Papers by Geoffrey Mitchell
Australian Journal of General Practice, 2020
This article is part three in a three-part series on whole-person care in general practice. Backg... more This article is part three in a three-part series on whole-person care in general practice. Background and objective Whole-person care (WPC) is a key characteristic of general practice, but it may not be consistently practised. Previous articles in this series suggest a model of WPC that views patients as multidimensional persons; has length, breadth and depth of scope; is founded on a strong doctor-patient relationship and involves a healthcare team. This article reports factors that general practitioners (GPs) believe affect their provision of WPC. Methods Semi-structured interviews were conducted with 20 Australian GPs or general practice registrars and analysed using grounded theory methodology. Results Participants identified overarching factors (time, perceived value of WPC) and factors related to immediate (interpersonal dynamic), local (practice structure, relationship between care providers) and broader (health system structure) contexts that affect WPC. They volunteered practical suggestions to support WPC. Discussion GPs believe that multiple factors acting at micro and macro levels affect WPC provision. These findings provide a basis for strategies to support WPC.
Social Science Research Network, 2019
Should doctors fear legal sanction for using opioids at the end of life?
The effects of centralised and specialised combined pharmacological and psychological interventio... more The effects of centralised and specialised combined pharmacological and psychological intervention compared with decentralised and non-specialised treatment in the early course of severe unipolar and bipolar affective disorders-design of two randomised clinical trials
Contemporary Clinical Trials Communications, 2020
Background: Children with ADHD and sleep problems have more caregiver deficits and decreased scho... more Background: Children with ADHD and sleep problems have more caregiver deficits and decreased school attendance than children with ADHD but without a sleep problem. We conducted an N-of-1 trial of melatonin for children with ADHD on stimulants. As a follow-up study, we aim to conduct a cost effectiveness analysis (CEA) of melatonin therapy by comparing costs of this condition (of using melatonin) to costs of the baseline condition (usual care with no N-of-1 trial). Methods: The CEA will compare participants who remained on melatonin vs those who chose to cease melatonin. Costs will be determined by medication cost to the caregiver(s), school/work absences, other sleep remedy costs, and health service utilization costs, including incidentals like parking. These costs will be determined at baseline, end of 6-week trial, and 6 months post-trial. We will also calculate Quality-Adjusted Life-Years (QALY) based on responses to PedsQL or SF-12v2 for patients and caregiver(s) and assess differences between remaining on melatonin or not; and assess the intermediate-term effectiveness and adverse effects of melatonin at 6 months. Discussion: We hypothesize that shorter sleep-onset-latency will be associated with improved QALYs for patients and caregivers. We also expect that targeting melatonin to positive responders will be cost effective both for individuals and society. Cost per QALY for positive responders to melatonin is useful for doctors when creating treatment plans since melatonin is not an over-the-counter pharmaceutical in Australia. Trial registration number: ACTRN12614000542695.
Innovation in Aging, 2019
People living with Alzheimer’s disease and related dementias (ADRD) must eventually stop driving.... more People living with Alzheimer’s disease and related dementias (ADRD) must eventually stop driving. While some will voluntarily retire, many others will continue to drive until a crisis. In Australia, like many other countries, general physicians/practitioners (“GPs”) play a key role in monitoring driving safety and driver retirement with their patients with ADRD. Advising patients about driving cessation is one of the most challenging aspects of clinical dementia care, complicated by limited time in consultations, lack of patient awareness and insight, and objective screening and assessment measures. We examined how to support best practice in relation to management of driving cessation with patients with ADRD through focus groups with 29 GPs and contrasted their perspectives with those of 11 retired drivers with ADRD. Focus groups and interviews were transcribed and thematically analysed. Themes discovered highlighted the importance of providing education about the effects of dement...
Contemporary Clinical Trials Communications, 2019
Background: Whiplash associated disorder (WAD), a common and disabling condition, incurs huge bur... more Background: Whiplash associated disorder (WAD), a common and disabling condition, incurs huge burden and costs to Australia. Yet, current treatments for whiplash are not very effective; improved outcomes are urgently needed. Clinical guidelines recommend simple analgesia (paracetamol and non-steroidal anti-inflammatory drugs) but there have been no trials of guideline-recommended drugs. This study will investigate the effectiveness of evidence-based advice (EBA), paracetamol, naproxen, and both paracetamol and naproxen, in reducing daily neck pain and preventing chronic neck pain after whiplash injury. Methods: This study is a pilot series of multi-cycle, double-blinded, randomised N-of-1 trials, nested in a multiple baseline design. The design will comprise three baselines of 5, 8 or 11 days duration. Post enrolment, participants will be randomly assigned to one of the baselines. Fifteen participants with acute (<2 weeks) Grade II WAD, experiencing at least moderate pain (NRS: � 5/10), and at risk of poor recovery will be recruited from hospitals in Queensland, Australia, and through local physiotherapists. Patients will receive EBA plus a randomised sequence of three cycles of ten day treatment triplets (paracetamol designated as a C phase, naproxen, designated as a D phase, and both paracetamol and naproxen, designated as an E phase). Discussion: We will test the effects of different treatments on the primary outcome of average neck pain intensity collected daily and at 4 and 7 months post-injury. Secondary outcomes, including disability, depression, posttraumatic stress symptoms, pain catastrophizing, and feasibility of study procedures, will also be evaluated. The results of this study will inform a larger trial aiming to strengthen the evidence on EBA and simple analgesics for WAD.
