Nicholas Zwar

University of New South Wales, Kensington, New South Wales, Australia

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Publications (111)211.83 Total impact

  • Mark F Harris, Nicholas A Zwar
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    ABSTRACT: General practice has experienced change over the past century driven by a variety of influences, the most important of which have been changes in the health needs of the population, the organisation of the workforce, and medicine itself. Over this time, general practice has developed as a profession through education and, ultimately, recognition of its specialist qualifications. There has been increasing organisational sophistication at the practice, regional and national levels. Despite contested scope of practice and vision of its future, general practice's place in the health system as a whole has been increasingly recognised and affirmed.
    The Medical journal of Australia. 07/2014; 201(1):S37-S40.
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    ABSTRACT: Although great progress has been made on tobacco control, smoking remains one of the most important causes of preventable disease and death in the Australian population. The general practice team has much to offer in helping smokers to quit.
    Australian family physician 06/2014; 43(6):348-354. · 0.71 Impact Factor
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    ABSTRACT: The gold standard for the diagnosis of chronic obstructive pulmonary disease (COPD) is spirometry, but there are barriers to its use in primary care. To externally validate the COPD Diagnostic Questionnaire (CDQ) as a diagnostic tool in patients at increased risk in Australian general practice and to compare its performance with other CDQ validation studies. Patients were recruited from 36 general practices in Sydney, Australia. Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse. The CDQ was collected and pre- and postbronchodilator spirometry was performed. Cases for whom complete CDQ data were present and the spirometry met quality standards were analysed. Of 1,631 patients who attended case-finding recruitment, 1,054 (65%) could be analysed. Spirometry showed 13% had COPD. The ability of the CDQ to discriminate between patients with and without COPD was fair, represented by the area under the receiver operating characteristic curve of 0.713. With a CDQ cut-off point value of 16.5 the sensitivity was 80% and specificity 47% and, at a cut-off point value of 19.5, the sensitivity was 63% and specificity 70%. The CDQ did not discriminate between patients with and without COPD accurately enough to use as a diagnostic tool in patients at increased risk of COPD in Australian general practice. Further research is needed on the value of the CDQ as a tool for selecting patients for spirometry.
    Primary care respiratory journal: journal of the General Practice Airways Group 02/2014;
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    Travel Medicine and Infectious Disease 01/2014; · 1.78 Impact Factor
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    BMJ (online) 01/2014; 348:f7535. · 17.22 Impact Factor
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    ABSTRACT: Guidelines for management of hypertension and lipids recommend using cardiovascular absolute risk (CVAR) to manage patients. This randomized controlled trial investigated the impact of CVAR assessment in family practice on management of cardiovascular risk, including prescription of antihypertensive and lipid-lowering medication. A cluster randomized controlled trial was conducted from 2008 to 2010 in Sydney, Australia. Family practices were randomized, and patients aged 45 to 69 years were invited to participate. Intervention family physicians (FP) were trained in use of CVAR, provided with an electronic CVAR calculator, and assessed their patients' absolute risk in a dedicated consultation. Control practice patients received a general health check. Primary outcome analyzed was the proportion of patients in each group on antihypertensive and/or lipid-lowering medication at 12 months. Multilevel logistic regression was performed to explore variables influencing changes in pharmacologic therapy. The study recruited 36 FPs from 34 practices and 1,074 patients, of which 906 (84.4%) completed 12-month follow-up. At 12 months, there was no significant difference between the intervention and control groups in proportion of patients on antihypertensives (31.2% vs 34.3%, P = .31), but control group patients were more likely to be on lipid-lowering medications (30.2% vs 22.7%, P = .01). After multilevel analysis, this difference was not present. Intensification or reduction of pharmacologic therapy was associated with meeting treatment targets for blood pressure and lipids but not with the CVAR or intervention group. Single-risk factor management remains a strong influence on FP prescribing practices. Shifting to an approach based on CVAR will require more intensive intervention.
