The General Practice Research Network: the capabilities of an electronic patient management system for longitudinal patient data

Using general practice clinical information system data for research: the case in Australia

General practice is often a patient’s first point of contact with the health system and the gateway to specialist services. In Australia, different aspects of the health system are managed by the Commonwealth Government and individual state / territory governments. Although there is a long history of research using administrative data in Australia, this split in the management and funding of services has hindered whole-system research. Additionally, the administrative data typically available for research are often collected for reimbursement purposes and lack clinical information.

General practices collect a range of patient information including diagnoses, medications prescribed, results of pathology tests ordered and so on. Practices are increasingly using clinical information systems and data extraction tools to make use of this information. This paper describes approaches used on several research projects to access clinical, as opposed to administrative, general practice data which to date has seen little use as a resource for research.

This information was accessed in three ways. The first was by working directly with practices to access clinical and management data to support research. The second involved accessing general practice data through collaboration with Primary Health Networks, recently established in Australia to increase the efficiency and effectiveness of health services for patients. The third was via NPS MedicineWise’s MedicineInsight program, which collects data from consenting practices across Australia and makes these data available to researchers.

We describe each approach including data access requirements and the advantages and challenges of each method. All approaches provide the opportunity to better understand data previously unavailable for research in Australia. The challenge of linking general practice data to other sources, currently being explored for general practice data, is discussed.

Finally, we describe some general practice data collections used for research internationally and how these compare to collections available in Australia.

Evolution of a register recall system to enable the delivery of better quality of care in general practice

Australian Divisions of General Practice have a key role to play in supporting general practitioners (GPs) to provide proactive, preventive care for their patients with cardiovascular disease (CVD) and diabetes. They can achieve this by providing them with quality improvement information generated by population health monitoring tools such as CARDIAB®™. CARDIAB®™ has prompted the development of standard minimum clinical datasets, enabled recording, monitoring and audit of quality of care and health outcomes for diabetes and cardiovascular patients who are locally enrolled in Division programs. It has also supported the improvement of services within general practice and local secondary care services. GPs have been able to audit their clinical performance and monitor quality of care and health outcomes in diabetes and cardiovascular disease. This article describes the evolution of the CARDIAB®™ database from the grass roots level to a nationally accepted database.

The influence of electronic medical record usage on nonverbal communication in the medical interview

This study examined nonverbal communication in relation to electronic medical record (EMR) use during the medical interview. Six physicians were videotaped during their consultations with 50 different patients at a single setting Veterans Administration Hospital. Three different office spatial designs were identified and named `open,' `closed' and `blocked'. The `open' arrangement put physicians in a position to establish better eye contact and physical orientation than did the alternative `closed' and `blocked' office configurations. Physicians who accessed the EMR and took `breakpoints' (short periods of no computer use and sustained eye contact with patients) used more nonverbal cues than physicians who tended to talk with their patients while continuously working on the computer. Long pauses in conversational turn taking associated with EMR use may have positively influenced doctor—patient communication. High EMR use interviews were associated with patients asking more questions than they did in low EMR use interviews. Implications for medical education and future research are discussed.

The management of severe hypertension in Australian general practice

BACKGROUND

Severe hypertension (SHT) (Blood Pressure, BP ≥ 180/110 mmHg) is associated with considerable morbidity and mortality, yet little is known about how it is managed. The purpose of this study is to examine the management of SHT by Australian general practitioners (GPs) and to explore its variance across patient characteristics and clinical practices.

METHODS

Review of electronic medical records for a year before and after a recorded measure of SHT in 7,499 patients by 436 GPs in 167 clinics throughout Australia during 2008-2009. Outcome measures included follow-up, referral, changes to antihypertensive drug treatment, and BP control (normotensive reading, BP < 140/90 mmHg, and whether subsequent recorded measures were also in the normal range--sustained normotension).

RESULTS

Of 7,499 patients with an electronic BP record of SHT, 94% were followed up (median time 14 days); 8% were referred to an appropriate specialist (median time 89 days--2% within 7 days) and 86% were managed by GPs. GPs initiated or changed antihypertensive drugs in 5,398 patients (72% of cohort); of these, 46% remained hypertensive (4% with SHT) and 7% achieved sustained normotension; 6% had no further electronic BP records. The remaining 14% had no medication changes; among these, 43% remained hypertensive (5% with SHT) and 3% achieved sustained normotension; 32% had no further electronic BP records. Some outcome measures displayed a variance across GP clinics that was mostly unexplained by patient or practice characteristics.

