A Real-World Analysis of Treatment Patterns and Clinical Characteristics Among Patients with COPD Who Initiated Multiple-Inhaler Triple Therapy in New Zealand

Purpose

Real-world data on maintenance treatment and prescription patterns provide insights into healthcare management among patients with chronic obstructive pulmonary disease (COPD), which benefits our understanding of current COPD treatment patterns in New Zealand.

Methods

We retrospectively analyzed real-world data from the HealthStat general practice database to evaluate treatment patterns among patients with COPD in New Zealand who initiated multiple-inhaler triple therapy (MITT): inhaled corticosteroid (ICS) + long-acting muscarinic antagonist + long-acting β₂-agonist (LABA). Our main objective described treatment patterns (class, duration, modification, persistence, and adherence) and characteristics of patients with COPD initiating MITT between 1 May 2016 and 30 April 2017, with 12-months’ follow-up. We also assessed the number of patients receiving MITT between 2015 and 2017, among a larger patient population receiving long-acting bronchodilator and ICS-containing therapies.

Results

Of 6249 eligible patients, 421 (mean age 67.3 years; mean number exacerbations at baseline 1.8) initiated MITT: 59.1% received combination ICS/LABA therapy prior to MITT initiation, and median treatment duration prior to MITT initiation was 350 days. Overall, 33.5% of patients remained on index treatment for 12 months. Of the remaining patients who modified treatment (on average at 144.4 days), those who had a direct switch (24.9%) or retreatment (13.5%) remained on MITT, 19.7% of patients stepped down to mono/dual therapy, and 8.3% discontinued treatment. Mean (standard deviation) persistence to any MITT over 12 months was 47.3 (50.0), and 53.4% of patients were considered adherent to MITT. Total proportions of patients receiving long-acting bronchodilator therapy and MITT increased between 2015 and 2017.

Conclusion

Most patients with COPD in New Zealand who initiated MITT had characteristics appropriate for triple therapy prescription, suggesting prescription behavior among general practitioners was largely consistent with treatment guidelines. Our findings may help optimize treatment decisions, with a focus on improving long-term triple therapy persistence and adherence.

Burden of illness in blood eosinophilic phenotype COPD patients in New Zealand

BACKGROUND

Real-world data on eosinophilic chronic obstructive pulmonary disease (COPD)'s clinical burden, in exacerbating/stable states, and the stability of blood eosinophil count (BEC) measurements are limited. We described measured BEC distributions among general practice COPD patients in New Zealand (NZ).

METHODS

This retrospective cohort study utilized the NZ-HealthStat primary care database. Participants were aged ≥40 years, with ≥1 BEC 6 months following a COPD diagnosis code during 2011-2012. Descriptive analyses included examinations of BEC stability and association with COPD exacerbations/treatments/comorbidities.

RESULTS

The most frequent COPD comorbidity was asthma (n = 1180/2909, 40.56%). Among COPD patients: 65% had BECs >150 cells/μL; 35% had BECs >300 cells/μL (non-mutually exclusive threshold categories). Treatment patterns were similar, except for more frequent inhaled corticosteroid (ICS)/long-acting beta₂-agonist use in COPD patients with asthma history (51%) than those without (31%). Factors associated with BECs >150 cells/μL in participants without ICS treatment included Māori/Pacific ethnicity, obesity, oral corticosteroid (OCS) use, and exacerbation history. When stratified by asthma history, ICS treatment, and neutrophil count above/below 5000 cells/μL, geometric mean BECs ranged from 136.70 to 398.52 cells/μL. Exploratory analyses showed a fair-good COPD/BEC measurement stability over 12 months.

CONCLUSIONS

Asthma was a common COPD comorbidity in NZ, particularly in Māori/Pacific patients. No overall relationship was observed between BEC/COPD exacerbations, which may reflect background ICS confounding. However, analyses in non-ICS treated participants suggested that Māori/Pacific patients with obesity and COPD, OCS treatment, exacerbation history, and/or elevated BECs are at the highest risk of COPD exacerbations. One BEC measurement appears a good indicator of a patient's BECs over time.

Long-Acting Bronchodilator Use in Chronic Obstructive Pulmonary Disease in Primary Care in New Zealand: A Retrospective Study of Treatment Patterns and Evolution Using the HealthStat Database

Purpose

Long-acting bronchodilator (LABD) use is the mainstay of pharmacologic treatment for chronic obstructive pulmonary disease (COPD). Few studies describe evolving patterns of LABD use in the setting of changing inhaler availability and updated clinical guidelines.

Methods

A retrospective cohort study in New Zealand using the HealthStat general practice database (01/2014 to 04/2018). Eligible patients (aged ≥40 years) had COPD and ≥1 LABD prescription (long-acting muscarinic antagonist [LAMA] and/or long-acting β₂-agonist [LABA]) during the index period (05/2015 to 04/2016). Demographics and clinical characteristics of all LABD users (overall/by treatment) were described at baseline. Patients starting LABD treatment during the index period, termed "new" users, were also described, as was their treatment evolution over 24 months of follow-up. Yearly LABD initiation rates were assessed from 2015 to 2017, covering changes to Pharmaceutical Management Agency criteria and clinical guidelines.

