Introduction
Method
Quantitative questionnaire analysis
Qualitative interview analysis
Results
Educational questionnaire results
Baseline N = 60 | End N = 37 | |
---|---|---|
Sex | ||
Male | 38 (64%) | 25 (69%) |
Female | 21 (36%) | 11 (31%) |
Unknown | 1 | 1 |
Age in years (mean) | 49 (41, 60) | 51 (40, 60) |
Unknown | 1 | 1 |
Education completed | ||
Complete | 39 (65%) | 37 (100%) |
Not complete | 21 (35%) | 0 (0%) |
Study arm | ||
Imaging | 18 (30%) | 14 (38%) |
Pathology | 20 (33%) | 12 (32%) |
Prescribing | 22 (37%) | 11 (30%) |
Baseline N = 60 | End N = 37 | |
---|---|---|
MHR confidence | ||
1—not confident | 14 (23%) | 0 (0%) |
2 | 14 (23%) | 0 (0%) |
3 | 8 (13%) | 4 (11%) |
4 | 19 (32%) | 20 (54%) |
5—extremely confident | 5 (8.3%) | 13 (35%) |
MHR use | ||
0 times | 16 (27%) | 0 (0%) |
1–10 times | 32 (53%) | 16 (43%) |
11–20 times | 7 (12%) | 13 (35%) |
21–30 times | 4 (6.7%) | 5 (14%) |
31 + times | 1 (1.7%) | 3 (8.1%) |
Appropriate MHR record | ||
Event Summary | 5 (8.3%) | 3 (8.1%) |
Medicines View Summary | 20 (33%) | 11 (30%) |
Shared Health Summary | 35 (58%) | 23 (62%) |
Prescribing arm | Pathology arm | Imaging arm | ||||
---|---|---|---|---|---|---|
Baseline N = 22 | End N = 11 | Baseline N = 20 | End N = 12 | Baseline N = 18 | End N = 14 | |
Deprescribing confidence | ||||||
1—not confident | 2 (9.1%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (5.6%) | 0 (0.0%) |
2 | 4 (18.2%) | 0 (0.0%) | 4 (20.0%) | 0 (0.0%) | 1 (5.6%) | 0 (0.0%) |
3 | 10 (45.5%) | 1 (9.1%) | 9 (45.0%) | 4 (33.3%) | 9 (50.0%) | 5 (35.7%) |
4 | 5 (22.7%) | 7 (63.6%) | 5 (25.0%) | 6 (50.0%) | 7 (38.8%) | 6 (42.9%) |
5—extremely confident | 1 (4.5%) | 3 (27.3%) | 2 (10.0%) | 2(16.7%) | 0 (0.0%) | 3 (21.4%) |
Deprescribing discussions | ||||||
0 times | 0 (0.0%) | 0 (0.0%) | 1 (5.0%) | 0 (0.0%) | 1 (5.6%) | 0 (0.0%) |
1–5 times | 10 (45.4%) | 0 (0.0%) | 6 (30.0%) | 3 (25.0%) | 5 (27.8%) | 2 (14.3%) |
6–10 times | 8 (36.4%) | 5 (45.4%) | 8 (40.0%) | 3 (25.0%) | 7 (38.9%) | 7 (50.0%) |
11–15 times | 2 (9.1%) | 3 (27.3%) | 4 (20.0%) | 3 (25.0%) | 3 (16.6%) | 3 (21.4%) |
16 + times | 2 (9.1%) | 3 (27.3%) | 1 (5.0%) | 3 (25.0%) | 2 (11.1%) | 2 (14.3%) |
Deprescribing frequency | ||||||
0 times | 2 (9.1%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
1–5 times | 8 (36.4%) | 2 (18.2%) | 11 (55.0%) | 2 (16.7%) | 7 (38.9%) | 3 (21.4%) |
6–10 times | 7 (31.8%) | 5 (45.4%) | 4 (20.0%) | 7 (58.3%) | 4 (22.2%) | 6 (42.9%) |
11–15 times | 3 (13.6%) | 3 (27.3%) | 2 (10.0%) | 0 (0.0%) | 5 (27.8%) | 2 (14.3%) |
16 + times | 2 (9.1%) | 1 (9.1%) | 3 (15.0%) | 3 (25.0%) | 2 (11.1%) | 30 (21.4%) |
Prescribing arm | Pathology arm | Imaging arm | ||||
---|---|---|---|---|---|---|
Baseline N = 21 | End N = 6 | Baseline N = 16 | End N = 9 | Baseline N = 18 | End N = 11 | |
Confidence in evidence based pathology ordering | ||||||
1—not confident | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
2 | 3 (14.3%) | 1 (16.7%) | 2 (12.5%) | 0 (0.0%) | 2 (11.2%) | 0 (0.0%) |
3 | 9 (42.9%) | 3 (50.0%) | 7 (43.8%) | 1 (11.1%) | 8 (44.4%) | 4 (36.4%) |
4 | 8 (38.0%) | 2 (33.3%) | 7 (43.8%) | 6 (66.7%) | 8 (44.4%) | 6 (54.5%) |
5—extremely confident | 1 (4.8%) | 0 (0.0%) | 0 (0.0%) | 2 (22.2%) | 0 (0.0%) | 1 (9.1%) |
Pathology review frequency | ||||||
0 times | 6 (28.6%) | 3 (50.0%) | 2 (12.5%) | 0 (0.0%) | 1 (5.6%) | 1 (9.1%) |
1–5 times | 8 (38.1%) | 3 (50.0%) | 9 (56.3%) | 5 (55.6%) | 10 (55.5%) | 5 (45.4%) |
6–10 times | 5 (23.8%) | 0 (0.0%) | 2 (12.5%) | 2 (22.2%) | 5 (27.7%) | 3 (27.3%) |
11–15 times | 2 (9.5%) | 0 (0.0%) | 2 (12.5%) | 1 (11.1%) | 1 (5.6%) | 1 (9.1%) |
16 + times | 0 (0.0%) | 0 (0.0%) | 1 (6.2%) | 1 (11.1%) | 1 (5.6%) | 1 (9.1%) |
Pathology regimen change frequency | ||||||
0 times | 1 (4.8%) | 0 (0.0%) | 0 (0.0%) | 1 (11.1%) | 0 (0.0%) | 0 (0.0%) |
1–5 times | 6 (28.6%) | 3 (50.0%) | 5 (31.3%) | 1 (11.1%) | 6 (33.3%) | 7 (63.6%) |
6–10 times | 10 (47.6%) | 0 (0.0%) | 1 (6.2%) | 2 (22.2%) | 7 (38.9%) | 2 (18.2%) |
11–15 times | 0 (0.0%) | 1 (16.7%) | 4 (25.0%) | 2 (22.2%) | 1 (5.6%) | 1 (9.1%) |
16 + times | 4 (19.0%) | 2 (33.3%) | 6 (37.5%) | 3 (33.4%) | 4 (22.2%) | 1 (9.1%) |
Prescribing arm | Pathology arm | Imaging arm | ||||
---|---|---|---|---|---|---|
