Prediction of general practice licensure/certification examination performance by a measure of 'questionable' activities in clinical practice: a retrospective cohort study

PURPOSE

'Low-value' clinical care and medical services are 'questionable' activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars' (trainees') performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP).

METHODS

The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars' scores on the three Fellowship examinations ('AKT', 'KFP', and 'OSCE' examinations) and pass/fail rates during 2012-21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was 'QUIT-CAI score percentage'-the percentage of times a registrar performed a QUIT-CAI clinical activity when 'at risk' (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option).

RESULTS

A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P = .001), poorer Key Features Problem scores (P = .003), and poorer Objective Structured Clinical Exam scores (P = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P = .043].

CONCLUSION

Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination).

Video versus telephone for telehealth delivery: a cross-sectional study of Australian general practice trainees

BACKGROUND

Remunerated telehealth consultations were introduced in Australia in 2020 in response to the COVID-19 pandemic. Videoconferencing has advantages over telephone-consulting, including improved diagnostic and decision-making accuracy. However, videoconferencing uptake in Australia has been low. This study aimed to establish prevalence and associations of video versus telephone consultations in Australian general practice (GP) registrars' practice.

METHODS

A cross-sectional analysis of data from 2020 to 2021 (three 6-monthly data-collection rounds) from the Registrars Clinical Encounters in Training (ReCEnT) study. GP registrars record details of 60 consecutive consultations every 6-month term, for a total of 3 terms. Univariable and multivariable logistic regression were performed within the Generalized Estimating Equations framework with the outcome video versus telephone.

RESULTS

102,286 consultations were recorded by 1,168 registrars, with 21.4% of consultations performed via telehealth. Of these, telephone accounted for 96.6% (95% CI: 96.3-96.8%) and videoconferencing for 3.4% (95% CI: 3.2-3.7%). Statistically significant associations of using videoconferencing, compared to telephone, included longer consultation duration (OR 1.02, 95% CI: 1.01-1.03 per minute; and mean 14.9 versus 12.8 min), patients aged 0-14 years old (OR 1.29, 95% CI: 1.03-1.62, compared to age 15-34), patients new to the registrar (OR 1.19, 95% CI: 1.04-1.35), part-time registrars (OR 1.84, 95% CI: 1.08-3.15), and areas of less socioeconomic disadvantage (OR 1.27, 95% CI: 1.00-1.62 per decile).

CONCLUSIONS

Registrars' telehealth consultations were mostly performed via telephone. Telephone use being associated with socioeconomic disadvantage has health equity implications. Future research should explore barriers to videoconferencing use and strategies to increase its uptake.

Prevalence and associations of provision of nursing home visits and home visits by early-career specialist general practitioners

OBJECTIVE

To establish prevalence and associations of provision of nursing home visits (NHV) and home visits (HV) by early-career specialist GPs. Of particular interest were associations of rurality with performing NHVs and HVs.

METHODS

A cross-sectional study.

DESIGN

A questionnaire-based study.

SETTING

Australian general practice.

PARTICIPANTS

Early-career specialist GPs, practising in Australia, who attained Fellowship between January 2016 and July 2018, inclusive, having completed GP training in NSW, the ACT, Eastern Victoria or Tasmania.

MAIN OUTCOME MEASURES

Current provision of NHV and HV.

RESULTS

NHV were provided by 34% of participants (59% in rural areas) and HV by 41% of participants (60% in rural areas). Remote, rural or regional practice location, as compared to major-city practice, was strongly associated with performing NHV as an early-career specialist GP; multivariable OR 5.87 (95% CI: 2.73, 12.6), p < 0.001, and with the provision of HV; multivariable OR 3.64 (95% CI: 1.63, 8.11), p = 0.002. Rurality of GP training (prior to attaining Fellowship) was significantly univariably associated with providing NHV and with providing HV as an early-career specialist GP. On multivariable analyses, these were no longer statistically significant.

CONCLUSION

Early-career specialist GPs located in regional/remote areas are more likely than their urban colleagues to provide NHV and HV.

Utilisation of in-consultation supervisor assistance in general practice training and personal cost to trainees: a cross-sectional study

Aim The aim of the study was to establish whether two previously described barriers to effective in-consultation assistance-seeking by general practice (GP) vocational specialist trainees (ie concern about patient impressions of their competence, and discomfort presenting to supervisors in front of patients) influenced the frequency of trainee in-consultation assistance-seeking from their supervisor. Methods This was a cross-sectional study nested in the Registrar Clinical Encounters in Clinical Training ongoing cohort study of Australian GP trainees. Trainee participants completed contemporaneous records of 60 consecutive patient consultations, including whether supervisory assistance was sought. Trainees also completed a cross-sectional survey including items eliciting their beliefs about patient impressions and their own discomfort in seeking in-consultation supervisory assistance. These were factors of interest in multivariable logistic regression analyses; the outcome factor in both regression models was the seeking of in-consultation supervisory assistance. Results In 2018, 778 trainees (778/876, response rate 89%) completed the cross-sectional survey. No association was found between the odds of in-consultation help-seeking and perceived decrease in patient impressions of trainee competence (OR = 1.09; 95% CI: 0.91, 1.31; P  = 0.36) or higher comfort presenting outside patients' hearing (OR = 0.9; 95% CI: 0.77, 1.05; P  = 0.19). Discussion Contrary to expected utility models of help-seeking, trainees may not consider personal discomfort or impression management to be important enough, compared to patient safety and other considerations, to influence decisions regarding in-consultation help-seeking. Clinical supervisors should, nevertheless, consider the potential personal costs to trainees and maintain trainee self-esteem and confidence by providing in-consultation assistance in front of patients as comfortably and effectively as possible.

Perceptions of the effectiveness of using patient encounter data as an education and reflection tool in general practice training

Introduction Patient encounter tools provide feedback and potentially reflection on general practitioner (GP) registrars' in-practice learning and may contribute to the formative assessment of clinical competencies. However, little is known about the perceived utility of such tools. Aim To investigate the perceived utility of a patient encounter tool by GP registrars, their supervisors, and medical educators (MEs). Methods General practice registrars, supervisors and MEs from two Australian regional training organisations completed a cross-sectional questionnaire. Registrars rated how Registrar Clinical Encounters in Training (ReCEnT), a patient encounter tool, influenced their reflection on, and change in, clinical practice, learning and training. Supervisors' and MEs' perceptions provided contextual information about understanding their registrars' clinical practice, learning and training needs. Results Questionnaires were completed by 48% of registrars (n  = 90), 22% of supervisors (n  = 182), and 61% of MEs (n  = 62). Most registrars agreed that ReCEnT helped them reflect on their clinical practice (79%), learning needs (69%) and training needs (72%). Many registrars reported changing their clinical practice (54%) and learning approaches (51%). Fewer (37%) agreed that ReCEnT influenced them to change their training plans. Most supervisors (68%) and MEs (82%) agreed ReCEnT reports helped them better understand their registrars' clinical practice. Similarly, most supervisors (63%) and MEs (68%) agreed ReCEnT reports helped them better understand their registrars' learning and training needs. Discussion ReCEnT can prompt self-reflection among registrars, leading to changes in clinical practice, learning approaches and training plans. Reaching its potential as an assessment for learning (as opposed to an assessment of learning) requires effective engagement between registrars, their supervisors and MEs.

General practice trainees' telehealth use during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Prompted by the COVID-19 pandemic, remuneration was introduced for Australian general practice telehealth consultations. General practitioner (GP) trainees' telehealth use is of clinical, educational, and policy importance. The aim of this study was to assess the prevalence and associations of telehealth versus face-to-face consultations amongst Australian GP registrars (vocational GP trainees).

