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VOLUME 2 • NUMBER 2 • JUNE 2010<br />
OF PRIMARY HEALTH CARE<br />
‘<strong>The</strong> importance <strong>of</strong><br />
prevention <strong>of</strong> heart<br />
attacks and strokes…<br />
makes us very ready<br />
to swallow the<br />
industry message<br />
(not to say the pills)’<br />
See Ethics page 165<br />
Original Scientific Paper<br />
Aspirin use in primary prevention <strong>of</strong><br />
cardiovascular disease<br />
See page 92<br />
Original Scientific Paper<br />
Resources GPs use to answer questions<br />
and for CME<br />
See page 100<br />
Original Scientific Paper<br />
Self-management support for chronic<br />
illness<br />
See page 124<br />
Original Scientific Paper<br />
Practice nurses and postgraduate<br />
education<br />
See page 142<br />
Back to Back<br />
Should we screen for attention deficit<br />
hyperactivity disorder?<br />
See page 155<br />
Pounamu<br />
Whanau ora approach to health care<br />
See page 163
contents<br />
VOLUME 2 • NUMBER 2 • june 2010<br />
OF PRIMARY HEALTH CARE<br />
issn 1172-6164 (Print)<br />
ISSN 1172-6156 (Online)<br />
90 Editorials<br />
From the Editor<br />
Population and individual health: the two faces <strong>of</strong> Janus<br />
Felicity Goodyear-Smith<br />
92 Original Scientific Papers<br />
Quantitative Research<br />
92 Aspirin for primary prevention: yes or no?<br />
Vanessa Selak, C Raina Elley, Sue Wells, Anthony Rodgers,<br />
Norman Sharpe<br />
100 What resources do Auckland general practitioners use for<br />
answering immediate clinical questions and for lifelong<br />
learning?<br />
Zachary Gravatt, Bruce Arroll<br />
105 Causes <strong>of</strong> excess hospitalisations among Pacific peoples in<br />
<strong>New</strong> <strong>Zealand</strong>: implications for primary care<br />
Faafetai Sopoaga, Ken Buckingham, Charlotte Paul<br />
111 GP practice variation in hospitalisation rates: a study <strong>of</strong><br />
Partnership Health–enrolled patients<br />
Ross Barnett, Laurence Malcolm<br />
118 Modifying the PACIC to assess provision <strong>of</strong> chronic illness<br />
care: An exploratory study with primary health care nurses<br />
Jenny Carryer, Claire Budge, Chiquita Hansen, Katherine Gibbs<br />
124 Providing and receiving self-management support for chronic<br />
illness: Patients’ and health practitioners’ assessments<br />
Jenny Carryer, Claire Budge, Chiquita Hansen, Katherine Gibbs<br />
Qualitative Research<br />
130 Ever decreasing circles: terminal illness, empowerment and<br />
decision-making<br />
Kate Richardson, Rod MacLeod, Bridie Kent<br />
136 Seeing patients first: creating an opportunity for practice<br />
nurse care?<br />
Tim Kenealy, Barbara Docherty, Nicolette Sheridan, Ryan Gao<br />
142 What influences practice nurses to participate in postregistration<br />
education?<br />
Anna Richardson, Jeffrey Gage<br />
Short Report<br />
150 Are unexplained vaginal symptoms associated with<br />
psychosocial distress? A pilot investigation<br />
Andreas Cohrssen, Uzma Aslam, Allison Karasz, Matthew Anderson<br />
155 Back to Back<br />
<strong>New</strong> <strong>Zealand</strong> general practice should adopt populationbased<br />
screening for attention deficit hyperactivity disorder<br />
(ADHD)<br />
Yes Tony Hanne; No Ross Lawrenson<br />
160 Continuing Pr<strong>of</strong>essional Development<br />
160 String <strong>of</strong> PEARLS about hypertension<br />
160 Cochrane Corner: NSAIDs for dysmenorrhoea<br />
Bruce Arroll<br />
161 Charms & Harms: Ginkgo biloba<br />
Joanne Barnes<br />
163 Pounamu: A whanau ora approach to health care for Maori<br />
Jacquie Kidd, Veronique Gibbons, Ross Lawrenson, Wayne Johnstone<br />
165 Ethics<br />
Too much information<br />
Grant Gillett, Donald Saville-Cook<br />
168 Letters to the Editor<br />
170 Book Review<br />
Interpreting in <strong>New</strong> <strong>Zealand</strong>, the pathway forward<br />
—Diana Clark and Caroline McGrath<br />
Reviewer: Ben Gray<br />
171 Policy Statement for Authors<br />
Conflict <strong>of</strong> interest in peer-reviewed medical journals: <strong>The</strong><br />
World Association <strong>of</strong> Medical Editors (WAME) position on a<br />
challenging problem<br />
Lorraine Ferris, Robert Fletcher<br />
174 Gems <strong>of</strong> <strong>New</strong> <strong>Zealand</strong> Primary Health Care Research<br />
176 About the Journal <strong>of</strong> Primary Health Care<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 89
EDITORIALs<br />
from the editor<br />
Population and individual health:<br />
the two faces <strong>of</strong> Janus<br />
Felicity Goodyear-<br />
Smith MBChB, MGP,<br />
FRNZCGP, Editor<br />
Correspondence to:<br />
Felicity Goodyear-Smith<br />
Pr<strong>of</strong>essor and Goodfellow<br />
Postgraduate Chair,<br />
Department <strong>of</strong> <strong>General</strong><br />
Practice and Primary<br />
Health Care, <strong>The</strong><br />
University <strong>of</strong> Auckland,<br />
PB 92019 Auckland,<br />
<strong>New</strong> <strong>Zealand</strong><br />
f.goodyear-smith@<br />
auckland.ac.nz<br />
<strong>The</strong> leading paper in this <strong>issue</strong> is Selak and<br />
colleagues’ Aspirin for primary prevention:<br />
yes or no? 1 <strong>New</strong> <strong>Zealand</strong> (NZ) cardiovascular<br />
disease (CVD) risk guidelines recommend aspirin,<br />
along with lipid and blood pressure–lowering<br />
drugs and lifestyle changes, for all people with a<br />
five-year CVD risk that is 15% or greater. 2 This<br />
recommendation still stands for secondary prevention<br />
(patients who have had a previous CVD<br />
event). However, a recent meta-analysis has cast<br />
doubt on whether the benefits <strong>of</strong> aspirin use outweigh<br />
the potential harms in primary CVD prevention,<br />
concluding that ‘in primary prevention<br />
without previous disease, aspirin is <strong>of</strong> uncertain<br />
net value’. 3 <strong>General</strong> practitioners (GPs) therefore<br />
face a clinical dilemma: should we prescribe aspirin<br />
(unless contraindicated <strong>of</strong> course) for primary<br />
prevention <strong>of</strong> CVD in at-risk patients?<br />
Selak et al.’s research gives us the answer. <strong>The</strong>y<br />
applied evidence-based modelling to the metaanalysis<br />
data (six randomised controlled trials<br />
involving 95 456 individuals without prior CVD<br />
randomised to aspirin or no aspirin) calculating<br />
the rates <strong>of</strong> benefit and <strong>of</strong> harm for men and<br />
women in 10-year age bands, at different levels<br />
<strong>of</strong> CVD risk, both for aspirin alone and also for<br />
aspirin combined with lipid and blood pressure–<br />
lowering drugs.<br />
<strong>The</strong>y found that the benefits <strong>of</strong> aspirin outweigh<br />
the harms for both men and women aged up to 80<br />
years with a five-year CVD risk >15% in primary<br />
prevention. However, harm may outweigh benefit<br />
for primary prevention for those over 80 years,<br />
particularly for men. In men aged 70–79, lipid<br />
and blood pressure–lowering therapies should be<br />
considered first and then the patient reassessed as<br />
to whether aspirin adds an additional net benefit.<br />
This study is a great example <strong>of</strong> translational<br />
research, using the analysis <strong>of</strong> secondary data<br />
to answer a clinical question. We can apply the<br />
evidence to decide whether we should confirm<br />
or change our practice for optimal health care<br />
outcomes. Studies such as this, assessing the marginal<br />
benefits and harms <strong>of</strong> starting and stopping<br />
medication, are the way <strong>of</strong> the future.<br />
<strong>The</strong> topic <strong>of</strong> primary prevention <strong>of</strong> CVD is also<br />
touched on in our ethics column. 4 <strong>The</strong> authors<br />
discuss the difficult balance that doctors need to<br />
find between providing patients with information<br />
on all the possible, but <strong>of</strong>ten rare, adverse<br />
effects <strong>of</strong> management options, and informing<br />
patients about every aspect <strong>of</strong> their condition and<br />
its treatment that they might consider significant.<br />
Statins, like aspirin, are used to prevent<br />
heart attacks and strokes. Statins can cause very<br />
rare but serious and potentially life-threatening<br />
events. Most people are able to accept the remote<br />
risk that something bad may happen, but a few<br />
may be overly concerned to the point that they<br />
‘make bad decisions from a faulty appraisal’<br />
<strong>of</strong> the evidence they are given. Ideally in the<br />
patient-centred approach a GP knows when a<br />
patient might misinterpret or become unrealistically<br />
anxious and tailors how much information<br />
about risks to impart, but the real world is not<br />
always this simple.<br />
<strong>The</strong>se two papers demonstrate the potential<br />
dilemma in practising both population and individual<br />
care. Like the Roman god Janus, we can<br />
be perceived as having two heads facing in opposite<br />
directions. <strong>The</strong> GP who gives statins and<br />
aspirin to his or her at-risk patients knows that a<br />
number are prevented from having a heart attack<br />
or a stroke, and that treating the practice population<br />
in this way leads to an overall improvement<br />
in a number <strong>of</strong> patients’ quality <strong>of</strong> life. However<br />
an individual patient may suffer a severe haemorrhagic<br />
stroke that can be attributed to taking the<br />
aspirin, or rhabdomyolysis and renal failure from<br />
90 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
EDITORIALs<br />
from the editor<br />
the statin. This is devastating for the person,<br />
their family and their GP. We may act for the<br />
greater good, but sometimes individuals will<br />
suffer harm.<br />
This theme is continued further in a letter to the<br />
editor by Wells and colleagues. 5 <strong>The</strong>y challenge<br />
an essay published in our December 2009 <strong>issue</strong><br />
which argued that using CVD risk pr<strong>of</strong>ile tools<br />
does not improve patient care nor outcomes. 6<br />
Wells et al. agree that merely knowing a patient’s<br />
risk score and giving one-<strong>of</strong>f advice is unlikely<br />
to lead to sustained changes in patient behaviour.<br />
However they provide evidence that integrating<br />
CVD risk pr<strong>of</strong>ile tools into practice management<br />
systems provides immediately available decision<br />
support and generates ‘a comprehensive, personalised<br />
set <strong>of</strong> evidence-based management recommendations’<br />
which can significantly improve<br />
quality <strong>of</strong> care.<br />
Indeed, such clinical decision support systems<br />
help bridge the gap between population and individual<br />
care, taking best evidence obtained from<br />
large populations and tailoring management to fit<br />
a particular patient in the context <strong>of</strong> his or her<br />
specific characteristics, risks and needs.<br />
This <strong>issue</strong> <strong>of</strong> the JPHC also includes a study<br />
exploring the sources that NZ GPs use both for<br />
lifelong learning and to answer clinical questions<br />
arising during consultation. 7 Increasingly GPs<br />
are using web-based tools and resources. This<br />
research was conducted by Zachary Gravatt as a<br />
summer studentship 2008–2009. Tragically, Zac<br />
died last year during his 4th year as a medical<br />
student, and sadly never saw his work in print.<br />
Research pertaining to practice nursing is prominent<br />
this <strong>issue</strong>. <strong>The</strong>re are two papers on chronic<br />
illness care, 8,9 another exploring the preventive<br />
care possibilities from patients seeing the practice<br />
nurse before the GP, 10 a study <strong>of</strong> the enablers and<br />
barriers for practice nurses to advance their pr<strong>of</strong>essional<br />
development, 11 and one addressing the<br />
skills palliative care nurses need to help terminally<br />
ill people remain in control <strong>of</strong> their day-to-day<br />
decisions for as long as possible. 12 <strong>The</strong>re are also<br />
two studies addressing variation in hospitalisation<br />
rates, particularly in Maori 13 and in Pacific<br />
people, 14 and a short report exploring a possible<br />
association <strong>of</strong> unexplained vaginal symptoms and<br />
psychological distress. 15<br />
In our usual features, two GPs go Back to Back<br />
on whether there should be population-based<br />
screening for attention deficit hyperactivity<br />
disorder, the String <strong>of</strong> PEARLS is about hypertension,<br />
Cochrane Corner examines the use <strong>of</strong><br />
NSAIDs for dysmenorrhoea, Charms and Harms<br />
covers the herbal remedy Ginkgo and Pounamu<br />
explains the whanau ora approach to health care.<br />
Again, this <strong>issue</strong> reflects the diversity that is<br />
primary health care.<br />
References<br />
1. Selak V, Elley R, Wells S, Rodgers A, Sharpe N. Aspirin<br />
for primary prevention: yes or no? J Primary Health Care.<br />
2010;2(2):92–9.<br />
2. <strong>New</strong> <strong>Zealand</strong> Guidelines Group. Assessment and management<br />
<strong>of</strong> cardiovascular risk: evidence-based best practice guideline.<br />
Wellington: NZGG; 2003 December. 220 p.<br />
3. Antithrombotic Trialists C, Baigent C, Blackwell L, et al. Aspirin<br />
in the primary and secondary prevention <strong>of</strong> vascular disease:<br />
collaborative meta-analysis <strong>of</strong> individual participant data from<br />
randomised trials. Lancet. 2009 May 30;373(9678):1849–60.<br />
4. Gillett G, Saville-Cook D. To much information? J Primary<br />
Health Care. 2010;2(2):165–7.<br />
5. Wells S, Riddell T, Jackson S. Cardiovascular disease risk pr<strong>of</strong>ile<br />
tools and <strong>New</strong> <strong>Zealand</strong>—absolutely the best way forward.<br />
Letter to the Editor. J Primary Health Care. 2010;2(2):168–9.<br />
6. Boland P, Moriarty H. Cardiovascular disease risk pr<strong>of</strong>ile tools<br />
and <strong>New</strong> <strong>Zealand</strong>—the best way forward? J Primary Health<br />
Care. 2009;1(4):328–31.<br />
7. Gravatt Z, Arroll B. What resources do Auckland general practitioners<br />
use for answering immediate clinical questions and<br />
for life-long learning? J Primary Health Care. 2010;2(2):100–4.<br />
8. Carryer J, Budge C, Hansen C, Gibbs K. Modifying the PACIC<br />
to assess provision <strong>of</strong> chronic illness care: an exploratory<br />
study with primary health care nurses. J Primary Health Care.<br />
2010;2(2):118–23.<br />
9. Carryer J, Budge C, Hansen C, Gibbs K. Providing and receiving<br />
self-management support for chronic illness: patients’<br />
and health practitioners’ assessments. J Primary Health Care.<br />
2010;2(2):124–9.<br />
10. Kenealy T, Docherty B, Sheridan N, Gao R. Seeing patients<br />
first: creating an opportunity for practice nurse care? J Primary<br />
Health Care. 2010;2(2):136–41.<br />
11. Richardson A, Gage J. What influences practice nurses to<br />
participate in post-registration education? J Primary Health<br />
Care. 2010;2(2):142–9.<br />
12. Richardson K, MacLeod R, Kent B. Ever decreasing circles:<br />
terminal illness, empowerment and decision-making. J Primary<br />
Health Care. 2010;2(2):130–5.<br />
13. Barnett R, Malcolm L. GP practice variation in hospitalisation<br />
rates–a study <strong>of</strong> Partnership Health enrolled patients. J<br />
Primary Health Care. 2010;2(2):111–7.<br />
14. Sopoaga F, Buckingham K, Paul C. Causes <strong>of</strong> excess hospitalisations<br />
among Pacific peoples in <strong>New</strong> <strong>Zealand</strong>: implications for<br />
primary care. J Primary Health Care. 2010;2(2):105–10.<br />
15. Cohrssen A, Aslam U, Karasz A, Anderson M. Are unexplained<br />
vaginal symptoms associated with psychosocial<br />
distress? A pilot investigation. J Primary Health Care.<br />
2010;2(2):150–4.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 91
ORIGINAL SCIENTIFIC PAPERS<br />
quantitative research<br />
Aspirin for primary prevention: yes or no?<br />
Vanessa Selak MBChB, MPH (Hons), FAFPHM, FNZCPHM; 1 C Raina Elley MBChB, FRNZCGP, PhD; 2<br />
Sue Wells MBChB, DipObs, MPH (Hons), PhD, FNZCPHM, RNZCGP; 3 Anthony Rodgers MBChB, DPH,<br />
FAFPHM, PhD; 4 Norman Sharpe MBChB, MD, DipABIM, DipABCVDis, FRACP, FACC (Medicine) 5<br />
1<br />
Clinical Trials Research Unit,<br />
School <strong>of</strong> Population Health,<br />
<strong>The</strong> University <strong>of</strong> Auckland,<br />
Auckland, <strong>New</strong> <strong>Zealand</strong><br />
2<br />
Department <strong>of</strong> <strong>General</strong><br />
Practice and Primary Health<br />
Care, School <strong>of</strong> Population<br />
Health, <strong>The</strong> University <strong>of</strong><br />
Auckland<br />
3<br />
Section <strong>of</strong> Epidemiology<br />
and Biostatistics, School<br />
<strong>of</strong> Population Health, <strong>The</strong><br />
University <strong>of</strong> Auckland<br />
4<br />
<strong>The</strong> George Institute for<br />
International Health, Sydney,<br />
NSW, Australia<br />
5<br />
<strong>New</strong> <strong>Zealand</strong> National<br />
Heart Foundation, Ellerslie,<br />
Auckland<br />
ABSTRACT<br />
Aim: To assess benefit versus harm <strong>of</strong> aspirin for cardiovascular disease (CVD) primary prevention by<br />
age group, gender and risk category and to interpret these results in light <strong>of</strong> current <strong>New</strong> <strong>Zealand</strong> CVD<br />
risk assessment and management guidelines.<br />
Methods: Rates <strong>of</strong> benefit (avoided vascular events) and harm (additional major extracranial bleeds)<br />
for each gender and age group were calculated from data from the six randomised controlled trials included<br />
in the Anti-Thrombotic Trialists’ (ATT) Collaboration meta-analysis. <strong>The</strong>se rates were applied to CVD<br />
risk categories to calculate the net benefit or net harm likely to occur from the use <strong>of</strong> aspirin in primary<br />
prevention <strong>of</strong> CVD as monotherapy and when added to lipid and blood pressure–lowering therapies.<br />
Results: Benefits <strong>of</strong> aspirin monotherapy outweigh the harms for both men and women aged up to<br />
80 years with calculated five-year CVD risk >15% in primary prevention. Harm may outweigh benefit for<br />
primary prevention for those over 80 years. For men 70–79 years the benefit <strong>of</strong> aspirin in primary prevention<br />
is marginal when added to lipid and blood pressure–lowering therapies.<br />
Discussion: <strong>The</strong> recent ATT Collaboration meta-analysis has raised doubts about the relative safety<br />
<strong>of</strong> aspirin in primary prevention <strong>of</strong> CVD. However, modelling by risk category and age group suggests<br />
that current guidelines are justified in recommending aspirin for primary prevention <strong>of</strong> CVD in those with<br />
five-year CVD risk ≥15% up to the age <strong>of</strong> 80 years. For men 70–79, consider lipid and blood pressure–<br />
lowering therapies first then reassess whether aspirin adds additional net benefit.<br />
KEYWORDS: Aspirin; primary prevention; cardiovascular disease; cardiovascular risk<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):92–99.<br />
CORRESPONDENCE TO:<br />
Vanessa Selak<br />
Clinical Trials Research<br />
Unit, <strong>The</strong> University<br />
<strong>of</strong> Auckland, PB 92019<br />
Auckland Mail Centre,<br />
Auckland, <strong>New</strong> <strong>Zealand</strong><br />
v.selak@ctru.auckland.ac.nz<br />
Introduction<br />
Cardiovascular disease (CVD) is <strong>New</strong> <strong>Zealand</strong>’s<br />
biggest killer and leading cause <strong>of</strong> loss <strong>of</strong><br />
healthy life years. 1 Current <strong>New</strong> <strong>Zealand</strong> (NZ)<br />
CVD risk assessment and management guidelines<br />
recommend that CVD preventive management<br />
decisions are based on an individual’s<br />
five-year absolute CVD risk. 2 All people with<br />
a five-year CVD risk 15% or greater should be<br />
considered for aspirin, lipid-lowering and blood<br />
pressure–lowering therapies (unless there are<br />
contraindications), in addition to lifestyle interventions,<br />
as necessary to reduce their absolute<br />
risk. This recommendation was made on the<br />
basis that the combination <strong>of</strong> aspirin, lipidlowering<br />
and blood pressure–lowering therapies<br />
is estimated to reduce CVD risk by at least 55%<br />
with a much lower risk <strong>of</strong> harm. 3 While the<br />
role <strong>of</strong> aspirin in the management <strong>of</strong> people<br />
with a prior CVD event remains undisputed,<br />
the recently published Anti-Thrombotic Trialists’<br />
(ATT) Collaboration meta-analysis has<br />
raised doubts about the relative safety <strong>of</strong> aspirin<br />
in the primary prevention <strong>of</strong> CVD. 4 We sought<br />
to model benefit versus harm <strong>of</strong> aspirin for<br />
CVD primary prevention for age group, gender<br />
and risk categories using data from the ATT<br />
Collaboration meta-analysis and to interpret<br />
these results in light <strong>of</strong> current NZ CVD risk<br />
assessment and management guidelines.<br />
92 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
ORIGINAL SCIENTIFIC PAPErS<br />