    American heart journal 01/2014; 167(1):28-35. · 4.65 Impact Factor
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    ABSTRACT: Background:Using the COPD Diagnostic Questionnaire (CDQ) as a selection tool for spirometry could potentially improve the efficiency and accuracy of chronic obstructive pulmonary disease (COPD) diagnosis in at-risk patients.Aim:To identify an optimal single cut point for the CDQ that divides primary care patients into low or high likelihood of COPD, with the latter group undergoing spirometry.Methods:Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse at various general practices in Sydney, Australia. The CDQ was collected and pre- and post-bronchodilator spirometry was performed. Cases with complete CDQ data and spirometry meeting quality standards were analysed (1,054 out of 1,631 patients). CDQ cut points were selected from a receiver operating characteristic (ROC) curve.Results:The area under the ROC curve was 0.713. A cut point of 19.5 had the optimal combination of sensitivity (63%) and specificity (70%) with two-thirds below this cut point. A cut point of 14.5 corresponded to a sensitivity of 91%, specificity of 35% and negative predictive value of 96%, and 31% of patients below this cut point.Conclusions:The CDQ can be used to select patients at risk of COPD for spirometry using one cut point. We consider two possible cut points. The 19.5 cut point excludes a higher proportion of patients from undergoing spirometry with the trade-off of more false negatives. The 14.5 cut point has a high sensitivity and negative predictive value, includes more potential COPD cases but has a higher rate of false positives.
    NPJ primary care respiratory medicine. 01/2014; 24:14024.
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    ABSTRACT: The international traveller needs to plan ahead to ensure medicines are available and used as directed for optimal therapeutic outcome. The planning needs to take account of legal and customs requirements for travelling with medicines for personal use. The standard advice by travel health providers is that travellers should check with the country of destination for requirements when travelling into the country with medicines for personal use. This is akin to introducing a barrier to care for this category of travellers. Innovative method of care for this group of traveller is needed.
    Travel Medicine and Infectious Disease 01/2014; · 1.78 Impact Factor
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    ABSTRACT: Background:Chronic obstructive pulmonary disease (COPD), a major cause of morbidity and mortality worldwide, often occurs in the presence of comorbidities, which may influence experience and management of the disease. No prior research seems to have gained perspectives of newly diagnosed primary care COPD patients in the context of multimorbidity.Aims:This qualitative study aimed to explore the impact of a new diagnosis of COPD in the context of multimorbidity and also sought to gain a better understanding of how patients react to the diagnosis and incorporate it into their lives.Methods:Participants were identified from a cohort of primary care patients with multimorbidity recently diagnosed with COPD. Data was collected via semi-structured interviews from nine male and eight female participants. Thematic analysis was performed and the data interpreted from a constructivist perspective.Results:Five core themes regarding COPD were induced: (i) reaction to diagnosis, (ii) impact on function and health behaviour, (iii) factors influencing self-management capacity, (iv) healthcare utilisation and (v) interplay of comorbidities. Most participants had difficulty recognising the importance of COPD and its long-term implications. For many, the salience of another chronic condition outweighed COPD. Self-management capacity and utilisation of healthcare services were challenged by low prioritisation of COPD among other comorbidities.Conclusions:This study provides an insight into how primary care patients feel about being diagnosed with COPD, as well as their prioritisation of the disease in the context of multimorbidity. It highlights the need for tailored education and personalised management incorporating patients' perspectives in primary care.
    NPJ primary care respiratory medicine. 01/2014; 24:14036.
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    ABSTRACT: Advance care planning provides patients with the ability to make their decisions known about how they would like to be treated if they lose capacity. Medical practitioners have a key role to play in providing information on advance care planning to their patients. This research explores their knowledge and attitudes to advance care planning and how this affects their practice. To assess NSW medical practitioners' knowledge and self-reported practice of Advance Care Planning. A survey of a random sample of 650 GPs, plus 350 medical specialists from specialties most often involved in end-of-life decisions. Respondents work-location post codes were subsequently used to assign respondents to one of NSW Area Health Services. Medical practitioners' knowledge of and practice pertaining to ACP. 34% of specialists (n=110) and 24% of GPs (n=150) responded; the majority of respondents had heard of all ACP options. However, respondents' understanding of the uses and legal requirements of the relevant ACP options vary widely. Respect for patient wishes expressed in advance directives is reassuringly high. The findings suggest significant misunderstanding by medical practitioners of terminologies and systems around substitute decision-making for incompetent persons. Further education and standardisation of terminologies and systems across different jurisdictions would assist in addressing these issues.. Low response rate, relating to only one legal jurisdiction, means results may not be generalisable.