Results

Across 2140 eligible patients, the most common index treatments were inhaled corticosteroid (ICS)/LABA (59.0%) and open triple therapy (LAMA+LABA+ICS; 26.7%). ICS/LABA therapy was highest in younger patients, with open triple therapy highest in older patients. Prior yearly exacerbation rates were lowest in those receiving monotherapy (LABA: 0.9/year; LAMA: 1.1/year) versus dual therapy (all 1.4/year) and open triple therapy (2.2/year). Of 312 new LABD users, ICS/LABA was the most common index treatment (69.6%), followed by LAMA monotherapy (16.0%). Continuous use with index treatment was 31.1% at 12 months and 13.5% at 24 months; mean time to treatment change was 175.5 and 244.1 days, respectively. Among patients modifying treatment at 24 months, 23.0% augmented, 7.0% switched, 45.6% re-started, and 24.4% discontinued/stepped down. Among patients initiating LABD each year from 2015 to 2017, LAMA prescription increased (17% to 46%) while ICS prescription remained stable (approximately 20%).

Conclusion

Predominant use of ICS/LABA (05/2015 to 04/2016) reflects available LABDs and previous restrictions on LAMA use in New Zealand.

Characterization and burden of severe eosinophilic asthma in New Zealand: Results from the HealthStat Database

Background

This retrospective cohort study aimed to characterize epidemiology, medication use and healthcare resource utilization (HCRU) of patients diagnosed with severe eosinophilic asthma (SEA) compared to other patients with asthma in New Zealand.

Methods

Adult patients with asthma with no concurrent diagnosis of Chronic Obstructive Lung Disease (COPD) were identified from the HealthStat primary care database and the National Minimum Dataset using asthma diagnosis, hospital codes and prescriptions. Patients with SEA were identified using a 1-year baseline period (2011) and were those with: inhaled corticosteroid prescription above medium dose (including high dose) plus controller medication, ≥2 exacerbations, and eosinophils ≥300 cells/μl (or ≥150 in 6 weeks prior to index date); patients were followed for 1 year (2012).

Results

160/3,276 (4.9%) asthmatics with available eosinophil counts met SEA criteria. Patients with SEA were more likely to be Māori, former smokers, have more comorbidities, higher mean BMI and higher neutrophil counts compared with other patients with asthma. In the follow up period, SEA patients had over 4 times as many exacerbations; incidence of exacerbations of the same frequency was highest in Māori patients.

Conclusions

Compared with other patients with asthma, SEA patients had over 1.5 times as many respiratory treatment prescriptions and higher all-cause HCRU and total healthcare costs; asthma-related healthcare costs were 3.6 times greater.

Dentition and nutritional status of aged New Zealanders living in aged residential care

BACKGROUND

Previous studies of the nutritional status of older individuals have used measures such as plasma vitamin and mineral levels, which can be difficult to interpret. The relationship between nutrition and dentition has been limited to studying exposures such as the number of posterior occluding pairs of teeth, edentulousness, and the number of natural teeth.

OBJECTIVES

To investigate the association between dentition status and nutritional status in a national survey of older New Zealanders living in aged residential care facilities.

MATERIAL AND METHODS

Secondary analysis of clinical oral status and nutrition data collected in 2012 in New Zealand's Older People's Oral Health Survey. The validated Mini Nutritional Assessment short format was used to categorize participants as "normal nutritional status," "at risk of malnutrition" or "malnourished."

RESULTS

Just under half of older New Zealanders living in aged residential care facilities were classified as either at risk of malnutrition or malnourished (with about one in sixteen in the latter category). The prevalence of malnutrition was higher among those in hospital-level and psychogeriatric-level care, as well as in those of high socioeconomic status. Individuals who were at risk of malnutrition had the most untreated dental caries and untreated coronal caries. Relative to their counterparts in nursing-home-level care, dentate individuals in hospital-level care were 2.4 times-and those in psychogeriatric-level care were 2.8 times-as likely to be malnourished or at risk of it.

CONCLUSIONS

Just under half of the New Zealanders living in aged residential care were at risk of malnutrition or were malnourished. Greater experience of untreated dental caries was associated with a higher rate of being malnourished or at risk of it. Poorer cognitive function and greater dependency were important risk indicators for malnutrition.

Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand

Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease (RHD), have largely disappeared from high-income countries. However, in New Zealand (NZ), rates remain unacceptably high in indigenous Māori and Pacific populations. The goal of this study is to identify potentially modifiable risk factors for ARF to support effective disease prevention policies and programmes. A case-control design is used. Cases are those meeting the standard NZ case-definition for ARF, recruited within four weeks of hospitalisation for a first episode of ARF, aged less than 20 years, and residing in the North Island of NZ. This study aims to recruit at least 120 cases and 360 controls matched by age, ethnicity, gender, deprivation, district, and time period. For data collection, a comprehensive pre-tested questionnaire focussed on exposures during the four weeks prior to illness or interview will be used. Linked data include previous hospitalisations, dental records, and school characteristics. Specimen collection includes a throat swab (Group A Streptococcus), a nasal swab (Staphylococcus aureus), blood (vitamin D, ferritin, DNA for genetic testing, immune-profiling), and head hair (nicotine). A major strength of this study is its comprehensive focus covering organism, host and environmental factors. Having closely matched controls enables the examination of a wide range of specific environmental risk factors.

The residual dentition among New Zealanders in aged residential care

BACKGROUND

Descriptions of the older population's dentition status are usually limited to indicators such as the edentulous proportion, the mean number of restored and missing teeth, and the proportion with a functional dentition, with very few reports describing in detail the nature of the residual dentition.

OBJECTIVES

This study described the residual dentition among older New Zealanders living in residential aged care facilities.

MATERIAL AND METHODS

Using national data from the Older People's Oral Health Survey, we determined the residual dentition arrangement and Kennedy classification for each dental arch. Individuals were categorised according to their maxillary-mandibular dental configuration. Data were weighted to make the estimates generalisable to the source population.