<strong>The</strong> effect <strong>of</strong> adding aspirin to a regime <strong>of</strong> lipid<br />
and blood pressure–lowering therapy among<br />
those with five-year CVD risk >15% was assessed<br />
for each sex / age category. <strong>The</strong> benefit <strong>of</strong> lipidlowering<br />
therapy (statin) and blood pressure–<br />
lowering therapy was estimated from recent<br />
meta-analyses <strong>of</strong> randomised controlled trials. 7,8<br />
Proportional reductions in the risk <strong>of</strong> coronary<br />
and cerebro vascular events associated with treatquantitative<br />
research<br />
Methods<br />
Design<br />
Evidence-based modelling <strong>of</strong> benefit and harm <strong>of</strong><br />
aspirin for primary prevention <strong>of</strong> CVD.<br />
Population<br />
This analysis used results from the ATT Collaboration<br />
meta-analysis, which included 95 456<br />
individuals without prior CVD who had been<br />
randomised to aspirin or no aspirin in six<br />
randomised controlled trials <strong>of</strong> at least 1000 nondiabetic<br />
participants each with at least two years<br />
<strong>of</strong> scheduled treatment. 4<br />
Analysis<br />
Expected CVD events<br />
<strong>The</strong> expected number <strong>of</strong> CVD events based on<br />
five-year CVD risk for a hypothetical population<br />
<strong>of</strong> 1000 people was calculated. For example,<br />
for a hypothetical cohort <strong>of</strong> 1000 people at 1%<br />
five-year CVD risk, 10 CVD events would be expected.<br />
<strong>The</strong> CVD outcomes included in Framingham-based<br />
prediction models (such as those used<br />
in NZ) are myocardial infarction, angina, stroke,<br />
transient ischaemia, congestive heart failure, peripheral<br />
vascular disease and CVD-related death. 5<br />
Benefit<br />
Rates <strong>of</strong> benefit (avoided vascular events) with aspirin<br />
were calculated by applying the proportional<br />
reduction in serious vascular events observed in<br />
the ATT Collaboration meta-analysis (12%, 99%<br />
confidence interval 6–18%) to the number <strong>of</strong> CVD<br />
events expected to be avoided in five years. This<br />
reduction was applied to progressively increasing<br />
five-year CVD risk groups (from 1% to 20%) for<br />
hypothetical populations <strong>of</strong> 1000 people who were<br />
also stratified by gender and 10-year age bands:<br />
50–59, 60–69, 70–79 and 80–89 years. Vascular<br />
events in the meta-analysis were defined as myocardial<br />
infarction, stroke (haemorrhagic or other),<br />
or death from a vascular cause (coronary heart disease<br />
death, stroke death, or other vascular death—<br />
including sudden death, death from pulmonary<br />
embolism, and death from any haemorrhage).<br />
WHAT GAP THIS FILLS<br />
What we already know: <strong>The</strong> benefits <strong>of</strong> aspirin outweigh the risks in<br />
people with a history <strong>of</strong> cardiovascular disease.<br />
What this study adds: <strong>The</strong> benefits <strong>of</strong> aspirin outweigh the risks in primary<br />
prevention <strong>of</strong> CVD in those with five-year CVD risk >15%, up to the age<br />
<strong>of</strong> 80 years, although in men 70–79 consider lipid and blood pressure–lowering<br />
therapies first then reassess whether aspirin adds additional net benefit.<br />
Harm<br />
Rates <strong>of</strong> harm (i.e. the difference between rates<br />
<strong>of</strong> non-fatal major extracranial bleeds in the<br />
aspirin and control groups) were provided by the<br />
ATT Collaboration meta-analysis for men and<br />
women aged 50–59 years (0.2% and 0.1%, respectively).<br />
Non-fatal major extracranial bleeds were<br />
mainly gastrointestinal and usually defined as a<br />
bleed requiring transfusion. Rates <strong>of</strong> harm were<br />
estimated for other age groups (60–69, 70–79<br />
and 80–89 years) by multiplying the rate for<br />
those aged 50–59 years by the rate ratio associated<br />
with age (per decade) identified by the ATT<br />
Collaboration meta-analysis for each additional<br />
decade (2.15, 95% confidence interval 1.93–2.39).<br />
Haemorrhagic stroke and fatal extracranial<br />
haemorrhage were included in vascular events<br />
(see above).<br />
Aspirin monotherapy<br />
Rates <strong>of</strong> benefit and harm were compared in<br />
CVD risk / sex / age categories to assess the net<br />
benefit or net harm likely from the use <strong>of</strong> aspirin<br />
in primary prevention <strong>of</strong> CVD and depicted in<br />
table format. 6<br />
Adding aspirin to lipid and blood pressure–<br />
lowering therapy<br />
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ment in people without a history <strong>of</strong> CVD were<br />
combined using the ratio <strong>of</strong> these events from<br />
the ATT Collaboration meta-analysis to produce a<br />
proportional reduction in the risk <strong>of</strong> CVD events.<br />
Rates <strong>of</strong> harm from the most serious adverse<br />
events associated with statins (rhabdomyolysis)<br />
and antihypertensives (adverse events serious<br />
enough to warrant discontinuation <strong>of</strong> antihypertensive<br />
therapy) were also estimated from metaanalyses<br />
<strong>of</strong> randomised controlled trials. 9,10<br />
Results<br />
Aspirin monotherapy<br />
<strong>The</strong> benefits <strong>of</strong> aspirin are estimated to exceed<br />
the harms at least fourfold among men 60–69<br />
years and women 70–79 who have a calculated<br />
five-year CVD risk >15% in primary prevention<br />
(see Table 1). In people one decade older (men<br />
70–79 and women 80–89) with the same CVD<br />
risk, the number <strong>of</strong> vascular events avoided by<br />
aspirin are still close to twice the harms. From<br />
the age <strong>of</strong> 80 years the harms <strong>of</strong> aspirin are likely<br />
to outweigh the benefits in primary prevention<br />
among men with five-year CVD risk at or just<br />
over 15%.<br />
Adding aspirin to lipid and blood pressure–<br />
lowering therapy<br />
For people with a five-year CVD risk <strong>of</strong> 15%,<br />
statin and antihypertensive therapy are estimated<br />
to reduce absolute CVD risk by 6.6% (relative<br />
risk reduction (RRR) <strong>of</strong> 26% and 24% for statin<br />
and antihypertensive therapy respectively applied<br />
in a stepwise fashion to produce an overall RRR<br />
<strong>of</strong> 44%) and increase absolute risk <strong>of</strong> serious side<br />
effects by 0.15% over a five-year period (see Figure<br />
1). <strong>The</strong> balance <strong>of</strong> benefits and risks varies by<br />
sex and age when aspirin is added to the regime.<br />
Aspirin is estimated to reduce absolute CVD risk<br />
by a further 1% (12% RRR), but absolute risk <strong>of</strong><br />
additional serious side effects (extracranial bleeding)<br />
is estimated to increase by 0.20% in men<br />
aged 50–59 years, 0.43% in men 60–69, 0.92% in<br />
men 70–79 and 1.99% in men 80–89. Absolute<br />
risk <strong>of</strong> additional serious side effects is estimated<br />
to increase by 0.10% in women aged 50–59 years,<br />
0.22% in women 60–69, 0.46% in women 70–79<br />
and 0.99% in women 80–89 (see Figure 2).<br />
Discussion<br />
This analysis found that the benefits <strong>of</strong> aspirin<br />
monotherapy outweigh the harms for both men<br />
and women aged up to 80 years with five-year CVD<br />
risk >15% in primary prevention. However, harm<br />
may outweigh benefit for primary prevention for<br />
those over 80 years, particularly for men. <strong>The</strong> proportional<br />
reduction in CVD risk is greater and the<br />
risk <strong>of</strong> serious adverse events is lower with statin<br />
and antihypertensive therapies than with aspirin.<br />
For men 70–79 years the benefit <strong>of</strong> aspirin in primary<br />
prevention is marginal when added to lipid<br />
and blood pressure–lowering therapies. <strong>The</strong>refore,<br />
current <strong>New</strong> <strong>Zealand</strong> CVD risk assessment and<br />
management guidelines are justified in recommending<br />
aspirin for primary prevention <strong>of</strong> CVD in<br />
those with five-year CVD risk ≥15%, up to the age<br />
<strong>of</strong> 80 years, although in men 70–79, lipid and blood<br />
pressure–lowering therapies should be considered<br />
first and additional net benefit <strong>of</strong> aspirin assessed.<br />
This analysis used the most recently published<br />
meta-analysis <strong>of</strong> randomised controlled trials<br />
<strong>of</strong> aspirin for the primary prevention <strong>of</strong> CVD<br />
to model the benefit and harm <strong>of</strong> aspirin. 4 <strong>The</strong><br />
proportional reduction <strong>of</strong> CVD (and increase in<br />
haemorrhagic stroke) with aspirin was assumed<br />
to be constant across sex and age groups. Aspirin<br />
has been shown to reduce CVD primarily<br />
by reducing myocardial infarctions in men and<br />
ischaemic strokes in women. 11 Modelling could<br />
be improved by updating the ATT Collaboration<br />
with more recent trials, 12 obtaining nationally<br />
representative data to provide more up-to-date<br />
and generalisable estimates for rates <strong>of</strong> serious<br />
adverse events and assessing the treatment effect<br />
<strong>of</strong> aspirin by sex and age groups.<br />
<strong>The</strong>re are differences in the way outcomes are<br />
defined that should be considered when interpreting<br />
results. Firstly, haemorrhagic strokes and<br />
fatal extracranial bleeds were included in the<br />
ATT Collaboration’s estimate <strong>of</strong> the proportional<br />
reduction in serious vascular events. This may<br />
explain why their estimate <strong>of</strong> the benefit <strong>of</strong> aspirin<br />
was lower than those previously reported. 2<br />
Secondly, the number <strong>of</strong> estimated CVD events<br />
and those avoided may be slightly overestimated<br />
by the NZ CVD risk assessment and management<br />
guidelines, which use the Framingham<br />
equation, because while the ATT Collaboration<br />
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Table 1. Estimated vascular events avoided and estimated additional extracranial bleeds associated with using aspirin for five years in hypothetical<br />
cohorts <strong>of</strong> 1000 people<br />
Estimated vascular events avoided † in 5 years, ‡ n<br />
5-year<br />
risk <strong>of</strong><br />
CVD<br />
event<br />
CVD<br />
events<br />
expected,<br />
*n<br />
Age<br />
50–59<br />
years<br />
Age<br />
60–69<br />
years<br />
Men<br />
Age<br />
70–79<br />
years<br />
Age<br />
80–89<br />
years<br />
Age<br />
50–59<br />
years<br />
Age<br />
60–69<br />
years<br />
Women<br />
Age<br />
70–79<br />
years<br />
Age<br />
80–89<br />
years<br />
1% 10 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2<br />
2% 20 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4<br />
3% 30 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6<br />
4% 40 4.8 4.8 4.8 4.8 4.8 4.8 4.8 4.8<br />
5% 50 6 6 6 6 6 6 6 6<br />
6% 60 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2<br />
7% 70 8.4 8.4 8.4 8.4 8.4 8.4 8.4 8.4<br />
8% 80 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.6<br />
9% 90 10.8 10.8 10.8 10.8 10.8 10.8 10.8 10.8<br />
10% 100 12 12 12 12 12 12 12 12<br />
11% 110 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2<br />
12% 120 14.4 14.4 14.4 14.4 14.4 14.4 14.4 14.4<br />
13% 130 15.6 15.6 15.6 15.6 15.6 15.6 15.6 15.6<br />
14% 140 16.8 16.8 16.8 16.8 16.8 16.8 16.8 16.8<br />
15% 150 18 18 18 18 18 18 18 18<br />
16% 160 19.2 19.2 19.2 19.2 19.2 19.2 19.2 19.2<br />
17% 170 20.4 20.4 20.4 20.4 20.4 20.4 20.4 20.4<br />
18% 180 21.6 21.6 21.6 21.6 21.6 21.6 21.6 21.6<br />
19% 190 22.8 22.8 22.8 22.8 22.8 22.8 22.8 22.8<br />
20% 200 24 24 24 24 24 24 24 24<br />
Estimated additional non-fatal extracranial bleeds § in 5 years, n<br />
2.0 4.3 9.2 19.9 1.0 2.2 4.6 9.9<br />
Areas shaded light grey indicate combinations <strong>of</strong> five-year CVD risk, sex and age for which the estimated number <strong>of</strong> additional extracranial bleeds are greater than or equal<br />
to the estimated number <strong>of</strong> vascular events avoided 6<br />
* Based on Framingham equation, i.e. including myocardial infarction, angina, stroke, transient ischaemia, congestive heart failure, peripheral vascular disease and CVDrelated<br />
death 5<br />
†<br />
Vascular events avoided defined as myocardial infarction, stroke (ischaemic, haemorrhagic or other), or vascular death (coronary heart disease death, stroke death, or<br />
other vascular death [which includes sudden death, death from pulmonary embolism, and death from any haemorrhage]) 4<br />
‡<br />
Assuming 12% proportional net reduction in vascular events 4<br />
§<br />
Calculated from number <strong>of</strong> excess non-fatal gastrointestinal or other extracranial bleeds (usually defined as a bleed requiring a transfusion) among those aged 50–59<br />
years and allocated to aspirin. Extrapolated to older age groups using rate ratio associated with age (2.15 per decade). Haemorrhagic stroke and fatal extracranial haemorrhage<br />
counted in vascular events (see above). 4<br />
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Figure 1. Cardiovascular events and serious side effects with addition <strong>of</strong> aspirin* to a regime <strong>of</strong> statin † and<br />
antihypertensive therapy ‡ over a five-year period in men with calculated five-year CVD risk >15%<br />
* Assuming 12% proportional reduction in CVD events with aspirin 4<br />
†<br />
Assuming 26% proportional reduction in CVD events with statin 7<br />
‡<br />
Assuming 24% proportional reduction in CVD events with antihypertensive 8<br />
§<br />
Assuming 0.05% rhabdomyolysis with statins, 0.1% experience adverse events serious enough to warrant discontinuation <strong>of</strong> antihypertensive<br />
therapy (as demonstrated with thiazides and ACE [angiotensin converting enzyme] inhibitors) 9 and extracranial bleeds as<br />
outlined in Table 1<br />
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Figure 2. Cardiovascular events and serious side effects with addition <strong>of</strong> aspirin* to a regime <strong>of</strong> statin † and<br />
antihypertensive therapy ‡ over a five-year period in women with calculated five-year CVD risk >15%<br />
* Assuming 12% proportional reduction in CVD events with aspirin 4<br />
†<br />
Assuming 26% proportional reduction in CVD events with statin 7<br />
‡<br />
Assuming 24% proportional reduction in CVD events with antihypertensive 8<br />
§<br />
Assuming 0.05% rhabdomyolysis with statins, 0.1% experience adverse events serious enough to warrant discontinuation <strong>of</strong> antihypertensive<br />
therapy (as demonstrated with thiazides and ACE [angiotensin converting enzyme] inhibitors) 9 and extracranial bleeds as<br />
outlined in Table 1<br />
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meta-analysis included only serious events<br />
such as myocardial infarction, stroke and death<br />
from CVD (or haemorrhage), the Framingham<br />
equation includes ‘s<strong>of</strong>ter’ CVD events such<br />
as angina, transient ischaemia and peripheral<br />
vascular disease. 5<br />
<strong>New</strong> <strong>Zealand</strong> CVD risk management guidelines<br />
use an adjusted Framingham equation. 2 Certain<br />
groups (on the basis <strong>of</strong> family history, ethnicity,<br />
diabetes status) are moved up one risk category<br />
(5%) during risk assessment and people with<br />
isolated high blood pressure or high cholesterol<br />
are categorised as being at >15% five-year CVD<br />
risk. <strong>The</strong> implications <strong>of</strong> this adjustment to the<br />
absolute benefit likely from medications such<br />
as aspirin in people who have been ‘upgraded’<br />
are not fully known, but there is no obvious<br />
reason to believe that the benefit gained would<br />
be different. However, one study has suggested<br />
that the risk assessment strategy currently used<br />
in <strong>New</strong> <strong>Zealand</strong> for ethnicity adjustment may<br />
be over-estimating risk, 13 while another suggests<br />
that for people who have diabetes with<br />
microalbuminuria, the Framingham equation<br />
underestimates risk substantially, and still underestimates<br />
risk with current adjustments. 14<br />
<strong>The</strong> ATT Collaboration found that the main<br />
risk factors for coronary disease were also risk<br />
factors for bleeding associated with aspirin. 4<br />
Whilst our analysis accounted for the risk<br />
factors with the greatest effect on bleeds (age<br />
and male sex), diabetes, smoking, mean blood<br />
pressure and body mass index have not been<br />
adjusted for.<br />
On the other hand, the ATT Collaboration<br />
meta-analysis is likely to overestimate current<br />
gastrointestinal bleeding rates with aspirin.<br />
<strong>The</strong>re has been an increase in the use <strong>of</strong> triple<br />
eradication therapy (for H. Pylori) and proton<br />
pump inhibitors, along with a reduction in the<br />
use <strong>of</strong> non-steroidal anti-inflammatory agents.<br />
Further, while efforts were made to balance the<br />
severity <strong>of</strong> benefit and harm events, side effects<br />
<strong>of</strong> comparable severity to ischaemic stroke or a<br />
coronary heart disease event are very rare.<br />
Our findings and recommendations are broadly<br />
consistent with, and if anything more conservative<br />
than, British and United States (US) guidelines.<br />
British guidelines advise that the benefit<br />
<strong>of</strong> aspirin in primary prevention outweighs<br />
harm in people aged over 50 years and with<br />
10-year CVD risk >20% (equivalent to five-year<br />
CVD risk >10% 15 ). 16 US guidelines recommend<br />
that aspirin is <strong>of</strong>fered to men 45–79 years and<br />
women 55–79 years when the potential benefit<br />
(reduction in myocardial infarction (MI) in men<br />
and ischaemic stroke in women) outweighs the<br />
potential harm <strong>of</strong> an increase in gastrointestinal<br />
haemorrhage. 6 <strong>The</strong>y estimate that the number<br />
<strong>of</strong> MIs prevented is closely balanced to the<br />
number <strong>of</strong> serious bleeding events when 10-year<br />
coronary heart disease risk is 4% for men 45–69,<br />
9% for men 60–69 and 12% for men 70–79 years<br />
(equivalent to five-year CVD risk 3, 6.75 and<br />
9%, respectively 15 ) . For women, the number <strong>of</strong><br />
ischaemic strokes prevented is estimated to be<br />
closely balanced to the number <strong>of</strong> serious bleeding<br />
events when 10-year stroke risk is 3% for<br />
women 55–59, 8% for women 60–69 and 11% for<br />
women 70–79 years.<br />
<strong>The</strong> proportional reduction with aspirin in the<br />
ATT Collaboration meta-analysis is comparable<br />
across ‘primary’ and ‘secondary’ prevention settings<br />
in cause-specific outcomes: major coronary<br />
events (Rate Ratio 0.82 in primary prevention<br />
vs 0.80 in secondary prevention), ischaemic<br />
stroke (0.86 vs 0.78) and serious vascular event<br />
(0.88 vs 0.81), 4 which questions the rationale for<br />
dichotimising CVD prevention. It is more likely<br />
that CVD risk and benefit from aspirin are on a<br />
continuum.<br />
In conclusion, the findings <strong>of</strong> this analysis<br />
reinforce the importance <strong>of</strong> basing preventive<br />
management decisions on CVD risk. CVD risk<br />
assessment is recommended prior to commencing<br />
aspirin, lipid-lowering and blood pressure–<br />
lowering therapy, and management decisions<br />
should generally be made on the basis <strong>of</strong> this<br />
assessment, according to current guidelines.<br />
From these analyses, aspirin should still be<br />
considered for primary prevention <strong>of</strong> CVD<br />
in those with five-year CVD risk >15%, up to<br />
the age <strong>of</strong> 80 years, although in men 70–79<br />
consider lipid and blood pressure–lowering<br />
therapies first and then reassess whether aspirin<br />
adds additional net benefit.<br />
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References<br />
1. World Health Organization. Global burden <strong>of</strong> disease. Death<br />
and DALY estimates for 2004 by cause for WHO member<br />
states. Geneva: World Health Organization; 2009.<br />
2. <strong>New</strong> <strong>Zealand</strong> Guidelines Group. <strong>New</strong> <strong>Zealand</strong> cardiovacsular<br />
guidelines handbook: a summary resource for primary care<br />
practitioners. 2nd ed. Wellington: <strong>New</strong> <strong>Zealand</strong> Guidelines<br />
Group; 2009.<br />
3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease<br />
by more than 80%. BMJ. 2003;326:1419–24.<br />
4. Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the<br />
primary and secondary prevention <strong>of</strong> vascular disease: collaborative<br />
meta-analysis <strong>of</strong> individual participant data from<br />
randomised trials. Lancet. 2009;373:1849–60.<br />
5. Anderson KM, Odell PM, Wilson PWF, Kannel WB. Cardiovascular<br />
disease risk pr<strong>of</strong>iles. Am Heart J. 1990;121:293–8.<br />
6. U.S. Preventive Services Task Force. Aspirin for the prevention<br />
<strong>of</strong> cardiovascular disease: U.S. Preventive Services Task Force<br />
Recommendation Statement. Ann Int Med. 2009;150:396–404.<br />
7. Brugts JJ, Yetgin T, Hoeks SE, Gotto AM, Shepherd J, Westendorp<br />
