Factors associated with reported pain on injection and reactogenicity to an OMV meningococcal B vaccine in children and adolescents

Pain on vaccine injection and subsequent site reactions of pain and swelling may influence confidence in vaccines and their uptake. This study aimed to identify factors associated with reported pain on injection and reactogenicity following administration of a strain specific meningococcal B outer membrane vesicle vaccine. A retrospective analysis of data was conducted from a phase II single center randomized observer-blind study that evaluated the safety, reactogenicity and immunogenicity of this vaccine in 2 cohorts of healthy 8 to 12 y old children. Vaccine administration technique was observed by an unblinded team member and the vaccine administrator instructed on standardized administration. Participants kept a daily diary to record local reactions (erythema, induration and swelling) and pain for 7 d following receipt of the vaccine. Explanatory variables were cohort, vaccine, age, gender, ethnicity, body mass index, atopic history, history of frequent infections, history of drug reactions, pain on injection, vaccinator, school population socioeconomic status, serum bactericidal antibody titer against the vaccine strain NZ98/254, and total IgG. Univariate and multivariable analyses were conducted using ordinal logistic regression for factors relating to pain on injection and reactogenicity. Perceived pain on injection was related to vaccine formulation, vaccine administrator and ethnicity. Reactogenicity outcomes varied with ethnicity and vaccine administrator. Maintaining community and parental confidence in vaccine safety without drawing attention to differences between individuals and groups is likely to become increasingly difficult. Vaccine administration technique alone has the potential to significantly reduce pain experienced on injection and local vaccine reactions.

Risk factors for community-acquired pneumonia in pre-school-aged children

AIM

To identify risk factors for children developing and being hospitalised with community-acquired pneumonia.

METHODS

Children <5 years old residing in urban Auckland, New Zealand were enrolled from 2002 to 2004. To assess the risk of developing pneumonia, children hospitalised with pneumonia (n= 289) plus children with pneumonia discharged from the Emergency Department (n= 139) were compared with a random community sample of children without pneumonia (n= 351). To assess risk of hospitalisation, children hospitalised with pneumonia were compared with the children discharged from the Emergency Department. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were used to estimate the risk of pneumonia and hospitalisation with pneumonia.

RESULTS

After adjustment for season, age and ethnicity there was an increased risk of pneumonia associated with lower weight for height (OR 1.28, 95% CI 1.10-1.51), spending less time outside (1.96, 1.11-3.47), previous chest infections (2.31, 1.55-3.43) and mould in the child's bedroom (1.93, 1.24-3.02). There was an increased risk of pneumonia hospitalisation associated with maternal history of pneumonia (4.03, 1.25-16.18), living in a more crowded household (2.87, 1.33-6.41) and one with cigarette smokers (1.99, 1.05-3.81), and mould in the child's bedroom (2.39, 1.25-4.72).

CONCLUSIONS

Lower quality living environments increase the risk of pneumonia and hospitalisation with pneumonia in New Zealand. Poorer nutritional status may also increase the risk of pneumonia. Improving housing quality, decreased cigarette smoke exposure and early childhood nutrition may reduce pneumonia disease burden in New Zealand.

Why do children hospitalised with pneumonia not receive antibiotics in primary care?

BACKGROUND

Although antibiotics are recommended for the primary care management of community-acquired pneumonia, a recent UK study reported that most children admitted to hospital had not received antibiotics.

OBJECTIVE

To describe primary care antibiotic use for children subsequently hospitalised with community-acquired pneumonia.

DESIGN/METHODS

A case series of 280 children <5 years old hospitalised with pneumonia in Auckland, New Zealand. Pneumonia was defined as an acute illness with cough or respiratory distress, the presence of tachypnoea or indrawing and an abnormal chest radiograph. Receipt of antibiotics was determined by parental report and medical record review.

RESULTS

Fewer than half (108, 39%) of the children had received an antibiotic before hospital admission. For 60 children (21%) there had been no opportunity to prescribe because the illness evolved rapidly, resulting in early hospital admission. For the remaining 112 children (40%) an opportunity to receive antibiotics was missed. The parent failed to obtain the antibiotic prescribed for 23 children (21% of 112), but in 24 children (21%) pneumonia was diagnosed but no antibiotic prescribed and in a further 28 children (25%) the diagnosis was not made despite parental report of symptoms suggesting pneumonia. Missed opportunities to prescribe were not associated with increased overall severity of symptoms at hospital presentation but were associated with an increased risk of: focal chest radiological abnormalities (rate ratio (RR)=2.14; 95% CI 1.49 to 2.83), peripheral leucocytosis >15×10(9)/l (RR=2.29; 95% CI 1.61 to 2.98) and bacteraemia (RR=6.68, 95% CI 1.08 to 58.44).