CONCLUSIONS

Most patients with SHT had at least one follow-up visit and 72% had initiation of, or changes to, antihypertensive drug treatment. Although most of the patients experienced some improvement, blood pressure control was poor. Some clinics showed better performance. Suggestions are made for the development of clinical standards to facilitate appropriate management of this dangerous condition.

Using suitability profiles to better inform consumers' choice of commonly used over-the-counter analgesics

Objective

To quantify the impact of labelled contraindications, precautions and warnings for use on the population that may take commonly used over-the-counter (OTC) analgesics.

Setting

Primary care: data were collected from a general practitioner database in Australia.

Methods

Patient data were audited retrospectively (n = 107553) to determine the number of patients with contraindications, warnings or precautions to the use of OTC paracetamol and the non-steroidal anti-inflammatory drugs aspirin and ibuprofen. The primary outcome measure was the suitability rate (i.e. the proportion of patients with no contraindications, warnings or precautions) of these commonly used analgesics.

Key findings

In this Australian dataset, the proportions of patients who had no contraindications, warnings or precautions to the use of paracetamol or ibuprofen were 98.1 and 76.9%, respectively (P = 0.0001); 83.4% of patients had no contraindications, warnings or precautions to the use of aspirin (P = 0.005 compared with paracetamol).

Conclusion

Of the three OTC analgesics examined, paracetamol is suitable for use by a larger proportion of the general population without the need to seek medical advice.

Co-prescribing of topical and systemic beta-blockers in patients with glaucoma: a quality use of medicine issue in Australian practice

PURPOSE

Prescribing topical beta-blockers for patients with glaucoma, who are also being treated with systemic beta-blockers, raises efficacy and safety concerns. This potentially inappropriate co-prescribing practice is a Quality Use of Medicine issue. This study aimed to quantify the extent of co-prescribing of topical and systemic beta-blockers in Australian clinical practice.

METHODS

This is a retrospective analysis of de-identified billing data for supply (surrogate marker for prescribing) of topical and systemic beta-blockers from the Pharmaceutical Benefits Scheme (1999-2004) to concessional patients supplied either topical or systemic beta-blockers. The primary outcome was the percentage of patients supplied systemic beta-blockers within the patient population supplied topical beta-blockers. This percentage was calculated for each financial year (July 1999-June 2004), age group (<65 years; 65-74 years; 75-84 years; > or =85 years) and sex.

RESULTS

Approximately 20% of patients supplied topical beta-blockers (representing Australian glaucoma patients) were also supplied systemic beta-blockers, equating to more than 20 000 patients per year. This percentage varied with age, but not with year or sex. The percentage of patients co-supplied topical and systemic beta-blockers was the lowest (13%) for patients <65 years and the highest (23%) for patients 75-84 years.

CONCLUSIONS

Pharmaceutical Benefits Scheme supply data shows that the potentially inappropriate practice of co-prescribing topical and systemic beta-blockers affects more than 20 000 concessional patients in Australia each year, particularly the elderly. This Quality Use of Medicine issue has now been quantified; doctors, pharmacists and patients must be made aware of the reduced efficacy and potential for more side-effects from this co-prescribing practice.

Evaluation of a national quality use of medicines service in Australia: an evolving model

RATIONALE

To describe the first phase of a global evaluation framework for the National Prescribing Service (NPS), with a focus on services for health professionals, and in particular highlight the lessons learnt from evaluation around the establishment and implementation of this national program.

METHODS

The agreed evaluation framework used mixed methods focused around a series of evaluation questions, aimed at measuring the overall effect of this new organization as well as the individual programs within it. The evaluation questions were determined a priori and were based on the objectives established by the organization in its first year of operation. A detailed analyses has been completed of: the process, scope and reach of program delivery using both quantitative and qualitative measures; changes in attitudes and knowledge measured through key informant interviews and surveys of professional groups and consumers; and changes in prescribing behaviour and savings to the Pharmaceutical Benefits Scheme (PBS) through analysis of prescription data. The evaluation period for this report was mid-1998 to mid-2004.

