Summary of the Eighth World Health Organization Global Initiative for Emergency and Essential Surgical Care Biennial Meeting

A summary of the eighth World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care (GIEESC) Biennial Meeting, which was held in conjunction with the Royal Australian College of Surgeons (RACS) eighty-eighth Annual Scientific Congress in Bangkok, Thailand.

Ketamine as a Prehospital Analgesic: A Systematic Review

Objective:Analgesia in the prehospital setting is an extremely important, yet controversial topic. Ketamine, a N-methyl D-aspartate (NMDA) receptor antagonist, has been commonly used in the prehospital setting, including recommendations by the US Department of Defense and by the Royal Australian College of Pain Medicine, despite the paucity of high-level evidence.Methods:Accordingly, a review of the literature was conducted using several electronic medical literature databases from the earliest available records to the time at which the search was conducted (October 2018).Results:The search strategy yielded a total of 707 unique papers, of which 43 were short-listed for full review, and ultimately, ten papers were identified as meeting all the relevant inclusion criteria. The included studies varied significantly in the prehospital context and in the means of administering ketamine. There was only low-grade evidence that ketamine offered a safe and effective analgesia when used as the only analgesic, and only low-grade evidence that it was as effective as alternative opioid options. However, there was moderate evidence that co-administration of ketamine with morphine may improve analgesic efficacy and reduce morphine requirement.Conclusions:Overall, ketamine as a prehospital analgesic may be best used in combination with opioids to reduce opioid requirement. It is suggested that future studies should use a standardized approach to measuring pain reduction. Future studies should also investigate short-term side effects and long-term complications or benefits of prehospital ketamine.

Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia

Background: This study evaluated the impact of multifaceted NPS MedicineWise programs conducted in 2009 and 2015 that targeted general practitioners (GPs) to reduce unnecessary prescribing of proton pump inhibitors (PPIs). Methods: Time series analyses was conducted of the dispensing rates of concessional PPI scripts between January 2006 and June 2016 using the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) databases in Australia. Participants were GPs with dispensed PPI prescriptions to concessional patients between January 2006 and June 2016. The interventions were national NPS MedicineWise PPI educational programs in 2009 and 2015 delivered to all practising GPs in Australia. The 2015 intervention coincided with the release of Choosing Wisely Australia recommendations from the Royal Australian College of General Practitioners (RACGP). Outcome measures included monthly dispensing rates of high/standard and low strength PPIs prescribed by GPs among concessional patients in Australia. Results : Following the 2009 NPS MedicineWise program we observed a 6.7% reduction in the expected dispensing rate of standard strength PPIs among concessional patients between January 2006 and March 2015, and a total 8.6% reduction by June 2016 following the launch of the 2015 program. We observed a significant increase of 5.6% in the dispensing rate of low strength PPIs among concessional patients between April 2009 and March 2015, and no significant change in trend following the 2015 program. Conclusions: The NPS MedicineWise programs were associated with reductions in the dispensing rate of high/standard strength PPIs and with an increase in the dispensing rate of low-strength PPIs by June 2016 although a causal relation was not confirmed. Although the rate of high/standard strength PPI prescribing is declining, these formulations still constitute the majority of PPIs used in Australia. Regular interventions to sustain and improve PPI management by GPs may be warranted.

Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia

Background: This study evaluated the impact of multifaceted NPS MedicineWise programs conducted in 2009 and 2015 that targeted general practitioners (GPs) to reduce unnecessary prescribing of proton pump inhibitors (PPIs). Methods: Time series analyses was conducted of the dispensing rates of concessional PPI scripts between January 2006 and June 2016 using the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) databases in Australia. Participants were GPs with dispensed PPI prescriptions to concessional patients between January 2006 and June 2016. The interventions were national NPS MedicineWise PPI educational programs in 2009 and 2015 delivered to all practising GPs in Australia. The 2015 intervention coincided with the release of Choosing Wisely Australia recommendations from the Royal Australian College of General Practitioners (RACGP). Outcome measures included monthly dispensing rates of standard and low strength PPIs prescribed by GPs among concessional patients in Australia. Results : Following the 2009 NPS MedicineWise program we observed a 6.7% reduction in the expected dispensing rate of standard strength PPIs among concessional patients between January 2006 and March 2015, and a total 8.6% reduction by June 2016 following the launch of the 2015 program. We observed a significant increase of 5.6% in the dispensing rate of low strength PPIs among concessional patients between April 2009 and March 2015, and no significant change in trend following the 2015 program. Conclusions: The NPS MedicineWise programs were associated with reductions in the dispensing rate of standard strength PPIs and with an increase in the dispensing rate of low-strength PPIs by June 2016 although a causal relation was not confirmed. Although the rate of standard strength PPI prescribing is declining, these formulations still constitute the majority of PPIs used in Australia. Regular interventions to sustain and improve PPI management by GPs may be warranted.

What influences trainee decisions to practise in rural and regional Australia?

Although international medical graduates (IMGs) make up a substantial part of the Australian rural general practice workforce, most research on factors associated with rural practice has focused on Australian medical graduates (AMGs). This study aimed to determine whether there were differences between IMGs and AMGs in terms of these factors. Registrars in training and recent fellows (Fellowship of the Royal Australian College of General Practitioners/Fellowship of the Australian College of Rural and Remote Medicine) who participated in training in rural and regional Australia were surveyed about practice models and rural practice. Almost two-thirds of participants were practicing or intending to practice in rural areas, with no difference between AMGs and IMGs. None of the variables associated with rural practice for AMGs was found to be associated with rural practice in IMGs in univariate binary regression analysis. Two key variables that are strongly associated with rural medical practice in the current literature, namely rural background and rural exposure, were not significant predictors of rural practice among IMGs. Due to the significant number of IMGs in regional training programs, any future incentives designed to improve rural recruitment and retention need to address factors relevant to IMGs.

Welcome to The Lucky Country: the Royal Australian College of General Practitioners deters overseas-trained academic general practitioners

In assessing overseas-trained general practitioners (GPs) applying for specialist recognition in Australia, the Royal Australian College of General Practitioners (RACGP) sets a minimum requirement of 2 days per week ‘undertaking general practice activities’ over the 3 years prior to application. The RACGP does not consider academic practice (i.e. relevant teaching and research) to be a ‘general practice activity’, thereby blocking overseas-trained full-time academic GPs from specialist recognition in Australia. The actions of the RACGP have implications for access to quality primary health care in Australia.

Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia

Background: This study evaluated the impact of multifaceted NPS MedicineWise programs conducted in 2009 and 2015 that targeted general practitioners (GPs) to reduce unnecessary prescribing of proton pump inhibitors (PPIs). Methods: Time series analyses was conducted of the dispensing rates of concessional PPI scripts between January 2006 and June 2016 using the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) databases in Australia. Participants were GPs with dispensed PPI prescriptions to concessional patients between January 2006 and June 2016. The interventions were national NPS MedicineWise PPI educational programs in 2009 and 2015 delivered to all practising GPs in Australia. The 2015 intervention coincided with the release of Choosing Wisely Australia recommendations from the Royal Australian College of General Practitioners (RACGP). Outcome measures included monthly dispensing rates of standard and low strength PPIs prescribed by GPs among concessional patients in Australia. Results : Following the 2009 NPS MedicineWise program we observed a 6.7% reduction in the expected dispensing rate of standard strength PPIs among concessional patients between January 2006 and March 2015, and a total 8.6% reduction by June 2016 following the launch of the 2015 program. We observed a significant increase of 5.6% in the dispensing rate of low strength PPIs among concessional patients between April 2009 and March 2015, and no significant change in trend following the 2015 program. Conclusions: The NPS MedicineWise programs were associated with reductions in the dispensing rate of standard strength PPIs, and with an increase in the dispensing rate of low-strength PPIs by June 2016 although a causal relation was not confirmed. Although the rate of standard strength PPI prescribing is declining, these formulations still constitute the majority of PPIs used in Australia. Regular interventions to sustain and improve PPI management by GPs may be warranted.