METHODS

Cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study, from 2020 to 2021 (three 6-month terms), including registrars in 3 of Australia's 9 Regional Training Organisations. In ReCEnT, GP registrars record details of 60 consecutive consultations, 6 monthly. The primary analysis used univariate and multivariable logistic regression, with outcome of whether the consultation was conducted via telehealth (phone and videoconference) or face-to-face.

RESULTS

1,168 registrars recorded details of 102,286 consultations, of which 21.4% (95% confidence interval [CI]: 21.1%-21.6%) were conducted via telehealth. Statistically significant associations of a telehealth consultation included shorter consultation duration (odds ratio [OR] 0.93, 95% CI: 0.93-0.94; and mean 12.9 versus 18.7 min); fewer problems addressed per consultation (OR 0.92, 95% CI: 0.87-0.97); being less likely to seek assistance from a supervisor (OR 0.86, 95% CI: 0.76-0.96) while being more likely to generate learning goals (OR 1.18, 95% CI: 1.02-1.37); and being more likely to arrange a follow-up consultation (OR 1.18, 95% CI: 1.02-1.35).

CONCLUSIONS

That telehealth consultations were shorter, with higher rates of follow-up, has GP workforce/workload implications. That telehealth consultations were less likely to involve in-consultation supervisor support, but more likely to generate learning goals, has educational implications.

'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).

The prevalence and associations of Australian early-career general practitioners' provision of after-hours care

INTRODUCTION

Access to after-hours care (AHC) is an important aspect of general practice service provision.

OBJECTIVE

To establish the prevalence and associations of early-career GPs' provision of AHC.

DESIGN

An analysis of data from the New alumni Experiences of Training and independent Unsupervised Practice (NEXT-UP) cross-sectional questionnaire-based study. Participants were early-career GPs (6-month to 2-year post-Fellowship) following the completion of GP vocational training in NSW, the ACT, Victoria or Tasmania. The outcome factor was 'current provision of after-hours care'. Associations of the outcome were established using multivariable logistic regression.

FINDINGS

Three hundred and fifty-four early-career GPs participated (response rate 28%). Of these, 322 had responses available for analysis of currently performing AHC. Of these observations, 128 (40%) reported current provision of AHC (55% of rural participants and 32% of urban participants). On multivariable analysis, participants who provided any AHC during training were more likely to be providing AHC (odds ratio (OR) 5.51, [95% confidence interval (CI) 2.80-10.80], p < 0.001). Current rural location and in-training rural experience were strongly associated with currently providing AHC in univariable but not multivariable analysis.

DISCUSSION

Early-career GPs who provided AHC during training, compared with those who did not, were more than five times more likely to provide after-hours care in their first 2 years after gaining Fellowship, suggesting participation in AHC during training may have a role in preparing registrars to provide AHC as independent practitioners.

CONCLUSION

These findings may inform future GP vocational training policy and practice concerning registrars' provision of AHC during training.

Exam prediction and the general Practice Registrar Competency Assessment Grid (GPR-CAG)

BACKGROUND

In GP training, identifying early predictors of poor summative examination performance can be challenging. We aimed to establish whether external clinical teaching visit (ECTV) performance, measured using a validated instrument (GP Registrar Competency Assessment Grid, GPR-CAG) is predictive of Royal Australian College of General Practitioners (RACGP) Fellowship examination performance.

METHODS

A retrospective cohort study including GP registrars in New South Wales/Australian Capital Territory with ECTV data recorded during their first training term (GPT1), between 2014 and 2018, who attempted at least one Fellowship examination. Independent variables of interest included the four GPR-CAG factors assessed in GPT1 ('patient-centredness/caring', 'formulating hypotheses/management plans', 'professional responsibilities', 'physical examination skills'). Outcomes of interest included individual scores of the three summative examinations (Applied Knowledge Test (AKT); Key Feature Problem (KFP); and the Objective Structured Clinical Examination (OSCE)) and overall Pass/Fail status. Univariable and multivariable regression analyses were performed.

RESULTS

Univariably, there were statistically significant associations (p < 0.01) between all four GPR-CAG factors and all four summative examination outcomes, except for 'formulating hypotheses/management plans' and OSCE score (p = 0.07). On multivariable analysis, each factor was significantly associated (p < 0.05) with at least one exam outcome, and 'physical examination skills' was significantly associated (p < 0.05) with all four exam outcomes.

DISCUSSION

ECTV performance, via GPR-CAG scores, is predictive of RACGP Fellowship exam performance. The univariable findings highlight the pragmatic utility of ECTVs in flagging registrars who are at-risk of poor exam performance, facilitating early intervention. The multivariable associations of GPR-CAG scores and examination performance suggest that these scores provide predictive ability beyond that of other known predictors.

General practice registrars training part-time: a cross-sectional analysis of prevalence and associations

While GPs are working fewer clinical hours and many GP trainees (registrars) do not foresee themselves working full-time in clinical practice, little is known of the epidemiology of registrars training part-time. We aimed to establish the prevalence of general practice part-time training (PTT), and part-time registrars' characteristics and practice patterns. A cross-sectional analysis was conducted of data from the Registrar Clinical Encounters in Training project, an ongoing cohort study of Australian GP registrars' clinical experiences over 60 consecutive consultations in each of three training terms. Univariable and multivariable logistic regression analyses were conducted with the outcome 'training part-time'. 1790 registrars contributed data for 4,135 registrar-terms and 241,945 clinical encounters. Nine hundred and twenty-two registrar-terms (22%, 95%CI:21%-24%) and 52,339 clinical encounters (22%, 95%CI:21%-22%) involved PTT. Factors associated with PTT were registrar characteristics - female gender, older age, in a later training stage, performing other regular medical work; practice characteristics - working in a higher socioeconomic status area; and patient characteristics - seeing more patients new to the registrar and seeing more patients from a non-English-speaking background. No consultation or consultation action factors were significantly associated with PTT. Registrars, practices, and patient associations have GP training implications. The lack of registrar consultation or consultation action associations suggests there may be limited impact of PTT on patient care.

Absolute cardiovascular risk assessment by Australian early-career general practitioners: a cross-sectional study

OBJECTIVE

To determine the prevalence and associations of general practice registrars' performing absolute cardio-vascular risk (ACVR) assessment (ACVRa).

DESIGN

A cross-sectional study employing data (2017-2018) from the Registrar Clinical Encounters in Training project, an ongoing inception cohort study of Australian GP registrars. The outcome measure was whether an ACVRa was performed. Analyses employed univariable and multivariable regression. Analysis was conducted for all patient problems/diagnoses, then for an 'at-risk' population (specific problems/diagnoses for which ACVRa is indicated).

SETTING

Three GP regional training organisations (RTOs) across three Australian states.

PARTICIPANTS

GP registrars training within participating RTOs.

