Australian Journal of Primary Health, 16 (3). pp. 221-223. Chapter 4. Cheffins, Tracy, Spillman, Margaret, Larkins, Sarah, and Heal, Clare (2011) Recommending vaccination general practice intervention with new parents. Australian Family Physician, 40 (6). pp. 437-439. Chapter 7. Cheffins, Tracey E., Twomey, Julie A., Grant, Jane A., and Larkins, Sarah L. (2012) An evaluation of the self-management support capacity of providers of chronic condition primary care. Australian Journal of Primary Health. 18 (2). pp. 112-115.
Date Deposited:	26 Feb 2014 23:53
FoR Codes:	11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111716 Preventive Medicine @ 50% 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111717 Primary Health Care @ 50%
SEO Codes:	92 HEALTH > 9202 Health and Support Services > 920299 Health and Support Services not elsewhere classified @ 50% 92 HEALTH > 9202 Health and Support Services > 920208 Health Inequalities @ 50%
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