A Review of the ACHS Clinical Indicator Program after 20 years

The Clinical Indicator Program, which was introduced into the Australian Council on Healthcare Standards’ accreditation program two decades ago, has grown from one set addressed by 115 healthcare organisations to 22 sets with data received from over 800 healthcare organisations, resulting in a national database which is unique in its clinical diversity, reflecting every major medical discipline involved in hospital practice. The process for Clinical Indicator selection and review remains with the providers of the care, but the selection criteria are better defined and the evidence base strengthened. Early responses to their introduction were encouraging as improvements in patient management and outcomes were sought and achieved following review of comparative data, and some examples of these are provided. Clinical Indicator revision remains an important and major task and the original Hospital- Wide set of Clinical Indicators is now in its 12th version. The development and use of Clinical Indicators is increasing world-wide, and in Australia there are other organisations, including the Australian Commission on Safety and Quality in Healthcare, looking at Clinical Indicators to further understand the performance of healthcare organisations. As clinical care changes, the challenges for the Australian Council on Healthcare Standards are to ensure the Clinical Indicators continue to reflect current practice, to retain clinician support, and also to ensure that the existence of its extensive and long-standing national clinical database is more widely known and utilised. Abbreviations: ACHS: Australian Council of Healthcare Standards; ACIR – Australasian Clinical Indicator Report; ANZICS – Australian and New Zealand Intensive Care Society; APD – Adult Patient Database; CI – Clinical Indicators; HCO – HealthCare Organisation; PIRT – Performance Indicator Reporting Tool; RACMA - Royal Australian College of Medical Administrators.

Australian general practitioner attitudes to clinical practice guidelines and some implications for translating osteoarthritis care into practice

Clinical practice guidelines (CPGs) have been shown to improve processes of care and health outcomes, but there is often a discrepancy between recommendations for care and clinical practice. This study sought to explore general practitioner (GP) attitudes towards CPGs, in general and specifically for osteoarthritis (OA), with the implications for translating OA care into practice. A self-administered questionnaire was conducted in January 2013 with a sample of 228 GPs in New South Wales and South Australia. Seventy-nine GPs returned questionnaires (response rate 35%). Nearly all GPs considered that CPGs support decision-making in practice (94%) and medical education (92%). Very few respondents regarded CPGs as a threat to clinical autonomy, and most recognised that individual patient circumstances must be taken into account. Shorter CPG formats were preferred over longer and more comprehensive formats, with preferences being evenly divided among respondents for short, 2–3-page summaries, flowcharts or algorithms and single page checklists. GPs considered accessibility to CPGs to be important, and electronic formats were popular. Familiarity and use of The Royal Australian College of General Practitioners OA Guideline was poor, with most respondents either not aware of it (30%; 95% confidence interval (CI) 27 – 41%), had never used it (19%; 95% CI 12 – 29%) or rarely used it (34%; 95% CI 25–45%). If CPGs are to assist with the translation of evidence into practice, they must be easily accessible and in a format that encourages use.

What do general practitioners consider support? Findings from a local pilot initiative

This paper reports the findings of a local pilot that was aimed to assess if making a local psychiatrist available would improve GP satisfaction with regard to responsiveness and access to specialist mental health services. A psychiatrist was made available via a telephone advice line for 1 h every day. Pre- and post-survey of all GPs was conducted to elicit GP satisfaction and suggestions. The pilot was conducted from Maitland, the base of Hunter Valley Mental Health Service. A total of 202 GPs in the area were contacted and surveyed; 17% responded to the pre-survey and 27% to the post-survey. Only 8% of the GPs used the telephone advice service. Despite low use, most responding GPs indicated that they would like to see the services continue. Most of the responding GPs (both users and non-users of this service) were not aware of or had not used the Royal Australian College of General Practitioners’ GP Psych Support initiative. Results from this pilot indicate that making a local psychiatrist available improves GP satisfaction with regard to responsiveness and access, despite low use. Further research is needed to establish if such a service can be made available at an area level and whether this would be cost effective.