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Last updated 14 October 2025

Improving type 2 diabetes management

"The Real 5As project has unpacked some of the important underlying factors that help GPs to support their patients in behaviour change. General practice plays an important role in supporting patients to achieve lifestyle change including smoking cessation, dietary improvements and reducing sedentary behaviour." - Dr Elizabeth Sturgiss

The 5As framework - Ask, Assess, Advise/Agree, Assist, Arrange - is a well-known structure for supporting behaviour change in general practice, but its effectiveness varies in real-world consultations.
Supported by research grant funding from the Australian General Practice Research Foundation and Diabetes Australia, this project explored how the 5As works for patients with type 2 diabetes, identifying when and why it succeeds, or falls short.

Using a realist approach, the team gathered insights from GPs, patients and experts, highlighting the importance of strong relationships, shared decision-making and GP confidence in behaviour change strategies.

While the 5As offers a valuable guide, the research found it often lacks practical tools for everyday use. More support is needed to help GPs translate the framework into meaningful, person-centred care.

These insights are shaping future training and guidelines to strengthen preventive care in general practice.

Improving COPD care in general practice

"Better education, stronger GP-hospital communication, and improved action plans can significantly enhance COPD care and reduce preventable hospitalisations." - Dr Bianca Perera

Dr Bianca Perera tackled a major issue in Australian healthcare—acute exacerbations of COPD (AECOPD), the leading cause of preventable hospitalisations. She believed general practice was key to improving care.

Supported by the Australian General Practice Research Foundation, Dr Perera’s research exposed critical gaps: inconsistent follow-ups, underused action plans, and poor hospital discharge summaries. Only 47% of GPs were familiar with the COPD-X guidelines, essential for managing the condition. These findings highlighted the urgent need for better GP support.

Dr Perera’s research is driving improvements in GP training and education and hospital-primary care communication, offering hope for a better, more effective approach to COPD management in general practice.

 Tackling sedentary behaviour in general practice

"GPs want to help patients reduce sedentary time but they need the right support. With practical tools and clear guidance, we can make this a normal part of everyday care and change lives in the process." - Professor Tania Winzenberg

Sitting too much is a silent threat to health, linked to chronic disease and early death. Yet with the right support, GPs can turn the tide.

Led by Professor Tania Winzenberg and supported by grant funding from the Australian General Practice Research Foundation and Diabetes Australia, this project found that while GPs understand the risks, many confuse sedentary behaviour with physical inactivity. Time pressure, unclear guidelines and uncertainty about who to target can make it challenging, and many GPs are unaware of the resources already available to help.

The opportunity is clear: with simple strategies and practical tools, GPs are ready and eager to make a difference.

This research shows how integrating sedentary behaviour management into everyday care can help prevent chronic disease, boost wellbeing and create better long term health outcomes for patients across Australia.

Informing quality end-of-life care

"For the first time, this research highlights the vital role of general practice in end-of-life care, showcasing its profound impact in delivering accessible, responsive, appropriate high-quality care” - Dr Matthew Grant

Dr Matthew Grant’s study, funded by the Australian General Practice Research Foundation together with HCF Research Foundation, highlights the crucial role of general practice in end-of-life care for cancer patients. Using large-scale linked data, it examined healthcare use in the final six months of life, when GPs play a vital role in patient care.

The study found that 88% of cancer patients saw a GP during this time, averaging 10.9 visits, mostly for symptom relief such as pain management. However, gaps remain, including limited access to home visit and medications for symptom management—underscoring the need for better GP-hospital coordination, ensuring patients receive the right support at home.

As the first Australian study linking GP data for end-of-life care, this research provides a valuable framework to improve primary care and ensure patients receive the best possible support in their final months.

Transforming chronic pain management

“Our new mobile phone app for patients with persistent pain helps identify their most effective non-drug self-management options. Integrating this digital tool into their general practice care offers a new, personalised approach to pain management” - Associate Professor Nancy Sturman

Chronic pain affects over 3.4 million Australians, making daily life challenging. To help address this, A/Prof Nancy Sturman and her team have developed StudyU, a groundbreaking digital tool that supports patients in managing pain without medication.

The app offers evidence-based treatments such as tai chi, exercise, meditation, and cognitive behavioural therapy. Patients can track their progress, while GPs receive real world, individualised, effectiveness data to personalise and refine care. A trial with 45–50 patients, funded by the Australian General Practice Research Foundation in partnership with Medibank Better Health Foundation and Motor Accident Insurance Commission MAIC is underway to assess its feasibility, usefulness, and acceptability in general practice.

By equipping patients with effective self-management strategies and providing GPs with better treatment tools, StudyU is paving the way for a new approach to chronic pain care in Australia.