CONCLUSIONS

Young children with community-acquired pneumonia may not receive an antibiotic before hospital admission because the illness evolves rapidly or the prescribed medicine is not given by parents. However, missed opportunities for appropriate antibiotic prescribing by health professionals in primary care appear to be common.

The General Practitioner–Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy

Objectives

There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for ‘medication reviews’ there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients.

Methods

A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed-up 3-monthly. The control group received usual care. The main outcome measures were Quality of Life (SF-36) and Medication Appropriateness Index.

Key findings

A total of 498 patients were enrolled in the study. The quality-of-life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study.

Conclusion

Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.

General practitioner perceptions of clinical medication reviews undertaken by community pharmacists

INTRODUCTION

Delivery of current health care services focuses on interdisciplinary teams and greater involvement of health care providers such as nurses and pharmacists. This requires a change in role perception and acceptance, usually with some resistance to changes. There are few studies investigating the perceptions of general practitioners (GPs) towards community pharmacists increasing their participation in roles such as clinical medication reviews. There is an expectation that these roles may be perceived as crossing a clinical boundary between the work of the GP and that of a pharmacist.

METHODS

Thirty-eight GPs who participated in the General Practitioner-Pharmacists Collaboration (GPPC) study in New Zealand were interviewed at the study conclusion. The GPPC study investigated outcomes of a community pharmacist undertaking a clinical medication review in collaboration with a GP, and potential barriers. The GPs were exposed to one of 20 study pharmacists. The semi-structured interviews were recorded and transcribed verbatim then analysed using a general inductive thematic approach.

FINDINGS

The GP balanced two themes, patient outcomes and resource utilisation, which determined the over-arching theme, value. This concept was a continuum, depending on the balance. Factors influencing the theme of patient outcomes included the clinical versus theoretical nature of the pharmacist recommendations. Factors influencing resource utilisation for general practice were primarily time and funding.

CONCLUSION

GPs attributed different values to community pharmacists undertaking clinical medication reviews, but this value usually balanced the quality and usefulness of the pharmacist's recommendations with the efficiency of the system in terms of workload and funding.

Community pharmacist perceptions of clinical medication reviews

INTRODUCTION

Changes in delivery of health care services has led to pressure for community pharmacists to extend their traditional role and become more involved with patient-focussed services such as medication reviews, in collaboration with general practitioners (GPs). This has not been generally implemented into routine practice, and many barriers have been suggested that inhibit community pharmacists extending their role. These have often focussed on physical or functional barriers. This study explores possible attitudinal factors that prevent increased participation of community pharmacists in medication reviews undertaken in collaboration with GPs.

METHODS

Twenty community pharmacist participants who participated in the General Practitioner-Pharmacist Collaboration (GPPC) study were interviewed. The GPPC study investigated the outcomes of community pharmacists undertaking a clinical medication review in collaboration with GPs, and the potential barriers. Semi-structured interviews were analysed using a general inductive thematic approach.

FINDINGS

Emerging themes were that community pharmacists perceived that they were not mandated to undertake this role, it was not a legitimate role, particularly from the business perceptive, and pharmacists were concerned that they lacked the skills and confidence to provide this level of input.

CONCLUSION

While there is concern that community pharmacists' skills are underutilised, there are probable attitudinal barriers inhibiting pharmacists from increasing their role in clinical medication reviews. Perceived legitimacy of the service was a dominant theme, which appeared to be related to issues in the business model. Further investigation should consider the use of a clinical pharmacist working within a general practice independent of a community pharmacy.

Community pharmacist perceptions of clinical medication reviews

INTRODUCTION: Changes in delivery of health care services has led to pressure for community pharmacists to extend their traditional role and become more involved with patient-focussed services such as medication reviews, in collaboration with general practitioners (GPs). This has not been generally implemented into routine practice, and many barriers have been suggested that inhibit community pharmacists extending their role. These have often focussed on physical or functional barriers. This study explores possible attitudinal factors that prevent increased participation of community pharmacists in medication reviews undertaken in collaboration with GPs. METHODS: Twenty community pharmacist participants who participated in the General Practitioner– Pharmacist Collaboration (GPPC) study were interviewed. The GPPC study investigated the outcomes of community pharmacists undertaking a clinical medication review in collaboration with GPs, and the potential barriers. Semi-structured interviews were analysed using a general inductive thematic approach. FINDINGS: Emerging themes were that community pharmacists perceived that they were not mandated to undertake this role, it was not a legitimate role, particularly from the business perceptive, and pharmacists were concerned that they lacked the skills and confidence to provide this level of input. CONCLUSION: While there is concern that community pharmacists’ skills are underutilised, there are probable attitudinal barriers inhibiting pharmacists from increasing their role in clinical medication reviews. Perceived legitimacy of the service was a dominant theme, which appeared to be related to issues in the business model. Further investigation should consider the use of a clinical pharmacist working within a general practice independent of a community pharmacy. KEYWORDS: Community pharmacy services; drug utilization review; primary healthcare; health plan implementation