RGJ, et al. <strong>The</strong> benefits <strong>of</strong> statins in people without<br />
established cardiovascular disease but with cardiovascular risk<br />
factors: meta analysis <strong>of</strong> randomised controlled trials. BMJ.<br />
2009;228:b2376.<br />
8. Law MR, Morris JK, Wald NJ. Use <strong>of</strong> blood pressure lowering<br />
drugs in the prevention <strong>of</strong> cardiovascular disease: meta-analysis<br />
<strong>of</strong> 147 randomised trials in the context <strong>of</strong> expectations from<br />
prospective epidemiological studies. BMJ. 2009;228:b1665.<br />
9. Law MR, Wald NJ, Morris JK, Jordan RE. Value <strong>of</strong> low dose<br />
combination treatment with blood pressure lowering drugs:<br />
analysis <strong>of</strong> 354 ranomised trials. BMJ. 2003;326:1427–34.<br />
10. Law MR, Wald NJ, Rudnicka AR. Quantifying effect <strong>of</strong> statins<br />
on low density lipoprotein cholesterol, ischaemic heart disease,<br />
and stroke: systematic reivew and meta-analysis. BMJ.<br />
2003;326:1423–9.<br />
11. Berger JS, Roncaglioni MC, Avanzini F, Pangrazzi I, Tognoni G,<br />
Brown DL. Aspirin for the primary prevention <strong>of</strong> cardiovascular<br />
events in women and men. JAMA. 2006;295(3):306–13.<br />
12. Belch J, MacCuish A, Campbell I, Cobbe S, Taylor R, Prescott<br />
R, et al. <strong>The</strong> prevention <strong>of</strong> progression <strong>of</strong> arterial disease<br />
and diabetes (POPADAD) trial: factorial randomised placebo<br />
controlled trial <strong>of</strong> aspirin and antioxidants in patients with<br />
diabetes and asymptomatic peripheral arterial disease. BMJ.<br />
2008;337:a1840.<br />
13. Riddell T, Wells S, Jackson R, Lee A-W, Crengle S, Bramley D,<br />
et al. Performance <strong>of</strong> Framingham cardiovascular risk scores<br />
by ethnic groups in <strong>New</strong> <strong>Zealand</strong>: PREDICT CVD-10. N Z Med<br />
J. 2010;123(1309).<br />
14. Elley CR, Robinson E, Kenealy T, Bramley D, Drury PL.<br />
Derivation and validation <strong>of</strong> a new cardiovascular risk score<br />
for people with type 2 diabetes: the <strong>New</strong> <strong>Zealand</strong> Diabetes<br />
Cohort Study (DCS). Diabetes Care. 2010;33(6).<br />
15. <strong>New</strong> <strong>Zealand</strong> Guidelines Group. Evidence-based best practice<br />
guideline. <strong>The</strong> assessment and management <strong>of</strong> cardiovascular<br />
risk. <strong>New</strong> <strong>Zealand</strong> Guidelines Group; 2003.<br />
16. British Hypertension Society. Statement on the use <strong>of</strong> aspirin.<br />
Fact File 01/2010, 2010.<br />
ACKNOWLEDGEMENTS<br />
Colin Baigent provided<br />
helpful comments<br />
during the preparation<br />
<strong>of</strong> this article.<br />
Funding<br />
Vanessa Selak is the<br />
recipient <strong>of</strong> a National<br />
Heart Foundation<br />
Research Fellowship.<br />
COMPETING INTERESTS<br />
VS, CE and AR are<br />
undertaking research into<br />
a cardiovascular polypill<br />
that includes aspirin,<br />
but have no financial<br />
interest in this product.<br />
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quantitative research<br />
What resources do Auckland general<br />
practitioners use for answering immediate<br />
clinical questions and for lifelong learning?<br />
Zachary BH Gravatt; 1 Bruce Arroll MBChB, PhD, FNZCPHM, FRNZCGP 2<br />
1<br />
Medical student<br />
(posthumous publication)<br />
2<br />
Department <strong>of</strong> <strong>General</strong><br />
Practice and Primary Health<br />
Care, Faculty <strong>of</strong> Medical<br />
and Health Sciences, <strong>The</strong><br />
University <strong>of</strong> Auckland,<br />
Auckland, <strong>New</strong> <strong>Zealand</strong><br />
ABSTRACT<br />
INTRODUCTION: <strong>General</strong> practitioners need to search for evidence to remain up-to-date with knowledge<br />
and to answer clinical questions that arise during consultations. In the past their main sources <strong>of</strong><br />
information have been via colleagues and books.<br />
Aim: To determine the resources Auckland GPs use to answer clinical questions and to maintain lifelong<br />
learning.<br />
Methods: One hundred questionnaires were mailed to Auckland GPs. <strong>The</strong>re were 33 replies (33%<br />
response rate). From this sample 10 were chosen at random and all agreed to be interviewed (100%<br />
response rate).<br />
Results: All participants were using Internet resources to obtain answers to clinical questions. Colleagues<br />
were also important for answering immediate questions, but not for future requirements. <strong>The</strong>re<br />
is possibly less use <strong>of</strong> paper book resources. <strong>The</strong> websites were used to obtain knowledge now and for<br />
future need, while paper books were only used for answering immediate questions.<br />
Discussion: <strong>The</strong> use <strong>of</strong> websites may be increasing in general practice for both immediate knowledge<br />
requirements and for lifelong learning. Colleagues are still a source <strong>of</strong> answers to immediate clinical questions,<br />
but textbooks may be less used. Empiric data are needed to monitor changes in answering clinical<br />
questions and the <strong>issue</strong> <strong>of</strong> lifelong learning requires more research.<br />
KEYWORDS: Education, medical, continuing; family practice; information management; information<br />
storage and retrieval; medical informatics; Internet<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):100–104.<br />
Correspondence to:<br />
Bruce Arroll<br />
Pr<strong>of</strong>essor and Head <strong>of</strong><br />
Department <strong>of</strong> <strong>General</strong><br />
Practice and Primary<br />
Health Care, Elaine Gurr<br />
Chair in <strong>General</strong> Practice,<br />
Faculty <strong>of</strong> Medicine and<br />
Health Science, <strong>The</strong><br />
University <strong>of</strong> Auckland<br />
PB 92019 Auckland<br />
<strong>New</strong> <strong>Zealand</strong><br />
b.arroll@auckland.ac.nz<br />
Introduction<br />
For medicine to continue to be respected as a<br />
pr<strong>of</strong>ession, evidence-based decision-making is<br />
required where this is possible. This in turn<br />
depends on physicians being able to understand<br />
how and why they make decisions. 1 In particular,<br />
evidence-based decision-making requires a ‘conscientious,<br />
explicit and judicious use <strong>of</strong> current<br />
best evidence in making decisions about the care<br />
<strong>of</strong> individual patients’. 2 It is this definition that<br />
underpins evidence-based medicine (EBM). By applying<br />
such a definition it becomes apparent that<br />
physicians’ knowledge following formal graduation<br />
will not remain current throughout their<br />
careers unless they develop skills enabling them<br />
to participate in lifelong learning (LLL). 3<br />
<strong>General</strong> practitioners (GPs) are likely to search<br />
for evidence for two primary reasons. <strong>The</strong> first<br />
is to keep up-to-date with new information 4<br />
and modern clinical opinion. This style <strong>of</strong> LLL<br />
and continuing medical education (CME) relies<br />
considerably on individuals’ own awareness <strong>of</strong><br />
strengths and weaknesses in their knowledge. 5<br />
It has been suggested that GPs have imperfect<br />
abilities to judge their own learning requirements<br />
and external assessment is one proposed<br />
solution to this. 6,7 Currently GPs believe CME<br />
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is advantageous and can lead to patient benefits. 8<br />
<strong>The</strong> literature suggests GPs may be somewhat<br />
misguided in this belief, because CME sessions<br />
only occasionally change health outcomes or<br />
result in pr<strong>of</strong>essional development. 9,10 This might<br />
result from a preponderance <strong>of</strong> poor quality CME<br />
activities with low levels <strong>of</strong> effectiveness. 11<br />
<strong>The</strong> second reason GPs might search for evidence<br />
is to answer questions generated by patients. 4<br />
However this can be an arduous and problematic<br />
task due to the time and effort required to navigate<br />
the large and ever-expanding wealth <strong>of</strong> medical<br />
information available. 4 Consequently, GPs may be<br />
unable to answer reliably 70% <strong>of</strong> clinical questions<br />
for which they have sought answers. 4 For certain<br />
questions electronic textbooks such as DynaMed,<br />
MDConsult and UpToDate might prove to be<br />
a reasonable resource for this problem. 12 <strong>The</strong>se<br />
electronic textbooks are comprehensive, reasonably<br />
evidence-based where such information is<br />
available, and can give answers to common clinical<br />
questions in a few minutes <strong>of</strong> searching.<br />
Previous research exploring the ways <strong>New</strong><br />
<strong>Zealand</strong> GPs answer patient questions has been<br />
reported. This demonstrated that, although the<br />
majority <strong>of</strong> GPs had access to computers, they<br />
were not the most frequently used source for<br />
answering patient questions. 13 Instead, answers<br />
are most likely to be sought from books, followed<br />
by colleagues. 13 <strong>The</strong>se patient questions were<br />
most likely to focus on <strong>issue</strong>s related to treatment<br />
or diagnosis. 13<br />
On the <strong>issue</strong> <strong>of</strong> information sources used to<br />
find answers to clinical questions, interesting<br />
differences arise between GPs and specialists. 4,14<br />
A 2005 <strong>New</strong> <strong>Zealand</strong> survey found that <strong>New</strong><br />
<strong>Zealand</strong> GPs want information that is presented<br />
concisely, clearly, timely, attractively and is<br />
‘owned’ and trusted by them. 16 GPs are unlikely<br />
to seek original research articles, but instead<br />
opt to conduct Internet searches. Specialists,<br />
however, are more likely to search the literature<br />
and journals or enter into correspondence with<br />
colleagues. 16 Family medicine residents who are<br />
trained in EBM are unlikely to perform evidencebased<br />
searches at the point <strong>of</strong> care, but instead<br />
use sources that allow them access to answers<br />
swiftly and conveniently. 4,16<br />
WHAT GAP THIS FILLS<br />
What we already know: GPs used colleagues and books in the past to<br />
answer immediate clinical questions. <strong>The</strong>re is no recent overview <strong>of</strong> how<br />
general practitioners acquire clinical information and keep up-to-date.<br />
What this study adds: Colleagues are still a common source <strong>of</strong> information,<br />
but it appears that paper books are being replaced with electronic resources.<br />
Websites are used both to answer clinical questions and to facilitate<br />
lifelong learning.<br />
<strong>The</strong> aim <strong>of</strong> this study was to determine the resources<br />
used by GPs for lifelong learning and to<br />
retrieve answers to clinical questions as they arise<br />
during a consultation.<br />
Methods<br />
One hundred questionnaires were mailed to a<br />
random selection <strong>of</strong> Auckland GPs using the<br />
Department <strong>of</strong> <strong>General</strong> Practice and Primary<br />
Health Care (Auckland University) database <strong>of</strong><br />
Auckland GPs. This database is regularly updated.<br />
<strong>The</strong> questionnaire asked about sources <strong>of</strong><br />
information (such as websites, books, colleagues,<br />
email), how <strong>of</strong>ten they were used and how <strong>of</strong>ten<br />
an ‘answer’ was found. <strong>The</strong>re were 33 replies<br />
(33% response rate). It was considered that the<br />
responders were likely to be interested GPs keen<br />
on lifelong learning.<br />
From this sample 10 were chosen at random<br />
and all agreed to be interviewed (100% response<br />
rate). <strong>The</strong> interview was conducted by<br />
telephone and notes were taken rather than an<br />
audio-recording. <strong>The</strong> interviewer had the GP’s<br />
answers to the original questionnaire to guide<br />
the GP through the interview. <strong>The</strong>se interviews<br />
were conducted between December 2008 and<br />
February 2009.<br />
<strong>The</strong> GPs were asked which sources <strong>of</strong> information<br />
they used for particular enquiries; specifically,<br />
websites, online text, journals (electronic or<br />
paper), paper books, colleagues, audits, prescribing<br />
sources and email feeds. For each answer<br />
the GP was asked for the name <strong>of</strong> the source, if<br />
payment was required, if it was a source accessed<br />
when needed (a ‘pull’ resource) or information<br />
that is sent to them routinely (a ‘push’ resource),<br />
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Table 1. Demographics <strong>of</strong> interviewed general practitioners<br />
Number <strong>of</strong> years since graduation<br />
Median years since graduation<br />
how <strong>of</strong>ten they got an answer to their question<br />
and whether this source was for a question now<br />
or for future reference.<br />
<strong>The</strong> study had ethics approval from <strong>The</strong> University<br />
<strong>of</strong> Auckland Human Participants Ethics<br />
Committee (Reference number 2008/427).<br />
<strong>The</strong> GPs’ responses are described and their resources<br />
listed in categories.<br />
Results<br />
17–35 years<br />
26 years<br />
Fellow <strong>of</strong> the RNZCGP 9/10 (90%)<br />
Male 5/10 (50%)<br />
Overseas-trained 5/10 (50%)<br />
Self-assessed electronic skills<br />
0=poor; 10=excellent<br />
Range 4.5–10<br />
Median 7.5<br />
<strong>The</strong> demographics <strong>of</strong> the 10 GPs interviewed<br />
indicate that they were senior members <strong>of</strong> the<br />
pr<strong>of</strong>ession, all but one were Fellows <strong>of</strong> the <strong>College</strong><br />
with a median <strong>of</strong> 26 years since graduation.<br />
<strong>The</strong>re were equal numbers <strong>of</strong> male and female<br />
and <strong>of</strong> NZ- and overseas-trained respondents.<br />
While there was a range in their self-assessed<br />
electronic skills, they generally judged these<br />
positively (Table 1).<br />
<strong>The</strong> sources they used are shown in Table 2. All<br />
accessed websites for information when needed<br />
(a ‘pull’ resource) both for immediate clinical<br />
questions and for future reference, and 50% used<br />
websites daily. Other resources commonly used<br />
when information was needed at the point <strong>of</strong><br />
care were paper books, MIMS catalogues and GP<br />
and specialist colleagues, whereas journals were<br />
used for updating knowledge. In general, they<br />
were more satisfied with the answers to their<br />
questions from Internet resources and colleagues<br />
than from books.<br />
<strong>The</strong> resources they used are in Table 3. A wide<br />
range <strong>of</strong> websites are listed, including medical<br />
e-learning sites, literature databases, e-texts,<br />
general search engines and topic-specific sites.<br />
Relatively few paper textbooks are listed.<br />
Discussion<br />
This study shows that all the participants were<br />
using the Internet both to seek information for<br />
questions requiring an answer now and for future<br />
learning. Half were using it daily. Colleagues and<br />
paper-based sources were only used daily by one<br />
<strong>of</strong> the participants and only used for immediate<br />
clinical questions.<br />
This may represent a change in information seeking<br />
when compared with another Auckland-based<br />
study in 2002 where computers were rarely used<br />
to answer clinical questions. Colleagues including<br />
Table 2. Details <strong>of</strong> use <strong>of</strong> sources<br />
Source Use at all Use daily Pull* Free to use Now/future †<br />
Websites 10/10 5/10 10/10 Majority 10/10 both<br />
Online textbook 2/10 0/10 2/10 1/10 1/10 now<br />
Journals<br />
(paper and electronic)<br />
8/10<br />
Range (each <strong>issue</strong><br />
to 1/year)<br />
6/10 8/10 7/10 future<br />
Paper book 8/10 1/10 7/10 4/10 7/10 now<br />
MIMS ‡ 7/10 5/10 6/10 5/10 5/10 now<br />
GP colleagues 7/10 1/10 7/10 7/10 7/10 now<br />
Specialist colleagues 6/10 0/10 6/10 6/10 6/10 now<br />
Pharmacist colleagues 2/10 0/10 2/10 2/10 2/10 now<br />
* Pull: information accessed when needed, v. push: a resource sent routinely to a clinician<br />
†<br />
Whether resource for answering clinical questions now or for future learning<br />
‡<br />
Only source <strong>of</strong> prescribing used (at the time, every GP in <strong>New</strong> <strong>Zealand</strong> was given a free copy from the publisher)<br />
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Table 3. Resources used by the 10 GPs<br />
Websites (‘pull’)<br />
Routine emails (‘push’)<br />
Journals (electronic or paper)<br />
and publications<br />
Paper books<br />
Colleagues<br />
Australian Menopause Society<br />
British Medical Journal Learning<br />
CDC travel medicine<br />
Cochrane reviews<br />
Dermnet<br />
Dilworth audiology<br />
e-medicine<br />
Everybody<br />
FamilyDoctor<br />
FpNotebook.com<br />
Goodfellow Club<br />
Google<br />
Google scholar<br />
Isabelhealthcare.com<br />
MD consult<br />
From PHOs<br />
From DHBs<br />
From MOH<br />
From hospital specialists<br />
ePulse (RNZCGP)<br />
Research reviews via email<br />
Wonca journal alerts<br />
Am J Clinical Nutrition<br />
Am J Medicine<br />
Australian Family Physician<br />
British Medical Journal<br />
BPAC Best Practice<br />
Casebook (Medical Protection Society)<br />
Consumer<br />
Evidence Based Medicine<br />
JAMA<br />
<strong>New</strong> <strong>Zealand</strong> Doctor<br />
<strong>New</strong> <strong>Zealand</strong> Family Physician<br />
<strong>New</strong> <strong>Zealand</strong> Medical Journal<br />
Clinical Evidence<br />
(BMJ)<br />
A Handbook for<br />
the Interpretation<br />
<strong>of</strong> Laboratory Tests<br />
(Diagnostic Medlab)<br />
Fitzpatrick’s<br />
Dermatology in<br />
<strong>General</strong> Medicine<br />
Grant's Atlas <strong>of</strong><br />
Anatomy<br />
Immunisation<br />
Handbook (Ministry<br />
<strong>of</strong> Health)<br />
<strong>The</strong> Merck Manual<br />
Murtagh’s <strong>General</strong><br />
Practice<br />
Diabetic nurse<br />
Laboratory<br />
specialist<br />
GP<br />
Hospital specialist<br />
Pharmacist<br />
Peer group<br />
Med Media patient info<br />
Medscape<br />
<strong>New</strong> <strong>Zealand</strong> guidelines<br />
Patient.co.uk<br />
P.E.A.R.L.<br />
(cochraneprimarycare.org)<br />
Pharmac<br />
Procare<br />
Pubmed<br />
RACGP online CME-CPD<br />
Real age<br />
RNZCGP<br />
SearchMedica<br />
University <strong>of</strong> Auckland<br />
Wikipedia<br />
GPs, specialists and pharmacists were still common<br />
sources <strong>of</strong> information. 13 <strong>The</strong> use <strong>of</strong> journal<br />
articles or searching for literature other than<br />
through search engines was rare. We were also<br />
surprised at the wide range <strong>of</strong> websites used and<br />
the fact that some were using web resources daily<br />
and some less <strong>of</strong>ten.<br />
A strength <strong>of</strong> this study is that each <strong>of</strong> the 10<br />
GPs was able to be interviewed in some depth<br />
about their information approaches. A limitation<br />
is that they are a self-selected group <strong>of</strong> highly<br />
motivated learners who probably represent one<br />
end <strong>of</strong> a spectrum <strong>of</strong> GPs and are not representative<br />
<strong>of</strong> all GPs. However, the study intended to<br />
interview such a group to see what innovations<br />
are possible in the primary care setting. It was<br />
not possible to do an in-depth interview on a<br />
wide range <strong>of</strong> GPs with the resources available to<br />
the study.<br />
In the words <strong>of</strong> McConaghy we agree that<br />
‘clinicians must learn the techniques and skills<br />
to focus on finding, evaluating and using<br />
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ACKNOWLEDGEMENTS<br />
Thank you to the GPs who<br />
participated in the project.<br />
relevant and valid information at the point<br />
<strong>of</strong> care. Clinicians also need sources for rapid<br />
retrieval <strong>of</strong> this information to integrate it into<br />
their daily practice and their careers <strong>of</strong> lifelong<br />
learning.’ 4 <strong>The</strong> GPs in our sample certainly<br />
have ‘sources for rapid retrieval’ and are using<br />
‘relevant’ information; they are probably also<br />
getting ‘valid’ information, given the resources<br />
they have nominated.<br />
Web resources have the potential to provide<br />
both immediate answers to clinical questions<br />
and contribute to lifelong learning. <strong>The</strong> possible<br />
change from textbooks to web resources has the<br />
additional advantages <strong>of</strong> providing clinicians<br />
with up-to-date information which is not possible<br />
with paper textbooks. Future research is needed<br />
and perhaps it would be worthwhile repeating<br />
the study <strong>of</strong> 2002 to see how answering clinical<br />
questions may have changed. 13 <strong>The</strong> <strong>issue</strong> <strong>of</strong> lifelong<br />
learning (knowledge for the future) needs<br />
more research.<br />
