Background: In Australia, the general practice sector faces significant challenges, leading to a re-evaluation of its predominantly fee-for-service (FFS) funding models. Aim: The aim of this study was to conduct a systematic review of reviews that evaluated the efficacy of funding models in general practice on quality outcomes in multidisciplinary primary and preventive care for people with complex chronic conditions, as well as the contextual factors that have influenced their implementation. Design and Setting: Only systematic reviews and meta-analysis were included. Search terms covered funding mechanisms, primary care, and general practice. The review followed PRISMA guidelines for systematic reviews. Methods: PubMed, Cochrane, Embase, CINAHL, PsycINFO, PAIS and Web of Science databases were searched in November 2023 for publications from 2010 onwards. Results: Twenty reviews were included. Blended payment models incorporating Pay-for-Performance (P4P) with either Capitation (CAPS) or FFS were associated with small improvements in quality outcomes particularly in multidisciplinary settings. Changes in intermediate health outcomes and process measures for people with complex chronic conditions were most evident in diabetes care but inconclusive for other health outcomes and conditions. Improvements were mainly observed in incentivised activities and in less rigorously designed studies, with ceiling effects and variation reported across healthcare systems. There was no evidence that introducing CAPS as part of blended payments improved quality of care. Conclusions: Although blended payment models show promise, evidence for the effectiveness of models including P4P is highly variable. If adopted, careful evaluation of each incentive’s impact on both quality and equity will be essential.

OBJECTIVES:To identify publications examining the enablers of and barriers to patient enrolment in primary care and its impact on continuity and quality of care; to assess the likely effectiveness of voluntary patient enrolment (MyMedicare) in Australia with regard to improving continuity of care and supporting other health care reforms. STUDY DESIGN:Scoping review of peer-reviewed journal article published in English during 1 January 2014 - 12 July 2024 that evaluated primary care enrolment models, including patient enrolment enablers and barriers. DATA SOURCES:PubMed, Cochrane Database of Systematic Reviews, Embase, CINAHL (Cumulated Index in Nursing and Allied Health Literature), PsycINFO, PAIS (Public Affairs Information Service), Web of Science, Scopus. The bibliographies of included articles were checked for further relevant publications. DATA SYNTHESIS:The database searches and bibliography checks identified 508 potentially relevant articles; we reviewed the full text of 66 articles after title and abstract screening, of which 24 publications met our inclusion criteria. Twenty-two of the included studies were undertaken in fifteen countries, including eleven in Canada, four in Australia, and two each in the United Kingdom and New Zealand; one publication compared schemes in twelve countries, one was a rapid review. The characteristics of patient enrolment models differ greatly between countries in both form and implementation, including the mandatory and voluntary components. We found little evidence that enrolment improved continuity of care. However, existing patient engagement with usual general practitioners was high among participants in many studies, and some studies involved patients who may already have had high levels of continuity of care. There is evidence that enrolment can support primary care reforms, including preventive care and the management of chronic conditions, and that other reforms, such as incentives and increased access to services can affect the enrolment of patients and practices. People in marginalised groups or with complex care needs are less likely to enrol with practices or practitioners. CONCLUSIONS:The Australian voluntary patient enrolment scheme should be continuously evaluated to assess levels of engagement by patients and general practices, drawing on the experiences of other countries in which similar schemes operate. Further assessment of overseas enrolment systems could identify reasons for the different experiences reported, as well as enablers of and barriers to successful implementation and better health outcomes.