General practitioner perceptions of clinical medication reviews undertaken by community pharmacists

INTRODUCTION: Delivery of current health care services focuses on interdisciplinary teams and greater involvement of health care providers such as nurses and pharmacists. This requires a change in role perception and acceptance, usually with some resistance to changes. There are few studies investigating the perceptions of general practitioners (GPs) towards community pharmacists increasing their participation in roles such as clinical medication reviews. There is an expectation that these roles may be perceived as crossing a clinical boundary between the work of the GP and that of a pharmacist. METHODS: Thirty-eight GPs who participated in the General Practitioner–Pharmacists Collaboration (GPPC) study in New Zealand were interviewed at the study conclusion. The GPPC study investigated outcomes of a community pharmacist undertaking a clinical medication review in collaboration with a GP, and potential barriers. The GPs were exposed to one of 20 study pharmacists. The semi-structured interviews were recorded and transcribed verbatim then analysed using a general inductive thematic approach. FINDINGS: The GP balanced two themes, patient outcomes and resource utilisation, which determined the over-arching theme, value. This concept was a continuum, depending on the balance. Factors influencing the theme of patient outcomes included the clinical versus theoretical nature of the pharmacist recommendations. Factors influencing resource utilisation for general practice were primarily time and funding. CONCLUSION: GPs attributed different values to community pharmacists undertaking clinical medication reviews, but this value usually balanced the quality and usefulness of the pharmacist’s recommendations with the efficiency of the system in terms of workload and funding. KEYWORDS: Family physicians; community pharmacy services; drug utilization review; primary healthcare; health plan implementation; qualitative research; interprofessional relations

What makes 'place' attractive to overseas-trained doctors in rural New Zealand?

The present paper investigates what keeps doctors 'in place' in New Zealand rural communities and what prompts their departure from practice. The study is based on in-depth interviews conducted with nine overseas-trained medical practitioners within rural areas in New Zealand during 2004. A thematic analysis was undertaken. The resulting narratives reveal the unintended circumstances under which respondents often arrived in their rural communities, as well as some of the 'pull' factors which a more relaxed rural lifestyle offers. Recurring themes relating to the attractiveness of place include community loyalty and the enjoyment of 'fully practicing medicine'. Themes which corroded the attractiveness of place included 'entrapment', lack of choice in secondary schooling, restricted spousal employment opportunities, the lack of cultural and entertainment activities, and difficulties accessing continuing medical education. The authors conclude that addressing the question of what makes 'place' attractive to overseas-trained general practitioners in rural New Zealand requires an understanding of place as context rather than mere location.

GPs' attitudes to discussing prognosis in severe COPD: an Auckland (NZ) to London (UK) comparison

BACKGROUND

A palliative care approach, as used routinely in cancer, is also valid for incurable chronic illnesses such as chronic obstructive airways disease (COPD). However, a London study recently reported that general practitioners (GPs), who provide most end-stage care for COPD patients, do not routinely discuss prognosis with these patients.

OBJECTIVE

To compare the views of GPs in Auckland, New Zealand (NZ) and London, United Kingdom (UK) on discussions of prognosis in severe COPD.

METHOD

A postal questionnaire of 509 randomly selected Auckland GPs. The questionnaire was almost identical to the UK one. Comparisons were made with aggregated statistics for the London sample as reported in published findings and personal communication with the London authors.

RESULTS

The Auckland response rate of 56% was similar to that of the London study (55%). Most GPs in both samples stated that discussions on prognosis are necessary in severe COPD and that GPs have an important role in discussing prognosis. Smaller proportions of both samples reported usually having such discussions, although Auckland GPs (55.6%) were more likely to hold the discussions than were London counterparts (40.7%). Auckland GPs were also more likely to agree that patients with severe COPD want to discuss prognosis and that patients value these discussions. One-third of the Auckland GPs and nearly half the London GPs believe that some patients with severe COPD who want to discuss prognosis are not given the opportunity to do so.

CONCLUSION

Auckland GPs are more open than their London counterparts to discussing prognosis in severe COPD. There is increased scope for GPs in London to discuss prognosis with these patients. Further support is needed for GPs in both countries who do not routinely discuss prognosis in severe COPD, but consider it is necessary to have these discussions.

Rural New Zealand health professionals' perceived barriers to greater use of the internet for learning

INTRODUCTION

The purpose of this research was to investigate rural North Island (New Zealand) health professionals' attitudes and perceived barriers to using the internet for ongoing professional learning.

METHODS

A cross-sectional postal survey of all rural North Island GPs, practice nurses and pharmacists was conducted in mid-2003. The questionnaire contained both quantitative and qualitative questions. The transcripts from two open questions requiring written answers were analysed for emergent themes, which are reported here. The first open question asked: 'Do you have any comments on the questionnaire, learning, computers or the Internet?' The second open question asked those who had taken a distance-learning course using the internet to list positive and negative aspects of their course, and suggest improvements.

