The Pattern of Opioid Management by Australian General Practice Trainees

'Low-value' clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs' practice

Nonevidence-based and 'low-value' clinical care and medical services are 'questionable' clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with their cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key nonevidence-based or low-value 'questionable' clinical practices. The study was nested in the Registrar Clinical Encounters in Training study-an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on Registrar Clinical Encounters in Training data from 2010 to 2020, was the score on the QUestionable In-Training Clinical Activities Index (QUIT-CAI), which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. A total of 3206 individual registrars (response rate 89.9%) recorded 406 812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15 560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training terms: incidence rate ratios (IRRs) of 0.91 [95% confidence interval (CI) 0.87, 0.95] and 0.85 (95% CI 0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12, 1.45), the patient being of non-English-speaking background (IRR 1.24; 95% CI 1.04, 1.47), the practice being in a higher socioeconomic area decile (IRR 1.01; 95% CI 1.00, 1.02), small practice size (IRR 1.05; 95% CI 1.00, 1.10), shorter consultation duration (IRR 0.99 per minute; 95% CI 0.99, 1.00), and fewer problems addressed in the consultation (IRR 0.84; 95% CI 0.79, 0.89) for each additional problem]. Senior registrars' clinical practice entailed less 'questionable' clinical actions than junior registrars' practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests that continuity should be supported and facilitated during GP training (and in established GPs' practice).

Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations

INTRODUCTION

Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence-based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain.

MAIN RECOMMENDATIONS

Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation; initiation of opioid deprescribing for persons with chronic non-cancer or chronic cancer-survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid-related adverse effects; gradual and individualised deprescribing, with regular monitoring and review; consideration of opioid deprescribing for individuals at high risk of opioid-related harms; avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated; avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence-based care, such as medication-assisted treatment of opioid use disorder; and use of evidence-based co-interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care.

CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES

To our knowledge, these are the first evidence-based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.

Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study

INTRODUCTION

Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing.

OBJECTIVE

The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation.

METHODS

This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥ 75 years admitted to the acute aged care service for ≥ 48 h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications.

RESULTS

Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) -3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0-24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04).

CONCLUSION

Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients.

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

BACKGROUND

During vocational general practice training, the content of each trainee's (in Australia, registrars') in-consultation clinical experience is expected to entail a breadth of conditions that exemplify general practice, enabling registrars to gain competency in managing common clinical conditions and common clinical scenarios. Prior to the Registrar Clinical Encounters in Training (ReCEnT) project there was little research into the content of registrars' consultations despite its importance to quality of training. ReCEnT aims to document the consultation-based clinical and educational experiences of individual Australian registrars.

METHODS

ReCEnT is an inception cohort study. It is comprised of closely interrelated research and educational components. Registrars are recruited by participating general practice regional training organisations. They provide demographic information about themselves, their skills, and their previous training. In each of three 6-month long general practice training terms they provide data about the practice where they work and collect data from 60 consecutive patient encounters using an online portal. Analysis of data uses standard techniques including linear and logistic regression modelling. The ReCEnT project has approval from the University of Newcastle Human Research Ethics Committee, Reference H-2009-0323.

DISCUSSION

Strengths of the study are the granular detail of clinical practice relating to patient demographics, presenting problems/diagnoses, medication decisions, investigations requested, referrals made, procedures undertaken, follow-up arranged, learning goals generated, and in-consultation help sought; the linking of the above variables to the presenting problems/diagnoses to which they pertain; and a very high response rate. The study is limited by not having information regarding severity of illness, medical history of the patient, full medication regimens, or patient compliance to clinical decisions made at the consultation. Data is analysed using standard techniques to answer research questions that can be categorised as: mapping analyses of clinical exposure; exploratory analyses of associations of clinical exposure; mapping and exploratory analyses of educational actions; mapping and exploratory analyses of other outcomes; longitudinal 'within-registrar' analyses; longitudinal 'within-program' analyses; testing efficacy of educational interventions; and analyses of ReCEnT data together with data from other sources. The study enables identification of training needs and translation of subsequent evidence-based educational innovations into specialist training of general practitioners.