RESULTS

1003 registrars (response rate 96.8%) recorded details of 69 105 problems either with Aboriginal and/or Torres Strait patients aged 35 years and older or with non-Indigenous patients aged 45 years and older. Of these problems/diagnoses, 1721 (2.5% (95% CI 2.4% to 2.6%)) involved an ACVRa. An ACVRa was 'plausibly indicated' in 10 384 problems/diagnoses. Of these, 1228 (11.8% (95% CI 11.2% to 12.4%)) involved ACVRa. For 'all problems/diagnoses', on multivariable analysis female gender was associated with reduced odds of ACVRa (OR 0.61 (95% CI 0.54 to 0.68)). There was some evidence for Aboriginal and/or Torres Strait Islander people being more likely to receive ACVRa (OR 1.40 (95% CI 0.94 to 2.08), p=0.10). There were associations with variables related to continuity of care, with reduced odds of ACVRa: if the patient was new to the registrar (OR 0.65 (95% CI 0.57 to 0.75)), new to the practice (OR 0.24 (95% CI 0.15 to 0.38)) or the problem was new (OR 0.68 (95% CI 0.59 to 0.78)); and increased odds if personal follow-up was organised (OR 1.43 (95% CI 1.24 to 1.66)). For 'ACVRa indicated' problems/diagnoses, findings were similar to those for 'all problems/diagnoses'. Association with Aboriginal and/or Torres Strait Islander status, however, was significant at p<0.05 (OR 1.60 (95% CI 1.04 to 2.46)) and association with female gender was attenuated (OR 0.88 (95% CI 0.77 to 1.01)).

CONCLUSION

Continuity of care is associated with registrars assessing ACVR, reinforcing the importance of care continuity in general practice. Registrars' assessment of an individual patient's ACVR is targeted to patients with individual risk factors, but this may entail ACVRa underutilisation in female patients and younger age groups.

Prevalence and associated skills of Australian general practice registrars seeing children with functional bowel and bladder problems

AIM

Functional bowel (constipation and faecal incontinence) and bladder (urinary incontinence and enuresis) problems in children are often treated by paediatricians yet should mostly be managed by general practitioners (GPs). To understand whether the necessary skills and knowledge are being built in general practice, this study aimed to establish the prevalence and associated skills of Australian general practice registrars managing children with functional bowel and bladder problems. Together as paediatricians and GPs, we use these data to determine how best to ensure high quality, equitable care for children.

METHODS

We drew on 16 rounds of data collection from the Registrar Clinical Encounters in Training (ReCEnT) multi-site cohort study (2010-2017) of general practice registrars' in-consultation experience. It included a measure of paediatric consultations in which a functional bowel or bladder problem was managed, as well as demographic information.

RESULTS

Out of 62 721 problems/diagnoses for paediatric patients (0-17 years), 844 (1.4%) were coded as functional bowel (n = 709; 1.13% (95% confidence interval, CI: 1.05-1.22)) and/or bladder (n = 135; 0.22% (95% CI: 0.18-0.25)) presentations. Registrars were more likely to prescribe medication for bowel problems (odds ratio (OR) = 2.22 (95% CI: 1.86-2.64)) than for all other problems, but less likely to prescribe medication (OR = 0.31 (95% CI: 0.18-0.52)) for night-time wetting and more likely to make a specialist referral (OR = 1.99 (95% CI: 1.22-3.25)) compared to all other problems.

CONCLUSIONS

Only a small proportion of children with functional bowel and bladder problems were seen by registrars despite high prevalence in the community and amenability to management in the general practice setting (i.e. generally low morbidity and low complexity) versus need for specialists. Registrars appeared to be managing functional bowel and bladder problems according to evidence-based guidelines, but with relatively high levels of referral. Given the inequitable access to specialist care, paediatricians should support local general practice management of these problems. This might include (i) engaging with training programs to ensure appropriate education and (ii) liaising with individual registrars/practices to provide management advice for individual or example cases.

Influenza presentations and use of neuraminidase inhibitors by Australian general practice registrars: a cross-sectional analysis from the ReCEnT study

OBJECTIVE

This study aims to establish prevalence and associations of (1) influenza and influenza-like illness (IILI) presentations to Australian general practice (GP) registrars (trainees) and (2) the use of neuraminidase inhibitors (NAIs) by GP registrars for new presentations of IILI, for the 10 years leading up to the COVID-19 pandemic in Australia (2010-2019).

DESIGN

This was a cross-sectional analysis of the Registrar Clinical Encounters in Training ongoing inception cohort study of the in-consultation experience and clinical behaviours of GP registrars. Data are collected by individual registrars three times (from 60 consecutive consultations each time) at 6 monthly intervals. Data include diagnoses/problems managed and medicines prescribed, along with multiple other variables. Univariate and multivariable logistic regression was used to establish associations of registrars seeing patients with IILI and of prescribing NAIs for IILI.

SETTING

Teaching practices within the Australian general practitioner specialist vocational training programme. Practices were located in five of the six Australian states (plus one territory).

PARTICIPANTS

GP registrars in each of their three compulsory 6-month GP training terms.

RESULTS

From 2010 to 2019, 0.2% of diagnoses/problems seen by registrars were IILI. 15.4% of new IILI presentations were prescribed an NAI. IILI diagnoses were less likely in younger (0-14) and older (65+) age groups, and more likely in an area of higher socioeconomic advantage. There was considerable variation in NAI prescribing between regions. There was no significant association of prescribing NAIs with age or Aboriginal and/or Torres Strait Islander patients.

CONCLUSIONS

IILI presentations were more likely among working-age adults and not among those groups at higher risk. Similarly, high-risk patient groups who would benefit most were not more likely to receive NAIs. The epidemiology and management of IILI has been distorted by the COVID-19 pandemic, but the burden of influenza in vulnerable populations must not be overlooked. Appropriately targeted antiviral therapy with NAIs influences outcomes for vulnerable patients. General practitioners manage the majority of IILI in Australia, and understanding GP IILI presentation and NAI prescribing patterns is a key first step to enabling sound and rational prescribing decisions for better patient outcomes.

Temporal patterns of antibiotic prescribing for sore throat, otitis media, and sinusitis: a longitudinal study of general practitioner registrars

BACKGROUND

Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship.

OBJECTIVES

To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis.

DESIGN

A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019.

PARTICIPANTS

ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate.

MAIN MEASURES

The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010-2019).

KEY RESULTS

Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86-0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86-0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001).

CONCLUSIONS

Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010-2019. However, educational (and other) interventions to further reduce prescribing are warranted.

Early-career general practitioners' perceptions of the utility of vocational training for subsequent independent practice

PURPOSE

To evaluate Australian early-career general practitioners' perceptions of the utility of their prior vocational training in preparing them for independent specialist practice. We hypothesised that in-practice teaching would be perceived as more useful than formal education delivered by Regional Training Organisations (RTOs).

METHODS AND MATERIALS

A cross-sectional questionnaire-based study of early-career general practitioners (RTO 'alumni'). The outcomes were Likert scale ratings of alumni's perceived impact of RTO education versus in-practice training on their preparedness for independent practice. Ratings were compared using Wilcoxon signed-rank tests. Multivariable linear regression was used to establish alumni characteristics associated with perceptions of utility of in-practice versus RTO-delivered education.

RESULTS

Three hundred and fifty-four alumni responded (response rate 28%). In-practice training was rated statistically significantly higher than RTO education for minor procedural skills, teaching skills, professional responsibilities, tolerating clinical uncertainty, and preparing for managing child and adolescent health, aged care, chronic disease, multi-morbidity and mental health. RTO education rated higher than in-practice training for practising evidence-based medicine and Aboriginal and Torres Strait Islander health. For a number of further areas, there was no statistically significant difference in alumni ratings of utility.

CONCLUSIONS

In-practice or RTO-led teaching was perceived as more useful for some components of independent practice, whilst for others there was no significant difference. The findings support recognition of the individual educational components of a blended education/training structure.

Temporal trends in, and associations of, early-career general practitioner prescriptions of second-line Type 2 Diabetes medications, 2010-2018

INTRODUCTION

Second-line pharmacotherapy for Type 2 Diabetes Mellitus ('diabetes') is necessary for optimal glycaemic control and preventing longer-term complications. We aimed to describe temporal trends in, and associations of, Australian general practitioner (GP) registrars' prescription, and initiation, of 'new' second-line oral agents (dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists) compared to sulphonylureas.