References<br />
1. Glasziou P. Why is evidence-based medicine important? Evid<br />
Based Med. 2006 ;11(5):133–5.<br />
2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson<br />
WS. Evidence based medicine: what it is and what it isn’t.<br />
BMJ. 1996;312:71–2.<br />
3. Miller SH, Thompson JN, Mazmanian PE, Aparicio A, Davis<br />
DA, Spivey BE, et al. Continuing medical education, pr<strong>of</strong>essional<br />
development, and requirements for medical licensure: a<br />
white paper <strong>of</strong> the Conjoint Committee on Continuing Medical<br />
Education. J Contin Educ Health Pr<strong>of</strong>. 2008;28(2):95–8.<br />
4. McConaghy JR. Evolving medical knowledge: moving toward<br />
efficiently answering questions and keeping current. Prim<br />
Care. 2006;33(4):831–7.<br />
5. Duffy FD, Holmboe ES. Self-assessment in lifelong learning<br />
and improving performance in practice: physician know<br />
thyself. JAMA. 2006;296(9):1137.<br />
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe<br />
KE, Perrier L. Accuracy <strong>of</strong> physician self-assessment compared<br />
with observed measures <strong>of</strong> competence: a systematic review.<br />
JAMA. 2006;296(9):1094.<br />
7. Tracey J, Arroll B, Barham P, Richmond D. <strong>The</strong> validity <strong>of</strong><br />
general practitioners’ self assessment <strong>of</strong> knowledge: cross<br />
sectional study. BMJ.1997:1426–8.<br />
8. Campion-Smith C, Smith H, White P, Baker E, Baker R, Holloway<br />
I. Learners’ experience <strong>of</strong> continuing medical education<br />
events: a qualitative study <strong>of</strong> GP principals in Dorset. Br J Gen<br />
Pract. 1998;48(434):1590.<br />
9. Treweek S, Flottorp S, Fretheim A, Havelsrud K, Krist<strong>of</strong>fersen<br />
DT, Oxman A, et al. What do general practitioners<br />
do to keep themselves up to date? Tidsskr Nor Laegeforen.<br />
2005;125(3):304–6.<br />
10. Davis D, O’Brien MAT, Freemantle N, Wolf FM, Mazmanian<br />
P, Taylor-Vaisey A. Impact <strong>of</strong> formal continuing medical<br />
education: do conferences, workshops, rounds, and<br />
other traditional continuing education activities change<br />
physician behavior or health care outcomes? JAMA.<br />
1999;282(9):867–74.<br />
11. Bloom BS. Effects <strong>of</strong> continuing medical education on<br />
improving physician clinical care and patient health: a review<br />
<strong>of</strong> systematic reviews. Int J Technol Assess Health Care.<br />
2005;21(03):380–5.<br />
12. Goodyear-Smith F, Kerse N, Warren J, Arroll B. Evaluation <strong>of</strong><br />
e-textbooks. DynaMed, MD Consult and UpToDate. Aust Fam<br />
Phys. 2008;37(10):878.<br />
13. Arroll B, Pandit S, Kerins D, Tracey J, Kerse N. Use <strong>of</strong> information<br />
sources among <strong>New</strong> <strong>Zealand</strong> family physicians with high<br />
access to computers. J Fam Pract. 2002;51(8):706.<br />
14. Bennett NL, Casebeer LL, Krist<strong>of</strong>co R, Collins BC. Family<br />
physicians’ information seeking behaviors: a survey comparison<br />
with other specialties. BMC Med Inform Decis Mak.<br />
2005;5:9.<br />
15. Dovey SM, Fraser TJ, Tilyard MW, Ross SJ, Baldwin KE, Kane<br />
D. ‘Really simple, summary, bang! That’s what I need.’ –Clinical<br />
information needs <strong>of</strong> <strong>New</strong> <strong>Zealand</strong> general practitioners<br />
and the resources they use to meet them. N Z Fam Physician.<br />
2006;33(1):18.<br />
16. Ramos K, Linscheld R, Schafer S. Real-time informationseeking<br />
behavior <strong>of</strong> residency physicians. Fam Med.<br />
2003;35(4):257–60.<br />
Funding<br />
This project was funded<br />
by a summer studentship<br />
in the Faculty <strong>of</strong> Medicine<br />
and Health Science, <strong>The</strong><br />
University <strong>of</strong> Auckland.<br />
COMPETING INTERESTS<br />
None declared.<br />
Zac Gravatt conducted research through a summer studentship in the Department <strong>of</strong> <strong>General</strong> Practice<br />
and Primary Health Care at the end <strong>of</strong> his 2nd medical school year. He was such a popular and good<br />
researcher that he was welcomed back for a second summer studentship at the end <strong>of</strong> 3rd year. This<br />
paper is the result <strong>of</strong> his second studentship. In July 2009, halfway through his 4th medical school year,<br />
Zac died suddenly and tragically <strong>of</strong> meningococcal C septicaemia. We would like to honour the great<br />
doctor and researcher Zac could have been should he have survived.<br />
104 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
ORIGINAL SCIENTIFIC PAPErS<br />
quantitative research<br />
Causes <strong>of</strong> excess hospitalisations among<br />
Pacific peoples in <strong>New</strong> <strong>Zealand</strong>: implications<br />
for primary care<br />
Faafetai Sopoaga MBChB, FRNZCGP, FAFPHM; Ken Buckingham PhD (Aberdeen), MSc (York), BSc (Bath);<br />
Charlotte Paul MBChB, PhD, FAFPHM<br />
ABSTRACT<br />
introduction: Pacific people suffer disproportionately poorer health and reduced life expectancy at<br />
birth compared to the total <strong>New</strong> <strong>Zealand</strong> population.<br />
Department <strong>of</strong> Preventive<br />
and Social Medicine,<br />
University <strong>of</strong> Otago,<br />
<strong>New</strong> <strong>Zealand</strong><br />
Aim: To assess causes <strong>of</strong> excess morbidity in the Pacific population, and identify lesser known or previously<br />
unknown causes which require further investigation.<br />
Methods: We obtained public hospital discharge data from July 2000 to December 2002. <strong>The</strong> population<br />
data were from the 2001 Census. Standardised discharge ratios were calculated to compare Pacific<br />
peoples with the total <strong>New</strong> <strong>Zealand</strong> population.<br />
Results: Pacific peoples were six times more likely to have a diagnosis <strong>of</strong> cardiomyopathy and gout,<br />
and four to five times <strong>of</strong> rheumatic fever, gastric ulcer, systemic lupus erythematosus (SLE), and diabetes.<br />
Respiratory diseases, skin abscesses, heart failure, cataracts, cerebral infarction and chronic renal failure<br />
were also significant causes <strong>of</strong> excess morbidity. Unexpected causes <strong>of</strong> excess morbidity included candidiasis,<br />
excess vomiting in pregnancy (hyperemesis gravidarum) and pterygium.<br />
discussion: <strong>The</strong> magnitude <strong>of</strong> established causes <strong>of</strong> excess morbidity among Pacific peoples were<br />
similar to our findings. Other causes <strong>of</strong> excess morbidity are less widely known, or are identified here for<br />
the first time. <strong>The</strong>se are systemic lupus erythematosus, hyperemesis gravidarum, cardiomyopathy, gastric<br />
ulcer, candidiasis and pterygium. <strong>The</strong> findings draw attention to specific causes <strong>of</strong> excess morbidity in Pacific<br />
communities where effective interventions are available in primary care, and where further research<br />
may identify preventive or curative interventions.<br />
KEYWORDS: Pacific peoples; primary care; hyperemesis gravidarum; morbidity; hospitalizations<br />
Introduction<br />
<strong>The</strong> Pacific population makes up approximately<br />
7% <strong>of</strong> the total <strong>New</strong> <strong>Zealand</strong> population from<br />
the 2006 Census. 1 Pacific people suffer disproportionately<br />
from poorer health and, in 2001,<br />
their life expectancy at birth was five years less<br />
compared to the total <strong>New</strong> <strong>Zealand</strong> population. 2,3<br />
<strong>The</strong> focus <strong>of</strong> many health intervention programmes<br />
is on addressing this disparity in health<br />
status. To decrease disparities it is important to<br />
understand the range <strong>of</strong> health problems which<br />
disproportionately affect Pacific peoples. Some <strong>of</strong><br />
these problems have already been identified from<br />
mortality and health survey data. 2–5 Nevertheless,<br />
there is limited information published on the<br />
occurrence <strong>of</strong> chronic conditions among Pacific<br />
peoples in <strong>New</strong> <strong>Zealand</strong>.<br />
This study was carried out as part <strong>of</strong> a health<br />
needs analysis for Pacific peoples commissioned by<br />
the Ministry <strong>of</strong> Health. Our aim was to determine<br />
the specific causes <strong>of</strong> hospital admissions which<br />
are significantly elevated in the Pacific population.<br />
This will provide information that may assist early<br />
diagnosis and treatment in primary care, and may<br />
result in better outcomes for Pacific peoples.<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):105–110.<br />
CORRESPONDENCE TO:<br />
Faafetai Sopoaga<br />
Department <strong>of</strong> Preventive<br />
and Social Medicine,<br />
University <strong>of</strong> Otago<br />
PO Box 913, Dunedin<br />
<strong>New</strong> <strong>Zealand</strong><br />
tai.ventura@otago.ac.nz<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 105
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quantitative research<br />
Methods<br />
We undertook a systematic examination <strong>of</strong> public<br />
hospital discharge diagnoses (as a measure <strong>of</strong><br />
morbidity) to determine which conditions are<br />
relatively important causes <strong>of</strong> morbidity among<br />
Pacific peoples compared to the total population<br />
in <strong>New</strong> <strong>Zealand</strong>. <strong>The</strong> results presented are<br />
for those who were admitted to hospital only.<br />
Patients who were seen at the emergency department<br />
and discharged were excluded.<br />
<strong>The</strong> hospital activity data used in this study were<br />
obtained from the <strong>New</strong> <strong>Zealand</strong> Health Information<br />
Service <strong>of</strong> the Ministry <strong>of</strong> Health, and relate<br />
to public hospital discharges for the period July<br />
2000 to December 2002. <strong>The</strong> population data<br />
were derived from Statistics <strong>New</strong> <strong>Zealand</strong> census<br />
data for 2001. Discharge diagnoses were coded to<br />
International Classification <strong>of</strong> Diseases (ICD) 10.<br />
‘Pacific peoples’ included anyone who reported<br />
sole Pacific Island ethnicity or Pacific Island ethnicity<br />
as well as another ethnic group or groups<br />
from hospital discharges.<br />
Standardised discharge ratios (SDRs) were<br />
calculated using the rate <strong>of</strong> discharges per capita<br />
by age group for the total population, applied to<br />
the age structure <strong>of</strong> the Pacific population. This<br />
provides an estimate <strong>of</strong> the expected number <strong>of</strong><br />
discharges that the Pacific population would have<br />
had, given its own population structure, but with<br />
discharge rates equal to those in the population<br />
at large. Effectively we adjust for the younger age<br />
structure <strong>of</strong> the Pacific population. <strong>The</strong> expected<br />
number <strong>of</strong> discharges for Pacific people formed<br />
the denominator, and the observed number <strong>of</strong><br />
discharges the numerator. SDRs higher than one<br />
thus imply higher standardised discharges among<br />
Pacific peoples compared to the total population.<br />
Further adjustment were made to the expected<br />
number <strong>of</strong> discharges to allow for the different<br />
fertility pattern <strong>of</strong> Pacific peoples. For those conditions<br />
that relate to pregnancies and births, we<br />
multiplied the expected number <strong>of</strong> hospitalisations<br />
by the relative birth rate for Pacific peoples<br />
compared to the population as a whole.<br />
Given the relatively small number <strong>of</strong> hospitalisation<br />
events, the frequency <strong>of</strong> occurrence in the<br />
two population groups can differ by chance. Confidence<br />
is usually represented statistically by confidence<br />
intervals (CIs); these intervals show the<br />
range <strong>of</strong> values in which we can be 95% confident<br />
that the ‘true’ value lies. <strong>The</strong> CIs for the SDRs<br />
were calculated using an algorithm described by<br />
Byar. 6 This algorithm makes allowances for the<br />
lower confidence we can place on estimates from<br />
smaller samples. Because the SDRs are distributed<br />
non-normally, we applied a log transformation<br />
before calculating the standardised distance from<br />
the mean in terms <strong>of</strong> the number <strong>of</strong> CIs. <strong>The</strong><br />
method is effectively a measure <strong>of</strong> our certainty<br />
that the disease differs from the population<br />
standard, and might be thought <strong>of</strong> as equivalent<br />
to a ‘z’ score. <strong>The</strong> ICD-10 diagnoses where the<br />
standardised distance from the mean was in the<br />
top 5% <strong>of</strong> values are presented.<br />
Permission for access to data was granted from<br />
the Ministry <strong>of</strong> Health.<br />
Results<br />
During the study period July 2000 to December<br />
2002, there were 2 831 789 discharges from<br />
all public hospitals in <strong>New</strong> <strong>Zealand</strong>. Of these,<br />
99 476 (3.5%) were identified as Pacific peoples.<br />
<strong>The</strong> number <strong>of</strong> people responding to the ethnicity<br />
question in the 2001 Census was 3 586 731<br />
(96%), and 231 801 (6.2 %) identified themselves<br />
as Pacific peoples. <strong>The</strong> apparent lower proportion<br />
admitted to hospital is because <strong>of</strong> differences in<br />
the age structure <strong>of</strong> the Pacific population compared<br />
to the total population.<br />
Table 1 shows the 24 discharge diagnoses which<br />
were most elevated for Pacific peoples; that is, the<br />
top 5% <strong>of</strong> values. Pacific peoples were around two<br />
to six times more likely to be discharged from<br />
hospital with these conditions. More specifically,<br />
Pacific peoples were six times more likely to have<br />
a diagnosis <strong>of</strong> cardiomyopathy and gout, and four<br />
to five times more likely to have rheumatic fever,<br />
gastric ulcer, systemic lupus erythematosus (SLE),<br />
diabetes and its associated complications. Respiratory<br />
diseases were also a significant cause <strong>of</strong><br />
excess morbidity with discharges for bronchiectasis<br />
nearly five times, and pneumonia at least two<br />
times more in comparison. Skin abscesses, heart<br />
failure, cataracts, cerebral infarction and chronic<br />
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renal failure were at least twice as likely to be<br />
discharge diagnoses. <strong>The</strong>re were some unexpected<br />
findings also, where Pacific peoples were five<br />
times more likely to have candidiasis, and ‘other<br />
disorders <strong>of</strong> the conjunctiva’ and two times more<br />
likely to have hyperemesis gravidarum compared<br />
to the total <strong>New</strong> <strong>Zealand</strong> population, after adjustment<br />
for fertility rates. When looking at the<br />
four-character ICD code for candidiasis, 90% <strong>of</strong><br />
Pacific cases were due to either cheilitis (candidiasis<br />
<strong>of</strong> the mouth) or enteritis. <strong>The</strong> four-character<br />
ICD code for other disorders <strong>of</strong> the conjunctiva<br />
showed 97% <strong>of</strong> cases were pterygium. Of the six<br />
WHAT GAP THIS FILLS<br />
What we already know: <strong>The</strong> main known causes <strong>of</strong> excess morbidity<br />
amongst Pacific peoples in <strong>New</strong> <strong>Zealand</strong> are respiratory and cardiovascular<br />
diseases, diabetes, gout, skin infections, rheumatic fever, and their associated<br />
complications.<br />
What this study adds: Causes <strong>of</strong> excess morbidity among Pacific people<br />
that are less well known, or reported here for the first time, are: cardiomyopathy,<br />
systemic lupus erythematosus, hyperemesis gravidarum, gastric ulcer,<br />
candidiasis, and pterygium. Early diagnosis and treatment <strong>of</strong> these conditions<br />
in primary care will reduce morbidity.<br />
Table 1. Public hospital discharges for Pacific peoples compared to the total population in <strong>New</strong> <strong>Zealand</strong>, July 2000 to December 2002<br />
Description<br />
3 digit<br />
ICD-10<br />
codes<br />
Standardised Discharge<br />
Ratio (age and fertility<br />
adjusted)<br />
Lower<br />
confidence<br />
limits<br />
Upper<br />
confidence<br />
limits<br />
Standardised<br />
distance from<br />
the mean<br />
N*<br />
Pneumonia, organism unspecified J18 2.35 2.27 2.43 12.91 3532<br />
Non–insulin-dependent diabetes E11 4.54 4.25 4.83 11.88 964<br />
Cardiomyopathy I42 6.26 5.65 6.91 9.11 389<br />
Gout M10 6.39 5.74 7.10 8.74 350<br />
Cutaneous abscess, furuncle and carbuncle L02 2.36 2.24 2.48 8.62 1571<br />
Acute bronchiolitis J21 1.83 1.76 1.90 7.94 2674<br />
Bronchiectasis J47 4.63 4.20 5.09 7.93 422<br />
Care involving dialysis Z49 5.67 5.02 6.39 7.19 272<br />
Heart failure I50 2.62 2.44 2.81 6.89 801<br />
Other disorders <strong>of</strong> conjunctiva H11 5.29 4.63 6.03 6.30 227<br />
Hyperemesis gravidarum O21 1.98 1.87 2.10 6.07 1230<br />
Other cataract H26 2.64 2.42 2.87 5.71 544<br />
Senile cataract H25 3.01 2.71 3.34 5.23 355<br />
Acute lower respiratory infection,<br />
unspecified<br />
J22 1.98 1.85 2.12 5.00 835<br />
Gastric ulcer K25 3.90 3.36 4.50 4.65 186<br />
Cellulitis L03 1.62 1.53 1.71 4.53 1377<br />
Other chronic obstructive pulmonary<br />
disease<br />
J44 1.88 1.76 2.02 4.51 793<br />
Asthma J45 1.46 1.39 1.52 4.36 2099<br />
Rheumatic fever I01 5.52 4.51 6.68 4.36 105<br />
Systemic lupus erythematosus (SLE) M32 3.87 3.28 4.54 4.14 150<br />
Diabetes mellitus in pregnancy O24 2.39 2.14 2.66 4.04 339<br />
Candidiasis B37 4.72 3.84 5.73 3.88 101<br />
Cerebral infarction I63 2.28 2.05 2.54 3.82 338<br />
Chronic renal failure N18 2.49 2.20 2.81 3.75 267<br />
* Number <strong>of</strong> hospital discharges for Pacific people.<br />
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most common diagnoses, pneumonia, acute bronchiolitis<br />
and asthma each resulted in over 2000<br />
admissions during this period. Skin infections,<br />
cellulitis, and hyperemesis gravidarum each were<br />
a cause <strong>of</strong> over 1000 admissions.<br />
Discussion<br />
Our results provide a description <strong>of</strong> the illnesses<br />
causing hospital admissions which most clearly<br />
affect Pacific peoples disproportionately compared<br />
to the total <strong>New</strong> <strong>Zealand</strong> population. Some <strong>of</strong><br />
these causes <strong>of</strong> morbidity were consistent with<br />
what is already known; however, there were also<br />
some unexpected findings. <strong>The</strong> cut-<strong>of</strong>f <strong>of</strong> the top<br />
5% was arbitrary, but chosen in order to include<br />
only differences which we were confident were<br />
not chance findings. Moreover, by taking the<br />
top 5% <strong>of</strong> conditions we satisfy the Bonferroni<br />
correction for multiple sampling (to allow for the<br />
possibility that some significant results would<br />
Public hospital discharge data, despite the<br />
limitations discussed, are a good measure<br />
<strong>of</strong> morbidity amongst Pacific peoples<br />
occur purely by chance when considering a large<br />
number <strong>of</strong> statistics). A number <strong>of</strong> conditions<br />
which are known to be higher amongst Pacific<br />
peoples were below this cut-<strong>of</strong>f. 2 For example,<br />
meningococcal infection (SDR 2.11), gastric<br />
cancer (SDR 2.98), and tuberculosis (SDR 3.57).<br />
Many <strong>of</strong> the illnesses resulting in admissions<br />
for Pacific peoples in this study can either be<br />
prevented, their severity reduced, or complications<br />
delayed, through effective primary care<br />
interventions.<br />
<strong>The</strong>re were some limitations in our study. It was<br />
a snapshot <strong>of</strong> morbidity and does not <strong>of</strong>fer any<br />
information about trends over time. ICD discharge<br />
diagnosis coding will contain errors, but<br />
these could not account for large differences. <strong>The</strong><br />
results show admissions not people. If Pacific people<br />
have a higher number <strong>of</strong> re-admissions than<br />
the total population, this could account for some<br />
<strong>of</strong> the excess. Because <strong>of</strong> potential differences in<br />
knowledge, access to services, and referrals for<br />
treatment, it may be that SDRs for Pacific peoples<br />
are higher (or lower) on average, for reasons that<br />
are unrelated to levels <strong>of</strong> morbidity. <strong>The</strong> most<br />
extreme SDRs, however, are likely to indicate<br />
conditions within the Pacific community that<br />
are associated with the highest levels <strong>of</strong> excess<br />
morbidity. Ethnicity data collection has improved<br />
since 1995 and there are changes in how ethnicity<br />
data are now collected. However, there are<br />
persisting <strong>issue</strong>s with the recording <strong>of</strong> ethnicity<br />
in <strong>New</strong> <strong>Zealand</strong> with underenumeration <strong>of</strong> Maori<br />
and Pacific peoples. 7–8 This means the elevated<br />