    Internal Medicine Journal 12/2013; · 1.82 Impact Factor
  • Joel J Rhee, Nicholas A Zwar, Lynn A Kemp
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    ABSTRACT: Abstract Background: Advance care planning (ACP) is thought to enhance patient autonomy and improve end-of-life care. However, there is evidence that when patients engage in ACP, the resultant plans are often not implemented. This has been attributed to either nonadherence by health professionals or inadequacies in ACP such as inaccessibility of the plans, plans providing ambiguous or conflicting instructions, and inappropriate focus on the completion of documents rather than communication. However, it is not known whether these postulated reasons are consistent with the experiences and views of health care professionals providing end-of-life care in the community. Objective: Our aim was to explore the perspectives of general practitioners (GPs) on factors influencing the implementation of ACPs. Methods: We conducted semi-structured, open-ended interviews of a purposive sample of 17 Australian GPs. Interview transcripts were analysed using constructionist grounded theory utilizing NVivo 9 software. Results: Factors that were considered to have an important influence on the implementation of ACPs include: ACP factors such as form, legal standing, accessibility, clarity, currency, and specificity; illness factors such as quality of life, function, diagnosis, prognosis, and prognostic certainty; family factors such as family attitudes to ACP and different conceptualizations on whether care is provided to individuals or to a family unit; and organizational and care setting factors such as health care facility's attitudes and policies in relation to end-of-life care. Conclusions: Problems in implementation of ACPs are multifactorial and not necessarily due to deliberate nonadherence by health professionals. Potential solutions to improve the clinical impact of ACP are discussed.
    Journal of palliative medicine 08/2013; · 1.84 Impact Factor
  • Nicholas Zwar
    Evidence-based medicine 08/2013;
  • Nicole Clancy, Nicholas Zwar, Robyn Richmond
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    ABSTRACT: A high proportion of smokers suffer from mental health problems including depression. Despite many of them wanting to stop smoking, low mood adversely affects their ability to quit. To explore the experiences of smokers with self-reported depression, the relationship of smoking with mental health problems and the experiences of smokers while trying to quit. The study also explored what help within the primary care setting could assist in quitting. Participants were recruited from a large general-practice-based smoking cessation trial. Participants who had indicated they were suffering from depression on a self-reported baseline survey were invited to participate. Semi-structured interviews were conducted over the telephone and digitally recorded. The interviews were transcribed and analysed using a phenomenological qualitative approach. Sixteen interviews were conducted (11 females, 5 males). Mood disturbances were frequently reported as triggers for smoking and low mood was seen as a barrier to quitting. Perceived benefits of smoking when depressed were limited and for many, it was a learned response. A sense of hopelessness, lack of control over one's life and a lack of meaningful activities all emerged as important factors contributing to continued smoking. Participants felt that their quit attempts would be aided by better mood management, increased self-confidence and motivation and additional professional support. Smoking and depression were found to be strongly interconnected. Depressed smokers interested in quitting may benefit from increased psychological help to enhance self-confidence, motivation and mood management, as well as a supportive general practice environment.
    Family Practice 07/2013; · 1.83 Impact Factor
  • Australian health review: a publication of the Australian Hospital Association 05/2013; · 0.70 Impact Factor
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    Barbara J Booth, Nicholas Zwar, Mark F Harris
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    ABSTRACT: BACKGROUND: Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. METHODS: This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. RESULTS: The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives -- re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. CONCLUSIONS: The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare.
    BMC Family Practice 04/2013; 14(1):51. · 1.61 Impact Factor
  • Nicholas Zwar
    Primary care respiratory journal: journal of the General Practice Airways Group 11/2012;
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    ABSTRACT: To evaluate a partnership model of care for patients with a diagnosis of chronic obstructive pulmonary disease (COPD).Design, setting and participants: Cluster randomised controlled trial with blinded outcome assessment of 44 general practices in south-western Sydney comprising 451 people with a diagnosis of COPD, conducted between 2006 and 2009. Participants from intervention group practices were visited at their home by a registered nurse with specific training in COPD care who worked with the general practitioner, the patient and other health professionals to develop and implement an individualised care plan based on best-practice guidelines. Participants from control group practices received usual care. The primary outcome was disease-related quality of life measured using the St George's Respiratory Questionnaire (SGRQ) at 12-month follow-up. Other outcomes were overall quality of life, lung function, smoking status, immunisation status, patient knowledge of COPD, and health service use. Of the 451 participants, 257 (57.8%) were confirmed as having COPD on post-bronchodilator spirometry. Follow-up was completed for 330 patients (73.2%). At 12 months, there was no statistically significant difference in the mean SGRQ scores between intervention and control groups (38.7 v 37.6; difference, 1.1; 95% CI, - 1.53-3.74; P = 0.41) or in measures of quality of life, lung function and smoking status. Compared with the control group, in the intervention group, attendance at pulmonary rehabilitation was more frequent (31.1% v 9.6%; OR, 5.16; 95% CI, 2.40-11.10; P = 0.002) and the mean COPD knowledge score was higher (10.5 v 9.8; difference, 0.70; CI, 0.10-1.21; P = 0.02). The nurse-GP partnership intervention did not have an impact on disease-related quality of life at 12-month follow-up. However, there was evidence of improved quality of care, in particular, in attendance at pulmonary rehabilitation and patient knowledge of COPD. Australian Clinical Trials Registry ACTRN012606000304538.