MATERIALS AND METHODS

A longitudinal analysis (2010-2018) of data from the Registrar Clinical Encounters in Training project. Analysis included any diabetes problem/diagnosis that involved prescription of sulphonylureas or 'new' oral agents. Simple and multiple logistic regression models were fitted within the generalised estimating equations framework.

RESULTS

2333 registrars recorded 6064 diabetes problems/diagnoses (1.4%). 835 problems/diagnoses involved sulphonylurea or 'new' medication prescription. Of these, 61.0% [95% CI:57.4-64.4] involved 'new' medication prescription. 230 problems/diagnoses involved sulphonylurea or 'new' medication initiation, with 77% [95%CI:70.8-82.1] involving a 'new' medication. There was a significant 52% per year increase in prescribing (OR = 1.52[95% CI:1.38-1.68],p<0.001), and a 77% per (two-to-three-year) time-interval increase in initiation (OR = 1.77,[95% CI:1.30-2.43],p = <0.001) of 'new' medications compared to sulphonylureas. 'New' medications were prescribed less for non-English-speaking patients. There was some regional variation in prescribing.

CONCLUSION

Registrar uptake of 'new' oral agents compared to sulphonylureas has increased rapidly.

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.

Provision of other medical work by Australian early-career general practitioners: a cross-sectional study

Introduction There is a trend towards GPs diversifying their role by working in health areas beyond general practice. However, little is known about whether this trend is apparent among early-career GPs once they make the transition from training to independent practice. Aim To describe the prevalence of and characteristics associated with early-career GPs providing other medical work. Methods A cross-sectional questionnaire-based study of GPs ('alumni') who had fellowed within the past 2 years from three of Australia's nine regional training programs. The outcome factor was provision of medical work in addition to clinical general practice. Associations of independent variables (encompassing alumni demographics, current practice characteristics and vocational training experience) with the outcome were estimated using univariate and multivariable logistic regression. Results Of 339 responding alumni, 111 (33%) undertook other regular medical work. Sixty-five (59%) of these were in medical education. In multivariable analysis, factors associated with providing other medical work were having a spouse/partner not in the workforce (odds ratio (OR) 5.13), having done any training part-time (OR 2.67), providing two or more of home visits, nursing home visits and after-hours care (OR 2.20), working fewer sessions per week (OR 0.74), and currently working in an area of lower socio-economic status (OR 0.84). Having dependent children (OR 0.27), and being female (OR 0.43) were associated with not providing other medical work. Discussion In this study, many early-career GPs are providing other medical work, particularly medical education. Acknowledging this is important to general practice workforce planning and education policy.

Antibiotic prescribing for upper respiratory tract infections and acute bronchitis: a longitudinal analysis of general practitioner trainees

BACKGROUND

Most antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis is inappropriate. Substantive and sustained reductions in prescribing are needed to reduce antibiotic resistance. Prescribing habits develop early in clinicians' careers. Hence, general practice (GP) trainees are an important group to target.

OBJECTIVES

We aimed to establish temporal trends in antibiotic prescribing for URTIs and acute bronchitis/bronchiolitis by Australian GP trainees (registrars).

METHODS

A longitudinal analysis, 2010-2019, of the Registrars Clinical Encounters in Training (ReCEnT) dataset. In ReCEnT, registrars record clinical and educational content of 60 consecutive consultations, on 3 occasions, 6 monthly. Analyses were of new diagnoses of URTI and acute bronchitis/bronchiolitis, with the outcome variable a systemic antibiotic being prescribed. The independent variable of interest was year of prescribing (modelled as a continuous variable).

RESULTS

28,372 diagnoses of URTI and 5,289 diagnoses of acute bronchitis/bronchiolitis were recorded by 2,839 registrars. Antibiotic prescribing for URTI decreased from 24% in 2010 to 12% in 2019. Prescribing for acute bronchitis/bronchiolitis decreased from 84% to 72%. "Year" was significantly, negatively associated with antibiotic prescribing for both URTI (odds ratio [OR] 0.90; 95% confidence interval [CI]: 0.88-0.93) and acute bronchitis/bronchiolitis (OR 0.92; 95% CI: 0.88-0.96) on multivariable analysis, with estimates representing the mean annual change.

CONCLUSIONS

GP registrars' prescribing for URTI and acute bronchitis/bronchiolitis declined over the 10-year period. Prescribing for acute bronchitis/bronchiolitis, however, remains higher than recommended benchmarks. Continued education and programme-level antibiotic stewardship interventions are required to further reduce registrars' antibiotic prescribing for acute bronchitis/bronchiolitis to appropriate levels.

Rural versus metropolitan comparison of processes of care in the community‐based management of TIA and minor stroke in Australia (an analysis from the INSIST study)

OBJECTIVES

To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia.

DESIGN

Inception cohort study between 2012 and 2016 with 12-month follow-up after index event (sub-study of INSIST).

SETTING

Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC).

PARTICIPANTS

Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care.

MAIN OUTCOME MEASURES

Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes.

RESULTS

Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants.

CONCLUSIONS

Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients.

Climate change and Australian general practice vocational education: a cross-sectional study

BACKGROUND

Climate change is a rapidly progressing threat to global health and well-being. For general practitioners (GPs) currently in training, the effects of climate change on public health will shape their future professional practice We aimed to establish the prevalence and associations of Australian GP registrars' (trainees') perceptions of climate change as it relates to public health, education, and workplaces.

METHODS

A cross-sectional questionnaire-based study of GP registrars of three Australian training organizations. The questionnaire assessed attitudes regarding adverse health effects of climate change (over the next 10-20 years), and agreement with statements on (i) integrating health impacts of climate change into GP vocational training, and (ii) GPs' role in making general practices environmentally sustainable.

RESULTS

Of 879 registrars who participated (response rate 91%), 50.4% (95% CI 46.8%, 54.0%) perceived a large or very large future health effect of climate change on their patients, and 61.8% (95% CI 58.6%, 65.0%) agreed that climate health impacts should be integrated within their education programme. 77.8% (95% CI 74.9%, 80.4%) agreed that GPs should have a leadership role in their practices' environmental sustainability. Multivariable associations of these attitudes included female gender, training region, and (for the latter two outcomes) perceptions of future impact of climate change on patient health.

CONCLUSIONS

GP registrars are motivated to receive climate health education and engage in environmentally sustainable practice. This may primarily reflect concern for future practice and patient care.

'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.

Prevalence and associations of rural practice location in early-career general practitioners in Australia: a cross-sectional analysis

OBJECTIVES

To: (1) establish the prevalence of urban, regional, rural and remote practice location of early-career general practitioners (GPs); and (2) examine demographic and training-related characteristics associated with working in regional, rural or remote areas post attainment of vocational general practice qualifications.

DESIGN

Cross-sectional, questionnaire-based study, combined with contemporaneously collected data from participants' prior vocational training.

SETTING

Australian general practice.

PARTICIPANTS

Newly vocationally qualified GPs (ie, within 6 months-2 years post fellowship) who had completed vocational training with regional training organisations in New South Wales, Australian Capital Territory, eastern Victoria, and Tasmania between January 2016 and July 2018.

PRIMARY OUTCOME MEASURE

Rurality of post-fellowship practice location, as defined by Modified Monash Model (MMM) geographical classifications, based on current practice postcode. Prevalence of regional/rural/remote ('rural') practice was described using frequencies, and associations of rural practice were established using multivariable logistic regression, considering a range of demographic factors and training characteristics as independent variables.