Baseline N = 21 | End N = 6 | Baseline N = 16 | End N = 9 | Baseline N = 18 | End N = 11 | |
Confidence in evidence based imaging | ||||||
1—not confident | 0 (0.0%) | 1 (16.7%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
2 | 3 (14.3%) | 0 (0.0%) | 2 (12.5%) | 3 (33.3%) | 2 (11.1%) | 0 (0.0%) |
3 | 10 (47.6%) | 1 (16.7%) | 8 (50.0%) | 3 (33.3%) | 7 (38.9%) | 3 (27.3%) |
4 | 8 (38.1%) | 4 (66.6%) | 6 (37.5%) | 2 (22.3%) | 8 (44.4%) | 5 (45.4%) |
5—extremely confident | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (11.1%) | 1 (5.6%) | 3 (27.3%) |
Frequency guideline use in back pain imaging | ||||||
0 times | 7 (33.3%) | 2 (33.3%) | 2 (12.5%) | 4 (44.5%) | 5 (27.8%) | 0 (0.0%) |
1–5 times | 8 (38.1%) | 3 (50.0%) | 11 (68.8%) | 3 (33.3%) | 8 (44.4%) | 5 (45.4%) |
6–10 times | 5 (23.8%) | 0 (0.0%) | 3 (18.7%) | 1 (11.1%) | 3 (16.7%) | 3 (27.3%) |
11–15 times | 1 (4.8%) | 1 (16.7%) | 0 (0.0%) | 0 (0.0%) | 2 (11.1%) | 3 (27.3%) |
16 + times | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (11.1%) | 0 (0.0%) | 0.0 (0.0%) |
Frequency discussed why not ordering imaging | ||||||
0 times | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
1–5 times | 12 (57.1%) | 1 (16.7%) | 9 (56.3%) | 2 (22.2%) | 9 (50.0%) | 3 (27.3%) |
6–10 times | 5 (23.8%) | 3 (49.9%) | 5 (31.3%) | 6 (66.7%) | 4 (22.2%) | 2 (18.2%) |
11–15 times | 1 (4.8%) | 1 (16.7%) | 1 (6.2%) | 0 (0.0%) | 2 (11.1%) | 4 (36.3%) |
16 + times | 3 (14.3%) | 1 (16.7%) | 1 (6.2%) | 1 (11.1%) | 3 (16.7%) | 2 (18.2%) |
Qualitative results
Number of participants | ||
---|---|---|
TRIAL ARM | Prescribing | 7 |
Pathology | 7 | |
Imaging | 5 | |
Sex | Female | 7 |
Male | 12 | |
Age | ≤ 45 | 8 |
≥ 46 | 11 | |
Practice size | ≤ 5 | 11 |
≥ 6 | 8 | |
RRMA | RA1-2 | 10 |
RA3-5 | 8 | |
RA6-7 | 1 | |
SEIFA | 1–5 | 12 |
6–10 | 7 |
Capability | Opportunity | Motivation |
---|---|---|
Increased engagement with and knowledge of MHR | Quarantined time to learn about MHR in a time-poor environment | Motivation to learn more about using MHR |
Increased knowledge about rational prescribing and test ordering post-intervention | Opportunity to learn more about rational prescribing and test ordering | Motivation to engage more with MHR and to incorporate its use into clinical practice |
Motivation to reflect on deprescribing and test ordering | ||
Greater agency in refusing low value testing |
Capability
Increased engagement with and knowledge of MHR
My sense is that there probably is a bit more stuff in there [MHR system] that I haven’t really managed. (GP21 pre, pathology, female)
I hadn’t realised that you could increasingly get the hospital results from it [MHR system] to be able to see the specialist investigations that they’ve done in the hospital is amazing. (GP21 post, pathology, female)
Sometimes it's a bit tricky when they say they have a health record done elsewhere... I don't know whether I'm actually not doing it properly... I don't know. (GP8 pre, prescribing, male)
I didn’t actually realise that it could be quite comprehensive, like it’s not just the health summary, it contains a lot of information from the hospital as well…. Now I use it a lot for patients who recently have been to hospital, and if you wait three or four days a lot of the results will be uploaded. (GP8 post, prescribing, male)
I wasn’t really doing much uploading of health summaries and things for patients because I just wasn’t sure how to do it and I didn’t want to accidentally upload the wrong thing… So, I think I did learn a lot from the experience. (GP7 post, imaging, female)
I think, became a bit more confident and familiar with the My Health Record, obviously. As a result, I’ve used it more than I would have otherwise. (GP4 post, prescribing, male)
I still don’t feel confident of what should I be uploading to the My Health Record. How do I make the most of the resources that are there? I guess, I’m just a bit unfamiliar with the technology and really how to get the most out of it. (GP16 post, imaging, female)
Increased knowledge about rational prescribing and test ordering post-intervention
I don’t know anything about that, I’m sorry. That’s an area I have to gain knowledge on [rational prescribing and test ordering]. (GP23 pre, prescribing, female)