rates observed may be an underestimation. On the<br />
other hand, the definition <strong>of</strong> Pacific ethnicity in<br />
the hospitalisation data and the census differ (the<br />
former prioritised Pacific, the latter prioritised<br />
Maori). This could lead to an overestimation <strong>of</strong><br />
the elevated rates in Pacific people, but any effect<br />
will be very small. Private hospital data were not<br />
included. If Pacific peoples use private hospitals<br />
less, this may result in an overestimation <strong>of</strong> the<br />
elevated rates. This is likely to be a minor problem<br />
for the conditions examined, as most <strong>of</strong> these<br />
are treated in public hospitals for everyone.<br />
<strong>The</strong> strengths <strong>of</strong> this study include the large<br />
number <strong>of</strong> admissions, hence the statistical<br />
power. Public hospital discharge data, despite<br />
the limitations discussed, are a good measure <strong>of</strong><br />
morbidity amongst Pacific peoples.<br />
Our results, compared to other published data,<br />
showed similar or higher excess rates for respiratory<br />
diseases, heart failure, rheumatic fever,<br />
cerebral infarction (stroke), and diabetes and<br />
other related conditions. For instance, the annual<br />
hospitalisation rate for pneumonia in Pacific children<br />
in Auckland was twice as high, while the<br />
national incidence <strong>of</strong> bronchiectasis was at least<br />
10 times higher compared to Europeans. 9,10 <strong>The</strong><br />
prevalence <strong>of</strong> diabetes in the Pacific population,<br />
at 23.5%, was higher compared to all other ethnic<br />
groups. 11 Pacific mortality from heart failure and<br />
stroke was at least double compared to the total<br />
population. 2 Cardiomyopathy was six times more<br />
common among Pacific peoples in our study,<br />
but there appears to be no previous research on<br />
this. We found that a whole range <strong>of</strong> respiratory<br />
illnesses were significantly more common among<br />
Pacific people. In terms <strong>of</strong> burden <strong>of</strong> disease (total<br />
numbers), respiratory diseases were the most<br />
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important. Many <strong>of</strong> these illnesses are influenced<br />
by socioeconomic and environmental conditions.<br />
We found Pacific peoples were at least six times<br />
more likely to have a diagnosis <strong>of</strong> gout, and four<br />
times more likely to have gastric ulcer. Research<br />
into the aetiology <strong>of</strong> gout in Pacific people had<br />
identified a potential genetic link, which may<br />
act in conjunction with diet and obesity. 12,13<br />
Indigenous Fijians had a higher prevalence <strong>of</strong><br />
gastric ulcers diagnosed by endoscopic examination<br />
than Fijian Indians. 14 Risk factors for gastric<br />
ulcers included helicobacter pylori (H.pylori)<br />
infection, non-steroidal anti-inflammatory drugs<br />
and smoking. 15–16 H.pylori IgG seropositivity<br />
has been shown to be highest in Pacific peoples<br />
compared to either Maori or people <strong>of</strong> European<br />
ethnicity. 17 Antibiotic treatment is effective for<br />
H.pylori eradication.<br />
We found Pacific peoples were at least 1.5 times<br />
more likely to have a diagnosis <strong>of</strong> cellulitis, and<br />
five times more likely to have rheumatic fever<br />
compared to the total <strong>New</strong> <strong>Zealand</strong> population.<br />
Cellulitis is caused by either Group A streptococcus<br />
or staphylococcus aureus. 18 A complication <strong>of</strong><br />
Group A streptococcus infection is acute rheumatic<br />
fever. Skin infections are more common<br />
among Pacific children. 3 High rates <strong>of</strong> rheumatic<br />
fever are linked to socioeconomic conditions, and<br />
consistent with previous findings for Maori and<br />
Pacific peoples. 2,19 Improved socioeconomic conditions<br />
and access to early diagnosis and treatment<br />
can reduce the development <strong>of</strong> complications.<br />
Most pregnant women experience some degree<br />
<strong>of</strong> nausea and vomiting. Previous research based<br />
on a review <strong>of</strong> medical notes found the incidence<br />
<strong>of</strong> hyperemesis gravidarum in Pacific Island<br />
women was higher compared to either Maori or<br />
Europeans. 20,21 We found Pacific women to be<br />
two times more likely to be hospitalised because<br />
<strong>of</strong> hyperemesis gravidarum compared to the total<br />
<strong>New</strong> <strong>Zealand</strong> population, and this accounted for<br />
a high burden <strong>of</strong> disease (over 1000 admissions<br />
in 2.5 years). Recent research showed a consistent<br />
association between hyperemesis gravidarum and<br />
H.pylori, with relief <strong>of</strong> symptoms after antibiotic<br />
treatment for H.pylori. 22,23 Given the higher<br />
prevalence <strong>of</strong> H.pylori this is a plausible cause <strong>of</strong><br />
hyperemesis gravidarum among Pacific women,<br />
although psychosocial factors and disorders <strong>of</strong><br />
thyroid function are also possible causes. 23 We<br />
could find no evidence that any clinical trial <strong>of</strong><br />
treatment <strong>of</strong> H.pylori in women with hyperemesis<br />
gravidarum has been undertaken.<br />
Candida is a commensal found in the mouth,<br />
stool and vagina. 18 Invasive candidiasis is a serious<br />
problem in diabetic patients. 24 Our results<br />
showed Pacific peoples were nearly five times<br />
more likely to be discharged with a diagnosis <strong>of</strong><br />
candida enteritis and cheilitis, compared to the<br />
total <strong>New</strong> <strong>Zealand</strong> population. <strong>The</strong>re has been no<br />
previous research on ethnic differences in susceptibility<br />
to candidiasis in <strong>New</strong> <strong>Zealand</strong>. Research<br />
is required to find out why Pacific peoples appear<br />
to be more susceptible.<br />
<strong>The</strong> prevalence <strong>of</strong> SLE is known to vary among<br />
people <strong>of</strong> different ethnic groups. 25–29 A review<br />
<strong>of</strong> medical notes in <strong>New</strong> <strong>Zealand</strong> in the 1980s<br />
showed a major difference in prevalence when<br />
comparing people <strong>of</strong> European ethnicity and Polynesians.<br />
30 <strong>The</strong> Polynesian ethnic group included<br />
Maori and Pacific peoples. Polynesians were 3.5<br />
times more likely to have SLE compared to the<br />
European population in <strong>New</strong> <strong>Zealand</strong>. Age standardised<br />
comparative mortality rates were also<br />
higher. Our findings are similar, with Pacific peoples<br />
four times more likely to have SLE compared<br />
to the total <strong>New</strong> <strong>Zealand</strong> population. It would<br />
be helpful to look at Maori and Pacific peoples<br />
separately, to provide clarity about morbidity and<br />
mortality from SLE in these ethnic groups.<br />
Pterygium is a ‘wedge-shaped fibrovascular<br />
growth <strong>of</strong> conjunctiva that extends onto the<br />
cornea’. 18 <strong>The</strong> prevalence is higher in countries<br />
nearer the equator, and appears to be associated<br />
with sun exposure. 31–32 We did not have information<br />
about the country <strong>of</strong> birth for Pacific peoples<br />
in this study. It is possible that the higher prevalence<br />
<strong>of</strong> cases seen is due to Pacific peoples from<br />
the Pacific Islands now living in <strong>New</strong> <strong>Zealand</strong>.<br />
This association does not appear to have been<br />
documented previously.<br />
Conclusion<br />
<strong>The</strong> established causes <strong>of</strong> excess morbidity<br />
among Pacific people—respiratory and cardio-<br />
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ACKNOWLEDGEMENTS<br />
We wish to acknowledge<br />
Dr Lianne Parkin, and<br />
Pr<strong>of</strong>essor Phillip Hill for<br />
peer review comments,<br />
and Shiva Nair (medical<br />
student) who was<br />
involved in the initial<br />
aspects <strong>of</strong> the research.<br />
FUNDING<br />
This study was supported<br />
by funds from the Ministry<br />
<strong>of</strong> Health, Dunedin Office.<br />
COMPETING INTERESTS<br />
None declared.<br />
vascular diseases, diabetes, gout, skin infections<br />
and their associated complications—were all<br />
considerably more common discharge diagnoses<br />
compared with the total population in this<br />
analysis. <strong>The</strong>se disorders are already the focus <strong>of</strong><br />
attention, and it is important for primary health<br />
care pr<strong>of</strong>essionals to continue working collaboratively<br />
with Pacific communities to improve<br />
health in these areas.<br />
Other causes <strong>of</strong> excess morbidity in Pacific peoples<br />
are less widely known, or are identified here<br />
for the first time. <strong>The</strong>se are cardiomyopathy, SLE,<br />
hyperemesis gravidarum, gastric ulcer, candidiasis<br />
and pterygium. <strong>The</strong> clinical implications<br />
are that improved knowledge amongst general<br />
practitioners <strong>of</strong> the excess risk <strong>of</strong> these conditions<br />
in Pacific peoples will lead to earlier diagnosis,<br />
treatment and improved outcomes. Further research<br />
is required to establish the cause <strong>of</strong> excess<br />
hyperemesis gravidarum in the Pacific population<br />
and the potential for treatment.<br />
Although a main focus on the broader socioeconomic<br />
determinants <strong>of</strong> health is appropriate in<br />
order to improve the health <strong>of</strong> Pacific peoples, it<br />
is important also to attend to specific causes <strong>of</strong><br />
morbidity where effective interventions are available,<br />
and where further research may identify<br />
preventive or curative interventions.<br />
References<br />
1. Statistics <strong>New</strong> <strong>Zealand</strong>. Pacific Peoples. Census 2006. Available<br />
from http://www.stats.govt.nz/census/2006-census-data.<br />
2. Ministry <strong>of</strong> Health and Pacific Islands Affairs. Tupu Ola Moui.<br />
Pacific Health Chart Book. Wellington; 2004.<br />
3. Ministry <strong>of</strong> Health. Our health, our future—Hauora Pakari,<br />
Koiora Roa: the health <strong>of</strong> <strong>New</strong> <strong>Zealand</strong>ers. Wellington; 1999.<br />
4. Ministry <strong>of</strong> Health. Portrait <strong>of</strong> health. Key results <strong>of</strong> the<br />
2002/2003 <strong>New</strong> <strong>Zealand</strong> Health Survey. Wellington; 2004.<br />
5. Ministry <strong>of</strong> Health. Tracking disparity. Trends in ethnic and<br />
socioeconomic inequalities immortality, 1981–2004. Wellington;<br />
2007.<br />
6. Rothman KJ, Boice JD, Jr. Epidemiologic analysis with a programmable<br />
calculator (NIH Publication). Washington DC: US<br />
Government Printing; 1979.<br />
7. Callister P, Didham R, Pooter D, Blakely T. Measuring ethnicity<br />
in <strong>New</strong> <strong>Zealand</strong>: developing tools for health outcomes analysis.<br />
Ethnicity and Health. 2007;12(4):299–320.<br />
8. Ministry <strong>of</strong> Health. Monitoring ethnic inequalities in health.<br />
Wellington; 2001.<br />
9. Twiss J, Metclafe R, Edwards E, Byrnes C. <strong>New</strong> <strong>Zealand</strong><br />
national incidence <strong>of</strong> brochiectasis ‘too high’ for a developed<br />
country. Arch Dis Child. 2005;90:737–40.<br />
10. Grant CC, Scragg D, Tan D, et al. Hospitalisation for pneumonia<br />
in children in Auckland, <strong>New</strong> <strong>Zealand</strong>. J Paediatr Child<br />
Health. 1998;34:355–9.<br />
11. Sundborn G, Metcalf P, Scragg R et al. Ethnic differences<br />
in the prevalence <strong>of</strong> new and known diabetes, impaired<br />
glucose tolerance and impaired fasting glucose. Diabetes<br />
Heart and Health Survey (DHAH), 2002–2003. Auckland,<br />
<strong>New</strong> <strong>Zealand</strong>. NZ Med J. 29 June 2007;120(1257). Available<br />
from: http://www.nzma.org.nz/journal/120-1257/2607/<br />
content.pdf.<br />
12. Simmonds HA, McBride MB, Hatfield PJ, et al. Polynesian<br />
women are also at risk for hyperuricaemia and gout because<br />
<strong>of</strong> a genetic defect in renal urate handling. Br J Rheumatol.<br />
1994;33:932–7.<br />
13. Gibson T, Waterworth R, Hatfield P, et al. Hyperuricaemia,<br />
gout and kidney function in <strong>New</strong> <strong>Zealand</strong> Maori men. Br J<br />
Rheumatol. 1984;23:276–82.<br />
14. Scobie BA, Beg F, Oldmeadows M. Peptic diseases compared<br />
endoscopically in indigenous Fijians and Indians. NZ Med J.<br />
1987;100:683–4.<br />
15. Sung J, Russell RI, Nyeomans, et al. Non steroidal antiinflammatory<br />
drug toxicity in the upper gastrointestinal tract.<br />
J Gateroenterol Hepatol. 2000; 15 Suppl: G 58–68.<br />
16. Kanto I, Nomura AM, Stemmermann GN, Chyou PH. A<br />
prospective study <strong>of</strong> gastric and duodenal ulcer and its<br />
relation to smoking, alcohol, and diet. Am J Epidemiol.<br />
1992;135:521–30.<br />
17. Fraser AG, Scragg R, Metclaff P, et al. Prevalence <strong>of</strong> Helicobacter<br />
pylori in different ethnic groups in <strong>New</strong> <strong>Zealand</strong><br />
children and adults. Aust NZ J Med. 1996;26:646–51.<br />
18. Fauci A, Braunwald E, Kasper D, Hauser S, Longo D, Jameson<br />
J, Loscalzo J, editors. Harrison’s principles <strong>of</strong> internal medicine.<br />
<strong>New</strong> York: McGraw-Hill, Health Pr<strong>of</strong>essions Division;<br />
c1991[1990 printing]. ISBN : 0070708908 (1-vol.ed).<br />
19. Neutze JM, Clarkson PM. Rheumatic fever an unsolved<br />
problem in <strong>New</strong> <strong>Zealand</strong>. NZ Med J. 1984;97:591–3.<br />
20. Jordan V, MacDonald J, Crichton S, et al. <strong>The</strong> incidence <strong>of</strong><br />
hyperemesis gravidarum is increased among Pacific Islanders<br />
living in Wellington. NZ Med J. 1995;108:342–4.<br />
21. Browning J, North R, Hayward P, et al. Hyperemesis gravidarum<br />
: a particular problem for Pacific Islanders. NZ Med J.<br />
1991;104:480.<br />
22. Quinla JD. Hill DA. Nausea and vomiting <strong>of</strong> pregnancy. Am<br />
Fam Physician. 2003;68:121–8.<br />
23. Verberg MF, Gillott DJ, Al-Fardan N, Grudzinskas GJ. Hyperemesis<br />
gravidarum, a literature review. Hum Reprod Update.<br />
2005;11:527–39.<br />
24. Heald AH, O’Halloran DJ, Richards K, et al. Fungal infection<br />
<strong>of</strong> the diabetic foot: two distinct syndromes. Diabet Med.<br />
2001;18:567–72.<br />
25. Siegel M, Lee SL. <strong>The</strong> epidemiology <strong>of</strong> systemic lupus erythematosus.<br />
Semin Arthritis Rheum. 1973;3:1–54.<br />
26. Segasothy M, Phillips PA. Systemic lupus erythematosus in<br />
Aborigines and Caucasians in central Australia: a comparative<br />
study. Lupus. 2001;10:439–44.<br />
27. Morton RO, Gershwin ME, Brady C, Steinberg AD. <strong>The</strong> incidence<br />
<strong>of</strong> systemic lupus erythematosus in North American<br />
Indians. J Rheumatol. 1976;3:186–90.<br />
28. Wilson WA, Hughes GRV. Rheumatic disease in Jamaica. Ann<br />
Rheum Dis. 1979;38:320–5.<br />
29. Frank AO. Apparent predisposition to systemic lupus<br />
erythematosus in Chinese patients in West Malaysia. Ann<br />
Rheum Dis. 1980;39:266–9.<br />
30. Hart HH, Grigor RR, Caughey DE. Ethnic differences in the<br />
prevalence <strong>of</strong> systemic lupus erythematosus. Ann Rheum<br />
Dis. 1983;42:529–32.<br />
31. Saw SM, Tan D. Pterygium: prevalence, demography, and<br />
risk factors. Ophthalmic Epidemiol. 1999;6:219–28.<br />
32. Threlfall TJ, English DR. Sun exposure and pterygium<br />
<strong>of</strong> the eye: a dose response curve. Am J Opthalmol.<br />
1999;128:280–7.<br />
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GP practice variation in hospitalisation rates:<br />
a study <strong>of</strong> Partnership Health–enrolled patients<br />
Ross Barnett MA, PhD; 1 Laurence Malcolm MD, FRCPE 2<br />
ABSTRACT<br />
Aim: This project aims to provide information to support the planning and implementation <strong>of</strong> strategies<br />
to reduce hospitalisation. It examines variations in hospital discharge rates between practice populations<br />
and the use <strong>of</strong> special general practice access funding.<br />
1<br />
Department <strong>of</strong> Geography,<br />
University <strong>of</strong> Canterbury,<br />
Christchurch, <strong>New</strong> <strong>Zealand</strong><br />
2<br />
Aotearoa Health, Lyttelton,<br />
<strong>New</strong> <strong>Zealand</strong><br />
Methods: Practice enrolment data for 345 254 patients enrolled with 102 Partnership Health Primary<br />
Health Organisation (PHO) general practices were sent to <strong>New</strong> <strong>Zealand</strong> Health Information Service. Data<br />
linked to the patient National Health Index (NHI) relating to hospital discharges were attached to the<br />
practice enrolment data for the two years ending June 2007 and returned to the researchers with the NHI<br />
numbers encrypted. Total discharges were 127 426.<strong>The</strong> data were analysed for rates <strong>of</strong> hospital discharges<br />
for different population groups and by general practice.<br />
Results: <strong>The</strong>re is a substantial variation in hospital discharge rates between general practices, but this<br />
is only partly accounted for by practice population characteristics. Furthermore while there is a strong<br />
social gradient in European admissions, this is much less true for Maori. <strong>The</strong>re was also a wide variation<br />
between practices in the uptake <strong>of</strong> High Use Health Cards, special funding for frequent attenders at general<br />
practices and ‘Care Plus’ funding for patients with chronic conditions. Practice deprivation, ethnicity<br />
and age only explained a minor part <strong>of</strong> this variation.<br />
Discussion: <strong>The</strong> high rate <strong>of</strong> unexplained practice variation in chronic care management and hospitalisation<br />
rates, especially for Maori, is <strong>of</strong> concern. Further investigation <strong>of</strong> the causes <strong>of</strong> such variability is<br />
needed as a first step in reducing hospitalisation.<br />
KEYWORDS: Hospitalization; ethnic groups; data collection<br />
Introduction<br />
Reduction <strong>of</strong> hospital admissions through greater<br />
intensity <strong>of</strong> care in primary health care has been<br />
strongly emphasised in many countries, including<br />
<strong>New</strong> <strong>Zealand</strong>. <strong>The</strong> evidence from the experience<br />
<strong>of</strong> Kaiser Permanente, a large United States<br />
Health Maintenance Organisation, is that hospital<br />
admissions can be halved through appropriate<br />
use <strong>of</strong> the primary care sector. 1 A key factor in<br />
this strategy is the organisational integration <strong>of</strong><br />
primary and secondary care such as is now being<br />
addressed by District Health Boards (DHBs).<br />
Canterbury DHB, in conjunction with the<br />
primary care sector in Christchurch including<br />
Pegasus Health, have sought to reduce demand<br />
upon emergency department and hospital services<br />
through primary care alternatives. Attention has<br />
now shifted to what has being hailed as the<br />
‘Canterbury Initiative’. 2 <strong>General</strong> practitioners<br />
and specialists are working together to develop<br />
and implement mutually acceptable solutions<br />
to common problems. One aim is to reduce<br />
unnecessary demands on hospital-based care,<br />
including admissions.<br />
Despite the importance <strong>of</strong> reducing hospital<br />
admissions, there has been little research examining<br />
variations in hospital admission rates between<br />
general practices. While studies <strong>of</strong> medical prac-<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):111–117.<br />
CORRESPONDENCE TO:<br />
Laurence Malcolm<br />
Pr<strong>of</strong>essor Emeritus<br />
University <strong>of</strong> Otago,<br />
Consultant Aotearoa Health<br />
Lyttelton RD 1, Canterbury,<br />
<strong>New</strong> <strong>Zealand</strong><br />
lm@cyberxpress.co.nz<br />
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tice variation are well documented in primary<br />
and secondary care, both in <strong>New</strong> <strong>Zealand</strong> 3–6 and<br />
elsewhere, 7–8 there has been little research that<br />
has specifically examined links between the two.<br />
That which has been conducted suggests that<br />
sociodemographic characteristics <strong>of</strong> practices explained<br />
most <strong>of</strong> the variation in overall admission<br />
rates and that the general practice characteristics<br />
considered added very little. 9–10<br />
If variation in admission rates cannot be accounted<br />
for by differences in patient morbidity,<br />
then questions arise regarding equity <strong>of</strong> access to<br />
hospital care, appropriateness <strong>of</strong> hospital referrals<br />
and admissions and the effectiveness <strong>of</strong> primary<br />
care. Given the recent emergence <strong>of</strong> Primary<br />
Health Organisations (PHOs) in <strong>New</strong> <strong>Zealand</strong>,<br />
While studies <strong>of</strong> medical practice variation are<br />
well documented in primary and secondary<br />
care, both in <strong>New</strong> <strong>Zealand</strong> and elsewhere,<br />