RESULTS

A total of 354 participants completed the questionnaire (response rate 28%) with 319 providing information for their current practice location. Of these, 100 (31.4%) reported currently practising in a rural area (MMM2-7). Factors most strongly associated with practising in a rural area included having undertaken vocational GP training in a rural location OR 16.0 (95% CI 6.79 to 37.9); p<0.001; and undertaking schooling in rural area prior to university OR 4.21 (1.98, 8.94); p<0.001.

CONCLUSIONS

The findings suggest that vocational training experience may have a role in rural general practice location post fellowship, attenuating the previously demonstrated 'leakage' from the rural practice pipeline.

Transitions in general practice training: quantifying epidemiological variation in trainees' experiences and clinical behaviours

BACKGROUND

General Practice training in Australia is delivered through the apprenticeship model. General Practice supervisors support trainees transitioning from hospital-based work towards competent independent community-based practice. The timing and manner in which support should be provided is still not well understood. This study aimed to establish the variation in clinical and educational experiences and behaviours, and location, of general practice trainees' consultations by stage of their vocational training. It was hypothesised that change is greater in earlier stages of training.

METHODS

A cross-sectional analysis of data (2010-2018) from the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing cohort study of Australian GP registrars' in-consultation clinical and educational experience and behaviours. Multinomial logistic regression assessed the association of demographic, educational, and clinical factors in different stages of training. The outcome factor was the training term.

RESULTS

Two thousand four hundred sixteen registrars contributed data for 321,414 patient consultations. For several important variables (seeing patients with chronic disease; new patients; seeking in-consultation information or assistance; ordering pathology and imaging; and working in a small or regional practice), odds ratios were considerably greater for comparisons of Term 1 and 3, relative to comparisons of Term 2 and 3.

CONCLUSION

Differences experienced in demographic, clinical and educational factors are significantly more pronounced earlier in registrars' training. This finding has educational and training implications with respect to resource allocation, trainee supervision and curriculum design. Sociocultural learning theory enables an understanding of the impact of transitions on, and how to support, general practice trainees and supervisors.

Influence of rurality on general practitioner registrars' participation in their practice's after-hours roster: A cross-sectional study

Objective

To investigate whether practice rurality and rural training pathway are associated with general practitioner registrars' participation in their practice's after‐hours care roster.

Design

A cross‐sectional analysis of data (2017‐2019) from the Registrar Clinical Encounters in Training study, an ongoing inception cohort study of Australian general practitioner registrars. The principal analyses used logistic regression.

Setting

Three national general practitioner regional training organisations across 3 Australian states.

Participants

General practitioner registrars in training within regional training organisations.

Main outcome measure

Involvement in practice after‐hours care was indicated by a dichotomous response on a 6‐monthly Registrar Clinical Encounters in Training study questionnaire item.

Results

1576 registrars provided 3158 observations (response rate 90.3%). Of these, 1574 (48.6% [95% confidence interval: 46.8‐50.3]) involved registrars contributing to their practice's after‐hours roster. In major cities, 40% of registrar terms involved contribution to their practice's after‐hours roster; in regional and remote practices, 62% contributed to the after‐hours roster. On multivariable analysis, both level of rurality of practice (odds ratio(OR) 1.75, P = .007; and OR 1.74, P = .026 for inner regional and outer regional/remote locations, respectively, versus major city) and rural training pathway of registrar (OR 1.65, P = .008) were significantly associated with more after‐hours roster contribution. Other associations were registrars' later training stage, larger practices and practices not routinely bulk billing. Significant regional variability in after‐hours care was identified (after adjusting for rurality).

Conclusion

These findings suggest that registrars working rurally and those training on the rural pathway are more often participating in practice after‐hours rosters. This has workforce implications, and implications for the educational richness of registrars' training environment.

One-Year Risk of Stroke After Transient Ischemic Attack or Minor Stroke in Hunter New England, Australia (INSIST Study)

Background: One-year risk of stroke in transient ischemic attack and minor stroke (TIAMS) managed in secondary care settings has been reported as 5-8%. However, evidence for the outcomes of TIAMS in community care settings is limited. Methods: The INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study was a prospective inception cohort community-based study of patients of 16 general practices in the Hunter-Manning region (New South Wales, Australia). Possible-TIAMS patients were recruited from 2012 to 2016 and followed-up for 12 months post-index event. Adjudication as TIAMS or TIAMS-mimics was by an expert panel. We established 7-days, 90-days, and 1-year risk of stroke, TIA, myocardial infarction (MI), coronary or carotid revascularization procedure and death; and medications use at 24 h post-index event. Results: Of 613 participants (mean age; 70 ± 12 years), 298 (49%) were adjudicated as TIAMS. TIAMS-group participants had ischemic strokes at 7-days, 90-days, and 1-year, at Kaplan-Meier (KM) rates of 1% (95% confidence interval; 0.3, 3.1), 2.1% (0.9, 4.6), and 3.2% (1.7, 6.1), respectively, compared to 0.3, 0.3, and 0.6% of TIAMS-mimic-group participants. At one year, TIAMS-group-participants had twenty-five TIA events (KM rate: 8.8%), two MI events (0.6%), four coronary revascularizations (1.5%), eleven carotid revascularizations (3.9%), and three deaths (1.1%), compared to 1.6, 0.6, 1.0, 0.3, and 0.6% of TIAMS-mimic-group participants. Of 167 TIAMS-group participants who commenced or received enhanced therapies, 95 (57%) were treated within 24 h post-index event. For TIAMS-group participants who commenced or received enhanced therapies, time from symptom onset to treatment was median 9.5 h [IQR 1.8-89.9]. Conclusion: One-year risk of stroke in TIAMS participants was lower than reported in previous studies. Early implementation of antiplatelet/anticoagulant therapies may have contributed to the low stroke recurrence.

Specificity of early-career general practitioners' problem formulations in patients presenting with dizziness: a cross-sectional analysis

OBJECTIVES

Dizziness is a common and challenging clinical presentation in general practice. Failure to determine specific aetiologies can lead to significant morbidity and mortality. We aimed to establish frequency and associations of general practitioner (GP) trainees' (registrars') specific vertigo provisional diagnoses and their non-specific symptomatic problem formulations.

DESIGN

A cross-sectional analysis of Registrar Clinical Encounters in Training (ReCEnT) cohort study data between 2010 and 2018. ReCEnT is an ongoing, prospective cohort study of registrars in general practice training in Australia. Data collection occurs once every 6 months midtraining term (for three terms) and entails recording details of 60 consecutive clinical consultations on hardcopy case report forms. The outcome factor was whether dizziness-related or vertigo-related presentations resulted in a specific vertigo provisional diagnosis versus a non-specific symptomatic problem formulation. Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.

SETTING

Australian general practice training programme. The training is regionalised and delivered by regional training providers (RTPs) (2010-2015) and regional training organisations (RTOs) (2016-2018) across Australia (from five states and one territory).

PARTICIPANTS

All general practice registrars enrolled with participating RTPs or RTOs undertaking GP training terms.

RESULTS

2333 registrars (96% response rate) recorded 1734 new problems related to dizziness or vertigo. Of these, 546 (31.5%) involved a specific vertigo diagnosis and 1188 (68.5%) a non-specific symptom diagnosis. Variables associated with a non-specific symptom diagnosis on multivariable analysis were lower socioeconomic status of the practice location (OR 0.94 for each decile of disadvantage, 95% CIs 0.90 to 0.98) and longer consultation duration (OR 1.02, 95% CIs 1.00 to 1.04). A specific vertigo diagnosis was associated with performing a procedure (OR 0.52, 95% CIs 0.27 to 1.00), with some evidence for seeking information from a supervisor being associated with a non-specific symptom diagnosis (OR 1.39, 95% CIs 0.92 to 2.09; p=0.12).