RESULTS

Out of 735 rural North Island health professionals surveyed, 430 returned useable questionnaires (a response rate of 59%). Of these, 137 answered the question asking for comments on learning, computers and the internet. Twenty-eight individuals who had completed a distance-learning course using the internet, provided written responses to the second question. Multiple barriers to greater use of the internet were identified. They included lack of access to computers, poor availability of broadband (fast) internet access, lack of IT skills/knowledge, lack of time, concerns about IT costs and database security, difficulty finding quality information, lack of time, energy or motivation to learn new skills, competing priorities (eg family), and a preference for learning modalities which include more social interaction. Individuals also stated that rural health professionals needed to engage the technology, because it provided rapid, flexible access from home or work to a significant health information resource, and would save money and travelling time to urban-based education.

CONCLUSIONS

In mid-2003, there were multiple barriers to rural North Island health professionals making greater use of the internet for learning. Now that access to broadband internet is available in all rural towns in New Zealand, there is a clear need to address the other identified barriers, especially the self-reported lack of IT skills, which are preventing many in the rural health workforce from gaining maximum advantage from both computers and the internet.

Teenage use of GP care for moderate to severe asthma in Auckland, New Zealand

OBJECTIVES

To describe and understand teenagers' frequency of attendance for General Practitioner (GP) care of moderate to severe asthma in the Auckland region.

METHODS

Ten Auckland schools identified 510 children aged 13-14 years with breathing problems, who were invited to complete a screening questionnaire. 271 children participated, of whom 114 had moderate to severe asthma.

RESULTS

39% of the 114 had made 0-1 GP visit for asthma, and 17% made 'greater than and equal to' 5 visits. Low attendees (0-1 visit) were disproportionately New Zealand European. High attendees ('greater than and equal to' 5 visits) tended to be Maori and/or Pacific Islanders. Half of the teenagers attended GP asthma care as often as it wanted, independently of ethnicity; 62% tell their parents when they cannot manage their asthma; and 29% must pay for GP care. Expected attendance was increased for Maori and Pacific students versus others by 77% (p=0002), and by asthma of increased severity (p<0.001). Teenager resistance to accessing GP asthma care reduced expected attendance by 24% (p=0.003).

CONCLUSIONS

Maori and Pacific peoples have traditionally faced barriers to accessing GP care, but their their more frequent attendance (than New Zealand Europeans) in this case, challenges whether such barriers persist, at least for acute care of moderate to severe asthma.

Few rural general practitioners use the Internet frequently in regard to patient care

AIMS

To benchmark North Island rural general practitioner (GP) access to computers and the Internet, both at work and home, and assess whether rural GPs are using the Internet in regard to patient care.

METHODS

Cross-sectional postal survey of all North Island rural GPs in mid-2003.

RESULTS

175 of 289 GPs (60.6%) returned useable questionnaires. Most (89.0%) reported computer availability at work when consulting, but even more had access to a computer at home (97.1%, p<0.01). Access to the Internet was also lower at work (68.6%) than at home (98.8%, p<0.01). Fewer GPs (p<0.05) reported ever using the Internet at work in regard to patients (56.5%) than at home (71.9%). Less than 10% of all GPs used the Internet three or more times a week at work (6.9%) or home (8.6%) in regard to patients. Of those with Internet access at work, 27.0% had broadband (fast Internet) access. Predictors of having (versus not having) work Internet access were computer availability in consultations (p=0.04).

CONCLUSIONS

Few North Island rural GPs use the Internet frequently in regard to patient care, despite increasing access to computers and the Internet, both at work and home.

GP discussion of prognosis with patients with severe chronic obstructive pulmonary disease: a qualitative study

BACKGROUND

Recent research shows that health professionals do not communicate about prognosis with patients with chronic obstructive pulmonary disease (COPD) as openly as with patients who have cancer.

AIM

To identify strategies that general practitioners (GPs) can use to facilitate discussion of prognosis with patients who have COPD.

DESIGN OF STUDY

Telephone interviews of 15 GPs and five respiratory consultants on the topic of discussing prognosis with patients who have severe COPD.

SETTING

Participating doctors worked in the Auckland region of New Zealand.

METHOD

GPs and consultants were selected purposively to detect unique and shared patterns from diversity in how prognosis is discussed with patients with severe COPD. An interview guide was developed from a literature review and results of our earlier postal survey of GPs. Transcripts of audiotaped interviews were analysed independently and then together by three authors, using a general inductive approach.

RESULTS

Seven strategies were identified that GPs had used or could use to facilitate discussion of prognosis with patients with COPD. These were: be aware of implications of diagnosis; use uncertainty to ease discussion; build relationship with patients; be caring and respectful; begin discussion early in disease course; identify and use opportunities to discuss prognosis; and work as a team.