Background Despite Australia’s universal health insurance scheme, Medicare, out-of-pocket costs (OOPC) for health care comprises 14 % of total health expenditure. People with chronic conditions spend a greater proportion of their incomes on health care than people without a chronic condition. Objective To review the qualitative literature examining experiences of OOPC of out-of-hospital care by people with chronic conditions and to discuss this in relation to current Australian health policy. Methods Systematic review and narrative synthesis of the qualitative literature examining OOPC for people with chronic conditions in Australia. Search: Pubmed, CINAHL Complete, Cochrane Library, PsycINFO and EconLit databases from 1999 to 10th April 2025. Results 37 studies met the inclusion criteria. Reduced or lost employment due to ill-health led to income loss, aggravating the financial burden of health management. While many people were able to access bulk-billing general practitioners, challenges in affording upfront and copayments for medical and allied health consultations, and medication costs were reported. Cost was the greatest barrier to accessing dental care. Trade-offs were described between health management and meeting basic living needs, particularly for people who earned too much to qualify for government welfare payments. Conclusion While Australian health policies effectively reduce the financial burden of health care for many people, distinct challenges exist for groups ineligible for concessional thresholds. Future research to identify the priorities and preferences of people with chronic conditions can further inform policy to improve the equity of health financing in Australia.

BackgroundStrong primary care (PC) services are the foundation of high-performing health care systems and can support effective responses to public health emergencies. Primary care practitioners (PCPs) and PC services played crucial roles in supporting global health system responses to the COVID-19 pandemic. However, these contributions have come at a cost, impacting on PC services and affecting patient care. This secondary analysis of data from an integrative systematic review across international PC settings aimed to identify and describe burdens and challenges experienced by PCPs and PC services in the context of their contributions to COVID-19 pandemic responses.MethodsWe conducted an integrative systematic review and narrative analysis, searching PubMed/Medline, Scopus, Proquest Central and Cochrane Database of Systematic Reviews, plus reference lists of key publications. Included studies were published in peer-reviewed English or Chinese language journals, and described collective responses to COVID-19 undertaken in PC settings or by PCPs. Narrative data regarding impacts on PC services and challenges experienced by PCPs were extracted and analysed using inductive coding and thematic analysis.ResultsFrom 1745 screened papers 108, representing 90 countries, were included. Seventy-eight contained data on negative impacts, challenges or issues encountered in PC. Ten 'pressure points' affecting PC during COVID-19 were identified, clustered in four themes: demand to adopt new ways of working; pressure to respond to fluctuating community needs; strain on PC resources and systems; and ambiguity in interactions with the broader health and social care system.ConclusionsPCPs and PC services made critical functional contributions to health system responsiveness during the COVID-19 pandemic. However, both practitioners and PC settings were individually and collectively impacted during this period as a result of changing demands in the PC environment and the operational burden of additional requirements imposed on the sector, offering lessons for future pandemics. This study articulates ten empirically derived 'pressure points' that provide an initial understanding of burdens and demands imposed on the international primary care sector during the COVID-19 pandemic. The impact of these contributions should inform future pandemic planning, guided by involvement of PCPs in public health preparedness and policy design.

Background Mental health conditions arising from work are a rapidly increasing burden for individuals, employers and society, and are challenging to diagnose and treat. Objective To assess the effectiveness of a multicomponent intervention on increasing general practitioners' (GPs') adherence to the 'Clinical guideline for the diagnosis and management of work-related mental-health conditions in general practice' (the Guideline) and improve patient work and health and work outcomes. Methods Pragmatic hybrid III parallel cluster randomised controlled trial involving Australian GPs and their patients. GP clinics were randomly assigned to receive the intervention (GP participation in an academic detailing session, enrolment into a virtual community of practice, and receipt of resources). Those assigned to the control group received no support related to the implementation of the Guideline. GP adherence to guideline recommendations was assessed at baseline and 9 months postbaseline, using virtual simulated patient scenarios (vignettes) describing a diverse range of patient circumstances. Patient work and health outcomes (using the 21-item Depression and Anxiety Stress Scale and 36-item short-form) were assessed using self-report surveys. Findings Thirty-eight intervention clusters (52 GPs) and 36 control clusters (46 GPs) contributed to the primary outcome data. Intervention clusters had significantly higher adherence scores than control clusters, by 0.98 points on a 0-9 scale (95% CI 0.38 to 1.58) with a Cohen's d of 0.67. Patients recruited from 30 intervention (n=99) and 17 control (n=55) clusters contributed to the secondary outcome data. No differences were detected for patients' work or health outcomes due to an underpowered sample. Conclusions GP adherence to the Guideline improved as a result of receiving the multicomponent intervention.Implications Purposively designed multicomponent implementation strategies to increase guideline-concordant care should be incorporated into guideline production activities and operationalised with guideline release to facilitate evidence-based care.Trial Registration number ACTRN12620001163998, November 2020

