The management of ear, nose, and throat (ENT) conditions in an Australian general practice

Introduction

The Bettering the Evaluation of Care and Health (BEACH) study was an audit of Australian General Practice conducted from 1998 to 2016, in which 1,000 general practitioners (GPs) were asked to provide data on 100 consecutive GP consultations each year (1). Ear, nose, and throat (ENT) and oral conditions were seen in up to 4% of GP consultations (2). Australia has a universal healthcare system called Medicare, which subsidizes up to 100% of the cost of general practice services to all Australian citizens and permanent residents (3). A dedicated study of the ENT conditions encountered and how they are managed in Australian general practice has not been conducted and would provide more detailed information to better inform teaching and resource allocation, and to identify which areas ENT specialists can optimise support for GPs. Furthermore, studies immediately prior to, during and post-coronavirus disease (COVID) lockdowns on ENT presentations in general practice in the Australian context would provide more contemporaneous information than the limited ENT data collected from the BEACH study. This study also seeks to describe what impact COVID lockdowns had on the presentation of ENT conditions in an Australian general practice in the eastern suburbs of Melbourne, the second most populous city in Australia (4). Melbourne also had the distinction, for a time, of being the most locked down city in the world (5). We present this article in accordance with the STROBE reporting checklist (available at https://www.theajo.com/article/view/10.21037/ajo-23-60/rc).

Methods

This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Eastern Health Human Research Ethics Committee (Reference No. LR23-067-103601). Because of the retrospective nature of the research, the requirements for informed consent were waived.

This study was a retrospective cohort study of all patients seen in a general practice in the eastern suburbs of Melbourne. During the study periods, the total number of GPs at the practice ranged from 5–6 GPs (4 of whom were full-time GPs throughout the study periods), which is typical for the average GP clinic in Australia (6). For each patient, data was collected on general patient characteristics (age and gender) and the type of ENT condition treated, and the management provided by the GP.

Data from consecutive patient consultations during the months of April in 4 consecutive years (2019, 2020, 2021, 2022) from the subject general practice were collected and the proportion of ENT conditions determined. April of each year was chosen as it was the month in which the first full COVID lockdown occurred in order to determine the impact of COVID lockdowns on GP presentations. Basic descriptive statistics were employed to characterize the types of ENT conditions seen and how these conditions were treated by GPs [scripts, over the counter (OTC) medication, procedures, specialist referral, investigations]. Consultations included were those that had a clearly defined ENT condition or symptoms and did not include the conditions where at least part of an ENT examination was conducted incidentally (e.g., respiratory tract infections) which were recorded separately.

Results

A total of 7,049 individual patient consultations were included in this study, with a total of 9,901 reasons for presenting. A majority of consultations were for female patients in each study period. The age of these patients was similar each year (see Table 1). The two most common reasons for presenting to the GP each year were immunisations and general check-ups (which included a range of services from blood pressure checks for script renewal, to comprehensive health assessments, e.g., 45–50-year-old health assessment, annual >75-year-old health assessments as outlined by Medicare).

The overall average number of reasons for presenting per consultation was similar in April 2020 and April 2022, and slightly higher in April 2019 and April 2021. When excluding consultations which included vaccinations as a reason for presentation, the number of reasons for presentation per consultation was more consistent (1.3–1.5 reasons for presenting) across the study periods (see Table 2).

ENT presentations were managed in 6–7% of consultations in each study period except for a drop to 4% in April 2020, the first lockdown of the COVID pandemic. When excluding consultations which included vaccinations as a reason for presentation, specific ENT conditions were managed in 9% of patient encounters in each study period except for a drop to 6% also in April 2020.

Otology conditions were the most common ENT conditions seen in each of the study periods (see Table 3) with cerumen being the most common specific reason for presentation (see Table 4). All ENT conditions seen in this study were documented (see Tables 4,5). The most common management outcome for ENT conditions was a script which occurred in 29–45% of patient encounters, or OTC medications, which were provided in 7–16% of patient encounters depending on the study period. Procedures, comprising mostly ear toilet, where performed by the GP in 6–15% of consultations for ENT conditions depending on the study period. Further investigations were ordered in 3–14% of patient encounters, and specialist or emergency department referrals were provided in 6–17% of patient encounters depending on the study period. No intervention (which included providing advice only) was indicated in 21–35% of patient encounters depending on the study period (see Table 6).

Initially, 28% of consultations for ENT conditions were telehealth when introduced in April 2020, and then subsequently 17–18% of consultations for ENT conditions in April 2021 and April 2022. This compared similarly with a telehealth consultation rate of 32% for all patient encounters in April 2020 and 18–19% in April 2021 and April 2022. No telehealth consultations were recorded in April 2019, the year prior to the introduction of a rebate for telehealth consultations by Medicare.

Discussion

ENT conditions are treated commonly in general practice with specific ENT conditions being seen in approximately 4–7% of consultations in this study. This is a higher number than previously documented and suggests that the average GP who sees 25–30 patients per day would see between 1 and 2 patients for a specific ENT condition per day, excluding the incidental ENT examinations that occur for other reasons such as in respiratory tract infections. When including respiratory tract infections, ENT assessment was required in up to 15% of consultations in this study, representing between 4 and 5 patients seen by the average GP per day. In this study 6–17% of consultations for ENT conditions resulted in a referral to the emergency department or a specialist. Conversely, 83–94% of ENT conditions were managed solely by the GP at that given patient encounter. This demonstrates that GPs are managing the majority of specific ENT conditions they see at most consultations. As such, there is a clear need to maintain good proficiency in the management of ENT conditions among GPs, for example, in maintaining high quality ENT teaching in general practice training and/or ongoing GP education through continuing professional development programs.

The impact of vaccinations during the study periods on the management of ENT presentations was analysed, in view of the concerted influenza and COVID vaccination programs affecting the 2020–2022 study periods, and was found to have minimal impact on the proportion of patient encounters for ENT conditions. The immediate impact of the initial COVID lockdown in April 2020 was demonstrated with a decrease in the proportion of ENT conditions seen, and an increase in the frequency of investigation referrals.

A limitation of this study was that it was confined to one location and to the month of April over a 4-year study period and may not necessarily account for seasonal fluctuations in ENT condition frequency that may occur. However, due to the impact of COVID, and the various unpredictable lockdowns that occurred during the study period, this was assessed as an appropriate time period for comparative assessment of the impact of COVID lockdowns. Furthermore, the previous BEACH study required an audit of 100 consecutive patients by GP participants, which may not have occurred at consistent times of the year, or may have been affected if the GP participants moved locations. The current study design reduced the impact of these potential variables, however, a corollary of this is that its generalisability was also reduced. Although prospective studies are considered the gold standard, they may have had the potential to alter GP participant behaviour in the BEACH study as GPs may have been more conscious of how their management decisions may be perceived. The retrospective design of the current study mitigated that risk.

This study demonstrated a higher proportion of ENT conditions per consultations as compared to previous studies of Australian general practice, highlighting the value in further investigating the ENT conditions that are seen more broadly in general practices across Australia, and how these conditions are managed. This information would further inform the development of improved policies and procedures that target the provision of optimal care to ENT patients seen in general practice ranging from GP training and education, to improved referral pathways that ENT specialists can provide to GPs attempting to access ENT services for their patients.

Acknowledgments

The authors would like to thank Hui Yi Chen for her contribution in data collection.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/10.21037/ajo-23-60/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-23-60/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-23-60/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-23-60/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Eastern Health Human Research Ethics Committee (Reference No. LR23-067-103601). Because of the retrospective nature of the research, the requirements for informed consent were waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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