CONCLUSION

A number of suggested strategies can be used to facilitate discussion of prognosis with patients who have severe COPD.

Attendance for general practitioner asthma care by children with moderate to severe asthma in Auckland, New Zealand

Attendance for general practitioner (GP) care of childhood asthma varies widely in New Zealand (NZ). There is little current research to account for the variations, although groups such as Māori and Pacific peoples have traditionally faced barriers to accessing GP care. This paper aims to describe and account for attendance levels for GP asthma care among 6-9 year-olds with moderate to severe asthma in Auckland, NZ. During 2002, randomly selected schools identified all 6-9 year-olds with possible breathing problems. Completion of a questionnaire by each parent/guardian indicated which children had moderate to severe asthma, and what characteristics influenced their access to GP asthma care. A multilevel, negative binomial regression model (NBRM) was fitted to account for the number of reported GP visits for asthma, with adjustment for clustering within schools. Twenty-six schools (89.7 percent) identified 931 children with possible breathing problems. Useable questionnaires were returned to schools by 455 children (48.9 percent). Results indicated 209 children with moderate to severe asthma, almost one in every three reportedly making 5 or more GP visits for asthma in the previous year. Māori, Pacific and Asian children were disproportionately represented among these 'high attendees'. Low attendees (0-2 visits) were mainly NZ Europeans. The NBRM (n=155) showed that expected visits were increased by perceived need, ill-health, asthma severity and, in particular, Māori and Pacific child ethnicity. It may be that Māori and Pacific children no longer face significant barriers to accessing GP asthma care. However, more likely is that barriers apply only to accessing routine, preventative care, leading to poor asthma control, exacerbations requiring acute care, and paradoxically an increase in GP visits. That barriers may increase total numbers of visits challenges the assumption, for all health systems, that access can be defined in terms of barriers that must be overcome to obtain health care.

Physician-patient relationship and medication compliance: a primary care investigation

PURPOSE

We assessed the relationship between 4 attributes of the physician-patient relationship and medication compliance.

METHODS

We conducted a waiting room survey of patients consulting 22 general practitioners in 14 randomly selected practices in Auckland, New Zealand (81% response rate). A total of 370 consecutive patients (75% response rate) completed survey instruments about 4 attributes of the physician-patient relationship. Continuity of care (assessed from use of a usual physician, length of continuity, and perceived importance of continuity) and trust in the physician were ascertained before the consultation. After the consultation the Patient Enablement Index measured the physician's ability to enable patients in self-care, and concordance between the patient and physician was measured by a 6-item inventory of perceived agreement about the presenting problem and management, were ascertained immediately after the consultation. Compliance with prescribed medication therapy was ascertained by telephone follow-up 4 days after the consultation.

RESULTS

Overall, 220 patients (61%) received a prescription, and 79% of these patients were taking the medication at follow-up. In a univariate analysis adjusted for clustering, only trust and physician-patient concordance were significantly related to compliance. In analysis further adjusted for health and demographic factors, physician-patient concordance was independently related to compliance (odds ratio = 1.34, 95% confidence interval, 1.04-1.72).

CONCLUSIONS

Primary care consultations with higher levels of patient-reported physician-patient concordance were associated with one-third greater medication compliance. An emphasis on understanding and facilitating agreement between physician and patient may benefit outcomes in primary care.

Is New Zealand according too much importance to continuous quality improvement in healthcare?

In late 2003, New Zealand's Ministry of Health published a 'systems approach' to help guide and plan quality improvements in the nation's health and disability sector. This approach emphasises a need for continuous quality improvement. We argue that the Ministry should align itself less exclusively with the 'the small steps of continuous quality improvement' and 'maintaining the gains'. Instead, it should encourage the adoption of a variety and combination of quality improvement strategies that include continuous quality improvement between the discontinuities that can occasion a need to re-engineer core processes for revolutionary, quantum gains in quality and safety.

The New Zealand Diabetes Passport Study: a randomized controlled trial of the impact of a diabetes passport on risk factors for diabetes-related complications

AIMS

To assess the efficacy (change in HbA1c) of a patient-held communication, self-empowerment and educational device for people with diabetes (the New Zealand Diabetes Passport) in patients with poor glycaemic control.

RESEARCH DESIGN AND METHODS

A 12-month, multicentre, general practice-based randomized controlled trial in urban, provincial and rural New Zealand involving 398 people with poorly controlled Type 1 or Type 2 diabetes. The intervention included a specifically designed and piloted New Zealand Diabetes Passport including information relating to diabetes knowledge, self-assessments, and guidance concerning how to engage with diabetes health professionals. The primary end point was change in HbA1c. Assessments were made at 0, 6 and 12 months.