RESULTS

Among the dentate 45% of the 987 clinically examined participants, the most prevalent configuration was maxillary tooth-bounded saddles against a partially dentate lower (24.7%; 95% CI: 20.4, 29.7). More younger participants generally had less tooth loss experience and had higher prevalence of Kennedy Classes II, III and IV. There were few sex differences, although more females had a fully dentate arch. Marked ethnic differences were observed: Māori were up to eight times as likely to have only mandibular anterior teeth remaining. Upper dentures were worn more than their lower counterpart. Age, sex and ethnic characteristics were associated with particular residual teeth configurations.

CONCLUSIONS

Having various degrees of tooth loss was the norm, with the upper tooth-bounded saddles against any partially dentate lower combination most common, and limited to females. An edentulous maxilla opposed by some standing teeth was observed in over one-quarter of the population, and most common among Māori and those who were older. Maxillary prostheses were much more common than mandibular ones. Caring for dentate older people in aged residential care is likely to be complicated by the wide range of dentition configurations.

Oral status, cognitive function and dependency among New Zealand nursing home residents

OBJECTIVES

To investigate clinical oral disease and its association with cognitive function and dependency among older New Zealanders in residential aged care.

MATERIAL AND METHODS

National survey of oral health in aged residential care throughout New Zealand. We classified residents into 1 of 3 levels of care: "low dependency care (or assisted living)"; "high dependency care"; or "specialist dementia care/psychogeriatric care." The Abbreviated Mental Test characterised cognitive function as "unimpaired" (scores of 7-10), "moderately impaired" (4-6) or "severely impaired" (0-3). Intra-oral examinations were conducted, along with a computer-assisted personal interview.

RESULTS

Most of the 987 clinically examined participants were either at low or high dependency care level, with another 1 in 6 in psychogeriatric care. Almost half overall had severely impaired cognitive function. Just under half of the sample had 1 or more natural teeth remaining. Negative binomial regression modelling showed that the number of carious teeth was lower among women and higher among those who were older, those with more teeth and in those with severely impaired cognitive function. Oral debris scores (representing plaque biofilm and other soft deposits on teeth) were higher in men, those with more teeth, and in those with severely impaired cognitive function.

CONCLUSIONS

Impaired cognitive function is a risk indicator for both dental caries and oral debris in aged residential care.

The incidence of acute otitis media in New Zealand children under five years of age in the primary care setting

INTRODUCTION

Acute otitis media (AOM) is a common childhood infection. Baseline data are required to evaluate potential changes in the epidemiology of AOM with new public health measures.

AIM

To estimate the incidence of AOM in children under five years of age in primary care in New Zealand.

METHODS

Using a cohort study design, consultation notes from 1 November 2008 to 31 October 2009 from 63 primary care facilities were analysed for new and recurrent episodes of AOM, complications, antimicrobial use and outcome.

RESULTS

There were 19 146 children in the sample. The raw incidence of AOM was 273 per 1000 children (27.3%; 95% CI 216-330). Of the 3885 children, 2888 (74%) had one episode of AOM and 152 (4%) of these children developed recurrent AOM. Incidence declined with age. There was no difference in incidence between Maori, Pacific and 'Other' ethnicities. Antibiotics were used to treat 2653 (51%) AOM episodes and 113 (4.3%) of these children re-presented within three days of antibiotic therapy for persistent symptoms. Tympanic membrane perforation was the only complication noted, observed in 62 (1%) episodes.

DISCUSSION

These data indicate that AOM is an important and frequent childhood infection in New Zealand. The show a significant decline in the use of antibiotics to manage AOM in concordance with accepted best practice. The complication rate of AOM is likely under-represented. This study enables future research into the effectiveness of current and future immunisations and changing management practices in New Zealand.

Potential unmet need for gout diagnosis and treatment: capture-recapture analysis of a national administrative dataset

OBJECTIVE

To estimate the degree of undercount of people diagnosed with gout in administrative datasets using capture-recapture methods.

METHODS

Hospitalization and drug dispensing claims (allopurinol or colchicine) data for all Aotearoa New Zealand were used to estimate the prevalence of gout in 2009 (n = 4 295 296). As a comparison, we calculated gout prevalence using a large primary care dataset using general practitioner diagnosis and prescribing records (n = 555 313). For each of these datasets, we estimated the undercount through capture-recapture analysis using a Poisson regression model. A two-list model was used, which included covariates such as age, gender, ethnic groups and New Zealand deprivation quintiles.

RESULTS

The crude prevalence of diagnosed gout in the Aotearoa New Zealand population aged ≥ 20 years was 3.75%. The covariate-adjusted capture-recapture estimate of those not recorded but likely to have gout was 0.92%, giving an overall estimated prevalence of 4.67% (95% CI 4.49, 4.90%) for the population aged ≥ 20 years. This amounts to 80% of people with gout being identified by the algorithm for the Aotearoa New Zealand data-that is being recorded in either lists of dispensing of allopurinol or colchicine or hospital discharge. After capture-recapture, gout prevalence for all males aged ≥ 20 years was 7.3% and in older (≥ 65 years) Māori and Pacific men was >30%.

CONCLUSION

Capture-recapture analysis of administrative datasets provides a readily available method for estimating an aspect of unmet need in the population-in this instance potentially 20% of those with gout not being identified and treated specifically for this condition.

National prevalence of gout derived from administrative health data in Aotearoa New Zealand

OBJECTIVE

Previous small studies in Aotearoa New Zealand have indicated a high prevalence of gout. This study sought to determine the prevalence of gout in the entire Aotearoa New Zealand population using national-level health data sets.

