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Biomedical subjects

Geoffrey K Mitchell

Publications and source records attributed to Geoffrey K Mitchell.

10 recordsLinked to original sources
PubMed2006

An audit of structured diabetes care in a rural general practice.

OBJECTIVE: To assess the impact of structured diabetes care in a rural general practice. DESIGN AND SETTING: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor's usual practice. PARTICIPANTS: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003. MAIN OUTCOME MEASURES: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1c] concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk. RESULTS: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, - 2.6 cm; blood pressure [systolic, - 3 mmHg; diastolic - 7 mmHg]; and serum lipid levels [total cholesterol, - 0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, - 0.4 mmol/L; triglycerides, - 0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, - 2.2%; proportion with foot lesions, - 14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with "ideal" blood pressure (systolic, < 130 mmHg; diastolic, < 80 mmHg) and LDL cholesterol level (< 2.5 mmol/L) of 6.4% and 20.5%, respectively. CONCLUSIONS: Implementing structured care in this rural general practice coincided with improved risk factor management, and may have contributed to the improvement. The greatest benefits were in patients with high cardiovascular risk.

Adult↗
PubMed2006

An n-of-1 trial service in clinical practice: testing the effectiveness of stimulants for attention-deficit/hyperactivity disorder.

OBJECTIVE: We sought to describe the clinical use of n-of-1 trials for attention-deficit/hyperactivity disorder in publicly and privately funded family and specialized pediatric practice in Australia. METHODS: We used a within-patient randomized, double-blind, crossover comparison of stimulant (dexamphetamine or methylphenidate) versus placebo or alternative stimulant using 3 pairs of treatment periods. Trials were conducted from a central location using mail and telephone communication, with local supervision by the patients' clinicians. PATIENTS: Our study population included children with clinically diagnosed attention-deficit/hyperactivity disorder who were aged 5 to 16 years and previously stabilized on an optimal dose of stimulant. They were selected because treatment effectiveness was uncertain. MAIN OUTCOME MEASURES: Our measures included number of patients recruited, number of doctors who used the service, geographic spread, completion rates, response rate, and post-n-of-1 trial decisions. RESULTS: Forty-five doctors across Australia requested 108 n-of-1 trials, of which 86 were completed. In 69 drug-versus-placebo comparisons, 29 children responded better to stimulant than placebo. Immediately posttrial, 19 of 25 drug-versus-placebo responders stayed on the same stimulant, and 13 of 24 nonresponders ceased or switched stimulants. In 40 of 63 for which data were available, posttrial management was consistent with the trial results. For all types of n-of-1 trials, management changed for 28 of 64 children for whom information was available. DISCUSSION: Attention-deficit/hyperactivity disorder n-of-1 trials can be implemented successfully by mail and telephone communication. This type of trial can be valuable in clarifying treatment effect when it is uncertain, and in this series, they had a noticeable impact on short-term management.

Adolescent↗
PubMed2005

A comparison of methodologies from two longitudinal community-based randomized controlled trials of similar interventions in palliative care: what worked and what did not?

BACKGROUND: Methodological challenges such as recruitment problems and participant burden make clinical trials in palliative care difficult. In 2001-2004, two community-based randomized controlled trials (RCTs) of case conferences in palliative care settings were independently conducted in Australia--the Queensland Case Conferences trial (QCC) and the Palliative Care Trial (PCT). DESIGN: A structured comparative study of the QCC and PCT was conducted, organized by known practical and organizational barriers to clinical trials in palliative care. RESULTS: Differences in funding dictated study designs and recruitment success; PCT had 6 times the budget of QCC. Sample size attainment. Only PCT achieved the sample size goal. QCC focused on reducing attrition through gate-keeping while PCT maximized participation through detailed recruitment strategies and planned for significant attrition. Testing sustainable interventions. QCC achieved a higher percentage of planned case conferences; the QCC strategy required minimal extra work for clinicians while PCT superimposed conferences on normal work schedules. Minimizing participant burden. Differing strategies of data collection were implemented to reduce participant burden. QCC had short survey instruments. PCT incorporated all data collection into normal clinical nursing encounters. Other. Both studies had acceptable withdrawal rates. Intention-to-treat analyses are planned. Both studies included sub-studies to validate new outcome measures. CONCLUSIONS: Health service interventions in palliative care can be studied using RCTs. Detailed comparative information of strategies, successes and challenges can inform the design of future trials. Key lessons include adequate funding, recruitment focus, sustainable interventions, and mechanisms to minimize participant burden.

Humans↗
PubMed2004

Doctors do not adequately look after their own physical health.

Studies of doctors' health have emphasised psychological health, and limited data have been collected on their physical health status. Doctors often fail to follow current preventive health guidelines for their physical health. About half of doctors do not have an established relationship with an independent general practitioner. This would enhance their health and provide a means of ready access to the healthcare system should a problem arise.

Attitude to Health↗
PubMed2004

Feedback of evidence into practice.

Concern about risks associated with medical care has led to increasing interest in quality improvement processes. Most quality initiatives derive from manufacturing, where they have worked well in improving quality by small, steady increments. Adaptations of quality processes to the healthcare environment have included variations emphasising teamwork; large, ambitious increments in targets; and unorthodox approaches. Feedback of clinical information to clinicians is a central process in many quality improvement activities. It is important to choose feedback data that support the objectives for quality improvement - and not just what is expedient. Clinicians need to be better educated about the quality improvement process to maintain the quality of their care.

Australia↗
PubMed2003

Palliative care at home: general practitioners working with palliative care teams.

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

Australia↗
PubMed2002

General practitioner attitudes to case conferences: how can we increase participation and effectiveness?

OBJECTIVES: To identify general practitioners' views on the barriers to using case conferencing (as outlined in the Medical Benefits Schedule (MBS) Enhanced Primary Care package) and to develop a set of principles to encourage greater GP participation in case conferences. DESIGN: Qualitative study, involving semistructured questions administered to focus groups of GPs, conducted between April and July 2001 as part of a broader study of case coordination in palliative care. PARTICIPANTS: 29 GPs from urban, regional, and rural areas of Queensland. PRINCIPAL FINDINGS: Many of the GPs' work practices militated against participation in traditionally structured case conferences. GPs thought the range of MBS item numbers should be expanded to cover alternative methods of liaison (eg, phone consultations with other service providers). The onerous bureaucratic processes required to claim reimbursement were an additional disincentive. CONCLUSIONS: GPs would probably be more likely to participate in case conferences if they were initiated by specialist services and arranged more flexibly to suit GP work schedules.

Attitude of Health Personnel↗
PubMed2002

How well do general practitioners deliver palliative care? A systematic review.

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.

Attitude of Health Personnel↗