RESULTS

Two hundred and twenty-two patients received the Passport, 176 the control booklet, coming from 69 and 66 general practitioners, respectively. Use of the Passport was associated with a relative reduction in HbA1c of 0.4% (P = 0.017) and a relative increase in weight of 1.0 kg/m2 (P = 0.028), but no changes in diabetes knowledge, attitudes to diabetes or risk factors for diabetic tissue damage.

CONCLUSIONS

The dissemination of the New Zealand Diabetes Passport, in isolation, was not associated with improvements in either diabetes knowledge or self-empowerment. While a small improvement in glycaemic control occurred, this was probably due to changes in insulin therapy in the intervention group. It is possible that linking the use of the Passport with other behavioural and educational interventions may make the Passport more useful. Further study is required to confirm the effect of such multifaceted interventions.

Is the PRIME (Primary Response In Medical Emergencies) scheme acceptable to rural general practitioners in New Zealand?

AIM

To ascertain the level of acceptance of the PRIME (Primary Response In Medical Emergencies) scheme by rural general practitioners (GPs) in New Zealand.

METHODS

A nationwide, anonymous, postal/email questionnaire was sent to 536 rural/semi-rural GPs, inquiring as to their involvement in and opinions of emergency care, and the acceptability of the PRIME scheme.

RESULTS

The overall response rate was 42%. PRIME training courses and PRIME equipment were regarded as excellent. However, concerns were raised by both PRIME and non-PRIME groups regarding the quality of triaging information given during emergencies and levels of remuneration for call-outs (especially medical call-outs). Additional concerns included lack of flexibility with the PRIME contract in some areas. Some GPs were also concerned that their involvement was less about providing a higher skill level in resuscitation than about filling the gaps in the already-stretched rural ambulance services, which was not the intention of the PRIME scheme.

CONCLUSIONS

The inclusion of rural GPs in emergency care teams needs to be recognised and adequately remunerated, and these issues should be reflected in the ongoing development of pre-hospital emergency service contracts.

GP care for moderate to severe asthma in children: what do infrequently attending mothers disagree with and why?

OBJECTIVES

Our aim was to identify and account for areas of disagreement with GP care for moderate to severe child asthma among mothers who infrequently use this care. Identifying and understanding these areas of disagreement has the potential to improve child access to GP care.

METHODS

This qualitative study in Auckland, New Zealand, used a general inductive approach to analyse 23 semi-structured, personal interviews during March-October 2001 with samples of 11 mothers of children with moderate to severe asthma, and 12 medical providers (10 in general practice and two in hospital emergency departments). Disagreement was defined by mothers' non-acceptance or disapproval of aspects of GP care they reported getting for child asthma.

RESULTS

Mothers and providers described four areas in which some mothers disagree with aspects of GP care for child asthma. Contributing to infrequent attendance, the areas are the validity of the diagnosis, the level of service provision, the effectiveness of care and the level of respect from practice staff. These areas revealed three groups of mothers. GP factors contributing to disagreements among mothers were reported to be inconsistent care; information deficits on asthma and individual children; a lack of commitment to identifying the cause(s) and self-management of asthma in children; and an unmet need for asthma management plans that incorporate families' knowledge, goals and preferences.

CONCLUSIONS

Disagreement, among mothers, with areas of GP care for child asthma contributes to non-attendance for this care. This paper identifies opportunities for GPs to keep disagreements to a minimum and facilitate access.

Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access?

BACKGROUND

Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access.

AIM

To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma.

DESIGN OF STUDY

A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach.

SETTING

Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland.

METHOD

Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature.

RESULTS

The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children.

CONCLUSION

A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children.

Reasons for poor understanding of when and how to access GP care for childhood asthma in Auckland, New Zealand

BACKGROUND

Attempts to explain why some patients lack the understanding needed to access GP care for childhood asthma are uncommon and have tended to be based on reported statistical associations.

OBJECTIVES

The aims of this study were to describe and account for poor patient understanding of when and how to access GP care for childhood asthma in Auckland, New Zealand.

METHODS

A general inductive approach was used to analyse 29 semi-structured, personal interviews, during March-May 2001, with Auckland key informants selected through maximum variation sampling. Informant checking and the literature supported the text analysis by two independent researchers.

RESULTS

Key informants reported wide variations in the extent to which guardians and asthmatic children understand when and how to access GP services. Two sets of barriers to patient understanding were identified. The first limits the willingness of people to seek understanding and the second limits their ability to understand, even if they want to understand.

CONCLUSIONS

Use of qualitative methodology was able to reveal barriers to patient understanding. Strategies operating at the GP and system levels were identified to help overcome these barriers.

Morale in general practice: crisis and solutions

AIM

To place the causes and level of psychological stress among general practitioners (GPs) within the context of the overall morale in the profession and to describe solutions suggested or achieved in response.

METHODS

Postal survey of a random sample of GPs in New Zealand. Levels of morale and psychological distress (GHQ-12) were assessed. Respondents scored categories of workload stress and generated solutions to perceived stressors.