RESULTS

The NPS has successfully implemented a complex, multi-faceted program across Australia. From 1998 to 2004, in addition to print material provided to all general practitioners (GPs) and pharmacists, 90% of all GPs have been actively involved in one or more educational activity; 116 of 120 divisions of general practice have coordinated local NPS programs; and 9% of pharmacists have actively participated in at least one educational activity. Sixty per cent of GPs and pharmacists rated the printed educational materials as good or very good. In the last three years, the NPS activities have generated savings in the range of $121-163 million to the PBS, owing to changes in prescribing practices.

CONCLUSION

The national evaluation framework has informed program delivery and ongoing design and development. Continued refinement of existing evaluation methods and further exploration of new techniques will remain a priority for the organization.

Co-morbidity in general practice

BACKGROUND

Co-morbidity, or the presence of more than one clinical condition, is gaining increased attention in epidemiological and health services research. However, the clinical relevance of co-morbidity has yet to be defined. In general practice, few studies have been conducted into co-morbidity, either at a single health care encounter, an episode of care, or for a defined time period.

AIMS

To describe the major co-morbidity cluster profiles recorded by general practitioners. Another aim of this study is to describe the common clusters of co-prescribing.

METHODS AND RESULTS

Twelve month data from patients attending 156 GPs from 95 practices around a six month period of January to June 2003 were analysed. This represented 840,961 encounters from about 200,000 individual patients at these participating practices. Co-morbidity and co-prescribing cluster profiles are represented by problems managed and reasons for prescribing for the top 10 presentations and top 10 prescribed drugs in the study period.

CONCLUSIONS

By analysing the 10 most prevalent problems and 10 most prevalent drugs prescribed in consultations in a community sample, other co-morbidities that are particular to general practice, for example hypertension and lipid disorders, can be uncovered. Whether these clusters are causally related or occur by chance requires further analysis.

The effects of restricting publicly subsidised temazepam capsules on benzodiazepine use among injecting drug users in Australia

OBJECTIVE

To assess the effect of a restriction on publicly subsidised temazepam 10 mg capsules upon the injection of benzodiazepines by injecting drug users (IDUs).

DESIGN AND PARTICIPANTS

Cross-sectional study of regular IDUs targeting periods before and after the policy change. Analysis of prescription data, including time-series analysis.

SETTING

Drug services in the capital cities of New South Wales, Victoria, Tasmania, Queensland and the Northern Territory.

MAIN OUTCOME MEASURES

Changes in prescriptions and patterns of benzodiazepine use; harms associated with benzodiazepine use.

RESULTS

There was a decrease in temazepam 10 mg capsule prescriptions and a corresponding increase in temazepam 10 mg tablet prescriptions after the policy change. IDU survey data suggested that IDUs continued to inject benzodiazepines and temazepam capsules. The frequency of the injection of capsules after the restriction appeared similar to that before the policy change. There was no change in the frequency of injection of tablets. Most IDUs reported obtaining their benzodiazepines from doctors, with substantial proportions obtaining capsules even after the restriction. About half the IDUs reported purchasing benzodiazepines on the street. Most IDUs who injected benzodiazepines reported injection-related problems.

CONCLUSION

Limiting the prescribing of temazepam capsules may have reduced their injection by some IDUs, but additional strategies are needed to reduce the misuse among this group. These may include further restriction of capsule preparations, continued education of doctors and IDUs, and the examination of prescribing practices of individual doctors.

Bisphosphonate use and subsequent prescription of acid suppressants

AIM

To determine the extent of prescribing of acid suppression agents associated with initiation of bisphosphonate therapy.

METHODS

This was a case control study, performed within the General Practice Network, Australia. The main outcome measure was re-attendance within six weeks from index bisphosphonate prescription for acid supression agents.

RESULTS

Of the bisphosphonate cases, 2.9%[95% confidence interval (CI) 1.8, 3.9] returned within 6 weeks for a prescription for proton pump inhibitor, histamine 2 receptor antagonist or antacid, compared with 0.9% of control patients (95% CI 0.5, 1.2). However, the bisphosphonate cases had significantly higher rates of previous use of nonsteroidal anti-inflammatory agents. After controlling for previous nonsteroidal anti-inflammatory drug use, the increased use of acid suppression agents was statistically significant, the odds ratio = 3.21 (95% CI 2.02, 5.11).

CONCLUSION

Bisphosphonate use appears to be associated with increased use of acid suppressant agents within 6 weeks of first supply.