    The Medical journal of Australia 10/2012; 197(7):394-8. · 2.85 Impact Factor
  • Joel J Rhee, Nicholas A Zwar, Lynn A Kemp
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    ABSTRACT: BACKGROUND: Advance care planning (ACP) has been gaining prominence for its perceived benefits for patients in enhancing patient autonomy and ensuring high-quality end-of-life-care. Moreover, it has been postulated that ACP has positive effects on families and health professionals and their relationship with the patient. However, there is a paucity of studies examining the views of GPs on this issue. OBJECTIVE: To explore GP views on the impact that ACP has on interpersonal relationships among those involved in the patient's care. METHOD: Semi-structured, open-ended interviews of a purposive sample of 17 GPs. Interview transcripts were analysed using constructionist grounded theory methodology with QSR NVivo 9 software. RESULTS: ACP was seen as having both positive and negative impacts on interpersonal relationships. It was thought to enhance family relationships, help resolve conflicts between families and health professionals and improve trust and understanding between patients and health professionals. Negatively, it could take the family's attention away from patient care. The link between ACP and interpersonal relationships was perceived to be bidirectional-the nature of interpersonal relationship that patients have with their families and health professionals has a profound impact on what form of ACP is likely to be useful. CONCLUSION: Our study highlights the importance that GPs place on the link between ACP and the patient's interpersonal context. This has implications on how ACP is conducted in primary care settings that are considerably different from other care settings in their emphasis on continuity of care and long-term nature of relationships.
    Family Practice 10/2012; · 1.83 Impact Factor
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    ABSTRACT: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD.The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities.The primary outcome measure is health-related quality of life, assessed with the St George's Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients' randomization groups. This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care. ACTRN12610000592044\
    Implementation Science 09/2012; 7:83. · 2.37 Impact Factor
  • Peter A Leggat, Nicholas Zwar, Bernie Hudson
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    ABSTRACT: The Travel Health Advisory Group (THAG), established in 1997, is a joint initiative between the travel industry and travel health professionals in Australia that aims to promote healthy travel. THAG seeks to promote cooperation in improving the health of travellers between the travel industry and travel medicine professionals and to raise public awareness of the importance of travel health. From 2011, THAG has been a Special Interest Group of The Australasian College of Tropical Medicine and its membership has been active in several areas, including web-based travel health information, travel health promotion, media releases, research and education in Australia. Information is given on the objectives, membership and an overview of the various activities of the group.
    Travel Medicine and Infectious Disease 09/2012; · 1.78 Impact Factor

Publication Stats

668 Citations
211.83 Total Impact Points


  • 2002–2014
    • University of New South Wales
      • School of Public Health and Community Medicine
      Kensington, New South Wales, Australia
  • 2004–2013
    • University of South Wales
      Понтиприте, Wales, United Kingdom
  • 2012
    • Australian Catholic University
      • National Centre for Clinical Outcomes Research (NaCCOR)
      Melbourne, Victoria, Australia
  • 2007–2012
    • Liverpool Hospital
      Liverpool, New South Wales, Australia
  • 2011
    • University of Newcastle
      • Discipline of General Practice
      Newcastle, New South Wales, Australia
  • 2008
    • University of Sydney
      Sydney, New South Wales, Australia
  • 2006
    • GlaxoSmithKline plc.
      Londinium, England, Belgium
  • 2005
    • Fairfield Hospital
      Fairy Meadow, New South Wales, Australia
  • 2000–2005
    • Western Sydney Area Health Service
      Blacktown, New South Wales, Australia
  • 1994–1999
    • The Royal Australian College of General Practitioners
      East Melbourne, Victoria, Australia