CONCLUSIONS

Australian GP registrars see dizzy patients as frequently as established GPs. The frequency and associations of a non-specific diagnosis are consistent with the acknowledged difficulty of making diagnoses in vertigo/dizziness presentations. Continuing emphasis on this area in GP training and encouragement of supervisor involvement in registrars' diagnostic processes is indicated.

Deprescribing in older patients by early-career general practitioners: Prevalence and associations

RATIONALE AND AIMS

Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs.

METHODS

A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines.

RESULTS

One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration).

CONCLUSION

These findings will have important implications for the education of GPs in deprescribing as a clinical skill.

Prescribing of long-acting reversible contraception by general practice registrars across different rural regions of Australia: A cross-sectional analysis of the Registrar Clinical Encounters in Training Study data

OBJECTIVE

To describe the pattern of prescribing long-acting reversible contraception by Australian general practitioner registrars across different classifications of rurality/urbanicity.

METHODS

A study nested within the Registrar Clinical Encounters in Training ongoing cohort study of Australian general practitioner registrars' in-consultation experience.

DESIGN

A cross-sectional analysis of Registrar Clinical Encounters in Training data collected 2010-2017. Type of contraception prescribed by general practitioner registrars to women aged 12-55 for contraception-related indications was documented. Chi-square statistical analysis was performed to assess association of specific long-acting reversible contraception methods with rurality/urbanicity.

SETTING/PARTICIPANTS

General practitioner registrars enrolled in the Australian General Practice Training program in regional training providers/organisations participating in Registrar Clinical Encounters in Training.

MAIN OUTCOME MEASURES

Long-acting reversible contraception was defined as etonogestrel implant, copper intrauterine device, levonorgestrel intrauterine device and medroxyprogesterone injection.

RESULTS

In all 1737 registrars recorded 4073 registrar rounds of data from 2010 to 2017 (response rate 96%). Type of long-acting reversible contraception prescribed differed significantly across Australian Statistical Geography Standards classification of rurality (Pearson's χ²  = 17, P = .002). Women living in outer regional/remote/very remote regions are prescribed proportionately more medroxyprogesterone injection and less levonorgestrel intrauterine device compared to major cities/inner regional areas.

CONCLUSIONS

Long-acting reversible contraception methods prescribed differ across different classifications of rurality. Women living in more rural/remote regions might have access difficulties for the levonorgestrel intrauterine device.

Brain Α-Tocopherol Concentration is Inversely Associated with Neurofibrillary Tangle Counts in Brain Regions Affected in Earlier Braak Stages: A Cross-Sectional Finding in the Oldest Old

Objectives

Higher vitamin E status has been associated with lower risk of Alzheimer's disease (AD). However, evidence of the association of vitamin E concentration in neural tissue with AD pathologies is limited.

Design

The cross-sectional relationship between the human brain concentrations of α- and γ-tocopherol and the severity of AD pathologies - neurofibrillary tangle (NFT) and neuritic plaque (NP) - was investigated.

Setting & Participants

Brains from 43 centenarians (≥ 98 years at death) enrolled in the Phase III of the Georgia Centenarian Study were collected at autopsy.

Measurements

Brain α- and γ-tocopherol concentrations (previously reported) were averaged from frontal, temporal, and occipital cortices. NP and NFT counts (previously reported) were assessed in frontal, temporal, parietal, entorhinal cortices, amygdala, hippocampus, and subiculum. NFT topological progression was assessed using Braak staging. Multiple linear regression was performed to assess the relationship between tocopherol concentrations and NP or NFT counts, with and without adjustment for covariates.

Results

Brain α-tocopherol concentrations were inversely associated with NFT but not NP counts in amygdala (β = -2.67, 95% CI [-4.57, -0.79]), entorhinal cortex (β = -2.01, 95% CI [-3.72, -0.30]), hippocampus (β = -2.23, 95% CI [-3.82, -0.64]), and subiculum (β = -2.52, 95% CI [-4.42, -0.62]) where NFT present earlier in its topological progression, but not in neocortices. Subjects with Braak III-IV had lower α-tocopherol (median = 69,622 pmol/g, IQR = 54,389-72,155 pmol/g) than those with Braak I-II (median = 72,108 pmol/g, IQR = 64,056-82,430 pmol/g), but the difference was of borderline significance (p = 0.063). γ-Tocopherol concentrations were not associated with either NFT or NP counts in any brain regions assessed.

Conclusions

Higher brain α-tocopherol level is specifically associated with lower NFT counts in brain structures affected in earlier Braak stages. Our findings emphasize the possible importance of α-tocopherol intervention timing in tauopathy progression and warrant future clinical trials.

Antibiotic prescribing patterns of general practice registrars for infective conjunctivitis: a cross-sectional analysis

INTRODUCTION Over-prescription of antibiotics for common infective conditions is an important health issue. Infective conjunctivitis represents one of the most common eye-related complaints in general practice. Despite its self-limiting nature, there is evidence of frequent general practitioner (GP) antibiotic prescribing for this condition, which is inconsistent with evidence-based guidelines. AIM To investigate the prevalence and associations of GP registrars' (trainees') prescription of antibiotics for infective conjunctivitis. METHODS We performed a cross-sectional analysis of the Registrar Encounters in Clinical Training (ReCEnT) ongoing prospective cohort study, which documents GP registrars' clinical consultations (involving collection of information from 60 consecutive consultations, at three points during registrar training). The outcome of the analyses was antibiotic prescription for a new diagnosis of conjunctivitis. Patient, registrar, practice and consultation variables were included in uni- and multivariable logistic regression analyses to test associations of these prescriptions. RESULTS In total, 2333 registrars participated in 18 data collection rounds from 2010 to 2018. There were 1580 new cases of infective conjunctivitis (0.31% of all problems). Antibiotics (mainly topical) were prescribed in 1170 (74%) of these cases. Variables associated with antibiotic prescription included patients' Aboriginal or Torres Strait Islander status, registrar organisation of a follow up (both registrar and other GP follow up), and earlier registrar training term (more junior status). DISCUSSION GP registrars, like established GPs, prescribe antibiotics for conjunctivitis in excess of guideline recommendations, but prescribing rates are lower in later training. These prescribing patterns have educational, social and economic consequences. Further educational strategies may enhance attenuation of registrars' prescribing during training.

Management of urinary tract infection by early-career general practitioners in Australia

RATIONALE, AIMS, AND OBJECTIVES

Urinary tract infection (UTI) is a common presentation to general practitioners (GPs). There is increasing antimicrobial resistance in urinary pathogens in many healthcare systems. Adherence to principles of antimicrobial stewardship is important to combat this problem. Our aim was to describe the prevalence of presentations of clinically diagnosed new UTI to early-career GPs, to describe management choices made, and to identify associations of prescribing antibiotics at the index consultation for UTI.

METHOD

This is a cross-sectional analysis of the Registrar Clinical Encounters in Training cohort study. Early-career GPs from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of three 6-month training terms. Proportions of problems being new UTIs, antibiotics prescribed, urine microscopy and culture ordered were calculated. Univariate and multivariable logistic regressions established associations of patient, registrar, and practice factors with prescribing antibiotics for a new UTI.