METHODS

We used hospitalization and drug dispensing claims for allopurinol and colchicine for the entire Aotearoa New Zealand population from the Aotearoa New Zealand Health Tracker (ANZHT) to estimate the prevalence of gout in 2009, stratified by age, gender, ethnicity and socio-economic status (n = 4 295 296).

RESULTS

were compared with those obtained from an independent large primary care data set (HealthStat, n = 555 313). Results. The all-ages crude prevalence of diagnosed gout in the ANZHT population was 2.69%. A similar prevalence of 2.89% was observed in the HealthStat population standardized to the ANZHT population for age, gender, ethnicity and deprivation. Analysis of the ANZHT population showed that gout was more common in Māori and Pacific people [relative risk (RR) 3.11 and 3.59, respectively], in males (RR 3.58), in those living in the most socio-economically deprived areas (RR 1.41) and in those aged >65 years (RR >40) (P-value for all <0.0001). The prevalence of gout in elderly Māori and Pacific men was particularly high at >25%.

CONCLUSION

Applying algorithms to national administrative data sets provides a readily available method for estimating the prevalence of a chronic condition such as gout, where diagnosis and drug treatment are relatively specific for this disease. We have demonstrated high gout prevalence in the entire Aotearoa New Zealand population, particularly among Māori and Pacific people.

The incidence of acute otitis media in New Zealand children under five years of age in the primary care setting

INTRODUCTION: Acute otitis media (AOM) is a common childhood infection. Baseline data are required to evaluate potential changes in the epidemiology of AOM with new public health measures. AIM: To estimate the incidence of AOM in children under five years of age in primary care in New Zealand. METHODS: Using a cohort study design, consultation notes from 1 November 2008 to 31 October 2009 from 63 primary care facilities were analysed for new and recurrent episodes of AOM, complications, antimicrobial use and outcome. RESULTS: There were 19 146 children in the sample. The raw incidence of AOM was 273 per 1000 children (27.3%; 95% CI 216–330). Of the 3885 children, 2888 (74%) had one episode of AOM and 152 (4%) of these children developed recurrent AOM. Incidence declined with age. There was no difference in incidence between Maori, Pacific and ‘Other’ ethnicities. Antibiotics were used to treat 2653 (51%) AOM episodes and 113 (4.3%) of these children re-presented within three days of antibiotic therapy for persistent symptoms. Tympanic membrane perforation was the only complication noted, observed in 62 (1%) episodes. DISCUSSION: These data indicate that AOM is an important and frequent childhood infection in New Zealand. The show a significant decline in the use of antibiotics to manage AOM in concordance with accepted best practice. The complication rate of AOM is likely under-represented. This study enables future research into the effectiveness of current and future immunisations and changing management practices in New Zealand. KEYWORDS: Otitis media; incidence; child, preschool; New Zealand, antibiotic

Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

Background

In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.

Results

Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.

Conclusion

The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.

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.

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.

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.

The development and implementation of the Chronic Care Management Programme in Counties Manukau

AIMS

To develop an effective and efficient process for the seamless delivery of care for targeted patients with specific chronic diseases. To reduce inexplicable variation and maximise use of available resources by implementing evidence-based care processes. To develop a programme that is acceptable and applicable to the Counties Manukau region.

METHODS

A model for the management of people with chronic diseases was developed. Model components and potential interventions were piloted. For each disease project, a return on investment was calculated and external evaluation was undertaken. The initial model was subsequently modified and individual disease projects aligned to it.

RESULTS

The final Chronic Care Management model, agreed in September 2001, described a single common process. Key components were the targeting of high risk patients, organisation of cost effective interventions into a system of care, and an integrated care server acting as a data warehouse with a rules engine, providing flags and reminders. Return on investment analysis suggested potential savings for each disease component from $277 to $980 per person per annum.

CONCLUSIONS

For selected chronic diseases, introduction of an integrated chronic care management programme, based on internationally accepted best practice processes and interventions can make significant savings, reducing morbidity and improving the efficiency of health delivery in the Counties Manukau region.

Establishing a Maori case management clinic

AIMS

The Maori Case Management Clinic Project aims to improve Maori health outcomes by establishing low cost, high quality, culturally appropriate primary care facilities in targeted areas, with a focus on the management of chronic illness. Further, the project aims to evaluate this 'by Maori for Maori' model of community healthcare delivery.

METHODS

Working in partnership with local Maori health providers, we analysed the available health utilisation and demographic data to choose the three best sites to establish new primary care facilities. We established the facilities with initial start-up funding from Counties Manukau District Health Board. Rigorous evaluation processes have been built into the project.

RESULTS

Enrollments at the first of the three clinics exceeded expectations. Client satisfaction as reported by independent evaluators was very high, with cost, cultural acceptability and convenience of location being the three most common reasons given for high satisfaction.

CONCLUSIONS

The model adopted has been positively received by the targeted population. Further evaluation will reveal whether this resulted in improved health outcomes.

Primary options for acute care: general practitioners using their skills to manage "avoidable admission" patients in the community

AIM

To enroll 600 primary care "avoidable admission" patients in a programme that utilised general practitioners to manage those patients in the community.

METHODS

The Primary Options for Acute Care (POAC) programme ran from 26 February to 31 December 2001. Using networks already established, primary care teams were invited to manage patients using any resources they required, up to a cost of approximately $266 per patient. If needed, a Service Coordinator was available to arrange investigations, care, or treatment.

RESULTS

From 26 February to 31 December 2001, 707 patients were enrolled in POAC by 100 GPs. 104 patients (15%) were eventually admitted to hospital. An average of $200.73 per patient per episode was spent (not including administrative costs). A wide variety of patients and diseases were managed. Patients and general practitioners reported high levels of satisfaction with the programme.

