Preventive care in general practice among healthy older New South Wales residents

Delivering brief physical activity interventions in primary care: a systematic review

BACKGROUND

Physical activity (PA) brief interventions (BIs) involving screening and/or advice are recommended in primary care but frequency of delivery is unknown.

AIM

To examine the extent to which PA BIs are delivered in primary care, and explore factors associated with delivery, receipt, and patient receptivity.

DESIGN AND SETTING

A mixed-methods systematic review of studies conducted worldwide, with a narrative synthesis of results.

METHOD

CINAHL, EMBASE, MEDLINE, and APA PsycINFO index databases were searched for qualitative and quantitative studies, dating from January 2012 to June 2020, that reported the level of delivery and/or receipt of PA BIs in primary care, and/or factors affecting delivery, receipt, and patient receptivity. Quality was assessed using the Mixed Methods Appraisal Tool. Attitudes towards and barriers to delivery were coded into the Theoretical Domains Framework and the Capability, Opportunity, and Motivation Behaviour model.

RESULTS

After screening a total of 13 066 records, 66 articles were included in the review. The extent of PA screening and advice in primary care varied widely (2.4%-100% and 0.6%-100%, respectively). PA advice was delivered more often to patients with a higher body mass index, lower PA levels, and/or more comorbidities. Barriers - including a lack of time and training/guidelines - remain, despite recommendations from the World Health Organization and National Institute for Health and Care Excellence that PA advice should be provided in primary care. Few studies explored patients' receptivity to advice.

CONCLUSION

PA BIs are not delivered frequently or consistently in primary care. Addressing barriers to delivery through system-level changes and training programmes could improve and increase the advice given. Understanding when patients are receptive to PA interventions could enhance health professionals' confidence in their delivery.

Engaging primary care providers in a mobile health strategy to support lifestyle change and blood pressure management

Objective

The delivery of lifestyle advice concerning diet and physical activity has been found to be suboptimal in primary care settings, including for patients who require this for clinical management. This pilot study aimed to evaluate the acceptability and feasibility of integrating a mobile health intervention into primary care to support patients with improving lifestyle behaviours for high blood pressure.

Methods

Thirty-one patients aged 40–70 years were recruited by seven general practitioners to trial a 6-month mobile health intervention that included videos, web-based education and text message reminders. Semi-structured interviews with general practitioners and patients explored intervention feasibility and acceptability. Web analytics were used to measure intervention use, and pre- and post-questionnaires measured patient ratings of content and behaviour changes.

Results

General practitioners and patients perceived the intervention to be an acceptable tool for supporting high blood pressure management. However, general practitioners reported recruitment challenges and patient engagement was limited for the web and video components. Questionnaires revealed no significant changes in behaviours, although the program was generally regarded by patients as motivating and some reported acquiring new knowledge and awareness. Patient suggestions for improvement included greater individualisation of content and opportunity for interaction with their general practitioner.

Conclusions

There is scope to improve lifestyle interventions for the management of high blood pressure in the busy primary care environment using supplementary mobile health strategies. Further intervention refinement and formative evaluation is required to identify strategies that can be integrated into routine care and achieve high patient engagement.

Characteristics of patients who access zero, one or multiple general practices and reasons for their choices: a study in regional Australia

Background

Most people in Australia visit a General Practitioner each year and are free to choose their General Practitioner and/or practice on each occasion. A proportion of people visit multiple general practices, which can reduce continuity of care, a core value of general practice. Utilisation of multiple general practices is associated with metropolitan residence and younger age. However, it is unclear which factors are associated with utilisation of multiple general practices in rural areas, where there are often General Practitioner workforce shortages and higher proportions of patients who may benefit from continuity of care, including older people and people living with chronic disease. The aim of this study was to compare the characteristics of people in a rural Australian area who accessed multiple general practices in the previous year with people who had accessed one practice, or none.

Methods

A cross-sectional survey assessed self-reported utilisation and perspective of general practice services, uses of multiple practices, associated reasons, lifestyle advice and screening services received in four regional Victorian towns. Households were randomly selected and residents aged 16+ were eligible to participate in the adult survey.

