In Australia, all parents must produce an ‘Immunisation History Statement’ before their child is enrolled in school [25] and parents receiving income support must also obtain a health check for children turning four years of age [26], thus presenting opportunities for general practice to identify young children at risk and intervene to reduce disparities. Our study confirmed the feasibility of delivering a multi-faceted intervention to increase HKCs in general practice. In the US multi-faceted preventive child health interventions have been assembled as combinations of single element interventions, often without a clear rational for their choice [13]. Grimshaw et al. observed that an increase in dose of “component interventions” did not always lead to an increased response and proposed that multi-faceted interventions should be “built upon a careful assessment of barriers and a coherent theoretical base” [27]. In our study the elements that constituted the HKC-intervention were determined using a theoretically based behavioural change system. This pilot study demonstrated that the assembled package of intervention-components successfully incorporated solutions to the barriers identified in our primary research. Findings suggest that by upskilling the practice nurse and by taking a team approach, GPs were able to streamline processes, incorporate evidence-based preventive health care, standardise and improve quality and increase self-efficacy, delivering HKCs. The duration of the study was not long enough to determine if proportions of children completing HKCs in these practices ever attained the state-wide average of approximately 22 % [15]. An aspect of the intervention that worked less well was the training module for clinicians. Despite a flexible approach, the research team noted that GP-attendance was frequently interrupted by clinical demands so that training was incomplete for approximately half of attendees. ‘E-learning’ provides a flexible training method for clinicians [28] and has been successfully applied to paediatrics [29], presenting a potential solution in future trials of the intervention.
A second problem related to difficulties collecting data. Software changes for practice C, in the year before the study, precluded collection of baseline data. In addition, practice A undertook ‘database cleansing’ during the study, which produced an apparent large decline in total and age-eligible populations. General practices in Australia do not have fixed lists of patients, so that when practices decide to update patient databases they must determine which patients still ‘actively attend’. The commonly accepted definition of an ‘active’ patient, ‘attending three or more times in the past two years’ [30] differed from the less conservative definition employed in this study - ‘any patient attending at least once in the last 12 months’. This definition was decided upon as families access healthcare on behalf of their children from a variety of sources, and may not attend one practice on three occasions over 2 years. This may partially explain the extremely low proportions of children we recorded completing HKCs. In practice A, changes in the way patients were recorded over the course of the study may have artificially inflated the proportions of children documenting BMI and HKC improvements, although analysis at 3 months already showed improved HKC counts.
This study did not determine children’s health outcomes, or the referrals made as a result of HKCs, an additional barrier that influenced practitioner motivation in our previous research. A record was made of how many times practitioners thought they had accessed resources to address the outcomes of HKCs, however. Both ‘Parent tip sheets’ and ‘Referral pathways’ were accessed, suggesting that a significant proportion of problems were managed in-house. Secondary screens were accessed by a total of five GPs but only one PN. This implies that within the HKC process there is a degree of role separation. GPs are more likely to assume responsibility for decision making when problems are identified within a HKC, a practice reinforced in our business model, PEDS interpretation and training.
This pilot project demonstrated significant changes in measures of HKC uptake and BMI. However, the before and after study design means that we cannot be certain that our intervention was the sole reason for the observed differences. Anecdotally, staff informed the project nurse that a software upgrade, installed midway through the project in all practices, automated and correctly categorised BMI for children undergoing same day readings of height and weight. This automated measure would have enabled PNs to interpret readings and could account for the improvements in proportions of children having BMI recorded outside of HKCs, during sick-child consultations. Discussions with HKC-Champions revealed that they were not calculating or interpreting BMI prior to the intervention, but did not elucidate whether other clinicians were doing so. Practitioners’ relative ambivalence towards measuring BMI for young children, which following intervention remained unchanged for some GPs, also suggests further education may be needed.
Results show that relatively large quality improvements were made across three different practice areas: office systems, equipment and examination techniques. The practice that started from the lowest base made the largest gains (practice C), but all practices improved across each domain.
Limitations
This intervention study employed a 3 month active intervention period with an additional 3 months of follow-up. It is not known if practices continued to deliver HKCs using this format following the study. It would be interesting to know, for example, if practices continued to acquire PEDS questionnaires or if systems can be maintained during staff turn-over. This study recorded equipment and processes but did not assess how effectively PNs conducted HKC-examinations. From the PEDS forms that were returned, it was estimated that a small proportion of children had concerns predictive for developmental delay. There was no way to determine if these problems were acted upon by the medical team or the parents. Future studies could be designed to address such issues.
This study was conducted in an area that serves large numbers of young families with pockets of high socioeconomic disadvantage and child developmental vulnerability [15]. It would, therefore, be important to test this intervention across diverse populations, allow longer follow-up periods and include control sites to avoid bias, before recommending full uptake.
Negative effects
It is possible that by concentrating on one area of preventive health care in general practice, another sector lost out. PNs’ responses noted diminished participation, or reduced confidence, in other aspects of preventive health. This appears to be a valid observation because it is unlikely that participants would recall their responses to pre-intervention questionnaires. In the US, different preventive services have been found to compete with each other for physicians’ time, as well as with acute care [31] and caution has already been expressed about the opportunity costs of preventive services in Australian general practice [32].
Lessons learned and steps towards a cluster randomised controlled trial
A cluster randomised (phase III) trial would provide further evidence of the effect size of the intervention and would test generalisability to other populations. Recruitment methods (through PHOs) will be extended to practice-based research networks already affiliated with the research team. It would be important to test the intervention in another Australian jurisdiction because Victoria’s CFN services operate differently to other states and may impact on GP service delivery, with a control arm to increase the strength of the study (usual care, including HKCs conducted without the practice based intervention).
This pilot study demonstrated that the intervention was acceptable and feasible, and confirmed the selection of outcome measures (an increase in the proportion of eligible children receiving HKCs and having BMI recorded, and significant quality improvements to practice processes and equipment). Data collection methods will extend over 12 months and the commonly accepted term for “active” patients will be adopted to maintain consistency within the data [30]. Paper-based surveys of practitioners will test GP and PN self-reported knowledge and self-efficacy (adapted from another preventive health study [33]) and health care utilisation following HKC will be captured (from government Medicare insurance services) to obtain important data regarding health outcomes. Arising from the pilot study was a recommendation to develop a web based module to streamline delivery of components of the training.