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Michael Low is employed by Monash Health and funded by a Royal Australasian College of Physicians (RACP) National Health and Medical Research Council (NHMRC) CRB Blackburn Scholarship. George Grigoriadis is employed by Monash Health and Alfred Health and funded by a Victorian Cancer Agency Clinical Research Fellowship. We thank Shahla Vilcassim (Monash Haematology) for her help in attaining the figure in .
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Objectives: To determine the rates at which people recently released from prison attend general practitioners, and to describe service users and their encounters.
Design, participants and setting: Prospective cohort study of 1190 prisoners in Queensland, interviewed up to 6 weeks before expected release from custody (August 2008 – July 2010); their responses were linked prospectively with Medicare and Pharmaceutical Benefits Scheme data for the 2 years after their release. General practice attendance was compared with that of members of the general Queensland population of the same sex and in the same age groups.
Main outcome measures: Rates of general practice attendance by former prisoners during the 2 years following their release from prison.
Results: In the 2 years following release from custody, former prisoners attended general practice services twice as frequently (standardised rate ratio, 2.04; 95% CI, 2.00–2.07) as other Queenslanders; 87% of participants visited a GP at least once during this time. 42% of encounters resulted in a filled prescription, and 12% in diagnostic testing. Factors associated with higher rates of general practice attendance included history of risky opiate use (incidence rate ratio [IRR], 2.09; 95% CI, 1.65–2.65), having ever been diagnosed with a mental disorder (IRR, 1.32; 95% CI, 1.14–1.53), and receiving medication while in prison (IRR, 1.82; 95% CI, 1.58–2.10).
Conclusions: Former prisoners visited general practice services with greater frequency than the general Queensland population. This is consistent with their complex health needs, and suggests that increasing access to primary care to improve the health of former prisoners may be insufficient, and should be accompanied by improving the quality, continuity, and cultural appropriateness of care.
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We thank Queensland Corrective Services for assistance with data collection, and Passports study participants for sharing their stories. We acknowledge the Australian Government Department of Human Services as the source of Medicare and Pharmaceutical Benefits Scheme (PBS) records. The Passports study was funded by a National Health and Medical Research Council (NHMRC) Strategic Award (409966). The HIP-Aus study is funded by a National Health and Medical Research Council Project grant (1002463). Stuart Kinner is supported by an NHMRC Senior Research Fellowship (APP1078168). The views expressed in this article are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services.
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Objective: To assess the number of pathology tests ordered by general practice registrars during their first 18–24 months of clinical general practice.
Design: Longitudinal analysis of ten rounds of data collection (2010–2014) for the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing, multicentre, cohort study of general practice registrars in Australia. The principal analysis employed negative binomial regression in a generalised estimating equations framework (to account for repeated measures on registrars).
Setting, participants: General practice registrars in training posts with five of 17 general practice regional training providers in five Australian states. The registrar participation rate was 96.4%.
Main outcome measure: Number of pathology tests requested per consultation. The time unit for analysis was the registrar training term (the 6-month full-time equivalent component of clinical training); registrars contributed data for up to four training terms.
Results: 876 registrars contributed data for 114 584 consultations. The number of pathology tests requested increased by 11% (95% CI, 8–15%; P < 0.001) per training term.
Conclusions: Contrary to expectations, pathology test ordering by general practice registrars increased significantly during their first 2 years of clinical practice. This causes concerns about overtesting. As established general practitioners order fewer tests than registrars, test ordering may peak during late vocational training and early career practice. Registrars need support during this difficult period in the development of their clinical practice patterns.
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This work was supported by an Education Research Grant from the Australian Department of Health (grant number, D14/17024). The ReCEnT project was funded until 2015 by the participating educational organisations: General Practice Training Valley to Coast, the Victorian Metropolitan Alliance, General Practice Training Tasmania, Adelaide to Outback GP Training Program, and Tropical Medical Training, all of which were funded by the Australian Government. From 2016, ReCEnT is funded by an Australian Department of Health commissioned research grant and supported by the GP Synergy Regional Training Organisation. We acknowledge the general practice registrars, general practice supervisors and practices who have participated in the ReCEnT project, and Neil Spike and Rohan Kerr for their contributions to the wider ReCEnT project.
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It must be — as an essential component of the response to the antimicrobial drug resistance problem
The growing threat of antimicrobial drug resistance (AMR) is attracting the attention of national governments and international organisations. In the words of Margaret Chan, Director-General of the World Health Organization, “We are hearing one alarm bell after another.”1 This is apparent in primary care, where the frequency of antibiotic-resistant infections is increasing. The emergence of AMR is a multifaceted societal problem that requires action from a range of actors, including the pharmaceutical, agricultural and food production industries.2 But it is the health care sector, where antibiotics are prescribed and patients with resistant infections are seen, that the impact of AMR is most acute. This is especially relevant in Australia, where antibiotic consumption is among the highest of the OECD countries.3
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The available evidence from the past 20 years of government interventions can inform future priorities
Australia is in a critical period of rural workforce policy reform. The Australian government is responding to a surge of domestic and international doctors, while addressing the pervasive problem of geographic and specialty maldistribution.1 There is renewed commitment to strengthen rural health policy and further develop a well skilled, adaptable rural general practitioner workforce. GPs underpin resilient, healthy rural and remote communities and are essential for a coordinated and efficient health system.2 This article seeks to inform future directions and research priorities by reflecting on 20 years of policy activity and outcomes.