there has been little research that has<br />
specifically examined links between the two<br />
with their increased focus on equity <strong>issue</strong>s in<br />
health policy, 11 it is imperative that research<br />
investigates such variations.<br />
This study is part <strong>of</strong> a larger set <strong>of</strong> studies examining<br />
relationships between primary and secondary<br />
care in Partnership Health general practices.<br />
<strong>The</strong>se include studies <strong>of</strong> the quality <strong>of</strong> PHO data<br />
compared with hospital data, 12 <strong>of</strong> hospital general<br />
practice/hospital data on cardiological services<br />
especially related to Maori, 13 and <strong>of</strong> ambulatory<br />
sensitive hospitalisations. 14<br />
With such considerations in mind, this paper has<br />
three main objectives:<br />
• To examine the extent <strong>of</strong> the variation in hospital<br />
discharge rates between general practices.<br />
• To determine the extent to which this variation<br />
can be explained by patient characteristics,<br />
in particular deprivation and ethnicity.<br />
• To determine the extent to which special<br />
access funding is associated with<br />
practice need characteristics and increased<br />
risks <strong>of</strong> hospitalisation.<br />
Methods<br />
<strong>The</strong> study is based on patient enrolment data<br />
provided by Partnership Health, which represents<br />
approximately 75% <strong>of</strong> the Canterbury district<br />
population and is the largest PHO in <strong>New</strong><br />
<strong>Zealand</strong>, with an enrolled population <strong>of</strong> 345 254<br />
in 2007 including 19 712 Maori and 6974 Pacific<br />
people. It has over 100 general practices based in<br />
Christchurch and Selwyn. 15 It has a broadly-based<br />
governance structure with strong representation<br />
from community groups including Maori and<br />
Pacific people.<br />
Partnership Health, in conjunction with Pegasus<br />
Health, has established a comprehensive practicebased<br />
database <strong>of</strong> its enrolled patients. <strong>The</strong><br />
almost complete recording <strong>of</strong> patients’ National<br />
Health Index (NHI) numbers is a key part <strong>of</strong> this<br />
database and enables linkages to be researched between<br />
this database and hospital discharges from<br />
data held by the <strong>New</strong> <strong>Zealand</strong> Health Information<br />
Service (NZHIS).<br />
Enrolment data for Partnership Health were<br />
provided by Pegasus Health. This included the<br />
NHI numbers for all patients enrolled to which<br />
was attached data relating to practice <strong>of</strong> enrolment,<br />
date <strong>of</strong> birth, gender, ethnicity, deprivation<br />
scores, High Use Health Cards (HUHCs)—a<br />
subsidy related to need for high use <strong>of</strong> general<br />
practice consultations—and Care Plus—a subsidy<br />
for patients with chronic conditions. <strong>The</strong> date <strong>of</strong><br />
the data set was October 2007.<br />
<strong>The</strong> data were sent directly to the NZHIS by<br />
Pegasus Health. <strong>The</strong> NHI was used to link<br />
the Partnership Health enrolment data to the<br />
National Minimum Data Set (NMDS) for all<br />
hospital discharges totalling 127 246 for those<br />
enrolled for the 2½ years ending 30 June 2007.<br />
<strong>The</strong> data added to the Partnership Health data set<br />
included ethnicity, and all the other variables associated<br />
with a hospital discharge including date<br />
<strong>of</strong> admission and discharge and diagnosis. <strong>The</strong><br />
linked data from NZHIS was returned to the re-<br />
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searchers with the NHIs encrypted. <strong>The</strong> NMDS<br />
data analysed were based upon the discharges <strong>of</strong><br />
all patients enrolled with Partnership Health over<br />
the two years ending 30 June 2007.<br />
In addition to calculating annual admission rates<br />
for age, gender, ethnicity, deprivation (meshblock<br />
domicile), HUHCs and Care Plus, crude annual<br />
rates were calculated for each general practice.<br />
<strong>The</strong>se are defined as the total number <strong>of</strong> admissions<br />
for each general practice per year per 1000<br />
patients registered at that practice. Rates were<br />
calculated for all 102 practices for which data<br />
were available.<br />
<strong>The</strong> association between admission rates and<br />
possible explanatory factors was investigated<br />
via stepwise multiple regression analysis. <strong>The</strong><br />
analyses <strong>of</strong> admission rates were undertaken as<br />
follows: First, controls were made for practice<br />
variations in age and sex by entering these into<br />
the model followed by other practice population<br />
variables, including deprivation, percentage<br />
Maori, percentage Pacific and percentage Asian<br />
patients. Second, the same process was then repeated<br />
using age/sex and other practice characteristics.<br />
<strong>The</strong> latter included practice size (number<br />
<strong>of</strong> enrolled patients), average number <strong>of</strong> patients<br />
per GP and the proportion <strong>of</strong> practice populations<br />
enrolled in Care Plus and with HUHCs. Third,<br />
all practice characteristics were included in the<br />
final model. Separate analyses were conducted for<br />
total, European and Maori patients.<br />
For the analyses predicting practice variations<br />
in the take-up <strong>of</strong> Care Plus, and in the use <strong>of</strong><br />
HUHCs, all variables were included in stepwise<br />
models, for total, European and Maori patients.<br />
<strong>The</strong> analyses were conducted with SPSS for Windows<br />
Version 15.<br />
Results<br />
Practice variations in discharge rates<br />
Figure 1 indicates extensive variation in crude<br />
discharge rates between practices. Crude discharge<br />
rates/1000 ranged from a low <strong>of</strong> 74/1000<br />
to 353/1000 around the mean <strong>of</strong> 184/1000<br />
(SD=38.0). <strong>The</strong> important question is, thus, to<br />
what extent can this variation be explained by<br />
WHAT GAP THIS FILLS<br />
What we already know: Despite the improving quality <strong>of</strong> general practice<br />
enrolment data, very little analysis has been undertaken to explore the<br />
use <strong>of</strong> the data in linking primary and secondary care utilisation.<br />
What this study adds: A new approach to analysis using the National<br />
Health Index numbers to link general practice data with other data sources,<br />
including national data on deprivation and ethnicity, demonstrates how primary<br />
health organisation data can reliably contribute to a district database.<br />
Figure 1. Annualised discharge rates for GP practices<br />
variation in practice populations or by other practice<br />
characteristics?<br />
Table 1 presents the results <strong>of</strong> the stepwise<br />
regression models containing age and other<br />
practice population characteristics. Three practice<br />
population characteristics emerged as significant<br />
predictors <strong>of</strong> total discharges: mean deprivation,<br />
Maori ethnicity and the percentage <strong>of</strong> Asian<br />
patients, the presence <strong>of</strong> whom tended to reduce<br />
admission rates. Similar results were obtained for<br />
European but not for Maori patients. Here both<br />
predictors were different and the cumulative R 2<br />
was much lower than for the other two models<br />
(0.271 vs 0.558 and 0.583). Also it is interesting<br />
that European discharge rates were higher in<br />
practices with a higher proportion <strong>of</strong> Maori (even<br />
after accounting for deprivation) and Maori rates<br />
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Table 1. Stepwise regression models for total discharge rates<br />
Factors included in model Coefficient P-value R 2 Cumulative R 2<br />
Total patients<br />
% patients 0–4 4.64 0.001<br />
% patients 65 and over 1.64 0.001<br />
Males per 100 females 0.03 0.799 0.092 0.092<br />
Mean deprivation 11.86 0.001 0.382 0.474<br />
% Maori 2.66 0.001 0.067 0.541<br />
% Asian -1.25 0.003 0.042 0.583<br />
European<br />
% patients 0–4 6.16 0.001<br />
% patients 65 and over 1.40 0.001<br />
Males per 100 females -0.09 0.931 0.088 0.088<br />
Mean deprivation 11.64 0.001 0.434 0.522<br />
% Maori 1.84 0.006 0.036 0.558<br />
Maori<br />
% patients 0–4 2.25 0.027<br />
% patients 65 and over 1.53 0.165<br />
Males per 100 females -0.07 0.615 0.014 0.014<br />
Mean deprivation 20.78 0.001 0.186 0.200<br />
% European 1.01 0.005 0.040 0.240<br />
% Pacific 1.52 0.047 0.031 0.271<br />
Table 2. Hospital discharge rates for Partnership Health enrolled patients by Care Plus and<br />
High Use Health Cards<br />
Standardised discharge rate<br />
95% confidence limit<br />
Care Plus 511 (499.7–522.3)<br />
No Care Plus 177 (175.3–178.7)<br />
Ratio 2.9<br />
HUHC 701 (665–736)<br />
No HUHC 168 (166.3–169.7)<br />
Ratio 4.2<br />
were also high in practices with more European<br />
and Pacific patients, although the effect <strong>of</strong> these<br />
factors was small compared to the effects <strong>of</strong> deprivation.<br />
Nevertheless, what is important is that<br />
ethnic mix had effects independent <strong>of</strong> deprivation<br />
in all three models.<br />
While there was a significant relationship, after<br />
controlling for age and sex, between the proportion<br />
<strong>of</strong> patients enrolled in Care Plus and<br />
hospitalisation rates, the effect disappeared when<br />
further controls were made for deprivation and<br />
other practice population characteristics.<br />
Practice variations in enrolment in Care Plus<br />
Partnership Health patients enrolled in Care<br />
Plus and with HUHCs have much higher<br />
discharge rates than those without, with the<br />
former being 2.9 times more likely to experience<br />
a hospital episode and the latter 4.2 times<br />
(Table 2). However, the question arises as to the<br />
extent to which GP practices vary in the extent<br />
to which they have developed chronic patient<br />
care programmes, like Care Plus, compared to<br />
HUHCs which is a subsidy approach tied to the<br />
number <strong>of</strong> GP visits.<br />
Even more so than for discharge rates, Figure 2<br />
indicates a considerable variation between<br />
practices in patient enrolment in Care Plus. Just<br />
over half <strong>of</strong> the Partnership Health practices had<br />
enrolment rates <strong>of</strong> less than 1%, while 12 practices<br />
had rates <strong>of</strong> enrolment over 5% and seven <strong>of</strong><br />
these were over 10%.<br />
Of the practice population and other characteristics,<br />
only the former help predict practice variations<br />
in Care Plus enrolment. For all patients,<br />
the percentage <strong>of</strong> Maori and the percentage aged<br />
75 years and over are the main predictors. This<br />
is also true for European patients, while for<br />
Maori only the percentage <strong>of</strong> Maori in a practice<br />
emerged as a significant predictor. Other variables,<br />
such as practice size, were not significant.<br />
For HUHCs the results (not shown) are similar,<br />
with older patients and deprivation being the<br />
main predictors in all three models (R 2 <strong>of</strong> 0.251,<br />
0.313 and 0.124 respectively).<br />
Discussion<br />
<strong>The</strong>re are two important findings <strong>of</strong> this<br />
research. First, the study confirms substantial<br />
variations in discharge rates between general<br />
practices in the Partnership Health PHO, with<br />
the highest rates more than double those <strong>of</strong> the<br />
lowest. <strong>The</strong> mean admission rate <strong>of</strong> 184 per 1000<br />
is almost identical to that reported by an English<br />
study. 9 Thus, while the level <strong>of</strong> practice variation<br />
in the current study is not unexpected, it is important<br />
because <strong>of</strong> the need to better understand<br />
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the reasons for such differences. <strong>The</strong>re is no<br />
universal standard on what constitutes a normal<br />
range <strong>of</strong> practice variation in admission rates, but<br />
clearly in an era <strong>of</strong> fiscal constraints and limits<br />
on the ability <strong>of</strong> hospitals to provide patient care,<br />
increasing our understanding <strong>of</strong> patient pathways<br />
to hospital and the role <strong>of</strong> GPs as ‘gatekeepers’<br />
would seem to be a high priority.<br />
Figure 2. Practice variations in enrolment in Care Plus<br />
While, as in other studies, 9–10 practice population<br />
characteristics were found to be the most significant<br />
factors explaining practice differences in<br />
discharge rates, these factors explained only 63%<br />
<strong>of</strong> the variation in total discharge rates, 58% <strong>of</strong><br />
the variation in European rates, but only 26% <strong>of</strong><br />
the variation in Maori rates. Other measures <strong>of</strong><br />
primary care service provision, such as practice,<br />
were insignificant. Substantial variation therefore<br />
remained.<br />
<strong>The</strong> most likely explanation, as suggested by<br />
the numerous studies <strong>of</strong> medical practice variation,<br />
which is ubiquitous in the health sector, is<br />
general practitioner variability in the assessment<br />
and treatment <strong>of</strong> patients. Variations in clinical<br />
decision-making could occur for a variety <strong>of</strong><br />
reasons, including uncertainty in diagnoses, 14<br />
which is associated with higher rates <strong>of</strong> investigations<br />
and follow-up and increased chances <strong>of</strong><br />
referral to hospital. 15 Pressure from patients, 16 GP<br />
relationships with local specialists 9 or patterns<br />
<strong>of</strong> social exclusion in primary care have also<br />
been suggested as contributory factors. With<br />
respect to the latter, overseas research indicates<br />
that the quality <strong>of</strong> care, especially in terms <strong>of</strong><br />
consultation time, is less in more disadvantaged<br />
practices. 17–18 While GP utilisation rates for<br />
deprived groups have increased in recent years, 11<br />
if social and ethnic variation exists in the quality<br />
<strong>of</strong> treatment provided to patients by GPs,<br />
then unmet need is likely to result in increased<br />
hospitalisation. This may well be one factor<br />
leading to relatively high rates <strong>of</strong> hospitalisation<br />
among Maori attending less deprived practices<br />
and why there was a lack <strong>of</strong> any clear relationship<br />
between practice deprivation and Maori<br />
hospitalisation rates.<br />
<strong>The</strong> second important finding <strong>of</strong> this research<br />
is the independent and <strong>of</strong>ten divergent effect <strong>of</strong><br />
ethnicity on hospitalisation rates. While Maori<br />
had the highest rates <strong>of</strong> admission, these were<br />
Table 3. Stepwise regression models for enrolment in Care Plus<br />
Factors included in model Unstandardised coefficient Beta P-value Cumulative R 2<br />
Total patients<br />
% Maori 0.24 0.33 0.001 0.079<br />
% 75 years and over 0.22 0.29 0.003 0.159<br />
European<br />
% 75 years and over 0.29 0.39 0.001 0.132<br />
% Maori 0.27 0.31 0.001 0.226<br />
Maori<br />
% Maori 0.28 0.36 0.001 0.129<br />
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inadequately explained by social demographic<br />
characteristics—in particular, deprivation. By<br />
contrast, after controlling for age, sex and<br />
deprivation, practices with larger Asian populations<br />
had much lower rates <strong>of</strong> hospitalisation.<br />
<strong>The</strong>se ethnic differences cannot be attributed to<br />
deprivation, but rather likely reflect the influence<br />
<strong>of</strong> other factors such as cultural variations<br />
in individual lifestyles, differences in dietary<br />
behaviour—the latter perhaps reflecting the<br />
length <strong>of</strong> residence <strong>of</strong> Asian immigrant groups in<br />
<strong>New</strong> <strong>Zealand</strong> (the ‘migrant’ effect). Better access<br />
to primary care on the part <strong>of</strong> Asian patients may<br />
also be a contributory factor.<br />
<strong>The</strong> third important finding is that the uptake<br />
<strong>of</strong> Care Plus is relatively incomplete and highly<br />
variable between practices. <strong>The</strong>se variations were<br />
only partly accounted for by age and ethnicity,<br />
but most <strong>of</strong> the practice variation in enrolment<br />
was unexplained by practice population characteristics.<br />
This is an important finding given<br />
In light <strong>of</strong> these findings, we suggest that there<br />
are three areas in particular where further<br />
research is necessary. First, with respect to local<br />
practice variations in admissions, it would be<br />
desirable to undertake a more in-depth study <strong>of</strong><br />
GP referral decisions in high and low income<br />
practices. Increased understanding <strong>of</strong> the referral<br />
process and the organisational environments<br />
affecting GPs’ ‘gatekeeping’ role would seem to<br />
be a high priority, especially given some research<br />
showing that a relatively high proportion <strong>of</strong><br />
referrals may be inappropriate. 20 A start has been<br />
made in this regard by examining patterns <strong>of</strong><br />
avoidable hospitalisation, 21 since this factor has<br />
been used extensively as an indicator <strong>of</strong> access<br />
to, and the overall effectiveness <strong>of</strong>, primary<br />
health care.<br />
Second, particular attention is needed to address<br />
ethnic variations in admission rates between<br />
practices and particularly why there is little <strong>of</strong><br />
a social gradient in Maori rates <strong>of</strong> hospitalisa-<br />
Increased understanding <strong>of</strong> the referral process and the organisational<br />
environments affecting GPs’ ‘gatekeeping’ role would seem to be a<br />
high priority, especially given some research showing that a relatively<br />
high proportion <strong>of</strong> referrals may be inappropriate<br />
the high hospitalisation rates <strong>of</strong> Care Plus (and<br />
HUHC) patients. For example, a previous study<br />
based in Christchurch South Health Centre 19<br />
showed that the 8.6% <strong>of</strong> patients with an HUHC<br />
generated 31.5% <strong>of</strong> discharges, 42.4% <strong>of</strong> bed days<br />
and had a longer average length <strong>of</strong> stay. Identifying<br />
such patients and ensuring that appropriate,<br />
more intensive, care is provided may be a<br />
strategy to significantly reduce their impact upon<br />
hospital services.<br />
Finally, GP practices with higher rates <strong>of</strong> enrolment<br />
in Care Plus did not have lower rates <strong>of</strong><br />
hospitalisation. This may be due to improved<br />
monitoring <strong>of</strong> conditions and a greater likelihood<br />
<strong>of</strong> arranged admissions among a group <strong>of</strong><br />
patients who previously were less likely to access<br />
primary care.<br />
tion. Thirdly, with respect to Care Plus, further<br />
work is needed to assess why patient enrolment<br />
in this programme has been so low and<br />
why so much variation occurs across individual<br />
practices. Also, given the cross-sectional nature<br />
<strong>of</strong> this study, it was not possible to assess the<br />
longer-term implications <strong>of</strong> Care Plus on hospitalisation<br />
rates.<br />
This study suggests that GP practices exhibit<br />
considerable variation in patterns <strong>of</strong> hospital<br />
admission and that practice population characteristics<br />
are particularly important in explaining<br />
this. Nevertheless, some <strong>of</strong> the variation can also<br />
be attributed to other practice characteristics, in<br />
particular the availability <strong>of</strong> special need funding<br />
designed to limit hospitalisation rates among<br />
older and more deprived patients.<br />
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In the light <strong>of</strong> these results, and in view <strong>of</strong><br />
the recent development <strong>of</strong> PHO performance<br />
measures, 15 we suggest that particular attention<br />
is needed to address variation between practices,<br />
especially in terms <strong>of</strong> ethnic differences in admission<br />
rates and in the uptake <strong>of</strong> access funding<br />
which appears to be inequitable.<br />
We suggest that health services research, while it<br />
has studied either primary or secondary care, has<br />
largely ignored the interface between these two<br />
sectors. In view <strong>of</strong> the development <strong>of</strong> integrated<br />
and managed care models <strong>of</strong> primary health care<br />
in many countries over the last decade, 11 this<br />
is an important omission in such studies and<br />
one that needs to be rectified if we are to have<br />
a fuller understanding <strong>of</strong> spatial and temporal<br />
trends in hospitalisation.<br />
13. Malcolm L, Barnett R. Utilization <strong>of</strong> inpatient cardiology<br />
