Residential aged care and general practice: workforce demographic trends, 1984-2000

Cross-sectional study of Australian medical student attitudes towards older people confirms a four-factor structure and psychometric properties of the Australian Ageing Semantic Differential

OBJECTIVES

The Australian Ageing Semantic Differential (AASD) survey was developed to quantify medical student attitudes towards older people. The purpose of this study is to examine psychometric properties of the survey and confirm its factor structure of four composites.

DESIGN

A cross-sectional study.

SETTING

Three medical schools in three Australian states: Victoria, Western Australia and South Australia.

PARTICIPANTS

Third-year or fourth-year medical students (n=188, response rate=79%).

OUTCOME MEASURES

In the previous AASD study, exploratory factor analysis supported a four-factor model consisting of 'Instrumentality' (I), 'Personal Appeal' (PA), 'Experience' (E) and 'Sociability' (S). Congeneric one-factor confirmatory factor analysis (CFA) were used to examine model fit for factors using a new student sample (n=188).Psychometric properties of survey items and factors.Post-hoc analysis of pooled data from this study and earlier AASD study (n=509).

RESULTS

Indices of fit (Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), root mean square error of approximation (RMSEA), standardised root mean square residual (SRMR)) for data to the factor model were: PA adequate fit (CFI=0.94, TLI=0.89, RMSEA=0.11 and SRMR=0.05), I good fit (CFI=0.99, TLI=0.99, RMSEA=0.04 and SRMR=0.03), S good fit (CFI=0.98, TLI=0.95, RMSEA=0.06 and SRMR=0.03) and E excellent fit (CFI=1.0, TLI=1.0, RMSEA=0.00 and SRMR=0.01).The AASD was internally consistent (Cronbach's alpha=0.84), without difference in mean student scores by institution. Mean AASD score was positive for medical students outside New South Wales (73.2/114).Mean I score for all Australian students was negative, with female respondents' mean E score significantly higher than their counterparts. A positive correlation between student age and I score was noted.

CONCLUSIONS

The AASD is internally consistent and generalisable within Australia, with acceptable structural validity for measuring medical student attitudes towards older people within a four-factor model. Student attitudes were positive globally and within all factors except I. Female students rated older persons E more positively. Older students recorded more positive attitudes towards I of older people.

Provision of palliative and end-of-life care in New Zealand residential aged care facilities: general practitioners' perspectives

This exploratory study examined general practitioners’ (GPs) perspectives on delivering end-of-life care in the New Zealand residential aged care context. A general inductive approach to the data collected from semi-structured interviews with 17 GPs from 15 different New Zealand general practices was taken. Findings examine: (1) GPs’ life experience; (2) the GP relationship with the facilities and provision of end-of-life care; (3) the GP interaction with families of dying residents; and (4) GP relationship with hospice. The nature of the GP relationship with the facility influenced GP involvement in end-of-life care in aged care facilities, with GPs not always able to direct a facility’s end-of-life care decisions for specific residents. GP participation in end-of-life care was constrained by GP time availability and the costs to the facilities for that time. GPs reported seldom using hospice services for residents, but did use the reputation (cachet) associated with hospice practices to provide an authoritative buffer for their end-of-life clinical decisions when talking with families and residents. GP training in end-of-life care, especially for those with dementia, was reported as ad hoc and done through informal mentoring between GPs.

Australian general practitioner attitudes to residential aged care facility visiting

Demographic trends suggest that the sustainability of the general practitioner (GP) Residential Aged Care Facility (RACF) workforce, worldwide and in Australia, is under threat, compromising the ongoing care of chronically ill RACF residents. It is therefore important to ascertain current GP attitudes towards this work, to better understand and hypothesise means of reversing this trend. To this end, during 2014 the views of 26 GPs and GP Registrars working in rural and regional New South Wales, Australia, were captured during focus group discussions and one-on-one interviews. Analysis of the qualitative date revealed that GP attitudes towards RACF visiting fell into five key themes: pleasure, duty, remuneration and logistics, hesitation, and frustration. The data also revealed that the overriding emotion GPs felt about RACF visitation was frustration with the avoidable delays and inefficiencies associated with the work. Despite the pleasure GPs derived from their work in RACFs and their sense of obligation to be involved, their hesitation and frustration was compounded by the work's perceived poor remuneration. This research suggests that the barriers to GP participation in RACF visiting were managerial rather than attitudinal, and that a strategic focus upon improving administrative and logistical support is needed.