CONCLUSION

POAC demonstrated the ability and willingness of primary care providers to successfully manage patients who traditionally would be sent to hospital, within a defined budget

General practitioners' assessments of the primary care caseload in Middlemore Hospital Emergency Department

AIM

To estimate the proportion of Middlemore Hospital Emergency Department (ED) attendances that GPs thought could be handled in primary care.

METHODS

A retrospective review of 300 randomly selected discharge summaries of non-admitted patients by 12 GPs.

RESULTS

Data were available from 278 discharges. Agreement between GP reviewers was "fair" (kappa = 0.34, Kendall's W = 0.48). In 50 cases, the GPs were unanimous that the case was a primary care case (18%). In two cases, there was unanimity that the case was an ED case (<1%). The 12 GPs assessed that an average of 56% (range 38-81%) of the cases they reviewed could have been handled in their surgeries yesterday with no extra resources. This suggests that 34% of the total ED caseload (ie, including admitted patients) could be managed in primary care.

CONCLUSIONS

A significant proportion of ED attendances at Middlemore Hospital could be handled in primary care; however, there is considerable variation in GP estimates of this proportion.

Integrating healthcare: the Counties Manukau experience

In 1998, Counties Manukau District Health Board (CMDHB) was experiencing rapidly increasing demands on its secondary services. It was finding it increasingly difficult to meet the health needs of its relatively deprived population. There was widespread evidence of "systems failure", with poor coordination of primary and secondary services. A strategic plan was devised to meet identified priorities and this was subsequently implemented with extensive community involvement. A "disruptive change" model was utilised. Thirty separate projects were undertaken to improve coordination and integration of health services. Brief summaries of all projects are presented, and full evaluations were performed of major projects. Factors critical to project success were: dedicated and effective leadership; involvement of clinical staff; early engagement of the Maori and Pacific community; careful selection of stakeholders; reassurance for providers about privacy issues; close monitoring of project progress; realistic timeframes; and adequate initial funding. CMDHB believes that the critical factor to success in improving the performance of the health sector will be the ability of our key leaders in primary and secondary care, in both management and clinical roles, to adopt a systems view to problem analysis and solution building

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.

How much variation in clinical activity is there between general practitioners? A multi-level analysis of decision-making in primary care

OBJECTIVES

There is considerable policy interest in medical practice variation (MPV). Although the extent of MPV has been quantified for secondary care, this has not been investigated adequately in general practice. Technical obstacles to such analyses have been presented by the reliance on ecological small area variation (SAV) data, the binary nature of many clinical outcomes in primary care and by diagnostic variability. The study seeks to quantify the extent of variation in clinical activity between general practitioners by addressing these problems.

METHODS

A survey of nearly 10 000 encounters drawn from a representative sample of general practitioners in the Waikato region of New Zealand was carried out in the period 1991-1992. Participating doctors recorded all details of clinical activity for a sample of encounters. Measures used in this analysis are the issuing of a prescription, the ordering of a laboratory test or radiology examination, and the recommendation of a future follow-up office visit at a specified date. An innovative statistical technique is adopted to assess the allocation of variance for binary outcomes within a multi-level analysis of decision-making.

RESULTS

As expected, there was considerable variability between doctors in levels of prescribing, ordering of investigations and requests for follow up. These differences persisted after controlling for case-mix and patient and practitioner attributes. However, analysis of the components of variance suggested that less than 10% of remaining variability occurred at the practitioner level for any of the measures of clinical activity. Further analysis of a single diagnostic group--upper respiratory tract infection--marginally increased the practitioner contribution.

CONCLUSIONS

The amount of variability in clinical activity that can definitively be linked to the practitioner in primary care is similar to that recorded in studies of the secondary sector. With primary care doctors increasingly being grouped into larger professional organisations, we can expect application of multi-level techniques to the analysis of clinical activity in primary care at different levels of organisational complexity.

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.

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.

Integrated disease management pilot for diabetes

A New Zealand diabetes program integrates management systems for hospitals and physician practices through a shared integrated care server (ICS), which supports collaborative patient management, virtual consults, and clinical feedback.

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.

Do physician practice styles persist over time? Continuities in patterns of clinical decision-making among general practitioners

OBJECTIVES

This study seeks to determine whether there are identifiable differences in patterns of clinical decision-making among family physicians, and whether these patterns persist over time.

METHODS

A representative cross-sectional survey of general practice encounters in the Waikato region of New Zealand in 1979-1980 was repeated in 1991-1992. Patterns of clinical decision-making were operationalised as practitioner rates for writing a prescription, ordering a laboratory test or radiological examination and the recommendation of a future follow-up office visit at a specified date. Comparable data were available for a cohort of 50 physicians in both surveys. Multi-level techniques and a simulation exercise were used to study the patterns of decision-making over time.

RESULTS

Raw, unadjusted correlations for the 50 family physicians between the two surveys were 0.24, 0.14 and 0.55 for rates of prescribing, investigations and follow-up, respectively. However, these correlations increased substantially, to 0.55, 0.41 and 0.70, once account was taken of case mix, data clustering and inter-practitioner variation in patient sample size. The extent of this recovery of the underlying correlations was confirmed in a parallel simulation exercise.

CONCLUSIONS

This study confirms the existence of substantial and durable individual practice styles in primary medical care, with implications for the development and successful implementation of clinical guidelines.

The early experience of general practitioners using Green Prescription

AIM

Sedentary lifestyle is a significant risk factor for increased morbidity and mortality in many medical conditions. A Hillary Commission initiative, Green Prescription is a written exercise prescription given by general practitioners (GPs) to sedentary patients to encourage physical activity. Our aim was to establish the extent to which GPs in the North Health region in 1997 issued with Green Prescription packages had used them, the circumstances under which they were used, and barriers to their use.