Results

Most people had attended a single general practice (78.9%), while 14.4% attended more than one practice and 6.7% attended no practices in the previous 12 months. Compared with utilisation of a single general practice, multiple general practice attendance in the previous year was associated with younger age (adjusted odds ratio (aOR 95% confidence interval) 0.98 per year (0.97–0.99), residence in the regional centre aOR 2.90(2.22–3.78), emergency department (ED) attendance in the last 12 months aOR 1.65(1.22–2.21) and no out of pocket costs aOR 1.36(1.04–1.79)). Reasons for multiple general practice attendance included availability of appointments, cost and access to specific services. Compared with multiple general practice attendance, those attending single practices reported more screening tests but similar frequency of lifestyle advice. People who accessed multiple practices were less likely to report very high satisfaction (51.7% vs 62.9% p < 0.001) or excellent degree of confidence in their doctor (42.0% vs 49.8% p = 0.006) than single practice attendees.

Conclusions

Those attending single practices report higher satisfaction and confidence in their GP and were less likely to attend ED. Further studies are required to test whether increasing availability of appointments and reducing out-of-pocket expenses would increase single practice attendance and/or decrease healthcare costs overall.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01341-4.

Prescription of physical activity in the management of high blood pressure in Australian general practices

This study investigated the prevalence of physical activity prescriptions in the management of high blood pressure (BP), the characteristics of people given these, and whether prescriptions were associated with the physical activity beliefs and practices of patients. A retrospective cohort study was undertaken, involving 365 general practitioners (GPs) from across Australia. The records of up to 20 patients per GP with high BP (N = 6512) were audited to identify physical activity and pharmacological prescriptions over four consecutive consultations. A sub-sample (n = 535) of patients completed a physical activity questionnaire. Physical activity prescriptions were recorded for 42.6% of patients with controlled BP, 39.5% for those with mild hypertension and 35.7% of those with moderate to severe hypertension. These were more likely in patients with cardiovascular disease (OR 1.41, 95% CI 1.23-1.62) and diabetes (OR 1.21, 95% CI 1.04-1.42), and less likely in those with moderate to severe hypertension (OR 0.80, 95% CI 0.69-0.94), aged 75 years and over (OR 0.62, 95% CI 0.51-0.74) and with high cholesterol (OR 0.73, 95% CI 0.57-0.94). Patients receiving a physical activity prescription were more likely to report this behaviour as important for their health and that they had increased their levels of participation. Most patients with high BP are not receiving physical activity prescriptions, and GPs show greater readiness to address this behaviour in patients with existing chronic disease. There is a need for efficacious and practical strategies for promoting physical activity that can be adopted in the routine management of high BP in general practice.

Preventing chronic disease in patients with low health literacy using eHealth and teamwork in primary healthcare: protocol for a cluster randomised controlled trial

INTRODUCTION

Adults with lower levels of health literacy are less likely to engage in health-promoting behaviours. Our trial evaluates the impacts and outcomes of a mobile health-enhanced preventive intervention in primary care for people who are overweight or obese.

METHODS AND ANALYSIS

A two-arm pragmatic practice-level cluster randomised trial will be conducted in 40 practices in low socioeconomic areas in Sydney and Adelaide, Australia. Forty patients aged 40-70 years with a body mass index ≥28 kg/m2 will be enrolled per practice. The HeLP-general practitioner (GP) intervention includes a practice-level quality improvement intervention (medical record audit and feedback, staff training and practice facilitation visits) to support practices to implement the clinical intervention for patients. The clinical intervention involves a health check visit with a practice nurse based on the 5As framework (assess, advise, agree, assist and arrange), the use of a purpose-built patient-facing app, my snapp, and referral for telephone coaching. The primary outcomes are change in health literacy, lifestyle behaviours, weight, waist circumference and blood pressure. The study will also evaluate changes in quality of life and health service use to determine the cost-effectiveness of the intervention and examine the experiences of practices in implementing the programme.