'Low-value' clinical care in general practice: associations of low value care in GP trainees' practice, including formative and summative examination performance - protocol for cross-sectional and retrospective cohort study analyses using the QUestionable In Training Clinical Activities (QUIT-CA) index

INTRODUCTION

'Low value' clinical care and overuse of medical services are 'questionable' clinical activities that entail provision of medical services that are more likely to cause harm than good or whose benefit is disproportionately low compared with its cost. This study will seek to establish clinical practice associations of a non-observed work-based assessment of general practitioner (GP) trainees' (registrars') questionable practice (the QUestionable In Training Clinical Activities (QUIT-CA) index). We will also explore association of the QUIT-CA index with a formative observed work-based assessment, and will establish if registrars' QUIT-CA indexes are associated with summative examination performance.

METHODS AND ANALYSIS

We will conduct three analyses, all using data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing (from 2010) cohort study in which Australian GP registrars record details of their in-consultation clinical and educational practice. The QUIT-CA index is compiled from ReCEnT consultation data. A cross-sectional analysis, using negative binomial regression, will establish clinical practice associations of the QUIT-CA index. A cross-sectional analysis using linear regression will be used to establish associations of QUIT-CA index with formative observed in-practice assessment (the General Practice Registrar-Competency Assessment Grid). A retrospective cohort study analysis using linear regression will be used to establish associations of the QUIT-CA index with summative examination performance (Royal Australian College of General Practice fellowship examinations results).

ETHICS AND DISSEMINATION

The study has ethical approval from the University of Newcastle HREC(H-2009-0323). Findings will be disseminated in peer-reviewed journal articles and conference presentations.

Evaluation of the Relationship Between Geographic Proximity and Treatment for People Referred to a Metropolitan Multidisciplinary Pain Clinic

OBJECTIVE

This study examined which patient characteristics are associated with traveling further to attend a metropolitan, publicly funded pain management service, and whether travel distance was associated with differences in treatment profile, duration, and percentage of appointments attended.

DESIGN

Cross-sectional observational cohort study.

METHOD

Patients ≤70 years of age with a single referral between January 2014 and June 2018 who had not died within 12 months of their first appointment and who had a usual place of residence were included (N = 1,684; mean age = 47.2 years; 55.5% female). Travel distance was calculated with the HERE Routing API on the basis of historical travel times for each scheduled appointment.

RESULTS

Median travel time was 27.5 minutes (Q1, Q3: 12.5, 46.2). Ordinal regression showed that women had 20% lower odds of traveling further, but people who were overweight or obese (odds ratio [OR] = 1.4-2.3), unemployed (OR = 1.27), or taking higher opioid dosages (OR = 1.79-2.82) had higher odds of traveling further. People traveling >60 minutes had fewer treatment minutes (median = 143 minutes) than people living within 15 minutes of the pain clinic (median = 440 minutes), and a smaller proportion of those traveling >60 minutes attended group programs vs. medical appointments only (n = 35, 17.0%) relative to those living within 15 minutes of their destination (n = 184, 32.6%). People living 16-30 minutes from the clinic missed the highest proportion of appointments.

CONCLUSIONS

Although people traveling further for treatment may be seeking predominantly medical treatment, particularly opioid medications, the present findings highlight the need to further explore patient triage and program models of care to ensure that people living with persistent disabling pain can access the same level of care, regardless of where they live.

The opioid-prescribing practices of Australian general practice registrars: an interview study

BACKGROUND

Approximately half of the opioids prescribed by Australian GP and GP registrars are for chronic non-cancer pain-despite limited therapeutic benefit, and serious risks of harm. Understanding the factors driving non-evidence-based opioid prescribing may improve GP training and education.

OBJECTIVE

To explore attitudes, beliefs, knowledge and self-reported factors influencing the opioid-prescribing decisions of Australian GP registrars.

METHODS

Telephone interviews were undertaken with 20 GP registrars in 2018-19. Interviews were 30-60 minutes in duration, audio-recorded and de-identified. Braun and Clarke's 6-phase framework was adopted for reflexive thematic analysis of data and managed using QSR NVivo software.

RESULTS

Twenty registrars were recruited; 8 men and 12 women. Three themes were identified.

SUPPORT AND SUPERVISION

Difficult chronic pain consultations negatively affected the registrar well-being. Registrars role modelled their supervisors' opioid-prescribing practices, even if they perceived it to be unsafe.