Home visits and nursing home visits by early-career GPs: a cross-sectional study

BACKGROUND

Home visits (HVs) and nursing home visits (NHVs) are accepted as core elements of general practice. There is concern regarding declining rates of HVs and an increasing demand for NHVs together with a perceived decreased willingness of younger GPs to provide these services.

OBJECTIVES

To establish the prevalence and associations of recently vocationally qualified GPs ('graduates') performing HVs and NHVs.

METHODS

A cross-sectional questionnaire-based study of recent (within 5 years) graduates of 3 of Australia's 17 regional general practice training programs. Outcome factors were performing, as part of current practice, HVs and NHVs. Factors associated with each outcome were assessed by logistic regression with graduate and current practice characteristics and vocational training experiences as independent variables.

RESULTS

Of 230 responding graduates, 48.1% performed HVs and 40.6% performed NHVs in their current clinical GP role. Factors associated with both HVs and NHVs were participating in in-practice clinical teaching/supervision [odds ratios (ORs) 2.65 and 2.66], conducting HVs/NHVs during training (ORs 5.05 and 10.8) and working full-time (ORs for part-time work 0.20 and 0.29). Further associations with performing HVs were older GP age (compared to <36 years: ORs 3.65 for 36-40 and 2.53 for 41+), smaller practice size (OR 0.53 for larger practices), Australian undergraduate education (OR 0.31 for non-Australian) and greater number of years in their current practice as a qualified GP (OR 1.25 per year).

CONCLUSIONS

Our findings of graduates' modest engagement with HVs and NHVs reinforce concerns regarding Australian general practice's capacity to accommodate the needs of an aging population.

AgedCare+GP: description and evaluation of an in-house model of general practice in a residential aged-care facility

This paper describes a medical model to provide in-house GP services to residents of aged-care facilities. Access to GP services for aged-care residents is decreasing, partially due to the changing demographic of the Australian GP workforce. The model we have developed is an in-house GP (AgedCare+GP) trialled in a publicly funded residential aged-care facility (RACF). The service model was based on the GP cooperative used in our after-hours general practice (AfterHours+GP). Briefly, the service model involves rostering a core group of GPs to provide weekly sessional clinics at the RACF. Financial contributions from appropriate Medicare Benefits Schedule (MBS) items for aged-care planning (including chronic conditions) provided adequate funds to operate the clinic for RACF residents. Evaluation of the service model used the number of resident transfers to the local emergency department as the primary outcome measure. There were 37 transfers of residents in the 3 months before the commencement of the AgedCare+GP and 11 transfers over a 3-month period at the end of the first year of operation; a reduction of almost 70%. This project demonstrates that AgedCare+GP is a successful model for GP service provision to RACF residents, and it also reduces the number of emergency department transfers.

An Insight Into the Delivery of a Palliative Approach in Residential Aged Care

Managing the complex care needs of older people is a global concern. General practitioners (GPs) play a pivotal role in aged care, yet little is known about their capacity to provide palliative care in nursing homes. This study aimed to investigate GPs' perceptions and understanding of a palliative approach. A convenience sample of rural GPs ( n = 13) participated in a series of three focus groups undertaken in August, 2005. These focus groups were all audio-taped, transcribed, and analyzed using thematic content analysis. Four key themes emerged: uncertainty about a palliative approach, a need to reorientate providers, the challenges of managing third parties, and making it work and moving forward. These preliminary findings suggest that integrating a palliative approach in aged care requires GPs to have a greater awareness of this paradigm and to be more effectively engaged in multidisciplinary care planning.

Medical services provided by general practitioners in residential aged‐care facilities in Australia

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.

General practitioner consultations at residential aged‐care facilities

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 > or = 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 > or = 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.

Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial

BACKGROUND

Poorly executed transfers of older patients from hospitals to long-term care facilities carry the risk of fragmentation of care, poor clinical outcomes, inappropriate use of emergency department services, and hospital readmission.

OBJECTIVE

This study was conducted to assess the impact of adding a pharmacist transition coordinator on evidence-based medication management and health outcomes in older adults undergoing first-time transfer from a hospital to a long-term care facility.