Background The COVID-19 pandemic had detrimental effects on routine health and social care as countries instituted widespread public health measures to control transmission of SARS-CoV-2. This affected care delivery for many chronic and non-communicable diseases, including oral health and dental diseases with implications in the postpandemic period.Objectives This scoping review, conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Review guidelines, aims to synthesise evidence regarding the impact of COVID-19 on access to dental services among children and their implications for future models of care, especially for children from low-income families, to inform policy decision making around subsidised dental services in Australia.Data sources PubMed, Web of Science, Embase, Cochrane Library of Systematic Reviews and Cochrane Central Register of Controlled Trials.Eligibility criteria Primary studies of any design published between 1 January 2020 and 31 July 2024. Included studies described provision of paediatric dental services, considered components of access or utilisation and were published in English. Excluded studies were those that only evaluated maxillofacial services.Data extraction and synthesis Data were extracted using a standardised template in MS Excel then analysed to thematically classify findings based on key areas of impact. Quality assessment of studies was not conducted.Results 54 articles from 17 countries were included. Studies identified reductions in service availability and utilisation, including patient and parent-driven demand. Changes to the configuration of services included greater rates of emergency treatment, reductions in use of aerosol-generating procedures and more use of teledentistry, as well as self-management and prevention approaches. Substantial delays to routine dental care, leading to more dental problems and ongoing need, especially untreated dental caries, were observed with a disproportionate impact on socioeconomically disadvantaged and vulnerable children and families.Conclusion The COVID-19 pandemic has had pronounced negative effects on the provision of primary and secondary dental care for children around the world. Access to care was affected by disruptions to service availability and by changes in demand for services related to parental anxiety around the risk of COVID-19 transmission. Delays in receipt of routine dental care and changes to oral health behaviours are likely to lead to an increased need for oral health services, with service adaptations needed to ensure this increased demand can be met.

Background:Mobile health (mHealth) apps are increasingly being used to capture patient health data, provide information, and guide self-management, with reported improvements in health care service delivery and outcomes. However, the impact of integrating mHealth app data into electronic medical record or electronic health record (EMR/EHR) systems remains underexplored. Objective:This study aims to identify what is known about the impact of integrating mHealth app data into EMR/EHR systems on health care delivery and patient outcomes. Methods:A scoping review was conducted to identify original studies that investigated the integration of patient-facing mHealth app data into EMR/EHR systems and the impact on health care outcomes. The PubMed, Embase, Web of Science, Cochrane Library, CINAHL, ProQuest, and PsycINFO databases were searched for papers published between January 2014 and July 2024. Two authors independently screened and extracted data on study characteristics, mHealth app features, details of integration with EMR/EHR systems, and effects on health care delivery and patient outcomes. Results:Nineteen studies with 113,135 participants were included. Among these, 6 were randomized clinical trial studies, 8 were conducted in the United States, 12 occurred in hospital settings, 15 involved adult participants, and 6 targeted diabetes management. Main features of the apps and EMR/EHR systems can be categorized into tracking or recording health data (n=19), app data integrated into EMR/EHR systems (n=19), app data summarized or presented on EMR/EHR interface (n=19), communication with the health care team (n=12), reminders or alerts (n=10), synchronization with other apps or devices (n=8), educational information (n=4), and using existing portal credentials to app access (n=2). Most studies reported benefits of integrating the app and EMR/EHR, such as enhanced patient education and self-management (n=5), real-time data recorded and shared with clinicians (n=4), support for clinical decision-making (n=3), improved communication between patients and clinicians (n=7), and improved patient outcomes (n=13). Challenges identified included high drop-off rates in app usage (n=3), limited accessibility due to device restrictions (n=3), incompatibility between mHealth apps and EMR/EHR systems (n=3), increased clinical workload in response to additional information (n=3), data accuracy issues due to network connectivity (n=1), and data security concerns (n=1). Conclusions:Evidence suggests that the effective integration of mHealth app data into EMR/EHR systems can enhance both clinicians' health care delivery and patients' health outcomes. However, current literature is limited, and future opportunities remain to examine the impact on long-term outcomes, such as mortality, readmissions, and costs, and assess the scalability and sustainability of integration among more broader health conditions and disabilities across diverse health care settings.