CONFIDENCE

Registrars lacked confidence in initiating, prescribing and weaning opioids, recognizing drug-seeking behaviours and declining to prescribe-but felt confident in their knowledge of opioid pharmacology.

SAFETY

Registrars were aware of evidence-based prescribing recommendations and risk reduction strategies but struggled to translate this into practice.

CONCLUSIONS

Non-evidence-based opioid prescribing by Australian GP registrars is multifactorial. Emotionally difficult pain consultations, poor supervision and low prescriber confidence may contribute to unsafe prescribing. Improving registrar prescribing may require interventions to improve risk reduction, training in communication and role modelling by supervisors.

Prevalence and sites of pain in remote-living older Aboriginal Australians, and associations with depressive symptoms and disability

BACKGROUND

Pain is a growing public health problem associated with significant health and functional implications. Limited data exist for Aboriginal Australians.

AIMS

To describe the prevalence, severity and sites of pain, analgesic use and associated factors, including depression and disability, in remote-living Aboriginal Australians.

METHODS

Cross-sectional study of 263 Aboriginal Australians aged ≥45 years from six remote Indigenous communities and the town of Derby in the Kimberley region of Western Australia between 2011 and 2013. Pain was assessed using a culturally adapted pain scale. Factors associated with pain were investigated with binary logistic regression.

RESULTS

One hundred and seventy (64.6%) participants reported having pain and 53 (20.2%) reported persistent pain. Of those reporting pain, 61 (35.9%) rated it as moderate and 70 (41.2%) as severe. The most common sites of pain were back and knee, and 38 (22.4%) participants with pain indicated three or more sites of pain. Only 70 (41.2%) participants with pain were on some type of analgesic medication. After adjustment, poor vision (odds ratio (OR) = 2.21; 95% confidence interval (CI) 1.22-4.00), hypertension (OR = 1.89; 95% CI 1.03-3.45) and heart problems (OR = 2.05; 95% CI 1.01-4.14) were associated with pain. Higher depression scores were associated with more persistent pain, but pain was not significantly associated with clinically relevant depressive symptoms, or requiring assistance with two or more personal and/or instrumental activities of daily living.

CONCLUSION

High levels of pain were reported, although the prevalence of persistent pain was comparable to the general population. Identifying risk factors, improving pain recognition and assessment and evaluating culturally tailored management approaches should be a priority.

Role legitimacy, comfort and confidence providing tobacco, alcohol and other drug care: a cross-sectional study of Australian early-career general practitioners

Australian general practitioners (GPs) see most Australians each year and, as tobacco, alcohol and other drug use (substance use) are common, GPs often see problematic, risky or dependent substance use. This study aimed to explore early-career GPs' role legitimacy, comfort and confidence managing patients with problematic use of tobacco, alcohol, psychoactive pharmaceutical or illicit substances.Using the '5A's framework: Ask, Assess, Advise, Assist and Arrange, we surveyed 251 early-career GPs (GP registrars) on role legitimacy, confidence managing patient substance use, and sources of clinical information, advice and support.There was strong agreement that managing substance use is a GP's role, with high levels of confidence 'Asking' (screening) about tobacco and alcohol use, which decreased across other substance classes. Early-career GPs reported lower levels of confidence 'Assessing' and 'Advising' (brief interventions); and much lower levels of confidence 'Assisting' (treating) and 'Arranging' (follow up and/or referral) for patients with substance issues across all substances, including tobacco. Participants were most likely to seek advice from senior colleagues in their practice.Early-career GPs reported lower than optimal levels of confidence for all substances. Our findings have important implications for educators globally. Education that improves confidence across all 5As for high-prevalence substances (tobacco and alcohol) while focusing on increasing comfort screening and improving understanding of referral pathway options for low-prevalence substances may improve early-career GPs' confidence. This could increase engagement in managing substance use issues potentially leading to better health and wellbeing outcomes for patients.