METHODS

433 GPs issued with packs were faxed a one-page questionnaire for immediate completion, with follow-up of non-responders.

RESULTS

The response rate was 73%, with 65% of respondents having written Green Prescriptions. Their main reasons for use were patient need for more exercise and presence of high-risk medical conditions such as hypertension, cardiovascular disease, obesity and diabetes. Reasons for non-use were: GP already giving advice about physical activity; concern that Green Prescription was patronising and simplistic; compliance issues and time restraints. Some requested a computerised version.

CONCLUSION

Non-responders may be non-users, hence we estimate that 48-65% of targeted GPs used Green Prescription. Barriers identified by GPs have assisted in Green Prescription development, which is now nationwide and assessed by independent researchers tri-annually.

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.

The "supply hypothesis" and medical practice variation in primary care: testing economic and clinical models of inter-practitioner variation

Medical practice variation (MPV) is marked, apparently ubiquitous across the health sector, well documented, and continues to be a focus of professional and policy interest. MPV have stimulated two paths of investigation, one economic in emphasis and the other more-clinical in orientation; while health economists have stressed the potential role of income incentives in medical decision-making, health services research has tended to emphasise clinical ambiguity as a factor in practitioner decisions. Both sets of explanations converge in an implicit "supply hypothesis" that posits contextual practitioner and practice attributes as influential in clinical decisions. Data on inter-practitioner variation are taken from a large and representative regional survey of general practitioners in New Zealand, a country in which unsubsidised fee-for-service is the predominant mode of remuneration in primary care. The paper assesses the impact on three important areas of clinical decision-making prescribing, test ordering, request for follow-up -- of three key conceptual dimensions -- income incentives, physician agency, and clinical ambiguity (operationalised as local doctor density, practitioner encounter initiation, and diagnostic uncertainty respectively). Predictions are made about inter-practitioner variations in the rate of clinical activity in the three areas. The results of the analysis using multi-level statistical techniques are: 1. the extent of competition -- local doctor density -- seems to have no effect on the pattern of clinical decision-making; 2. doctor-initiated visits are, if anything, associated with lower rates of intervention; 3. diagnostic uncertainty is associated with higher rates of investigations and follow-up, both of which have clinical plausibility; 4. there is no significant interaction effect between density and uncertainty. It is concluded that, for the clinical activities studied and for the practitioner attributes as operationalised in this investigation, a clinical, rather than an economic, model of practitioner decision-making provides a more plausible interpretation of inter-practitioner variation in rates of clinical activity in general practice. The "supply hypothesis" requires further analytical refinement and empirical assessment before it can be applied as a generic explanatory framework for MPV.

Practice nurses in the Waikato, 1991-1992, I: Occupational profile

AIMS

To describe the personal characteristics, working conditions, clinical activities and professional development of a representative sample of practice nurses in the Waikato during the period 1991-1992.

METHODS

The data are from a survey of practice nurses drawn from a larger study of general practice carried out in the Waikato (the WaiMedCa Study). Eighty-nine percent of the 107 practices in the region participated in the study. The practice nurse survey was carried out on the 189 nurses working in these practices. Of these 149 replied, representing a response rate of 79%.

RESULTS

On average, there was one nurse for each solo practice and two in most other practices. Only two practices--both solo--did not employ a nurse. Practice nurses were female and aged between 30 and 50. While only one-third had received a postgraduate qualification, two-thirds had been to recent professional development courses. The majority had worked as a practice nurse for between one and ten years. Nurses averaged just under 15 telephone contacts a day and 28 face-to-face contacts a week. Nurses' workload comprised general measurements and assessments, monitoring and surveillance procedures (such as diabetes, asthma and child development), and counselling and women's health activities.

CONCLUSION

Practice nurses are an accepted and essential part of primary health care in New Zealand. However, their potential is probably underdeveloped and they could be more fully utilised for a wider range of nursing functions.

Trends in general practice in the Waikato, 1979-80/1991-92, II: Social variations in service use and clinical activity

AIMS

To document trends in ethnic group and occupational class differences in the use of general practitioner services and in patterns of clinical activity for the Hamilton Health District of the Waikato over the period 1979-80 to 1991-92.

METHODS

The data are drawn from a baseline and a follow-up survey of general practice in the Waikato region representing a one per cent sample of all in-surgery, in-hours, week-day encounters at two points in time. The data were recorded by participating general practitioners in four collection weeks spaced over the period of a year. In total, 9468 and 10,235 patient encounter forms were completed respectively.

RESULTS

Over a period in which service availability and rates of medical contact grew, there was a relatively greater increase in utilisation among Maori and lower socioeconomic groups: between the two surveys the ratio of Maori to non-Maori rates increased from 0.8 to 1.0 and the ratio of visits for lower to higher socioeconomic groups grew from a differential of 2.5 to one of 3.1. More serious conditions apart, these changes seemed to occur uniformly regardless of the severity, amenability or susceptibility of the condition presented to the general practitioner. Changes in ethnic group and occupational class patterns of service activity almost exactly mirrored these trends.

CONCLUSIONS

A notable relative increase in rates of contact for primary medical care among Maori and lower socioeconomic groups seems to have accompanied the growth in the 1980s of the availability of general practitioner services in this region of New Zealand.

Trends in general practice in the Waikato, 1979-80/1991-92, I: Practitioner availability, service use and clinical activity

AIMS

To document trends in availability and use of general practitioner services and in patterns of clinical activity for the Waikato over the period 1979-80 to 1991-92.