Medical Journal of Australia, 2004
Specialist palliative care services and services involved in the pre-palliative phase of a patien... more Specialist palliative care services and services involved in the pre-palliative phase of a patient's disease must accept GPs as an integral part of the care team The number of Australians requiring palliative care is set to rise as the population ages. Although specialist palliative care services now cover most regions of Australia, rationing will be inevitable. Addressing the gaps and shortfalls to enable successful care of dying people will always require general practitioners to shoulder most of this clinical load.
BMJ Supportive & Palliative Care, 2019
BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands ... more BackgroundGeneral practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide end-of-life care (EoLC) as the population ages. To enhance primary palliative care (PC), the care they provide needs to be understood to inform best practice models of care.ObjectiveTo provide a comprehensive description of the self-reported role and performance of GPs and GPNs in (1) specific medical/nursing roles, (2) communication, (3) care co-ordination, (4) access and out-of-hours care, and (5) multidisciplinary care.MethodSystematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.ResultsFrom 6209 journal articles, 29 reviewed papers reported the GPs’ and GPNs’ role in EoLC or PC practice. GPs report a central role in symptom management, treatment withdrawal, non-malignant disease management and terminal sedation. Information provision included breaking bad news, prognosis and pl...
Healthcare, 2019
Anticipatory planning for end of life requires a common language for discussion among patients, f... more Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged ‘SENS’-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the p...
BMJ open, Jan 14, 2018
The importance of 'whole person' or 'holistic' care is widely recognised, particu... more The importance of 'whole person' or 'holistic' care is widely recognised, particularly with an increasing prevalence of chronic multimorbidity internationally. This approach to care is a defining feature of general practice. However, its precise meaning remains ambiguous. We aimed to determine how the term 'whole person' care is understood by general practitioners (GPs), and whether it is synonymous with '[w]holistic' and 'biopsychosocial' care. Systematic literature review. MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, Proquest Dissertations and Theses, Science.gov (Health and Medicine database), Google Scholar and included studies' reference lists were searched with an unlimited date range. Systematic or literature reviews, original research, theoretical articles or books/book chapters; specific to general practice; relevant to the research question; and published in English were included. Included literature was critically ...
BMJ supportive & palliative care, Jan 25, 2018
With an increasing ageing population in most countries, the role of general practitioners (GPs) a... more With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important. To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference. Systematic literature review. Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases. From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of G...
BMC palliative care, Jan 5, 2018
Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries&#... more Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries' populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent. The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable. Participants (...
Trials, Jan 23, 2018
N-of-1 trials have a potential role in promoting patient-centered medicine in developing countrie... more N-of-1 trials have a potential role in promoting patient-centered medicine in developing countries. However, there is limited academic literature regarding the use of N-of-1 trials in the clinical care of patients in resource-poor settings. To assess the extent of use, purpose and treatment outcome of N-of-1 trials in developing countries. A systematic review of clinical N-of-1 trials was conducted between 1985 and September 2015 using PubMed, Embase, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials. Grey literature databases and clinical trial registers were also searched. This review included randomized, multi-cycle, crossover within individual patient trials involving drug intervention. Quality assessment and data extraction were conducted by two independent reviewers. Out of 131 N-of-1 trials identified, only 6 (4.5%) were conducted in developing countries. The major reason that N-of-1 trials were used was to provide evidence on feasibility, effectiv...
Trials, Jan 10, 2017
Hypertension is one of the leading causes of morbidity and mortality in Ethiopia. Treatment usual... more Hypertension is one of the leading causes of morbidity and mortality in Ethiopia. Treatment usually involves lifelong medication use. Enalapril is a common drug for the treatment of hypertension in Ethiopia. However, the drug is expensive and, therefore, there is limited capacity for people to afford the treatment. Locally produced Enalapril is a cost-effective solution to treat the disease. However, as local medicines regulation does not include bioequivalence tests on locally produced drugs, physicians and patients need assurance about the effectiveness and safety of local generics. Evidence on therapeutic equivalence is needed on these untested local drugs. This is a hospital-based, randomized, partially blinded, three-cycle crossover trial in single patients, comparing a locally produced version of enalapril with enalapril imported from Europe. Patients involved in this trial are not blinded, as there is no local facility to produce relatively small numbers of placebos or encaps...