Opportunities and challenges for physical rehabilitation with indigenous populations

Indigenous peoples in colonised countries internationally experience a disproportionately high burden of disease and disability. The impact of many of these conditions, such as musculoskeletal pain, can be ameliorated by participating in physical rehabilitation. However, access by Indigenous peoples to physical rehabilitation is low. Overcoming barriers for Indigenous peoples to access high-quality, effective, culturally secure physical rehabilitation should be a priority. Physical rehabilitation outcomes for Indigenous peoples can be enhanced by addressing health system, health service, and individual clinician-level considerations. System-level changes include a greater commitment to cultural security, improving the funding of physical rehabilitation to Indigenous communities, building the Indigenous physical rehabilitation workforce, and developing and using Indigenous-identified indicators in quality improvement. At the health service level, physical rehabilitation should be based within Indigenous health services, Indigenous people should be employed as physical rehabilitation professionals or in allied roles, and cultural training and support provided to the existing physical rehabilitation workforce. For clinicians, a focus on cultural development and the quality of communication is needed. Indigenous ill-health is complex and includes societal and social influences. These recommendations offer practical guidance toward fair, reasonable, and equitable physical rehabilitation outcomes for Indigenous peoples.

Challenges of opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines: a qualitative analysis

BACKGROUND

Chronic prescription opioid use is a major international public health issue associated with significant harms, including increased risk of hospitalisation, morbidity and death. Guidance for healthcare professionals on when and how to deprescribe or reduce opioids is required. A key step for guideline development for deprescribing pharmacotherapy is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of healthcare professional stakeholders on the challenges associated with opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines.

METHODS

A qualitative study was undertaken with a purposive sample of healthcare professionals including prescribers, pharmacists and nurses. An initial cohort of participants was identified at the 2018 Australian Deprescribing Network annual meeting and two focus groups were conducted (n=20). Individual interviews were conducted with a further 11 healthcare professionals. Focus groups and interviews were audio-recorded and transcribed verbatim. Data underwent inductive thematic analysis using a phenomenological perspective.

RESULTS

Healthcare professionals viewed opioid deprescribing as a challenge and identified several key barriers to deprescribing in clinical practice. Medication, patient, prescriber and health system level challenges were identified. Participants requested evidence-based guidance on the withdrawal of opioid therapies and suggested that prospective opioid deprescribing guidelines require a multitarget, multimodal intervention strategy that addresses patient psychosocial factors and incorporates behavioural change techniques.

CONCLUSION

Opioid deprescribing was perceived as a complex and challenging practice with continued prescribing the default behaviour. Evidence-based opioid deprescribing guidelines may be a valuable resource for clinicians to support clinical decision-making and reduce suboptimal opioid use.

Stringent Control of Opioids: Sound Public Health Measures, but a Step Too Far in Palliative Care?

PURPOSE OF REVIEW

Opioids are the only class of drug with the proven ability to control severe pain. The introduction of stringent opioid prescribing restrictions has inevitably impacted upon the ability of those prescribing opioids for advanced life-limited disease to practice as previously and could limit the supply of adequate pain relief to patients with cancer. This review considers the evidence that symptom management of patients with advanced cancer contributes to the "opioid problem" and whether there is adequate recognition of the risks involved.

RECENT FINDINGS

The literature suggests that the risk of opioid abuse is low in the palliative care population as is the risk of legal consequences for doctors prescribing opioids at the end of life. However, as many patients with cancer are living longer or surviving with chronic pain, palliative care physicians must be cognisant not only of the risks of long term opioid use but also of the risk of opioid misuse. Adherence to evidence or consensus-based guidelines is necessary to avoid inappropriate prescribing. In palliative care, it is appropriate not only to exercise a reasonable degree of opioid control and surveillance, primarily for the good of society, but also to ensure that the ability to treat pain in patients with advanced malignant disease is not compromised.

Unmet Needs of Aboriginal Australians With Musculoskeletal Pain: A Mixed-Method Systematic Review

OBJECTIVE

Musculoskeletal pain (MSP) conditions are the biggest cause of disability, and internationally, indigenous peoples experience a higher burden. There are conflicting reports about Aboriginal Australians and MSP. We conducted a systematic review to describe the prevalence, associated factors, impacts, care access, health care experiences, and factors associated with MSP among Aboriginal Australians.

METHODS

We used a systematic search of quantitative and qualitative scientific and grey literature (PROSPERO# CRD42016038342). Articles were appraised using the Mixed Methods Appraisal Tool. Due to study heterogeneity, a narrative synthesis was conducted.