METHODS

The data are drawn from a baseline and a follow-up survey of general practice in the Waikato region representing a 1% sample of all in-surgery, in-hours, week-day encounters at two points in time. The data were recorded by participating general practitioners in four collection weeks spaced over the period of a year. In total, 9468 and 10,235 patient encounter forms were completed.

RESULTS

While the number of general practitioners increased by a half over the period, average workload declined by a fifth, the inflation-adjusted value of the usual adult fee increased by nearly 50% and visits went up by an average of a half a visit a year. Clinical activity declined for prescribing but increased for referral and follow-up.

CONCLUSIONS

The increase in availability of general practitioners over the last decade has been associated with significant changes in patterns of practice organisation, service utilisation and clinical activity. Further research is required into the potential impact of greater service availability on patient demand and resource use.

Maori/non-Maori patterns of contact, expressed morbidity and resource use in general practice: data from the Waikato Medical Care Survey 1991-2

AIMS

To compare patterns of contact, expressed morbidity and resource use in primary care for a representative sample of patients of Maori and non-Maori background.

METHODS

The data are drawn from a survey of general practice in the Waikato region representing a one per cent sample of all week day encounters. The data were recorded by participating general practitioners in four collection weeks spaced over the period of a year. In total, 12,833 patient encounter forms were completed.

RESULTS

Annual rates of general practitioner contact for Maori are slightly lower than those for patients of non-Maori background. The case-mix pattern of general practitioner contact is very similar between the two groups. There is a limited correspondence between ethnic patterns of general practitioner usage and health need (as measured by mortality levels and rates of public hospital discharge).

CONCLUSIONS

The near equivalence in ethnic rates of general practitioner contact revealed in this study contrasts strikingly both with the level of hospitalisation for Maori, which is nearly double that of non-Maori, and with the difference in mortality rates (30% higher for Maori). Attention devoted to improving access to general practitioner services among Maori may be necessary if important areas of ill health and hospital resource use are to be addressed effectively.

Patterns of general practitioner usage among Pacific people: indicative results from the Waikato Medical Care Survey 1991-2

AIMS

To report patterns of medical contact in a representative sample of Pacific people attending the general practitioner.

METHODS

The data were drawn from a survey of general practice in the Waikato region representing a one per cent sample of all weekday encounters. In total, 12,833 patient encounter forms were completed. Just over one per cent of all encounters were recorded for patients of Pacific Islands background.

RESULTS

Rates of medical contact for Pacific patients were lower-3.4 visits per year versus 4.5 for the whole sample-fewer follow up visits were requested (71% versus 76.2%), presentation was delayed (4.9 days from onset versus 3.7 for the sample) and there was an apparently lower level of rapport achieved.

CONCLUSION

Overall levels of medical contact and return visits among Pacific patients appear to be lower and presentation delayed in this Waikato sample.

The community services card and utilisation of general practitioner services

AIMS

To examine the relationship between holding a community services card and the utilisation of general practitioner services.

METHODS

A 1 year retrospective notes review from a random sample of 5637 general practitioner records.

RESULTS

CSC holders consulted their family doctor an average of 0.9 more times per year than non card holders. The CSC remained a significant predictor (p<0,0001) of consultation rate after controlling for age, gender, high user status and five common chronic conditions. Although holding a CSC had no significant effect on prescribing rate, CSC holders received significantly more prescription items per annum (6.74 items vs 4.89 items).

CONCLUSIONS

The CSC is a significant predictor of utilisation. The CSC identifies people who use more resources than people who do not hold the card, in terms of number of consultations and number of prescription items per year.

Geographical variations in the organisation of general practice

AIMS

To describe organisational characteristics of New Zealand general practice and to investigate inter-regional variations in these characteristics.

METHODS

Data were collected by standardised questionnaires from general practitioners in Auckland, Waikato and Taranaki. The Waikato data were collected in July-August 1991 by postal survey, the Taranaki data were collected May-June 1992 by postal survey and the Auckland data were collected December 1990 to January 1991 by face-to-face interview.

RESULTS

The response rates were Auckland 98% (167/171), Waikato 84% (185/220) and Taranaki 79% (79/100). There were significantly more overseas trained graduates in rural areas than in urban areas. Average practice size was 2.3 full time equivalent doctors, with each 100 doctors employing 71 nurses and 77 receptionists. The number of patients seen per week ranged from 109-141. Almost all (95%) general practitioners operated appointment systems. One in five general practitioners had patients in private hospitals, and more than half (58%) had patients in rest homes. At the time of interview, 29% of Auckland general practitioners used computers in their practices compared with over 50% in Waikato and Taranaki (p < 0.05). A smaller proportion of Auckland general practitioners had access to age/sex registers and fewer Auckland general practitioners had a recall system. Of Auckland general practitioners with recall systems, a greater proportion used them for mammograms, blood pressure and lipid measurements compared with elsewhere.

CONCLUSIONS

There are some significant regional variations in the functional characteristics of general practice in New Zealand which should be taken into account when planning primary care services in different regions. Should budget holding and managed care be introduced, computerised practices will be required. This will have significant resource implications.

Rational prescribing and interpractitioner variation. A multilevel approach

There are marked geographical variations in rates of medical and surgical intervention at every level of aggregation and in every aspect of medical practice. These data raise a range of important theoretical, methodological, and policy issues. Much the same pattern of variation characterizes the prescription and consumption of therapeutic drugs. Data from a survey of general practice in New Zealand confirm the existence of extensive variability in prescribing. Multilevel techniques are deployed to isolate the specific interpractitioner element in this variability. Controlling for patient, diagnostic, and practitioner variables improves the predictive power of the model but does not reduce the extent of interpractitioner variability in prescribing rates. The existence of such variability raises questions about the role of clinical uncertainty and professional autonomy in the promotion of rational therapeutics in medical practice.