Improving the management of prediabetes

"This research not only advances our understanding of prediabetes management but also builds a stronger research culture in primary care. It’s a step forward in bridging the gap between research and clinical practice." - Dr Soumya Soumya

Supported by research grant funding from the Australian General Practice Research Foundation and Diabetes Australia, this groundbreaking study led by researchers at the University of Adelaide explored the potential of metformin to slow the progression from prediabetes to type 2 diabetes.

Using de-identified health records from more than 2 million patients, the study found that metformin significantly improved blood sugar control in high-risk individuals, with sustained benefits up to 24 months after starting treatment.

With only 10.2% of newly diagnosed patients prescribed metformin, the findings highlight an opportunity to better support those for whom lifestyle change alone is challenging.

The research also informed policy discussions, guided future guideline development, and built research capacity in general practice through training and collaboration.

By demonstrating metformin’s cost-effective potential, this study helps GPs deliver more proactive, evidence-based care to the 3.3 million Australians living with prediabetes before diabetes takes hold.

Assisting in diabetes self-management  

"What really stood out was the opportunity to better involve patients in their care. Many weren’t aware of the goals set in their GP management plans, highlighting just how powerful truly collaborative, patient-centred goal setting can be in improving engagement and outcomes." - Dr Hannah Woodall

Supported by research grant funding from the Australian General Practice Research Foundation and Diabetes Australia, Dr Hannah Woodall’s research is transforming how GPs approach chronic disease care by rethinking goal setting. Her study uncovered that many patients were unaware of the goals included in their GP management plans, highlighting a missed opportunity to actively involve them in their own care.

By analysing patient records and conducting interviews with patients and GPs, the research identified key barriers including time constraints, competing priorities and limited patient involvement. The findings reinforced that realistic, personalised goals, set in collaboration with patients, lead to better health outcomes.

This work has already informed clinical practice and secured a $938,000 grant to co-design a culturally safe goal setting tool with Aboriginal and Torres Strait Islander communities and healthcare professionals.

Now continuing through Dr Woodall’s PhD, this research is helping reshape general practice by supporting meaningful conversations, shared decisions and improved chronic disease management.

Improving emotional support in diabetes care

"Clinically, this research has changed my practice when caring for people with type 2 diabetes. I pay careful attention to the language I use, consider that diabetes may be a source of distress (even with optimal glycaemic control) and acknowledge the ‘invisible work’ in diabetes self-care." - Dr Rita McMorrow

Many Australians with type 2 diabetes (T2D) experience emotional and psychological distress, yet this critical aspect of care is often overlooked.

Supported by research grant funding from Australian General Practice Research Foundation and Diabetes Australia, Dr McMorrow’s research addressed this gap by developing PROM-GP, a digital tool that helps GPs identify and manage diabetes distress using the validated PAID (Problem Areas in Diabetes) scale.

PROM-GP has improved the way GPs and nurses talk with patients about emotional wellbeing, leading to more holistic, person-centred diabetes care.

The research has already shaped clinical practice and informed national guidelines. The PAID scale is now embedded in toolkits used across Australian clinics and has been included in the Management of Type 2 Diabetes: A Handbook for General Practice (2024), ensuring wider influence on how emotional support is delivered in everyday practice.

Enhancing mastitis care for breastfeeding mothers

“By understanding how GPs treat mastitis, we can improve guidelines, support breastfeeding mothers, and ensure better care” - Professor Lisa Amir

Mastitis is a painful condition that drives many breastfeeding mothers to seek GP care. However, it was unclear whether treatments aligned with best-practice guidelines.

Supported by the Australian General Practice Research Foundation and Therapeutic Guidelines Ltd, Prof Lisa Amir and her team analysed MedicineInsight data and interviewed Australian GPs. They found that 92% of mastitis consultations involved antibiotic prescriptions—mostly in line with guidelines. However, diagnostic tools such as ultrasounds and milk cultures were rarely used, revealing potential gaps in diagnosis and treatment.

These findings informed updates to Therapeutic Guidelines and GP training, equipping GPs with clearer recommendations for mastitis management and supporting better care for breastfeeding mothers, while promoting responsible antibiotic use.

Closing the Gap in diabetes care  

"One of the most important aspects of this research was ensuring that Aboriginal and Torres Strait Islander voices are heard. Having Indigenous researchers like Dr Natalie Pink and Ms Antoinette Liddell involved ensures that the study reflects community needs and leads to real change." - Professor Nigel Stocks

Diabetes is a major health issue for Aboriginal and Torres Strait Islander people, especially in rural areas. This study, supported by research grant funding from Australian General Practice Research Foundation and Diabetes Australia, showed that while GPs are strong in checking blood sugar, cholesterol and blood pressure, weight and waist size – also crucial for managing diabetes – are often missed.

