Confidence and attitudes of general practitioners towards dementia

Like most Western countries Australia faces a radical increase in the prevalence of dementia. Currently dementia is the second leading cause of death in Australia and the leading cause of death among women, with approximately 376,000 cases in 2016 projected to increase to 1,100,890 by 2056[1]. The cost of supporting people with dementia was estimated to be $9.1 billion in 2017, and projected to increase 81% to $25.8 billion by 2036, and $36.8 billion by 2056. As such dementia represents a significant public health issue facing Australian society in the 21st century. It is widely acknowledged that facilitating the timely diagnosis of dementia offers the opportunity for patients and their families to plan for the future, access treatments and support services, reduce family member stress, enable caregivers (who, in most cases, are family members) to adapt to the caregiver role, provide effective support and delay admission to residential aged care. Importantly, early diagnosis enables people with dementia to actively participate in decision making about the future whilst they are able. General practitioners (GPs) play a key role in supporting people with dementia and their families across the dementia trajectory. Importantly they have a primary role in facilitating a dementia diagnosis, a point which many GPs acknowledge. Indeed, in the majority of cases involving dementia the GP is the first health professional to be consulted. Yet while the literature suggests GPs have positive attitudes toward caring for people with dementia, many people with dementia symptoms remain undiagnosed. Of concern, evidence suggests that a third of GPs never disclose a dementia diagnosis or do not routinely disclose a diagnosis to a patient. Moreover, recent research highlights that just over half of adults with probable dementia have either not been diagnosed or were unaware of their diagnosis. There are several potential reasons why dementia diagnosis rates remain low, or why a diagnosis might be delayed. Patient barriers include stigma, reluctance to know a diagnosis of dementia, refusal to be tested or treated, concealment of symptoms, together with minimisation of, or ignoring early signs and symptoms. From a GP perspective, barriers to diagnosis often revolve around the difficulties associated with diagnosing dementia given the often-complex presentations, especially in its early stages. Evidence also highlights problems with GPs' knowledge and skill deficits, while low rates of diagnosis or delayed diagnosis have also been associated with a GP's attitudes surrounding the benefits of making a diagnosis, the efficacy of medical treatments and/or confidence in their clinical abilities to not only diagnose and communicate a diagnosis, but also treat and or manage dementia related symptoms. While training has been shown to increase the knowledge of participants, research has also indicated that knowledge is only one part of the equation in the translation of knowledge into clinical practice, and that attitudes and perceptions of self-efficacy play a key role in relation to how a GP might approach management of dementia. A survey that is both valid and can reliably measure these constructs provides insights into how educational interventions impact on attitudes and confidence, as well as providing a basis from which to develop future interventions that specifically target any deficiencies in either. Research aims While several studies have utilised questionnaires to measure both the attitudes and confidence of GPs as they relate to dementia, most of these have been cross sectional or ad hoc in nature and/or are unsuitable for use within a pre-test post-test scenario. Further, very few have undertaken a comprehensive assessment of their validity and or reliability. Therefore, the main aim of this research has been to develop a reliable and valid tool to measure the attitudes and confidence of GPs both at baseline (or as a 'one off' measure) and after an educational intervention. Consequently, the aims of this research were to: 1. develop and test a preliminary tool to measure the attitudes and confidence of GPs towards the diagnosis, treatment, and management of dementia; 2. refine and validate the tool including with confirmatory analysis. Further, undertake a comparative analysis of GP participants to test the efficacy of the tool in relation to group differences and in measuring the confidence and attitudes of GPs as they relate to the diagnosis, treatment, and management of dementia; 3. employ the validated survey to measure the impact of dementia education workshops on GP Registrars and GP Supervisors. Method The sample frame comprised General Practitioner Registrars (GPRs) and General Practitioner Supervisors (GPS) undertaking dementia education workshops in five Australian states, while purposive sampling was employed to recruit participants. Phase one involved the collation of potential survey items to be included in the tool via a literature review. Potential items were evaluated for content and face validity via the use of focus groups and an expert panel. Reliability and sensitivity to change were established through an analysis of pilot data and the preliminary model developed using principal component analysis (PCA). Stage two involved the use of confirmatory factor analysis (CFA) to refine the tool and evaluate construct and discriminant validity. Stage three involved testing the tool in a cohort of participants in dementia education workshops conducted throughout Australia. Results Initial results indicated that the preliminary survey exhibited sound psychometric properties with items exhibiting reliability and sensitivity to change. Subsequent refinement CFA resulted in a 3 factor, 15 item tool exhibiting good fit and sensitivity to group differences where expected. Use of the tool in dementia education workshops indicated significant increases in confidence and attitudes for participants in both GP Supervisor and GP Registrar workshops, with GPRs exhibiting the strongest effect as a result of the educational intervention. The preliminary study indicated the General Practitioner Attitudes and Confidence Scale - Dementia (GPACS-D) comprised four potential subscales describing (a) confidence in clinical abilities; (b) support for early diagnosis, quality of life and care; (c) engagement; and (d) communication about dementia progression. Results were interpreted with reference to theories of behaviour that relate to attitudes, perceptions of self-efficacy and an intention to act or actual behaviour. Reliability and sensitivity to change were acceptable. Internal reliability scores indicated moderate to good internal consistency. In its preliminary form the tool was restricted to item level analysis because the preliminary scales had not been confirmed via confirmatory factor analysis to establish both construct and discriminant validity. Subsequent refinement and validation via CFA reduced the original 20 item GPACS -D to 15 items comprising three subscales. These include Attitude to care, Confidence in clinical abilities and Engagement. Post hoc analyses eliminated Attitude towards communication. The grouping of each item within each factor is reflective of reported barriers to early or timely diagnosis. Construct and discriminant validity were evidenced by goodness of fit statistics and inter item correlations. Results from the administration of the GPACS-D provided insights into GPR and GP Supervisor attitudes and confidence in relation to each of the subscales. Intra group analysis revealed significant change because of the intervention, while inter group analysis identified significant differences between GPR and Supervisor groups in relation to each of the subscales. GP Supervisorsrecorded a higher score for each subscale at baseline and after the intervention for Confidence in clinical abilities and Engagement, while GPRs recorded a significantly higher score for attitude to care post workshop. The GPR group also recorded the greatest effect for Confidence in clinical abilities and Engagement as a result of the intervention. Discussion GP attitudes towards dementia and perceived confidence in clinical abilities have been identified as barriers to the timely diagnosis of dementia. While traditionally, knowledge and skills have been the focus of educational interventions, the impact of attitude and confidence have increasingly been recognised as crucial in GP response to the diagnosis and treatment/management of dementia. In order to assess the impact of any educational intervention, tools that accurately measure not only change in knowledge/skills but also attitudes are fundamental, because the manner in which dementia is approached and managed has been identified as a gap in preparation for practice. Attitude is a key determinant in the assessment of dementia and a tool that accurately measures attitudes and confidence is important in the development and assessment of any educational intervention aimed at changing or affecting behaviour. The General Practitioners Attitude and Confidence Scale - Dementia (GPACS-D) was designed to measure GP confidence and attitudes towards the management of dementia as well as gauging the impact of dementia educational interventions and any change in attitudes and confidence as a result of an educational intervention. Further the use of subscales provides a more in-depth understanding of the attributes of attitudes and confidence as they relate to dementia in general practice. Through the targeting of specific components of attitude and confidence in educational interventions, positive change in clinical practice might be achieved to enhance the quality of care for people with dementia. Conclusion Current tools used to measure attitudes and or confidence have been limited in their scope. Results from this study indicate that the GPACS-D is a reliable and valid tool that is us...