services including by Maori: a study <strong>of</strong> hospital discharges for<br />
patients enrolled with Partnership Health practices for the two<br />
years ending June 2007. N Z Med J. In press.<br />
14. Barnett R, Malcolm L. Practice and ethnic variations in avoidable<br />
hospital admission rates in Christchurch, <strong>New</strong> <strong>Zealand</strong>.<br />
Health & Place. 2010;16:199–208.<br />
15. Partnership Health. Partnership Health Annual Report.<br />
Christchurch: Partnership Health; 2008.<br />
16. Wyke S, Campbell G and Maciver S. Provision <strong>of</strong>, and patient<br />
satisfaction with, primary care services in a relatively affluent<br />
area and a relatively deprived area <strong>of</strong> Glasgow. Br J Gen Pract.<br />
1992;42:271–75.<br />
17. Furler JS. <strong>The</strong> inverse care law revisited: impact <strong>of</strong><br />
disadvantaged location on accessing longer GP consultation<br />
times. Med J Aust. 2002;177:80–83.<br />
18. Malcolm L, Wright L, Carson S. Integrating primary and secondary<br />
care: the case <strong>of</strong> Christchurch South Health Centre.<br />
N Z Med J. 2000;113:514–7.<br />
19. Ministry <strong>of</strong> Health. Review <strong>of</strong> the Implementation <strong>of</strong> Care Plus.<br />
Wellington 2006.<br />
References<br />
1. Feachem R, Sekhri N, White K. Getting more for their dollar:<br />
a comparison <strong>of</strong> the NHS with California’s Kaiser Permanente.<br />
BMJ. 2002;324:135–43.<br />
2. <strong>New</strong> <strong>Zealand</strong> Doctor. Canterbury’s Hot Initiative.1 July<br />
2009:17. www. nzdoctor.co.nz<br />
3. Davis P, Gribben B, Lay-Yee R, Scott A. How much variation<br />
in clinical activity is there between general practitioners? A<br />
multi-level analysis <strong>of</strong> decision-making in primary care. Jour<br />
Health Serv Res Policy. 2002;7:202–208.<br />
4. Davis P, Gribben B, Scott A, Lay-Yee R. <strong>The</strong> ‘supply’ hypothesis<br />
and medical practice variation in primary care: testing<br />
economic and clinical models <strong>of</strong> inter-practitioner variation.<br />
Soc Sci Med. 1999;50:407–418.<br />
5. Love T, Dowell AC, Salmond C, Crampton P. Quality indicators<br />
and variation in primary care: modelling GP referral patterns.<br />
Fam Pract. 2004;21:160–165.<br />
6. Brown L, Barnett JR. Influence <strong>of</strong> bed supply and health care<br />
organisation on regional and local patterns <strong>of</strong> diabetes related<br />
hospitalisation. Soc Sci Med. 1992;35:1157–1170.<br />
7. Verstappen W, Riet GT, Van der Weijden T, Hermsen J, Grol<br />
R. Variation in requests for imaging investigations by general<br />
practitioners: a multi-level analysis. Jour Health Serv Res<br />
Policy. 2005;10:25–30.<br />
8. Wilkin D, Smith A. Explaining variation in general practitioner<br />
referrals to hospital. Fam Pract. 1987;4:160–169.<br />
9. Reid FDA, Cook DG, Majeed A. Explaining variation in hospital<br />
admission rates between general practices: cross sectional<br />
study. BMJ. 1999;319:98–103.<br />
10. Saxena S, George J, Barber J, Fitzpatrick J, Majeed A. Association<br />
<strong>of</strong> population and practice factors with potentially<br />
avoidable admission rates for chronic diseases in London:<br />
cross sectional analysis. Jour <strong>Royal</strong> Soc Med. 2006;99:81–89.<br />
11. Barnett JR, Barnett P. Reinventing primary care: the <strong>New</strong><br />
<strong>Zealand</strong> case compared. In: Crooks, VA and Andrews, GJ<br />
(editors). Primary health care: people, practice, place. London:<br />
Ashgate; 2008. p 149–165.<br />
12. Malcolm L, Barnett R. <strong>General</strong> practice records can provide<br />
a more reliable data base for district health services analysis<br />
than national hospital data: analysis <strong>of</strong> Partnership Health<br />
general practice data. Submitted for publication.<br />
ACKNOWLEDGEMENTS<br />
<strong>The</strong> authors are grateful<br />
to Pegasus Health and<br />
NZHIS for the supply <strong>of</strong><br />
hospitalisation data linked<br />
to PHO practice records.<br />
FUNDING<br />
<strong>The</strong> authors are grateful to<br />
Partnership Health PHO for<br />
the funding <strong>of</strong> this study.<br />
COMPETING INTERESTS<br />
None declared.<br />
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quantitative research<br />
Modifying the PACIC to assess provision <strong>of</strong><br />
chronic illness care: An exploratory study with<br />
primary health care nurses<br />
Jenny Carryer RN, PhD, FCNA (NZ), MNZM; 1 Claire Budge PhD; 2 Chiquita Hansen RN, MPhil (Nursing); 2<br />
Katherine Gibbs RN, MMS 2<br />
1<br />
Massey University,<br />
Palmerston North,<br />
<strong>New</strong> <strong>Zealand</strong><br />
2<br />
MidCentral DHB,<br />
Palmerston North,<br />
<strong>New</strong> <strong>Zealand</strong><br />
ABSTRACT<br />
Introduction: In line with Wagner’s Chronic Care Model, the Patient Assessment <strong>of</strong> Chronic Illness<br />
Care (PACIC) has been developed to evaluate chronic illness care delivery from the patient's perspective.<br />
Modification <strong>of</strong> the instrument to assess the same aspects <strong>of</strong> care delivery from the health practitioner’s<br />
perspective would enable individual practitioners to evaluate their own provision <strong>of</strong> self-management<br />
support, and would also enable a more direct comparison between care provided and care received<br />
within the chronic illness context.<br />
Aim: To explore the potential <strong>of</strong> a modified PACIC instrument to assess individual health practitioners’<br />
delivery <strong>of</strong> care to chronic illness patients with a sample <strong>of</strong> primary health care nurses.<br />
Methods: Seventy-seven primary care nurses completed the modified PACIC, reworded to ask about<br />
care provision rather than receipt <strong>of</strong> care. An additional seven cultural sensitivity items were included, as<br />
were questions about the suitability <strong>of</strong> the types <strong>of</strong> chronic illness care and who should be providing the<br />
care.<br />
Results: <strong>The</strong> modified PACIC items appear to be appropriate for use with health practitioners. Agreement<br />
that the types <strong>of</strong> care described in the PACIC should be provided was almost unanimous, and the<br />
predominant view was that self-management support should be provided by both nurses and doctors.<br />
Mean scale scores were higher than those generally reported from studies using the PACIC.<br />
Discussion: <strong>The</strong> results <strong>of</strong> this first evaluation <strong>of</strong> a modified PACIC suggest that the original items<br />
plus the cultural sensitivity items can be used to assess self-management support by individual health<br />
practitioners.<br />
KEYWORDS: Chronic illness; self-management; primary health care, nurses<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):118–123.<br />
Correspondence to:<br />
Jenny Carryer<br />
Pr<strong>of</strong>essor <strong>of</strong> Nursing,<br />
School <strong>of</strong> Health<br />
and Social Services,<br />
Massey University,<br />
PB 11222 Palmerston<br />
North, <strong>New</strong> <strong>Zealand</strong><br />
J.B.Carryer@massey.ac.nz<br />
Introduction<br />
<strong>The</strong> Chronic Care Model (CCM) developed by<br />
Wagner and colleagues at the MacColl Institute<br />
1,2 has received considerable attention in<br />
recent years as a suitable framework for delivery<br />
<strong>of</strong> primary care to people living with chronic<br />
illness, and has been promoted in a range <strong>of</strong><br />
countries such as Australia, 3 England, 4 Scotland<br />
5 and <strong>New</strong> <strong>Zealand</strong>. 6 <strong>The</strong> model consists <strong>of</strong><br />
six components (community resources, health<br />
organisation, self-management support, delivery<br />
system design, decision support, and clinical<br />
information systems) which together encompass<br />
the health care provider, patient and community<br />
interactions necessary for planned chronic illness<br />
care. Two instruments have been developed to<br />
measure the application <strong>of</strong> the Chronic Care<br />
Model in practice: the Assessment <strong>of</strong> Chronic<br />
Illness Care (ACIC) 7 designed to be used with<br />
teams <strong>of</strong> care providers, and the Patient Assessment<br />
<strong>of</strong> Chronic Illness Care (PACIC) 8 developed<br />
for patients.<br />
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Project outline<br />
As part <strong>of</strong> a larger scale study <strong>of</strong> chronic illness<br />
care provision and experience, we wanted to evaluate<br />
chronic care provision from the perspective<br />
<strong>of</strong> health care providers in one District Health<br />
Board (DHB) region <strong>of</strong> <strong>New</strong> <strong>Zealand</strong>. Recent<br />
changes in the health care system have seen the<br />
establishment <strong>of</strong> chronic care teams consisting <strong>of</strong><br />
general practitioners (GPs), practice nurses, specialist<br />
nurses and allied health practitioners such<br />
as dieticians, podiatrists, physiotherapists etc.<br />
working within Primary Health Organisations<br />
(PHOs). Our longitudinal study aims to evaluate<br />
the development <strong>of</strong> these teams. However,<br />
as the teams are only just being established, we<br />
also wanted to explore care provision from the<br />
perspective <strong>of</strong> individual practitioners and needed<br />
a suitable evaluation tool. While the ACIC is<br />
generally considered appropriate for assessing<br />
provision <strong>of</strong> care, we decided to use a modified<br />
version <strong>of</strong> the PACIC instead. <strong>The</strong>re were two<br />
rationales for this decision. Firstly, the ACIC was<br />
not considered to be the best tool for individual<br />
practitioners to use as it is designed to be completed<br />
as a result <strong>of</strong> discussion amongst a chronic<br />
care team—thus representing a team opinion.<br />
Secondly, we were interested in the possibility<br />
<strong>of</strong> obtaining responses that could be directly<br />
compared to those generated by the PACIC, thus<br />
contrasting practitioners’ and patients’ views on<br />
the same dimensions <strong>of</strong> care. Consequently we<br />
obtained permission from the MacColl Institute<br />
to modify the PACIC to suit our purposes.<br />
<strong>The</strong> Patient Assessment <strong>of</strong><br />
Chronic Illness Care (PACIC)<br />
In developing the PACIC, Glasgow and colleagues<br />
tested 46 items, originally generated by<br />
chronic illness care experts, with 130 patients. 8<br />
Twenty items were retained because they<br />
demonstrated adequate variability, were easily<br />
understood by patients and best represented<br />
the underlying constructs <strong>of</strong> the Chronic Care<br />
Model. In a study <strong>of</strong> 283 people with one or more<br />
chronic illnesses, they provided a psychometric<br />
evaluation <strong>of</strong> the PACIC. <strong>The</strong> measure was presented<br />
as having an overall score, calculated by<br />
averaging across scores on all 20 items, with good<br />
internal consistency represented by a Cronbach’s<br />
alpha <strong>of</strong> 0.93. Glasgow et al. 8 also divided the<br />
WHAT GAP THIS FILLS<br />
What we already know: <strong>The</strong> PACIC instrument has been designed to<br />
assess how well elements <strong>of</strong> Wagner’s Chronic Care Model are being met by<br />
practitioners providing chronic illness care. <strong>The</strong> instrument enables people<br />
living with chronic illness to rate the care they receive.<br />
What this study adds: This exploratory study proposes a modification<br />
and extension <strong>of</strong> the PACIC so that it can be applied to the provision <strong>of</strong> care<br />
and can be completed by an individual health practitioner. <strong>The</strong> extra items<br />
allow for the assessment <strong>of</strong> the appropriateness <strong>of</strong> chronic illness care for<br />
people <strong>of</strong> different ethnicities.<br />
items into groups <strong>of</strong> three to five, resulting in<br />
five a priori scales based on key components <strong>of</strong><br />
the CCM named Patient activation (items 1–3),<br />
Delivery system design/Decision support (items<br />
4–6), Goal setting/Tailoring (items 7–11), Problemsolving/Contextual<br />
(items 12–15) and Follow-up/<br />
Coordination (items 16–20). <strong>The</strong>se represented<br />
five <strong>of</strong> the six CCM components. <strong>The</strong> sixth was<br />
not exemplified as the authors felt that patients<br />
would be unable to report on clinical information<br />
systems or health care organisation. <strong>The</strong>y<br />
conducted a confirmatory factor analysis to evaluate<br />
the goodness <strong>of</strong> fit <strong>of</strong> the items to the scale<br />
structure and reported it to be moderate. Item 16<br />
was described as having a relatively poor fit but,<br />
as contact following a visit was considered to be<br />
essential, it was left in the measure.<br />
Since then, McIntosh 9 examined the factor<br />
structure using the items from four <strong>of</strong> the PACIC<br />
subscales with a general population, aiming to<br />
measure their experiences with the health care<br />
system. He concluded that the data better fitted a<br />
two-factor model which he labelled Whole Person<br />
Care and Coordination <strong>of</strong> Care. He acknowledged<br />
that the lack <strong>of</strong> consistency between his and<br />
Glasgow’s findings may have resulted from the<br />
sampling differences, but the other measures<br />
he tested retained their structure despite being<br />
applied to a general sample. Other authors 11 have<br />
also raised questions about the factor structure<br />
<strong>of</strong> the PACIC. While their principal components<br />
analysis suggested the existence <strong>of</strong> five factors,<br />
the items were distributed differently to how the<br />
original authors proposed.<br />
Previous modifications <strong>of</strong> the PACIC have<br />
included an extension <strong>of</strong> the measure to develop<br />
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the PACIC 5As version, 10 and translations into<br />
different languages. <strong>The</strong> 5As extension was based<br />
on the 5A model <strong>of</strong> behavioural change (assess,<br />
advise, agree, assist and arrange) and involved the<br />
addition <strong>of</strong> six items which, in combination with<br />
subsets <strong>of</strong> the original 20, enabled the assessment<br />
<strong>of</strong> practitioners’ counselling aimed at improving<br />
patients’ self-management. In addition there have<br />
been translations into Spanish, 12 Dutch 11 and<br />
German 13 for use with different patient populations,<br />
but no previous attempts have been made<br />
to use the tool with health care providers.<br />
<strong>The</strong> aim <strong>of</strong> this exploratory project was to evaluate<br />
a new version <strong>of</strong> the PACIC, the focus being<br />
on content validation <strong>of</strong> the modification to see<br />
whether it is appropriate to apply the same items<br />
from the perspective <strong>of</strong> health practitioners<br />
rather than patients, as was originally intended.<br />
This included collecting participants’ views on<br />
the items included in the measure and finding<br />
out who they thought should be providing<br />
chronic illness care. For this project, the modification<br />
process involved rewording the PACIC<br />
items so that they could be used to evaluate care<br />
provided to chronic illness patients, rather than<br />
care received by them as the measure was originally<br />
intended. <strong>The</strong> new version is referred to as<br />
the modified PACIC (MPACIC).<br />
Methods<br />
Sample<br />
Using a list <strong>of</strong> regional primary care nurses held<br />
by the DHB, a questionnaire, plus an information<br />
sheet and a reply paid envelope, was posted to<br />
241 primary health nurses in the DHB region. A<br />
reminder letter was sent two weeks later. Seventy-seven<br />
(32%) questionnaires were returned. This<br />
study received ethical approval from the Central<br />
Ethics Committee.<br />
Materials<br />
<strong>The</strong> questionnaire consisted <strong>of</strong> a modified version<br />
<strong>of</strong> the PACIC. In modifying the original<br />
instrument, the content <strong>of</strong> the questions was left<br />
the same but the question stem was changed to<br />
read ‘when caring for a person with a chronic<br />
illness, how <strong>of</strong>ten do you…’ and each question<br />
was altered to fit the care provision context. An<br />
example <strong>of</strong> the item modification is as follows:<br />
Original wording:<br />
During the last six months, when receiving care for<br />
my chronic illness I was asked for my ideas when<br />
we made a treatment plan.<br />
Modified wording:<br />
When caring for a person with a chronic illness,<br />
how <strong>of</strong>ten do you ask for their ideas when making a<br />
treatment plan?<br />
<strong>The</strong> response options remained unchanged as<br />
‘almost always’, ‘most <strong>of</strong> the time’, ‘sometimes’,<br />
‘generally not’ and ‘almost never’, numerically<br />
scored as 5 to 1 respectively. <strong>The</strong> items are listed<br />
in the appendix in the web version <strong>of</strong> this paper.<br />
As well as altering the focus from care receipt to<br />
care provision, a section containing seven new<br />
items was added to address cultural sensitivity in<br />
care provision. Maori have poorer health status<br />
than non-Maori, regardless <strong>of</strong> income, educational<br />
and socioeconomic level 14 and the Ministry <strong>of</strong><br />
Health is committed to addressing health disparities<br />
following three Treaty <strong>of</strong> Waitangi (Te Tiriti<br />
o Waitangi) principles: partnership, participation<br />
and protection. 15 <strong>The</strong> seven cultural sensitivity<br />
items added to the MPACIC were developed<br />
by Maori nurses in discussion with the project<br />
advisory team. <strong>The</strong> items, following the stem, are<br />
presented below:<br />
When caring for a person with chronic illness, how<br />
<strong>of</strong>ten do you…<br />
appropriately involve the whanau/family in<br />
•<br />
the care and management <strong>of</strong> their condition?<br />
gather information or feedback from<br />
•<br />
whanau/family members?<br />
educate the whanau/family on prevention <strong>of</strong><br />
•<br />
the chronic condition where appropriate?<br />
screen the whanau/family where ap-<br />
•<br />
propriate—including risk factors?<br />
alter or modify your care due to their ethnicity?<br />
•<br />
<strong>of</strong>fer another culturally appropriate service if<br />
•<br />
there is one available?<br />
ask them if there are cultural or ethnic <strong>issue</strong>s<br />
•<br />
that you need to be aware <strong>of</strong>?<br />
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Two extra questions were added to each <strong>of</strong> the<br />
MPACIC items enquiring about whether the type<br />
<strong>of</strong> care outlined in the item should be provided<br />
(yes or no) and, if so, by whom (GP, nurse or<br />
both). <strong>The</strong> first was done partly as a validation <strong>of</strong><br />
the content <strong>of</strong> the PACIC since if the respondents<br />
did not see some type <strong>of</strong> care as being important<br />
they would presumably not be providing<br />
it. <strong>The</strong> second addition was included in order to<br />
explore the ‘division <strong>of</strong> labour’ notion <strong>of</strong> a team<br />
approach to chronic illness care. It was thought<br />
that views may differ on who was responsible for<br />
providing certain types <strong>of</strong> care, with a possible<br />
consequence being that some types were being<br />
neglected as different types <strong>of</strong> health practitioners<br />
thought somebody else was, or should be,<br />
taking responsibility.<br />
Data analysis<br />
Responses were entered into SPSS for Windows<br />
Version 15.0 and analyses included examination<br />
<strong>of</strong> item distributions, total scale means, and interitem<br />
correlations.<br />
Results<br />
MPACIC (20 items)<br />
Examination <strong>of</strong> the item frequencies showed<br />
that most items had either a normal or negatively<br />
skewed distribution, suggesting that most<br />
nurses rated their chronic illness care neutrally<br />
or positively. This picture was borne out by the<br />
mean item scores which ranged (out <strong>of</strong> a possible<br />
score <strong>of</strong> 5) from 3.42 for ‘provide a written list<br />
<strong>of</strong> things they should do to improve their health’<br />
to 4.52 for ‘consider their values and traditions<br />
when recommending treatments’. <strong>The</strong> mean total<br />
PACIC scores ranged from 2.3 to 4.9 out <strong>of</strong> a possible<br />
5, with a mean score <strong>of</strong> 3.99. This equates to<br />
care being provided most <strong>of</strong> the time on average.<br />
<strong>The</strong>re were very little missing data and what<br />