BMC medicine, Jul 10, 2017
Current trends in population ageing show that, in the near future, while more people will live lo... more Current trends in population ageing show that, in the near future, while more people will live longer, more will also die at any one time. Health systems, as well as individual practitioners, are only just becoming aware of the extent of this problem. Health systems will have to rapidly change practice to manage the number of people dying in the coming years, many with complex multimorbid conditions. The changes involved should include a personal recognition by all health professionals of their role in caring for the dying, and healthcare education must include end-of-life care management as part of the core curriculum. Further, health systems must improve integration between primary care and specialist clinicians to ensure the burden is shared efficiently across the system. Finally, it should be recognised that end-of-life care is not terminal care, but should be anticipated months or sometimes years ahead through advance care planning for known future complications by the patient&...
International psychogeriatrics, Oct 27, 2017
Palliative care for nursing home residents with advanced dementia is often sub-optimal due to poo... more Palliative care for nursing home residents with advanced dementia is often sub-optimal due to poor communication and limited care planning. In a cluster randomized controlled trial, registered nurses (RNs) from 10 nursing homes were trained and funded to work as Palliative Care Planning Coordinators (PCPCs) to organize family case conferences and mentor staff. This qualitative sub-study aimed to explore PCPC and health professional perceptions of the benefits of facilitated case conferencing and identify factors influencing implementation. Semi-structured interviews were conducted with the RNs in the PCPC role, other members of nursing home staff, and physicians who participated in case conferences. Analysis was conducted by two researchers using a thematic framework approach. Interviews were conducted with 11 PCPCs, 18 other nurses, eight allied health workers, and three physicians. Perceived benefits of facilitated case conferencing included better communication between staff and ...
BMJ supportive & palliative care, Jan 14, 2017
The general practitioner (GP) has a critical role in an integrated model of palliative care as th... more The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care. (1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care. MEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined...
BMC palliative care, Jan 9, 2016
Providing end of life care in rural areas is challenging. We evaluated in a pilot whether nurse p... more Providing end of life care in rural areas is challenging. We evaluated in a pilot whether nurse practitioner (NP)-led care, including clinical care plans negotiated with involved health professionals including the general practitioner(GP), ± patient and/or carer, through a single multidisciplinary case conference (SMCC), could influence patient and health system outcomes. Setting - Australian rural district 50 kilometers from the nearest specialist palliative care service. Adults nearing the end of life from any cause, life expectancy several months. Intervention- NP led assessment, then SMCC as soon as possible after referral. A clinical care plan recorded management plans for current and anticipated problems and who was responsible for each action. Eligible patients had baseline, 1 and 3 month patient-reported assessment of function, quality of life, depression and carer stress, and a clinical record audit. Interviews with key service providers assessed the utility and feasibility...
Trials, 2016
Background: Attention-deficit/hyperactivity disorder (ADHD) is a common neurological disorder aff... more Background: Attention-deficit/hyperactivity disorder (ADHD) is a common neurological disorder affecting 5 % of children worldwide. A prevalent problem for children with ADHD is initial insomnia. The gold standard treatment to manage ADHD symptoms is stimulant medications, which may exacerbate the severity of existing initial insomnia. Currently, no gold standard treatment option exists for initial insomnia for these children. Melatonin, a hormone and a popular natural health product, is commonly provided to children by parents and recommended by healthcare providers, but high quality pediatric evidence is lacking. Methods/design: This trial is a multicenter randomized triple-blind, placebo-controlled, parallel-group, randomized, controlled trial (RCT), in which each participant is offered an N-of-1 trial. An N-of-1 trial is a multiple-crossover, randomized, controlled trial conducted in a single individual. For the N-of-1 trial, each participant will undergo three pairs of treatment/placebo periods; each period is 1 week in length. Half the participants will have melatonin in the first period, the other half will start with placebo, and this will make up the parallel-group RCT. The primary outcome will be mean difference in sleep onset latency as measured by sleep diaries. A comparison of treatment effects yielded by the RCT data versus the aggregated N-of-1 trial data will also be assessed. Discussion: This trial will provide rigorous evidence for the effectiveness of melatonin in children with ADHD on stimulants who experience initial insomnia. Further, this study will provide the first prospectively planned head-to-head comparison of RCT data with pooled data from a series of N-of-1 trials. Aggregated N-of-1 trials may be a powerful tool to produce high quality clinical trial evidence.
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Papers by Geoffrey Mitchell