RESULTS

Of 536 articles identified, 18 were included (14 quantitative, 4 qualitative), of high (n = 11), medium (n = 2), and low (n = 5) quality. Prevalence of MSP in Aboriginal populations was similar to or slightly higher than the non-Aboriginal population (prevalence rate ratio 1.1 for back pain, 1.2-1.5 for osteoarthritis [OA], and 1.0-2.0 for rheumatoid arthritis). Aboriginal people accessed primary care for knee or hip OA at approximately half the rate of non-Aboriginal people, and were less than half as likely to have knee or hip replacement surgery. Communication difficulties with health practitioners were the main reason why Aboriginal people with MSP choose not to access care. No articles reported interventions.

CONCLUSION

Findings provide preliminary evidence of an increased MSP burden among Aboriginal Australians, and particularly for OA, a mismatch between the disease burden and access to health care. To increase accessibility, health services should initially focus on improving Aboriginal patients' experiences of care, in particular by improving patient-practitioner communication. Implications for care and research are outlined.

Protecting Pain Patients. The Evaluation of a Chronic Pain Educational Intervention

Introduction

Advocacy and commercially funded education successfully reduced barriers to the provision of long-term opioid analgesia. The subsequent escalation of opioid prescribing for chronic noncancer pain has seen increasing harms without improved pain outcomes.

Methods

This was a one-group pretest-posttest design study. A multidisciplinary team developed a chronic pain educational package for general practitioner trainees emphasizing limitations, risk-mitigation, and deprescribing of opioids with transition to active self-care. This educational intervention incorporated prereadings, a resource kit, and a 90-minute interactional video case-based workshop incorporated into an education day. Evaluation was via pre- and postintervention (two months) questionnaires. Differences in management of two clinical vignettes were tested using McNemar's test.

Results

Of 58 eligible trainees, 47 (response rate = 81.0%) completed both questionnaires (36 of whom attended the workshop). In a primary analysis including these 47 trainees, therapeutic intentions of tapering opioid maintenance for pain (in a paper-based clinical vignette) increased from 37 (80.4%) pre-intervention to 44 (95.7%) postintervention (P = 0.039). In a sensitivity analysis including only trainees attending the workshop, 80.0% pre-intervention and 97.1% postintervention tapered opioids (P = 0.070). Anticipated initiation of any opioids for a chronic osteoarthritic knee pain clinical vignette reduced from 35 (74.5%) to 24 (51.1%; P = 0.012) in the primary analysis and from 80.0% to 41.7% in the sensitivity analysis (P = 0.001).

Conclusions

Necessary improvements in pain management and opioid harm avoidance are predicated on primary care education being of demonstrable efficacy. This brief educational intervention improved hypothetical management approaches two months subsequently. Further research measuring objective changes in physician behavior, especially opioid prescribing, is indicated.

Opioid analgesic use in Australia and The Netherlands: a cross-country comparison

Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To compare the use of OA in two countries in order to better understand these trends. Setting Outpatient settings in Australia and The Netherlands. Method We analysed publicly available government data on outpatient OA dispensing over 15 years (2000-2014). We compared dispensing trends for specific OA and explored medical (national clinical guidelines), contextual and policy-related factors to explain differences in use between the two countries. Main outcome measure OA prescribing in Australia and The Netherlands, absolute volume of use, preferred types of opioids and changes over time. Results The average annual increase in OA prescribing was 10% in Australia and 8% in The Netherlands between 2000 and 2014. In 2014, the total use of OA was 10.0 daily defined doses (DDD)/1000 population/day in Australia and 9.4 DDD/1000 population/day in The Netherlands. In Australia, the most commonly prescribed opioids were oxycodone and tramadol, compared to fentanyl and tramadol in The Netherlands. We found differences in prescribing guidelines, culture of prescribing and regulatory frameworks that could explain some of the observed differences. Conclusion OA prescribing has increased remarkably in both countries between 2000 and 2014 but the types of prescribed OA vary. Differences in national evidence-based guidelines influenced the types of OA used. Prescribing culture as well as regulatory policies and costs, may also contribute to the different patterns of OA use.