The Waikato Medical Care (WaiMedCa) Survey 1991-1992

Objective. The main objective of this study is to provide a comprehensive description of general practice in the Waikato, an area which represents many aspects of New Zealand. Accurate, detailed and up to date information in this area is needed for future planning of medical education and the provision of health services. Survey method. The survey was conducted over one year, from September 1991 to August 1992. Participating general practitioners and practice nurses recorded details of a sample of patient encounters in the surgery or on home visits. Each participant was assigned four single weeks for data gathering over the course of the year. A one in five sub-sample of patients was also given questionnaires to complete immediately and two weeks after the consultations. This component of the study was reported elsewhere. Participants. A list of all active general practitioners working within the area covered by the Waikato Area Health board was constructed. All were contacted during May and June 1991 and asked to contribute to the study. During this initial, recruiting stage the practitioners and their practice nurses were asked to provide details of their professional background and to outline the structure, functions and size of their practices. Data collection. The variables studied included: provider characteristics (age, gender, qualifications, type of practice and services offered); patient attributes (age, gender, ethnicity, benefit category and occupation); patient reasons for encounter (up to four per encounter); doctor diagnoses (again up to four per encounter); drugs prescribed and or other treatments provided; tests and investigations ordered and referrals made; planned follow up and subjective view on the encounter. Data were centrally coded by trained staff. Patient reasons for encounter were coded according to NAMCS, practitioner diagnoses were classified into OXMIS, and drugs prescribed were allocated into the ATC classification system. Participation rate. 87% of practitioners (182/209), 89% of practices (95/107), and 80% of practice nurses (150/189) completed the initial recruitment survey. The participation rate at the first phase of the encounter survey was 80.5% (169/210), but this had dropped to 65.7% (136/207) by the fourth collection week. An overall response rate of 68.6% was achieved, representing successful collection of encounter data in 562 of 819 potential doctor recording weeks. On average, general practitioners recorded 109 encounters per week, from which they selected on average a sample of 23 patients for the survey. They described 141 problems per 100 encounters, of which 49 were new. On average general practitioners made less than three home visits per 100 encounters.(ABSTRACT TRUNCATED AT 400 WORDS)

The impact of the new subsidy regime in general practice in New Zealand

The first substantial change in the New Zealand health care reforms was the introduction in February 1992 of a new subsidy and charging regime in general practice. The paper reports on a comparison of data collected before and after the changes, drawing on GP-patient encounter information. Overall, seasonally adjusted levels of utilisation were maintained in the stage before the introduction of the new regime, declined 15% immediately following the changeover and stabilised thereafter. All patient groups were affected by the decline. Although the elderly were temporarily exempt from the changes, their consultations fell by 10%. Utilisation among beneficiaries--minor gainers from the changes--dropped by 30%. Children were more affected overall, adults less so. There was also some suggestion of greater falls for the lowest socio-economic groups. Activities under the direct control of the practitioner--prescribing and the ordering of tests--showed either little turbulence or no clear pattern of change. It is concluded that, although primary care subsidies and charges had been reshaped to favour poorer people, six months after the introduction of these changes there had been no corresponding redistribution of medical care consumed. Indeed, there is a suggestion that some of the groups ostensibly the target of increased assistance may have been adversely affected by the overall decline in utilisation.

Satisfaction with access to general practitioner services in south Auckland

AIMS

To describe satisfaction with access to general practitioner services in south Auckland.

METHODS

A random population survey of established residents was undertaken with the sample drawn from electoral rolls. A questionnaire was administered face-to-face by trained interviewers. Satisfaction was graded using a five point scale, with standard "smiley faces" as visual cues.

RESULTS

Overall satisfaction levels are high, ranging from 3.00 to 4.41 out of a maximum of 5. The lowest satisfaction is reported with charges (3.00), home visiting (3.31), weekend services (3.39), after hours services (3.48), and waiting times (3.55). Satisfaction is lowest amongst Polynesians and the 18-29 age group.

CONCLUSIONS

General practitioners could increase patient satisfaction with access by reducing patient charges and waiting times, and by improving access to services not provided at their usual premises during normal hours. Further research is needed into reasons for low satisfaction in the nonEuropean and younger age groups.

Do access factors affect utilisation of general practitioner services in south Auckland?

AIMS

To describe basic features of access to general practitioner services in south Auckland, and to examine the effect of different factors on utilisation of general practitioner services with particular attention to access issues.

METHODS

A random population survey of relatively established residents was undertaken with the sample drawn from electoral rolls. A questionnaire was administered face-to-face by trained interviewers.

RESULTS

Ninety-eight percent of respondents claimed to have a regular family doctor. The median travelling time to a respondent's general practitioner was 10 minutes. Ninety-five percent of respondents' general practitioners operated appointment systems. The median waiting time was 20 minutes, 30% felt the doctors fees stopped them going to the doctor sometimes. The average reported visiting rate was 6.9 visits per year. Poor perceived health, longer times with a given doctor and long waiting times were associated with decreased utilisation. Demographic factors were not associated with utilisation. Patient fees were not associated with utilisation in the sample. Only 23% of the variation in utilisation could be explained by the model.

CONCLUSIONS

Long waiting times are associated with decreased utilisation in this population. Although there is significant dissatisfaction with general practitioner fees, this does not manifest itself in decreased utilisation. Only a small proportion of the variation in utilisation can be explained by linear models of the variables studied.