Abstract Introduction General practitioners (GPs) encounter challenges in managing patients with work-related mental-health conditions. The Implementing work-related Mental-health guidelines in general PRacticE (IMPRovE) trial assessed the effectiveness of a multifaceted intervention in implementing the “Clinical guideline for the diagnosis and management of work-related mental-health conditions in general practice” (the Guideline). Methods Using a pragmatic hybrid III parallel cluster randomized controlled trial, GP clinics committed to recruiting employed adults with work-related mental-health conditions were allocated to either control or intervention group. Intervention clinics received academic detailing, enrolment into a virtual community-of-practice, and resources related to the Guideline. Control clinics were waitlisted until trial completion. The sum of GPs’ responses to simulated patient scenarios at baseline and 9-months post-baseline provided a measure of their adherence to the Guideline. Results GP recruitment occurred from December 2020 to February 2022. A total of 38 intervention clinics (52 GPs) and 36 control clinics (46 GPs) contributed to the primary outcome data. After adjusting for the stratification variables and clustering, GPs in the intervention arm had significantly higher adherence scores than those in the control arm, by 0·98 points on a 0 to 9 scale 95% confidence interval: 0.38, 1.58) with a Cohen’s d of 0.67; indicating a moderate to large effect. Discussion GP adherence to the Guideline improved in those receiving our multifaceted intervention, indicating that one or more components of the intervention was sufficient to change GP behavior. Conclusion For guidelines to be useful it is imperative that more attention is given towards strategies that aid implementation.

Background Assessing the fidelity of intervention components enables researchers to make informed judgements about the influence of those components on the observed outcome. The ‘Implementing work-related Mental health guidelines in general PRacticE’ (IMPRovE) trial is a hybrid III trial aiming to increase adherence to the ‘Clinical Guidelines for the diagnosis and management of work-related mental health conditions in general practice’. IMPRovE is a multifaceted intervention, with one of the central components being academic detailing (AD). This study describes the fidelity to the protocol for the AD component of the IMPRovE intervention. Method All AD sessions for the trial were audio-recorded and a sample of 22% were randomly selected for fidelity assessment. Fidelity was assessed using a tailored proforma based on the Modified Conceptual Framework for fidelity assessment, measuring duration, coverage, frequency and content. A descriptive analysis was used to quantify fidelity to the protocol and a content analysis was used to elucidate qualitative aspects of fidelity. Results A total of eight AD sessions were included in the fidelity assessment. The average fidelity score was 89.2%, ranging from 80 to 100% across the eight sessions. The sessions were on average 47 min long and addressed all of the ten chapters in the guideline. Of the guideline chapters, 9 were frequently discussed. The least frequently discussed chapter related to management of comorbid conditions. Most general practitioner (GP) participants used the AD sessions to discuss challenges with managing secondary mental conditions. In line with the protocol, opinion leaders who delivered the AD sessions largely offered evidence-based strategies aligning with the clinical guideline recommendations. Conclusions/implications The IMPRovE AD intervention component was delivered to high fidelity. The sessions adhered to the intended duration, coverage, frequency, and content allowing participating GPs to comprehend the implementation of the guideline in their own practice. This study also demonstrates that the Modified Conceptual Fidelity Framework with a mixed methods approach can support the assessment of implementation fidelity of a behavioural intervention in general practice. The findings enhance the trustworthiness of reported outcomes from IMPRovE and show that assessing fidelity is amenable for AD and should be incorporated in other studies using AD. Trial registration Australian New Zealand Clinical Trials Registry ACTRN 12620001163998, November 2020.