METHODS

This randomized, single-blind, controlled trial enrolled hospitalized older adults awaiting transfer to a long-term residential care facility for the first time. Patients were randomized either to receive the services of the pharmacist transition coordinator (intervention group) or to undergo the usual hospital discharge process (control group). The intervention included medication-management transfer summaries from hospitals, timely coordinated medication reviews by accredited community pharmacists, and case conferences with physicians and pharmacists. The primary outcome was the quality of prescribing, measured using the Medication Appropriateness Index (MAI). Secondary outcomes were emergency department visits, hospital readmissions, adverse drug events, falls, worsening mobility, worsening behaviors, increased confusion, and worsening pain.

RESULTS

One hundred ten older adults (67 women, 43 men; mean [SD] age, 82.7 [6.4] years) were recruited from 3 metropolitan hospitals and assigned to 85 metropolitan long-term care facilities. Fifty-six patients were randomized to the intervention group and 54 to the control group; 44 patients in each group were evaluable at 8-week follow-up. There were no significant differences in baseline characteristics between treatment groups, with the exception of the number of medications discontinued during hospitalization: a mean of 1.1 more drugs was discontinued in the control group compared with the intervention group (P = 0.011). The majority of patients (35 [62.5%] in the intervention group, 41 [76.0%] in the control group) changed physicians as part of the transition to a long-term care facility. At 8-week follow-up, there was no change in MAI from baseline in the intervention group, whereas it had worsened in the control group (mean [95% CI], 2.5 [1.4-3.7] vs 6.5 [3.9-9.1], respectively; P = 0.007). Patients who received the intervention and were alive at follow-up exhibited a significant protective effect of the intervention against worsening pain (relative risk ratio [95% CI], 0.55 [0.32-0.94]; P = 0.023) and hospital usage (i.e., the combination of emergency department visits and hospital readmissions) (0.38 [0.15-0.99]; P = 0.035), but did not differ from control patients in terms of adverse drug events (1.05 [0.66-1.68]), falls (1.19 [0.71-1.99]), worsening mobility (0.39 [0.13-1.15]), worsening behaviors (0.52 [0.25-1.10]), or increased confusion (0.59 [0.28-1.22]). When data for patients who had died were included, the intervention had no effect on hospital usage in all patients (0.58 [0.28-1.21]).

CONCLUSIONS

Older people transferring from hospital to a long-term care facility are vulnerable to fragmentation of care and adverse events. In this study, use of a pharmacist transition coordinator improved aspects of inappropriate use of medicines across health sectors.

The evolution of the general practice workforce in Australia, 1991–2003

OBJECTIVE

To examine changes between 1991 and 2003 in the characteristics of active recognised general practitioners in Australia.

DESIGN

We compared self-reported GP characteristics from the 1990-91 Australian Morbidity and Treatment Survey (AMTS) with those from the 1999 and 2003 Bettering the Evaluation and Care of Health (BEACH) surveys, after standardisation for age and sex to the respective sample frames. AMTS and BEACH are cross-sectional, paper-based, national surveys.

PARTICIPANTS

Three random samples of 473 (1990-91), 980 (1998-99) and 1008 (2002-03) GPs who had claimed at least 1500 A1 (ie, general practice) Medicare items in the preceding year (in the AMTS) or 375 general practice Medicare items in the preceding 3 months (in the BEACH surveys).

MAIN OUTCOME MEASURES

Changes in distribution of GP sex, GP age, number of sessions per week, practice size and location, country of graduation, and postgraduate training.

RESULTS

Between 1991 and 2003, the proportion of female GPs rose from 19.3% to 35.2%; GPs aged < 35 years dropped from 22.3% to 10.0%, and those aged >or= 55 years increased from 21.4% to 31.6%. Between 1999 and 2003, the proportion of male GPs working < 6 sessions/week increased from 6.1% to 11.4%, while the proportion working >or= 11 sessions/week fell from 23.8% to 17.1%. Between 1991 and 2003, the proportion of solo practitioners nearly halved (25.5% v 13.7%); the proportion of GPs in practices of >or= 4 partners increased from 34.3% to 59.8%; the proportion of Australian graduates fell from 81.4% to 72.2%; and the proportion of graduates from Asia and Africa increased. Over the same period, the proportion of GPs with Fellowship of the Royal Australian College of General Practitioners more than doubled (17.8% v 36.4%). All of these differences were statistically significant (P < 0.001).

CONCLUSION

Changes in characteristics of the practising GP population will affect consultative services and the balance between supply and demand for these services. These changes should be considered in future workforce planning.