RESULTS

One thousand three hundred thirty-three early-career GPs diagnosed 2850 new UTIs from 189 736 consultations (1.5%; 95% CI, 1.4-1.6). Antibiotics were prescribed at 86% (95% CI, 84.7-87.2) of these index consultations. Antibiotic choice followed Australian therapeutic guideline recommendations. Urine microscopy and culture were requested at the index consultation less than recommended by guidelines in men, 69.2% (95% CI, 62.6-75.1), and children, 80.8% (95% CI, 76.4-84.6). Adults were significantly more likely to be treated with antibiotics at the index consultation than children under 16.

CONCLUSIONS

A new UTI is a common presentation to Australian early-career GPs. There is general adherence to guidelines for antibiotic choice in UTIs. Further research is needed, however, to understand some decisions made when managing UTI in children and men. This may reflect diagnostic uncertainty with consequent attention to antibiotic stewardship by deferring antibiotic prescription.

Delayed prescribing of antibiotics for acute respiratory infections by GP registrars: a qualitative study

BACKGROUND

Antibiotic prescribing for acute self-limiting respiratory tract infections (ARTIs) in Australia is higher than international benchmarks. Antibiotics have little or no efficacy in these conditions, and unnecessary use contributes to antibiotic resistance. Delayed prescribing has been shown to reduce antibiotic use. GP registrars are at a career-stage when long-term prescribing patterns are being established.

AIM

To explore experiences, perceptions and attitudes of GP registrars and supervisors to delayed antibiotic prescribing for ARTIs.

DESIGN AND SETTING

A qualitative study of Australian GP registrars and supervisors using a thematic analysis approach.

METHOD

GP registrars and supervisors were recruited across three Australian states/territories, using maximum variation sampling. Telephone interviews explored participants' experience and perceptions of delayed prescribing of antibiotics in ARTIs. Data collection and analysis were concurrent and iterative.

RESULTS

A total of 12 registrars and 10 supervisors were interviewed. Key themes included the use of delayed prescribing as a safety-net in cases of diagnostic uncertainty or when clinical review was logistically difficult. Delayed prescribing was viewed as a method of educating and empowering patients, and building trust and the doctor-patient relationship. Conversely, it was also seen as a loss of control over management decisions. Supervisors, more so than registrars, appreciated the psychosocial complexity of ARTI consultations and the importance of delayed antibiotic prescribing in this context.

CONCLUSION

Better awareness and understanding by GP registrars of the evidence for delayed antibiotic prescription may be a means of reducing antibiotic prescribing. Understanding both registrar and supervisor usage, uncertainties and attitudes should inform educational approaches on this topic.

The Characteristics of Patients With Possible Transient Ischemic Attack and Minor Stroke in the Hunter and Manning Valley Regions, Australia (the INSIST Study)

Background: Transient ischemic attack (TIA) and minor stroke (TIAMS) are risk factors for stroke recurrence. Some TIAMS may be preventable by appropriate primary prevention. We aimed to recruit “possible-TIAMS” patients in the INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study.

Methods: A prospective inception cohort study performed across 16 Hunter–Manning region, Australia, general practices in the catchment of one secondary-care acute neurovascular clinic. Possible-TIAMS patients were recruited from August 2012 to August 2016. We describe the baseline demographics, risk factors and pre-event medications of participating patients.

Results: There were 613 participants (mean age; 69 ± 12 years, 335 women), and 604 (99%) were Caucasian. Hypertension was the most common risk factor (69%) followed by hyperlipidemia (52%), diabetes mellitus (17%), atrial fibrillation (AF) (17%), prior TIA (13%) or stroke (10%). Eighty-nine (36%) of the 249 participants taking antiplatelet therapy had no known history of cardiovascular morbidity. Of 102 participants with known AF, 91 (89%) had a CHA2DS2-VASc score ≥ 2 but only 47 (46%) were taking anticoagulation therapy. Among 304 participants taking an antiplatelet or anticoagulant agent, 30 (10%) had stopped taking these in the month prior to the index event.

Conclusion: This study provides the first contemporary data on TIAMS or TIAMS-mimics in Australia. Community and health provider education is required to address the under-use of anticoagulation therapy in patients with known AF, possibly inappropriate use of antiplatelet therapy and possibly inappropriate discontinuation of antiplatelet or anticoagulation therapy.

Prevalence and associations of prescribing of long-acting reversible contraception by general practitioner registrars: a secondary analysis of ReCEnT data

OBJECTIVE

Long-acting reversible contraception (LARC) is the most effective form of contraception but use in Australia is low. Uptake of LARC prescribing by early-career general practitioners (GPs) has important implications for community reproductive health. We aimed to investigate the prevalence and associations of Australian GP registrars' LARC prescribing.

METHODS

A cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) cohort study 2010-2017. GP registrars collected data on 60 consecutive consultations on three occasions during their training. The outcome factor was prescription of LARC (compared with non-LARC). A secondary analysis was performed with problems involving prescription of LARC (compared with other problems). Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.

RESULTS

1737 registrars recorded 5382 problems/diagnoses involving women aged 12-55 years in which contraception was prescribed. 1356 (25%) involved LARC. Significant multivariable associations of prescribing LARC included patient age (OR 2.85, 95% CI 3.17 to 3.74, for age 36-45 years compared with age 12-18 years), practice rurality - inner-regional (OR 1.47, 95% CI 1.22 to 1.79) and outer-regional/remote/very remote (OR 1.47 95% CI 1.15 to 1.87) compared with major cities, practices in areas of lower socioeconomic status (SES) (OR 0.93, 95% CI 0.91 to 0.96 for SES by decile), generating learning goals (OR 1.37, 95% CI 1.04 to 1.79), in-consultation assistance-seeking (OR 1.58, 95% CI 1.24 to 2.01), and the registrar having reproductive health-related postgraduate qualifications (OR 1.33, 95% CI 1.01 to 1.76).

CONCLUSIONS

The prevalence of LARC prescribing by Australian GP registrars is higher than has been previously estimated in established GPs. Postgraduate qualifications in reproductive health are associated with prescribing LARC. Prescribing practice differs according to rurality and relative socioeconomic disadvantage.

Prevalence and Associations of General Practice Registrars' Management of Impetigo: A Cross-Sectional Analysis From the Registrar Clinical Encounters in Training (ReCEnT) Study

Background

Impetigo is a mild bacterial skin infection of childhood that is usually managed empirically in primary care.

Objective

To establish the prevalence and associations of impetigo in general practice (GP) registrars' consultations.

Methods

Cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study data.

Results

Impetigo was managed in 0.24% of problems and 0.43% of consultations. Patient variables associated with impetigo presentations were younger age and impetigo as a new problem, while patients with non-English-speaking backgrounds were less likely to present with impetigo. Associated registrar variables were being new to the registrar and practicing in outer regional/remote locations. Compared with all other problems/diagnoses, impetigo more often involved information seeking, ordering pathology, and prescription of medication, but less often involved follow-up or referral.

Conclusions

Impetigo accounts for 0.43 per 100 GP registrar consultations in Australia. Association with outer regional/remote areas may reflect climate and socioeconomic factors that predispose to impetigo. Associated pathology requests may reflect a lack of confidence in GP registrars' management of impetigo. Cultural differences may exist regarding health-seeking behavior relating to impetigo.

Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP's management of impetigo

OBJECTIVE

To establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18 months in general practice).

DESIGN

A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study.

SETTING

ReCEnT is an ongoing multisite cohort study of Australian registrars' in-consultation clinical practice across five Australian states.

PARTICIPANTS

Registrars participating in ReCEnT from 2010 to 2017.

OUTCOME MEASURES

Management of impetigo with systemic antibiotics.

RESULTS

1741 registrars (response rate 96%) provided data from 384 731 problems identified in 246 434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95% CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95% CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95% CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95% CI 1.37 to 3.33; p=0.01).