ETHICS AND DISSEMINATION

The study has been approved by the University of New South Wales (UNSW) Human Research Ethics Committee (HC17474) and ratified by the University of Adelaide Human Research Ethics committee. There are no restrictions on publication, and findings of the study will be made available to the public via the Centre for Primary Health Care and Equity website and through conference presentations and research publications. Deidentified data and meta-data will be stored in a repository at UNSW and made available subject to ethics committee approval.

TRIAL REGISTRATIONREGISTRATION NUMBER

ACTRN12617001508369; Pre-results.

An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: evaluation of the preventive evidence into practice cluster randomised controlled trial

BACKGROUND

Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care.

METHODS

PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores.

RESULTS

Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes.

CONCLUSIONS

The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

Cardiovascular disease screening in general practice: General practitioner recording of common risk factors

The assessment and screening of individual risk factors for cardiovascular disease (CVD) is a critical component of CVD prevention strategies in general practice (GP). This study sought to examine current CVD risk factor recording as recommended by Australian guidelines for the management of absolute cardiovascular disease risk. A retrospective analysis of routine GP data from 149,306 GP patients aged 45years and above in eastern Melbourne was conducted. Data were collected from GP clinics located throughout inner east Melbourne from July 2011 to September 2014 through the Melbourne East Monash General Practice Database. Recording of primary risk factors necessary for CVD screening as recommended by the national guidelines was assessed, and logistic regression with generalised estimating equations was used to estimate associations between patient characteristics and risk factor recording. 137,976 (92.4%) patients were found to have had at least one risk factor recorded, 62,214 (41.7%) had the Framingham risk factors recorded (lipids, blood pressure, smoking status), while only 1957 (1.3%) had all risk factors recorded. Females (Odds Ratio [OR]: 0.72, 95% Confidence Interval [CI]: 0.65, 0.81), and those identified with diabetes (OR: 12.26, 95% CI: 9.58, 15.68) were less and more likely to have documented risk factors, respectively. Given the role of GPs in the prevention and management of CVD, it is important to improve the identification of high risk patients through screening and recording of CVD risk factors. Strategies are therefore needed to encourage ongoing CVD risk factor recording to support preventive care by GPs.

[Counseling and preventive action in elderly population in hospitals and residences in Spain]

Objetivos

Conocer el perfil sociosanitario de los pacientes mayores atendidos en consultas; conocer las acciones preventivas que se llevan a cabo, de forma rutinaria, en hospitales, residencias geriátricas y otros centros asistenciales en España.

Diseño

Estudio descriptivo transversal, basado en un cuestionario a médicos que atienden a población mayor de 65 años en España (2013).

Emplazamiento

Centros de diferentes comunidades autónomas en España.

Participantes: Un total de 420 médicos de hospitales, residencias y otros centros. Se obtuvieron datos de 840 consultas a pacientes geriátricos.

Mediciones principales

Variables principales de resultados: dependencia, comorbilidad, motivo de consulta, actuación en consulta y recomendación de estilos de vida saludable. Factor asociado, tipo de institución en la que se atendió al paciente. Análisis de prevalencias y diferencias con Chi-cuadrado.

Resultados

El 66,7% presentaban dependencia, siendo mayor entre las mujeres: 68,9% vs 62,4% (p = 0,055). El 88,6% de mujeres atendidas con 85 o más años presentaban comorbilidad, mientras que en hombres de ese mismo grupo de edad eran un 79,8%. Solo un 6,6% de pacientes con comorbilidad recibieron recomendaciones saludables durante la consulta. El 79,6% de pacientes atendidos en hospitales recibieron recomendaciones de estilo de vida saludable, mientras que en las residencias geriátricas las recibieron el 59,62% de los pacientes (p < 0,001).

Conclusiones

Se detecta una escasa acción preventiva y de promoción de la salud hacia las personas mayores, con diferencias entre hospitales y residencias geriátricas. Parece necesario incentivar la actitud promotora de salud y las intervenciones preventivas en la práctica clínica gerontológica.