I was put into the prescribing arm and through the webinar I learnt about the resources that could be used for deprescribing and how it could be done safely and involving patients in making that decision about reducing the pill burden… I never knew about some of the resources that they had given us through the course about each medication that could be safely deprescribed (GP23 post, prescribing, female)
Opportunity
Quarantined time to learn about MHR in a time-poor environment
I have used it a little bit in that we have been trying to get some of our patients on board, although it normally falls off the bottom of the to do list. So I'm finding that, although I intend to sign people up, actually getting to the point where I'm signing them up and activating the file isn't always happening… at the end it just fell off the bottom of the learning list. (GP16 pre, imaging, female)
It's quite difficult because it's several extra steps that we need to do in an already time poor environment. (GP14 pre, pathology, female)
Look, it’s really slow to upload, so it’s just a clunky thing... So I guess in a way, I’m hoping that it [the education intervention] then gives me almost a bit of quarantined time to really have a better look at it and see what else is there and see how else I can be using it. (GP21 pre, pathology, female)
I’m just thinking about looking at it now [MHR], where I didn’t even bother with most of my patients… (GP16 post, imaging, female)
I’m hoping that through education, I’ll be a better proponent for the tool, and that I’ll use the tool more effectively… So any means by which I could increase efficiency with utilising that tool will go on to better serve me. (GP25 pre, prescribing, male)
The education. I think it might make me more efficient. I mean, in GP practice, you're doing a whole lot of things at the same time, and so to upload at the same time as doing everything else, if you're more slick at doing it because you've practiced and been educated, I think it's better. (GP12 pre, prescribing, female)
I know that our practice is very guilty of this, that things get left on for years when a patient is no longer using them, and it [the education intervention] would make me go through and check everything, make sure that what was on their medication list was current, and then I would upload that on to the eHealth record as the most recent summary. So I guess, yeah, for that reason it just enthused me to do that perhaps a bit more than I would otherwise. (GP12 post, prescribing, female)
Opportunity to learn more about rational prescribing and test ordering
Part of me that’s a bit pleased that I’m in the pathology arm because I’m not quite sure how it will change what I do with that. (GP21 pre, pathology, female)
I wasn’t expecting but found (the education intervention) very useful just that review of which tests are not overly helpful and how often we order them. So, I wasn’t expecting that but it was good to sort of re-cap that. (GP21 post, pathology, female)
With prescription, that is an arm in particular that I have not utilised before, so this will be quite interesting to see the impact… I really have definitely been under-utilising it… It doesn’t inform my current practice, My Health Record, and it probably should and hopefully post-education there will be a change. (GP25 pre, prescribing, male)
Prior to going on to the study, I was aware of the need for deprescribing… it helped to consolidate that fact, but more importantly, it gave me a structure… an arsenal of resources… it's given me a starting block… and the information on how to better arm that conversation between me and the patient. (GP25 post, prescribing, male)
Motivation
Motivation to learn more about using MHR
To be quite frank with you, anything about My Health Record would be good, because at the moment, I understand its benefits. I kind of have used it, but not very much… So learning how to use it in the most useful way for when I do... (GP7 pre, imaging, female)
So, learning how to utilise My Health Record to be a more efficient GP was kind of my aim and I think also allowing patients to be on their front foot, so learning how to upload…I can see the benefit of having the uploaded view of the patient because there’s so much that you can access. So, I think I did learn a lot from the experience. (GP7 post, imaging, female)