CONCLUSIONS

Australian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.

General practice registrars' experiences of antenatal care: A cross-sectional analysis

BACKGROUND

General practitioners play an important role in diagnosis and ongoing management of pregnancies. Some GP registrars entering GP training may have had no post-graduate experience in obstetrics and gynaecology. GP registrars' involvement in antenatal care is under-researched.

AIMS

This study aimed to determine the prevalence and associations of Australian GP registrars' clinical consultations involving antenatal care.

MATERIALS AND METHODS

A cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) cohort study. GP registrars record details of 60 consecutive consultations during each of three six-month training terms. Associations of managing pregnancy-related problems (compared to all other problems) were analysed using univariate and multivariable logistic regression. Independent variables included registrar, practice, patient, consultation and educational factors.

RESULTS

Antenatal care comprised 3277 (1.1%) of registrar problems/diagnoses. Consultations involving pregnancy-related problems were significantly associated with registrars being female, in term three, younger, and having post-graduate qualifications in obstetrics/gynaecology. Patients were significantly more likely to be from a non-English speaking background. Pregnancy-related problems/diagnoses were more likely to be seen in lower socioeconomic areas. Consultation factors significantly associated with a pregnancy-related problem/diagnosis included ordering imaging, ordering pathology, arranging referrals, and a longer duration of consultation. Registrars were less likely to prescribe medication or generate learning goals.

CONCLUSIONS

GP registrars see fewer antenatal problems compared to established GPs. Male registrars, especially, have significantly less exposure to antenatal care, suggesting potential limitation of opportunity to gain skills and experience in antenatal care.

Australian general practice registrars and their experience with postpartum consultations: A cross-sectional analysis of prevalence and associations

BACKGROUND

In Australia, general practitioners (GPs) are recognised as an essential source of postpartum care. However, there remains a paucity of research pertaining to this, and in particular, to that of GP trainees (in Australia, termed 'registrars'). Previous post-graduate experience in obstetrics and gynaecology (O&G) is not a prerequisite for GP training, and thus, it is imperative that vocational training provides adequate exposure to postpartum consultations.

AIM

To investigate the prevalence and associations of Australian GP registrars' (trainees') experience in postpartum care.

MATERIALS AND METHODS

A cross-sectional study employing data from the Registrar Clinical Encounters in Training (ReCEnT) project. ReCEnT is an ongoing cohort study where GP registrars record 60 consecutive consultations mid-way through each training term. The outcome variable was postpartum problem/diagnosis (compared to all other problems/diagnoses). The independent variables included registrar, practice, patient, consultation, clinical and educational factors. Analyses employed univariate and multivariable regression.

RESULTS

Analysis included 2234 registrars (response rate 96.1%), 289 594 consultations, and 453 786 problems/diagnoses. Postpartum care (897) comprised 0.2% (95% CI: 0.19-0.21) of all problems/diagnoses in 0.3% (95% CI: 0.27-0.31) of all consultations. Significant multivariable associations included registrar's gender (female) and obtainment of post-graduate O&G qualifications. Postpartum consultations were longer and resulted in more learning goals being generated.

DISCUSSION

An overall low prevalence was established. Both male registrars, and those without pre-existing O&G qualifications, may have particularly limited experience. These findings should inform educational policy and practice regarding postpartum care experience in general practice training.

New alumni EXperiences of Training and independent Unsupervised Practice (NEXT-UP): protocol for a cross-sectional study of early career general practitioners

INTRODUCTION

General practice in Australia, as in many countries, faces challenges in the areas of workforce capacity and workforce distribution. General practice vocational training in Australia not only addresses the training of competent independent general practitioners (GPs) but also addresses these workforce issues. This study aims to establish the prevalence and associations of early career (within 2 years of completion of vocational training) GPs' practice characteristics; and also to establish their perceptions of utility of their training in preparing them for independent practice.

METHODS AND ANALYSIS

This will be a cross-sectional questionnaire study. Participants will be former registrars ('alumni') of three regional training organisations (RTOs) who achieved general practice Fellowship (qualifying them for independent practice) between January 2016 and July 2018 inclusive. The questionnaire data will be linked to data collected as part of the participants' educational programme with the RTOs. Outcomes will include alumni rurality of practice; socioeconomic status of practice; retention within their RTO's geographic footprint; workload; provision of nursing home care, after-hours care and home visits; and involvement in general practice teaching and supervision. Associations of these outcomes will be established with logistic regression. The utility of RTO-provided training versus in-practice training in preparing the early career GP for unsupervised post-Ffellowship practice in particular aspects of practice will be assessed with χ² tests.

ETHICS AND DISSEMINATION

Ethics approval is by the University of Newcastle Human Research Ethics Committee, approval numbers H-2018-0333 and H-2009-0323. The findings of this study will be widely disseminated via conference presentations and publication in peer-reviewed journals, educational practice translational workshops and the GP Synergy Research subwebsite.

The International comparison of Systems of care and patient outcomes In minor Stroke and Tia (InSIST) study: A community-based cohort study

RATIONALE

Rapid response by health-care systems for transient ischemic attack and minor stroke (TIA/mS) is recommended to maximize the impact of secondary prevention strategies. The applicability of this evidence to Australian non-hospital-based TIA/mS management is uncertain.

AIMS

Within an Australian community setting we seek to document processes of care, establish determinants of access to care, establish attack rates and determinants of recurrent vascular events and other clinical outcomes, establish the performance of ABC2-risk stratification, and compare the processes of care and outcomes to those in the UK and New Zealand for TIA/mS.

SAMPLE SIZE ESTIMATES

Recruiting practices containing approximately 51 full-time-equivalent general practitioners to recruit 100 TIA/mS per year over a four-year study period will provide sufficient power for each of our outcomes.

METHODS AND DESIGN

An inception cohort study of patients with possible TIA/mS recruited from 16 general practices in the Newcastle-Hunter Valley-Manning Valley region of Australia. Potential TIA/mS will be ascertained by multiple overlapping methods at general practices, after-hours collaborative, and hospital in-patient and outpatient services. Participants' index and subsequent clinical events will be adjudicated as TIA/mS or mimics by an expert panel.

STUDY OUTCOMES

Process outcomes-whether the patient was referred for secondary care; time from event to first patient presentation to a health professional; time from event to specialist acute-access clinic appointment; time from event to brain and vascular imaging and relevant prescriptions. Clinical outcomes-recurrent stroke and major vascular events; and health-related quality of life.

DISCUSSION

Community management of TIA/mS will be informed by this study.

Early career GPs, mental health training and clinical complexity: a cross-sectional analysis

Patients with mental health conditions commonly present in General Practice. Mental health curricula are broad. We do not know that trainees are exposed to the learning they require. This study aimed to establish the prevalence, characteristics and associations of GP trainees' management of mental health problems. This paper presents a cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing multisite cohort study of Australian GP trainees (registrars) documenting their clinical experiences over 60 consecutive consultations. Univariate and multivariable logistic regression analyses were conducted with outcome of the problem/diagnosis being a mental health condition. 1659 trainees provided data on 218,325 consultations and 340,453 problems/diagnoses. Mental health conditions were associated with patients being male, of Aboriginal or Torres Strait Islander or English-speaking background. Trainee characteristics were being more senior and having trained in Australia. Practice characteristics included being in low socioeconomic areas. Trainees sought less help for mental health concerns than they did for other problems. While early-career GPs see a broad range of mental health conditions, they may benefit from training to manage patients from cross-cultural contexts. They may also need support to generate appropriate learning goals and seek assistance if they are to continue to deepen competence.