The results highlight strong GP engagement but also clear areas for improvement. They provide a strong foundation for reshaping diabetes care to be more equitable, culturally safe, and outcomes-focused for Aboriginal and Torres Strait Islander communities, no matter where people live.

Led by Dr Natalie Pink (Nyikina woman, rural GP) and Ms Antoinette Liddell (Wajarri woman, Aboriginal health researcher), the research team developed new tools to support culturally safe care, help patients set health goals, and encourage greater involvement in their own care.

This work lays the groundwork for a future where all Aboriginal and Torres Strait Islander people can access stronger, fairer, and more culturally connected diabetes care, wherever they call home.

Guidelines That Work for Everyone: Embedding Equity into Everyday Practice

“Future development of clinical guidelines needs to reflect on the impact on equity. This is to ensure that guidelines do not inadvertently widen healthcare equity gaps. We have worked closely with the Therapeutic Guidelines to enact changes in their online clinical practice guidelines to ensure they are more helpful for GPs” - Professor Elizabeth Sturgiss

General Practitioners working at the “deep end” of disadvantage often care for patients facing trauma, poverty, and social exclusion yet clinical guidelines rarely reflect this complexity.

With support from grant from the Australian General Practice Research Foundation and Therapeutic Guidelines Limited, Professor Elizabeth Sturgiss explored how GPs use Therapeutic Guidelines in practice.

The research identified practical ways to embed equity into clinical guidance. GPs emphasised that equity information must be intentionally included, aligned with the purpose of each guideline, and presented in a clear, usable format that fits into everyday clinical workflows.

Findings were shared with Therapeutic Guidelines, leading to usability improvements and a commitment to equity-focused updates. The project also built research capacity and inspired future GP researchers.

Helping Doctors Support Mental Health in Pregnancy

"GPs are often the first point of contact for women navigating mental health in pregnancy, yet may lack the confidence, resources, or support they need to make informed decisions. This research aims to change that." - Dr Jacqueline Frayne

Dr Jacqueline Frayne’s research sheds light on a critical gap in general practice. GPs often manage complex mental health needs in pregnancy sometimes without sufficient training or access to key resources or services. The study, supported by a grant from the Australian General Practice Research Foundation and Therapeutic Guidelines Limited, found that nearly two thirds of GPs were unaware of Australia’s primary perinatal mental health resource COPE, despite high confidence in prescribing some medications. Rural GPs reported greater prescribing confidence, likely due to broader exposure combined with limited access to psychiatric services.

The research also highlights the importance of understanding patient experiences. Women with severe mental illnesses face difficult medication decisions and need clear information, continuity of care, and space for their voices to be heard. Improving GP education including early perinatal psychiatric training, promoting awareness of evidence based tools, and supporting multidisciplinary care will help deliver safer and more supportive outcomes for mothers and babies across Australia.

Enabling greater access to aged care

"Virtual Care can help aged care residents get better access to their usual general practice. By working with residents, carers, GPs and aged care staff, we can develop services that improve care quality and support better, safer care for older Australians." - Professor Meredith Makeham

More than 1.3 million Australians rely on aged care, and ensuring timely GP access is vital to their wellbeing. Yet limited GP availability, outdated funding, and logistical barriers have long made this challenging. While virtual care expanded during COVID-19, many early solutions lacked video functionality.

Now, research led by Professor Meredith Makeham has successfully trialled a video-enabled virtual care platform in the Sydney North Health Network, funded by the Australian General Practice Research Foundation and Medibank Better Health Foundation. Co-designed with GPs, aged care staff, and carers, the platform has improved communication, streamlined workflows, and enhanced care quality. Outcomes will guide investment, training, and policy changes, paving the way for stronger, more connected aged care across Australia.

Improving the Management of Pre-Diabetes

"This research not only advances our understanding of prediabetes management but also builds a stronger research culture in primary care. It’s a step forward in bridging the gap between research and clinical practice" - Dr Soumya Soumya

This study, led by Dr Soumya Soumya from the University of Adelaide and supported by an Australian General Practice Research Foundation and Diabetes Australia Research Grant, explored how metformin could help prevent the progression from prediabetes to type 2 diabetes.

Using de-identified health records from more than 2 million patients, the research showed that metformin significantly improved blood sugar control in high-risk individuals, with benefits sustained for up to two years after treatment began.

Despite this potential, only 10.2 percent of newly diagnosed patients were prescribed metformin. The findings highlight a missed opportunity to support those who may find lifestyle changes challenging on their own.

The study also informed policy and guideline development and strengthened research capacity in general practice through collaboration and training.

By demonstrating the value of early intervention, this research helps GPs deliver more proactive, cost-effective care for millions of Australians at risk.