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The availability of new antiviral agents opens the way for increasing GP involvement in the management of hepatitis C
The new direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infections became available on the Pharmaceutical Benefits Scheme in March 2016. In September 2016, already over 10% of the estimated 230 500 Australians with chronic HCV infection had been treated.1 While such rapid uptake was unanticipated, it may represent the low-hanging fruit of the HCV epidemic: patients already enlisted in tertiary clinics waiting for treatment. From an epidemiological perspective, the remaining untreated patients may fall under the radar of tertiary-based clinics. If Australia is to capitalise on the opportunities of universal access to DAA therapies, it will require the concerted efforts of general practitioners to improve rates of diagnosis, assessment, treatment and follow-up in the community.
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Objective: To compare the current rate of antibiotic prescribing for acute respiratory infections (ARIs) in Australian general practice with the recommendations in the most widely consulted therapeutic guidelines in Australia (Therapeutic Guidelines).
Design and setting: Comparison of general practice activity data for April 2010 – March 2015 (derived from Bettering the Evaluation and Care of Health [BEACH] study) with estimated rates of prescribing recommended by Therapeutic Guidelines.
Main outcome measures: Antibiotic prescribing rates and estimated guideline-recommended rates per 100 encounters and per full-time equivalent (FTE) GP per year for eight ARIs; number of prescriptions nationally per year.
Results: An estimated mean 5.97 million (95% CI, 5.69–6.24 million) ARI cases per year were managed in Australian general practice with at least one antibiotic, equivalent to an estimated 230 cases per FTE GP/year (95% CI, 219–240 cases/FTE/year). Antibiotics are not recommended by the guidelines for acute bronchitis/bronchiolitis (current prescribing rate, 85%) or influenza (11%); they are always recommended for community-acquired pneumonia (current prescribing rate, 72%) and pertussis (71%); and they are recommended for 0.5–8% of cases of acute rhinosinusitis (current prescribing rate, 41%), 20–31% of cases of acute otitis media (89%), and 19–40% cases of acute pharyngitis or tonsillitis (94%). Had GPs adhered to the guidelines, they would have prescribed antibiotics for 0.65–1.36 million ARIs per year nationally, or at 11–23% of the current prescribing rate. Antibiotics were prescribed more frequently than recommended for acute rhinosinusitis, acute bronchitis/bronchiolitis, acute otitis media, and acute pharyngitis/tonsillitis.
Conclusions: Antibiotics are prescribed for ARIs at rates 4–9 times as high as those recommended by Therapeutic Guidelines. Our data provide the basis for setting absolute targets for reducing antibiotic prescribing in Australian general practice.
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This investigation was supported by the Centre for Research Excellence in Minimising Antibiotic Resistance from Acute Respiratory Infections, funded by the National Health and Medical Research Council (1044904).
Between April 2010 and March 2015, the BEACH program was funded by the Australian Government Department of Health and Ageing, the Australian Government Department of Veterans’ Affairs, AstraZeneca (Australia), bioCSL (Australia), Novartis Pharmaceuticals Australia, AbbVie, Merck, Sharp and Dohme (Australia), Pfizer Australia, GlaxoSmithKline Australia, Sanofi-Aventis Australia, Bayer Australia, and the National Prescribing Service. The funding bodies did not influence the concept, design or conduct of the research, nor the preparation of this article; no financial support was provided for preparing the manuscript. Christopher Del Mar has received funding (personal and institutional) from the Australian Commission for Safety and Quality in Health Care (ACSQHC) and British United Provident Association (BUPA) for consulting (regarding shared decision making).
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The exclusion of migrants and members of ethnic minorities from clinical trials is common and can compromise the generalisability of research findings.1 Reasons for these exclusions are complex, but communication difficulties probably contribute.1
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Abstract
Objectives: To estimate cumulative live birth rates (CLBRs) following repeated assisted reproductive technology (ART) ovarian stimulation cycles, including all fresh and frozen/thaw embryo transfers (complete cycles).
Design, setting and participants: Prospective follow-up of 56 652 women commencing ART in Australian and New Zealand during 2009–2012, and followed until 2014 or the first treatment-dependent live birth.
Main outcome measures: CLBRs and cycle-specific live birth rates were calculated for up to eight cycles, stratified by the age of the women (< 30, 30–34, 35–39, 40–44, > 44 years). Conservative CLBRs assumed that women discontinuing treatment had no chance of achieving a live birth if had they continued treatment; optimal CLBRs assumed that they would have had the same chance as women who continued treatment.
Results: The overall CLBR was 32.7% (95% CI, 32.2–33.1%) in the first cycle, rising by the eighth cycle to 54.3% (95% CI, 53.9–54.7%) (conservative) and 77.2% (95% CI, 76.5–77.9%) (optimal). The CLBR decreased with age and number of complete cycles. For women who commenced ART treatment before 30 years of age, the CLBR for the first complete cycle was 43.7% (95% CI, 42.6–44.7%), rising to 69.2% (95% CI, 68.2–70.1%) (conservative) and 92.8% (95% CI, 91.6–94.0) (optimal) for the seventh cycle. For women aged 40–44 years, the CLBR was 10.7% (95% CI, 10.1–11.3%) for the first complete cycle, rising to 21.0% (95% CI, 20.2–21.8%) (conservative) and 37.9% (95% CI, 35.9–39.9%) (optimal) for the eighth cycle.
Conclusion: CLBRs based on complete cycles are meaningful estimates of ART success, reflecting contemporary clinical practice and encouraging safe practice. These estimates can be used when counselling patients and to inform public policy on ART treatment.