RESULTS

The response rate was 448/ 658 (68%). Potent causes of work stress were excessive paperwork, bureaucracy, multiple problem consultations, time pressures and combining work with family life. Overall mean 5 point Likert scale ratings for perceived stress and morale were 3.47 (SD 0.98) for morale, and 4.15 (SD 0.85) for stress. GHQ scores: of 448 respondents 143 (33%) scored 4-8, and 43 (10%) scored >8. The most commonly suggested solutions were simplifying paperwork, increasing the General Medical Subsidy, increasing locum provision and providing united professional representation.

CONCLUSIONS

Potent sources of stress and low morale continue to affect New Zealand general practice, with significant numbers of GPs recording high levels of psychological distress. Morale was higher than in the UK, but lower than in Ireland. GPs have developed a range of potential solutions they would like implemented.

Challenges for District Health Boards as needs assessors

DHBs face the foregoing challenges in the current and future environment, as they take on democratic representation for the population, particularly in health needs assessment, consultation, prioritization and health service purchasing. Need and objectives must be clearly defined at an early stage in the context of resource constraints and timeframes that will challenge the ability of Boards to conduct needs assessments. Consultation with the community and other, expert groups must inform needs assessments. But it is not clear how the prioritization process will work, particularly regarding the ability of local agendas for purchasing of health services that complement the national agenda. Recent health crises have shown that DHBs, without Government support, cannot easily meet such challenges in the new decentralised environment. Consideration must therefore be given to how these identified challenges for DHBs as needs assessors can best be met.

Quality of care indicators for population-based primary care in New Zealand

AIM

To develop a set of non-invasive, evidence-based, population-based quality of care indicators for primary care in New Zealand and to test their feasibility.

METHODS

New Zealand, British and Australian publications were reviewed and a set of quality of care indicators was constructed. These were trialed on data collected from seventeen fully computerised practices from the FirstHealth network of general practices.

RESULTS

28 indicators are proposed in five categories: smoking cessation, preventive health activities, prescribing quality, chronic disease management and data quality. We were able to calculate ten indicators from data already collected routinely, a further twelve could be calculated now with more sophisticated data queries and six would require the trial practices to collect further data.

CONCLUSIONS

While any set of indicators is arbitrary there are sufficient research data to support a set of evidence-based, population-focused, quality of care indicators in New Zealand primary health care. In computerised practices these indicators can be calculated from routinely collected data.

Quality improvement within Independent Practitioner Associations: lessons from New Zealand

AIMS

To ascertain what quality improvement activities are being performed by associations of general practitioners (GPs) in New Zealand, to find out how they are supporting these activities, and learn about their experience of the process.

METHOD

A cross sectional questionnaire study of 25 independent practitioner associations (IPAs) in New Zealand.

RESULTS

All respondents (n=25) believed quality improvement was a responsibility of their organization, and for 48% it was their highest priority. All organizations carried out and supported a range of quality improvement activities. The major perceived barriers to quality improvement were negative attitudes and lack of time and money to support the process. Strategies to overcome these barriers included providing comparative data to staff in a peer group setting and providing financial incentives, management support and education.

CONCLUSIONS

Considerable quality improvement activity is occurring in primary care in New Zealand. A variety of barriers to the process and methods of overcoming them have been identified by some, but not all IPAs.

Coping strategies in the self-management of chronic heart failure

BACKGROUND

A patient's psychological adaptation to heart failure can influence its impact on his or her life. However, attempts to understand how patients cope mentally with severe emotional strain have led to inconsistent use of a plethora of concepts, making communication and clinical care difficult.

OBJECTIVES

The aim of the present study was to develop a framework for conceptualizing how patients with chronic heart failure cope mentally with their illness, and then use the framework to suggest how GPs can facilitate patient self-care.

METHODS

We systematically reduced and reassembled the narrative texts of personal, semi-structured interviews until their interpretation was complete. The interviews were conducted during late 1999 with 62 heart failure patients under GP care in 30 practices across central Auckland, New Zealand.

RESULTS

Our framework describes four coping strategies: avoidance, disavowal, denial and acceptance. Disavowal provides a distinct coping strategy through which patients, who basically understand the threat to their life situations, seek hope through positively reconstructing this threat. Use of this strategy was highly salient regardless of patients' age, the length of time since their recorded diagnosis or the degree of self-reported limitation of recent physical function due to heart failure. Only over age 70 were avoidance and acceptance also highly salient among patients whose heart failure was diagnosed at least 3 years previously and had mildly limited their recent physical function.

CONCLUSION

Many different heart failure patients use disavowal to palliate the emotional strain and find hope. Disavowal is not a problem to deal with but a process GPs can facilitate by implementing a range of suggested strategies through methods such as story telling.