Motivation to engage more with MHR and to incorporate its use into clinical practice
Coming out of the [education] program, I feel really guilty that I never looked [at MHR]… but now actually coming back, yeah it has actually changed the way I look at things and doing more searching for online results, which I did this morning for a patient. (GP3 post, pathology, male)
I've made some changes as in I’m getting used to the process of using My Health Record for a patient. But it will become like a habit, the same as looking at the patient’s medications when I am seeing new patients, patients who come back or a new patient, and do all the medications. (GP19 post, pathology, female)
It seemed to be a way of getting information to us as how to use things like My Health Record, in line with imaging for me… the ways to have guidelines, to appropriate imaging and the like, where to look for those sorts of things, and that’s – that’s been extremely useful. (GP10 post, imaging, male)
I suppose I was aware of it in a sense but not using it, so it was good to learn a bit more about it I suppose in a practical sense of how to use it for the benefit of my patients. (GP6 post, pathology, male)
Motivation to critically reflect on rational prescribing and test ordering
It’s very easy to lull into “this is my shortcut for this, and therefore I’ll just click that and it will order all these tests”. Whereas trying to think more critically about a patient, I’ve been trying to do that a lot more… I am sort of questioning, do I really need to do this test? (GP14 post, pathology, female)
Look, I think it will be useful to reflect on what my referral to imaging practice is because I know from NPS audits that I order some things more than my peers and other things less. So I guess it would be interesting to actually look at that and reflect on it and to feel that the things I'm referring for that are best practice. (GP16 pre, imaging, female)
I’ve started to think more about what I’m ordering. I’ve started to say “no” more to some patients when I feel the test isn’t really clinical indicated, and feel more confident with that, saying “no” rather than just ordering a test just to make sure, because the patients pushing for it. (GP16 post, imaging, female)
It was actually quite helpful from a reflection point of view, and I think that for me at least, that was what sort of changed my behaviour, having to reflect back on the cases that I’ve done… having to submit those cases, pushing me into doing, having that first step in, and changing how I order tests. (GP14 post, pathology, female)
Greater agency in refusing low value test ordering
Part of me that’s a bit pleased that I’m in the pathology arm because I’m not quite sure how it will change what I do with that. (GP21 pre, pathology, female)
It just gave me a bit more agency to be able to say to people, “Look actually, we’ve checked the TSH every 12 or 18 months for the last four or five years, and it’s always been normal, and this is what the evidence tells us and if we have several readings that are normal, that really the chance of there being anything abnormal without any symptoms developing, is really incredibly low, and I don’t think we need to check it again”. (GP21 post, pathology, female)
I'm in the pathology arm. I'm hoping that it highlights what I'm ordering too much of, or I'm not ordering enough of or how I'm not comparing with my peers. (GP11 pre, pathology, male)
It was really useful… and absolutely applicable for general practice… I’ve been a GP 30 years, I do try and think about what I order with my pathology tests and this has really brought it into focus for me and I’m far more comfortable now not ordering tests… I’ve got a 98-year-old guy who keeps insisting that we measure his PSA. I’ve now got the courage to say to him, “Mate, are you going to live another 7 years?” I’m not going to do it this time. (GP11 post, pathology, male)
It will become like a habit, the same as looking at the patient’s medications when I am seeing new patients, patients who come back or a new patient, and do all the medications. (GP19 post, pathology)