People with multiple unhealthy lifestyles are less likely to consult primary healthcare

BACKGROUND

Behavioural interventions are often implemented within primary healthcare settings to prevent type 2 diabetes and other lifestyle-related diseases. Although smoking, alcohol consumption, physical inactivity and poor diet are associated with poorer health that may lead a person to consult a general practitioner (GP), previous work has shown that unhealthy lifestyles cluster among low socioeconomic groups who are less likely to seek primary healthcare. Therefore, it is uncertain whether behavioural interventions in primary healthcare are reaching those in most need. This study investigated patterns of GP consultations in relation to the clustering of unhealthy lifestyles among a large sample of adults aged 45 years and older in New South Wales, Australia.

METHODS

A total of 267,153 adults participated in the 45 and Up Study between 2006 and 2009, comprising 10% of the equivalent demographic in the state of New South Wales, Australia (response rate: 18%). All consultations with GPs within 6 months prior and post survey completion were identified (with many respondents attending multiple GPs) via linkage to Medicare Australia data. An index of unhealthy lifestyles was constructed from self-report data on adherence to published guidelines on smoking, alcohol consumption, diet and physical activity. Logistic and zero-truncated negative binomial regression models were used to analyse: (i) whether or not a person had at least one GP consultation within the study period; (ii) the count of GP consultations attended by each participant who visited a GP at least once. Analyses were adjusted for measures of health status, socioeconomic circumstances and other confounders.

RESULTS

After adjustment, participants scoring 7 unhealthy lifestyles were 24% more likely than persons scoring 0 unhealthy lifestyles not to have attended any GP consultation in the 12-month time period. Among those who attended at least one consultation, those with 7 unhealthy lifestyles reported 7% fewer consultations than persons with 0 unhealthy lifestyles. No effect modification was observed.

CONCLUSION

To optimise the prevention of lifestyle-related diseases, interventions for positive behavioural change need to incorporate non-primary healthcare settings in order to reach people with multiple unhealthy lifestyles.

An objective index of walkability for research and planning in the Sydney metropolitan region of New South Wales, Australia: an ecological study

BACKGROUND

Walkability describes the capacity of the built environment to support walking for various purposes. This paper describes the construction and validation of two objective walkability indexes for Sydney, Australia.

METHODS

Walkability indexes using residential density, intersection density, land use mix, with and without retail floor area ratio were calculated for 5,858 Sydney Census Collection Districts in a geographical information system. Associations between variables were evaluated using Spearman's rho (ρ). Internal consistency and factor structure of indexes were estimated with Cronbach's alpha and principal components analysis; convergent and predictive validity were measured using weighted kappa (κw) and by comparison with reported walking to work at the 2006 Australian Census using logistic regression. Spatial variation in walkability was assessed using choropleth maps and Moran's I.

RESULTS

A three-attribute abridged Sydney Walkability Index comprising residential density, intersection density and land use mix was constructed for all Sydney as retail floor area was only available for 5.3% of Census Collection Districts. A four-attribute full index including retail floor area ratio was calculated for 263 Census Collection Districts in the Sydney Central Business District. Abridged and full walkability index scores for these 263 areas were strongly correlated (ρ=0.93) and there was good agreement between walkability quartiles (κw=0.73). Internal consistency ranged from 0.60 to 0.71, and all index variables loaded highly on a single factor. The percentage of employed persons who walked to work increased with increasing walkability: 3.0% in low income-low walkability areas versus 7.9% in low income-high walkability areas; and 2.1% in high income-low walkability areas versus 11% in high income-high walkability areas. The adjusted odds of walking to work were 1.05 (0.96-1.15), 1.58 (1.45-1.71) and 3.02 (2.76-3.30) times higher in medium, high and very high compared to low walkability areas. Associations were similar for full and abridged indexes.

CONCLUSIONS

The abridged Sydney Walkability Index has predictive validity for utilitarian walking, will inform urban planning in Sydney, and will be used as an objective measure of neighbourhood walkability in a large population cohort. Abridged walkability indexes may be useful in settings where retail floor area data are unavailable.