Non-invasive methods for measuring data quality in general practice

AIM

To develop non-invasive methods of measuring the quality of data recorded in general practice.

METHODS

Laboratory and pharmaceutical claims data from fourteen practices (44 doctors) from the FirstHealth network of general practices were examined to determine the extent to which valid minimum bounds on expected rates of diagnosis coding could be established. These were compared with recorded rates in patient notes to measure completeness of diagnosis recording. Data completeness was measured for demographic data and a marker for the accuracy of gender coding was developed from diagnosis data.

RESULTS

Minimum rates of diagnosis could be established for asthma, diabetes (NIDDM and IDDM), ischaemic heart disease, hypothyroidism, bipolar affective disorder and Parkinson's disease. Minimum bounds for the number of patients requiring monitoring of warfarin and digoxin levels were also established. These expected minimum rates were combined with measures of completeness of age, gender, ethnicity and smoking data, and a gender coding accuracy measure, to produce a set of fourteen data quality indicators. Pass/fail thresholds on each indicator were set and each of the fourteen practices was scored on the number of passes they achieved. The scores ranged from three to nine out of fourteen passses.

CONCLUSIONS

Non-invasive data quality measures may be useful in providing feedback to general practitioners as part of a data quality improvement cycle. The sensitivity of this method will decline as data quality improves.

Problem gamblers: do GPs want to intervene?

AIM

To survey GPs' attitudes towards problem gamblers and knowledge to successfully intervene.

METHODS

100 GPs, randomly selected for gender and geographical distribution, were anonymously surveyed by questionnaire through the Royal New Zealand College of General Practitioners.

RESULTS

80 GPs responded (80% of those surveyed). There was strong support (85%) for problem gambling being within a GP's mandate, for involvement in treatment of problem gambling (72%) and for their having a role in supporting a family where a member has a gambling problem (80%). There was less confidence in: raising the issue of gambling with patients (53%), in knowledge of resources (38%) and in having the necessary training to intervene (19%).

CONCLUSIONS

GPs see problem gambling as a legitimate role for their intervention, however, they have concerns around their competency and knowledge of resources. The provision of undergraduate and postgraduate training may assist to remove barriers to an accepted role in primary health.

A future for primary health care in New Zealand

The attempt to implement a health market in New Zealand by separating funders and providers in 1992 has not delivered improved health outcomes. Indeed there is increasing concern that deprived populations are not accessing appropriate health care. This article describes the models of primary care that have evolved in the new environment and suggests that these new structures, given appropriate support, are ideally placed to increase the focus of primary care on population health. A capitation funding model with patient enrolment and low fee-for-service barriers is proposed as the most promising model for delivering improved health outcomes. The model incorporates a needs-based funding formula, locality health needs assessment, an increased role for primary care nurses and improved responsiveness to local communities, especially Maori.

Issues in patient compliance

Patient compliance refers to the willingness and ability of an individual to follow health-related advice, to take medication as prescribed, to attend scheduled clinic appointments and to complete recommended investigations. It is a major health issue, with outcomes related to levels of morbidity, mortality and cost utilisation. Poor compliance has been reported as the most common cause of nonresponse to medication, with evidence to show that patients who adhere to treatment recommendations have better health outcomes than those who do not adhere, even when taking a placebo. Evidence-based practice guidelines, founded on clinical, behavioural and educational concepts, provide a means of measuring outcomes related to health status, patient satisfaction and cost-benefit issues, and may help to ensure that responsibility for compliance is shared between the clinician and the patient.

New Zealand general practice computerisation; attitudes and reported behaviour

AIMS

To gather information from general practitioners regarding aspects of computerisation including whether certain tasks should be computerised and whether those tasks were in fact computerised at their practice.

METHODS

Five hundred general practitioners randomly selected throughout New Zealand were sent a postal survey in May 1995. Results were then collated and analysed.

RESULTS

The response rate was 54% (268). Computerisation is becoming a necessity according to 85% of responders and a computer was used for at least one task by 84% of doctors. Computer use during consultation interfered unduly with doctor-patient communication according to 43% of responders. Privacy issues had not been dealt with adequately for 33% of responders. The five most frequently computerised tasks were; maintaining an age-sex register (81% of responders), recalls (80%), administration (77%), making appointments (50%) and word processing (49%). The number of doctors in a practice and responders' RNZCGP membership status appeared predictive of task computerisation. Responders' gender, year of graduation and their membership on the Indicative General Practitioners Register were not statistically significant factors for determining attitudinal and behavioural responses.

CONCLUSIONS

The low response rate limits generalisation but the trends in the results are important. Reported tasks with greatest potential for computerisation were doctor education; checking drug interactions/contraindications; patient education; tasks relating to interfacing with laboratories; and database enquires of patients. Significant concerns among responders were perceived interference with doctor patient communication and privacy issues. Eighty-four percent of responders use the computer for at least one task.