was missing resulted from a range <strong>of</strong> people not<br />
answering an item rather than one or two people<br />
not responding to several items.<br />
Pearson’s correlations between items ranged<br />
from 0.02 to 0.70 with the majority <strong>of</strong> correlations<br />
being in the low moderate range (mean<br />
r=0.34). Cronbach’s alpha for the total scale was<br />
0.91 and although this would not improve if any<br />
individual items were removed, examination <strong>of</strong><br />
the corrected item-total and squared multiple<br />
correlations suggested that items 16 and 18 were<br />
contributing less to the total scale than the other<br />
items. Both <strong>of</strong> these items demonstrated limited<br />
variability and were more weakly correlated with<br />
the other items.<br />
<strong>The</strong> seven new items received mean scores<br />
between 3.53 and 3.92, and correlations between<br />
items ranged from 0.15 to 0.73. <strong>The</strong> most<br />
strongly correlated items were the first two,<br />
both relating to involvement <strong>of</strong> family/whanau<br />
in chronic illness management. Despite the correlation<br />
being relatively strong, the distributions<br />
were different, and the pattern <strong>of</strong> correlations<br />
with other cultural sensitivity items, while being<br />
in the same strength range, were not identical.<br />
When these seven new items were combined<br />
with the other 20 MPACIC items, the range<br />
<strong>of</strong> scale scores was similar, ranging from 2.33<br />
to 4.85 with a mean score <strong>of</strong> 3.94. Cronbach’s<br />
alpha for the extended scale was 0.93. One <strong>of</strong><br />
these new items (number 5) had a relatively low<br />
corrected item-total correlation when compared<br />
to the other items and again displayed slightly<br />
more limited variability.<br />
As this was an exploratory project, space was provided<br />
for respondents to supplement their ratings<br />
with any comments or feedback they wanted to<br />
provide. <strong>The</strong> strongest message arising from the<br />
additional comments was that the care provided<br />
needed to be suited to the individual concerned,<br />
for example ‘this is done when appropriate, it<br />
depends on where the person is on their health<br />
journey at that time’. Similarly, a number <strong>of</strong> comments<br />
related to things being done sometimes<br />
but not at every appointment, for example ‘(this)<br />
may not be done at every consultation but is an<br />
integral part <strong>of</strong> ongoing care’.<br />
Appropriateness <strong>of</strong> care<br />
As stated earlier, two additional questions were<br />
tagged onto the PACIC items; whether the care<br />
should be provided for people with a chronic<br />
illness and, if so, by whom. <strong>The</strong> agreement that<br />
the types <strong>of</strong> care itemised should be provided was<br />
almost unanimous, with 15 <strong>of</strong> the 20 original<br />
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items and four <strong>of</strong> the seven new items receiving<br />
100% support. <strong>The</strong> lowest support was provided<br />
for the screening <strong>of</strong> whanau/family where appropriate,<br />
but only two respondents (2.2%) disagreed<br />
that this should be provided.<br />
In terms <strong>of</strong> who should be providing chronic<br />
illness care ‘both GPs and nurses’ was the<br />
predominant response. All but one <strong>of</strong> the items<br />
(number 16) received this response from at least<br />
50 (72.5%) <strong>of</strong> the nurses; 29 (32.6%) felt that it<br />
was the responsibility <strong>of</strong> both GPs and nurses<br />
to contact people after a visit to see how things<br />
were going, but 44 (49.4%) considered this to be<br />
for nurses rather than GPs to carry out. In general,<br />
support for the itemised types <strong>of</strong> care being<br />
specifically part <strong>of</strong> the nurse’s role ranged from<br />
1.4% to 60.3% (one to 53 respondents). Support<br />
for types <strong>of</strong> care being specifically part <strong>of</strong> the<br />
whether the types <strong>of</strong> self-management care covered<br />
by its items are being provided by nurses<br />
for the people with chronic illness whom they<br />
see in primary practice.<br />
From the MPACIC total score it was clear that<br />
the nurses in this study perceived themselves as<br />
providing a better level <strong>of</strong> care than the patients<br />
in previous studies have indicated that they are<br />
receiving. <strong>The</strong> mean score was higher than those<br />
found with the PACIC in research with patients<br />
with various chronic conditions, 8 with diabetes<br />
10,16,17 or with osteoarthritis. 13<br />
<strong>The</strong> importance <strong>of</strong> providing health care that is<br />
appropriate and sensitive to patients’ ethnicity<br />
through the cultural competence <strong>of</strong> practitioners<br />
is widely documented as a way <strong>of</strong> decreasing<br />
inequalities in health care and reducing health<br />
<strong>The</strong> Chronic Care Model promotes provision <strong>of</strong> chronic illness care<br />
that requires a transformation <strong>of</strong> the health care system in order to<br />
provide proactive care aimed at keeping people healthy rather than<br />
acute, reactive care provided once symptoms have taken hold and<br />
people are no longer managing<br />
GP’s role ranged from 0% to 4.5% (zero to four<br />
respondents) with the highest support indicated<br />
for the screening <strong>of</strong> family/whanau being part<br />
<strong>of</strong> the GP role, although another four (4.5%) felt<br />
it should be performed by nurses and 81 (91.0%)<br />
by both.<br />
Discussion<br />
<strong>The</strong> Chronic Care Model promotes provision<br />
<strong>of</strong> chronic illness care that requires a transformation<br />
<strong>of</strong> the health care system in order to<br />
provide proactive care aimed at keeping people<br />
healthy rather than acute, reactive care provided<br />
once symptoms have taken hold and people are<br />
no longer managing. <strong>The</strong> ACIC and PACIC<br />
instruments have been designed with patient<br />
self-management as a primary focus and this<br />
study has adapted the PACIC in order to assess<br />
disparities. 18–19 <strong>The</strong> additional seven items designed<br />
to address cultural sensitivity in chronic<br />
illness care appeared to work well and may add<br />
a useful dimension to measurement in this area<br />
where people <strong>of</strong> various ethnicities are part <strong>of</strong> the<br />
patient population.<br />
This paper has considered the individual items <strong>of</strong><br />
the MPACIC and has combined them as an overall<br />
scale. Subscale scores are reported in a separate<br />
paper. 20 Future work with a larger sample should<br />
be conducted to enable analysis <strong>of</strong> the potential<br />
factor structure <strong>of</strong> the items. Inclusion <strong>of</strong> other<br />
primary care practitioners such as general practitioners<br />
would also be advisable.<br />
<strong>The</strong> results <strong>of</strong> this first application <strong>of</strong> a modified<br />
PACIC suggest that the items can be used to<br />
assess chronic illness care provision by individual<br />
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health practitioners, and that the content <strong>of</strong> the<br />
items was considered an appropriate part <strong>of</strong> both<br />
nurses’ and general practitioners’ roles. Due to<br />
the small number <strong>of</strong> respondents we were unable<br />
to examine any underlying structure <strong>of</strong> the<br />
items and further work with a larger sample is<br />
needed with respect to this. <strong>The</strong> modified instrument<br />
may add useful information to that gained<br />
from application <strong>of</strong> the PACIC and ACIC when<br />
evaluating care provision for people living with<br />
chronic illness and could enable a comparison between<br />
the care practitioners consider themselves<br />
to be providing and that which patients report<br />
they are receiving.<br />
References<br />
1. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J,<br />
Bonomi A. Improving chronic illness care: translating evidence<br />
into action. Health Aff (Millwood). 2001;20(6):64–78.<br />
2. Bodenheimer T, Wagner EH, Grumbach. Improving<br />
primary care for patients with chronic illness. JAMA.<br />
2002;288:1775–1779.<br />
3. Si D, Bailie R, Cunningham J, Robinson G, Dowden, M, Stewart<br />
A, Connors C, Weeramanthri T. Describing and analysing<br />
primary health care system support for chronic illness care in<br />
Indigenous communities in Australia’s Northern Territory—<br />
use <strong>of</strong> the Chronic Care Model. BMC Health Services<br />
Research. 2008;8:112.<br />
4. Lester H, Gask L. Delivering medical care for patients with<br />
serious mental illness or promoting a collaborative model <strong>of</strong><br />
recovery? Br Journal <strong>of</strong> Psychi. 2006;188:401–402.<br />
5. Wales A. A national health knowledge network to support the<br />
patient journey. Health Inform Libraries J. 2008;25:99–102.<br />
6. Rea H, Kenealy T, Wellingham J, M<strong>of</strong>fitt A, Sinclair G, McAuley<br />
S, et al. Chronic care management evolves towards integrated<br />
care in Counties Manukau, <strong>New</strong> <strong>Zealand</strong> [Viewpoint].<br />
NZ Med J. 2007;120(1252):2489.<br />
7. Bonomi AE, Glasgow RE, Wagner EH, Von Korff M. Assessment<br />
<strong>of</strong> chronic illness care (ACIC): a practical tool for quality<br />
improvement. HSR. 2001;37:791–820.<br />
8. Glasgow RE, Wagner E, Schaefer J, Mahoney L, Reid R,<br />
Greene S. Development and validation <strong>of</strong> the Patient<br />
Assessment <strong>of</strong> Chronic Illness Care (PACIC). Med Care.<br />
2005;43:436–444.<br />
9. McIntosh CN. Examining the factorial validity <strong>of</strong> selected<br />
modules for the Canadian Survey <strong>of</strong> Experiences with Primary<br />
Health Care. Working Paper. Statistics Canada; 2008. [Cited<br />
2009 July 22]. Available from: http://dsp-psd.pwgsc.gc.ca/<br />
collection_2008/statcan/82-622-X/82-622-XIE2008001.pdf<br />
10. Glasgow RE, Whitesdies H, Nelson CC, King DK. Use <strong>of</strong><br />
the Patient Assessment <strong>of</strong> Chronic Illness Care (PACIC)<br />
with diabetic patients: relationship to patient characteristics,<br />
receipt <strong>of</strong> care, and self-management. Diab Care.<br />
2005;28(11):2655–2661.<br />
11. Wensing M, van Lieshout J, Jung HP, Hermsen J, Rosemann<br />
T. <strong>The</strong> Patient Assessment Chronic Illness Care (PACIC)<br />
questionnaire in <strong>The</strong> Netherlands: a validation study in rural<br />
general practice. BMC Health Serv Research. 2008;8:182.<br />
12. Aragones A, Schaefer EW, Stevens D, Gourevitch M N, Glasgow<br />
R E and Shaha NR. Validation <strong>of</strong> the Spanish translation<br />
<strong>of</strong> the Patient Assessment <strong>of</strong> Chronic Illness Care (PACIC)<br />
Survey. Prev Chronic Dis. 2008;5(4):A113.<br />
13. Rosemann T, Laux G, Droesemeyer S, Gensichen J, Szecsenyi<br />
J. Evaluation <strong>of</strong> a culturally adapted German version <strong>of</strong> the<br />
Patient Assessment <strong>of</strong> Chronic Illness Care (PACIC 5A)<br />
questionnaire in a sample <strong>of</strong> osteoarthritis patients. J Eval Clin<br />
Pract. 2007;13(5):806–13.<br />
14. Howden-Chapman P and Tobias M. Social inequalities in health:<br />
<strong>New</strong> <strong>Zealand</strong> 1999. Wellington: Ministry <strong>of</strong> Health; 2000.<br />
15. Ministry <strong>of</strong> Health. Improving Maori health: a guide for<br />
Primary Health Organisations. Wellington, NZ; 2004. [Cited<br />
2009 July 30]. Available from: http://www.moh.govt.nz<br />
16. Glasgow RE, Whitesides H, Nelson CC, King D K. Use <strong>of</strong><br />
the Patient Assessment <strong>of</strong> Chronic Illness Care (PACIC)<br />
with diabetic patients: relationship to patient characteristics,<br />
receipt <strong>of</strong> care, and self-management. Diab Care.<br />
2005;28(11):2655–2661.<br />
17. Szecsenyi J, Rosemann T, Joos S, Peters-Klimm F, Miksch<br />
A. German diabetes disease management programs are appropriate<br />
for restructuring care according to the Chronic Care<br />
Model: an evaluation with the Patient Assessment <strong>of</strong> Chronic<br />
Illness Care instrument. Diab Care. 2008;31(6):1150–1154.<br />
18. Fisher TL, Burnet DL, Huang ES, Chin MH, Kagney KA.<br />
Cultural leverage: interventions using culture to narrow<br />
racial disparities in health care. Med Care Res Rev.<br />
2007;64:243S–282S<br />
19. Paez KA, Allen JK, Carson KA, Cooper LA. Provider and<br />
clinical cultural competence in a primary care setting. Soc Sci<br />
Med. 2008;66(5):1204–1216.<br />
20. Carryer J, Budge C, Hansen C, Gibbs K. Providing and receiving<br />
self-management support for chronic illness: Patients’ and<br />
health practitioners’ assessments. JPHC. 2010; 2(2):124–129.<br />
ACKNOWLEDGEMENTS<br />
We wish to thank the<br />
MacColl Institute for<br />
permission to modify<br />
the PACIC. We also<br />
thank Dr John Spicer<br />
for his advice during the<br />
writing <strong>of</strong> this paper.<br />
FUNDING<br />
We thank the<br />
MidCentral DHB for<br />
funding this project.<br />
COMPETING INTERESTS<br />
None declared.<br />
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quantitative research<br />
Providing and receiving self-management<br />
support for chronic illness: Patients’ and<br />
health practitioners’ assessments<br />
Jenny Carryer RN, PhD, FCNA (NZ), MNZM; 1 Claire Budge PhD; 2 Chiquita Hansen RN, MPhil (Nursing); 2<br />
Katherine Gibbs RN, MMS 2<br />
1<br />
Massey University,<br />
Palmerston North,<br />
<strong>New</strong> <strong>Zealand</strong><br />
2<br />
MidCentral DHB,<br />
Palmerston North,<br />
<strong>New</strong> <strong>Zealand</strong><br />
ABSTRACT<br />
Introduction: Providing care for people with chronic illness is a major <strong>issue</strong> for health practitioners<br />
around the world, especially as populations age. Encouraging self-management is beneficial in terms <strong>of</strong><br />
relieving the burden on the health system and promoting better health and adherence to medication and<br />
advice amongst this group.<br />
Aim: To measure the level <strong>of</strong> self-management support being provided to and received by people living<br />
with chronic illness in a District Health Board (DHB) region.<br />
Methods: Self-report questionnaires (PACIC) were completed by 341 people living with chronic illness<br />
to measure the self-management support they receive from general practitioners and nurses. A modified<br />
version <strong>of</strong> the PACIC was used with 12 GPs and 77 primary health nurses in the same region to assess the<br />
provision <strong>of</strong> self-management support.<br />
Results: Patients’ assessments suggest that they are receiving intermittent self-management support<br />
for their chronic illness. A comparison <strong>of</strong> ratings <strong>of</strong> different health practitioners revealed that nurses<br />
were reported to be providing support more consistently than GPs. <strong>The</strong> health practitioners rated themselves<br />
as providing self-management support more <strong>of</strong>ten than the patients reported receiving it. Many<br />
clinicians also suggested that not all forms <strong>of</strong> support are appropriate for everyone, suggesting the need<br />
to tailor support to the individual.<br />
Discussion: Chronic illness support needs to be considered within the context <strong>of</strong> the individual and to<br />
be embedded in an ongoing relationship between the person and the provider. Findings highlight the benefits<br />
<strong>of</strong> a multidisciplinary team approach to self-management support and education in chronic illness care.<br />
KEYWORDS: Chronic disease; self care; primary health care; primary nursing care; physicians, family<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):124–129.<br />
Correspondence to<br />
Jenny Carryer<br />
Pr<strong>of</strong>essor <strong>of</strong> Nursing,<br />
School <strong>of</strong> Health<br />
and Social Services,<br />
Massey University,<br />
PB 11222 Palmerston<br />
North, <strong>New</strong> <strong>Zealand</strong><br />
J.B.Carryer@massey.ac.nz<br />
Introduction<br />
Chronic conditions have been identified by<br />
the World Health Organization as the twentyfirst<br />
century health care challenge due to the<br />
escalating incidence and the social and economic<br />
costs which accompany them. In 2006<br />
the NZ National Health Committee presented<br />
a report to the Minister <strong>of</strong> Health which<br />
outlined chronic conditions as a major driver<br />
for inequalities and an area where there were<br />
significant opportunities to review and revise<br />
the nature <strong>of</strong> service provision. 1 In line with<br />
international literature, a key component <strong>of</strong><br />
that advice was a move towards increasing the<br />
capacity <strong>of</strong> people with chronic illness to better<br />
understand and manage their own conditions.<br />
This has become variously known as<br />
self-management or self-care support.<br />
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Self-management has been defined as:<br />
1) engaging in activities that promote health, build<br />
physiologic reserve and prevent adverse sequelae; 2)<br />
interacting with health care providers and adhering<br />
to recommended treatment protocols; 3) monitoring<br />
physical and emotional status and making<br />
appropriate management decisions on the basis <strong>of</strong><br />
the results <strong>of</strong> self-monitoring; and 4) managing the<br />
effects <strong>of</strong> illness on the patient’s ability to function<br />
in important roles and on emotions, self-esteem and<br />
relationships with others. 2<br />
This suggests the need for self-management support<br />
from health pr<strong>of</strong>essionals, defined as ‘the<br />
systematic provision <strong>of</strong> education and supportive<br />
interventions to increase patients’ skills and confidence<br />
in managing their health problems, including<br />
regular assessment <strong>of</strong> progress and problems,<br />
goal setting, and problem-solving support’. 3<br />
<strong>The</strong> need for self-management is tw<strong>of</strong>old; firstly,<br />
engaging patients in the decisions and management<br />
<strong>of</strong> their condition(s) results in better<br />
adherence to medication, more positive health<br />
behaviours and better outcomes, even when<br />
treatment has proved ineffective, 4 and, secondly,<br />
self-management can reduce the strain on the<br />
health system <strong>of</strong> coping with the increasing<br />
level <strong>of</strong> chronic illness in the population. Selfmanagement<br />
is a core dimension <strong>of</strong> the Chronic<br />
Care Model 5 which is widely accepted in the US<br />
and around the world. Bodenheimer 6 suggests<br />
that the provision <strong>of</strong> self-management support<br />
requires a team approach to: giving information;<br />
teaching disease-specific skills; negotiating health<br />
behaviour change; providing training in problemsolving<br />
skills; assisting with the emotional impact<br />
<strong>of</strong> having a chronic disease; providing regular<br />
and sustained follow-up and encouraging active<br />
participation in the management <strong>of</strong> the disease.<br />
<strong>The</strong> aim <strong>of</strong> this study was to measure the level <strong>of</strong><br />
self-management support being provided for and<br />
received by people living with chronic illness in<br />
the MidCentral DHB region. Here we report on<br />
the completed first phase <strong>of</strong> a two-phase study.<br />
Phase one will be replicated 15 months later to<br />
assess naturally occurring developments in recognition<br />
that this is an area <strong>of</strong> ongoing learning and<br />
development for primary health care services.<br />
WHAT GAP THIS FILLS<br />
What we already know: Facilitating self-management is an important<br />
aspect <strong>of</strong> chronic illness care, both to decrease demands on the health<br />
system and to improve patient outcomes. Previous research has explored the<br />
support provided by health practitioners, but little consideration has been<br />
given to how the impact <strong>of</strong> that support might differ when provided by health<br />
practitioners from different disciplines.<br />
What this study adds: This study shows that nurses are perceived to<br />
provide more self-care support than GPs. A multidisciplinary team approach<br />
to the provision <strong>of</strong> chronic illness care is likely to best meet the needs <strong>of</strong> individuals<br />
living with chronic illness.<br />
Methods<br />
Sample<br />
In this study, two sets <strong>of</strong> data were collected; one<br />
from people living with one or more chronic illness/es,<br />
the other from general practitioners (GPs)<br />
and primary health nurses providing chronic<br />
illness care. <strong>The</strong> patient sample was recruited by<br />
sending letters <strong>of</strong> invitation; firstly to all who<br />
had attended any ambulatory chronic illness<br />
clinic during the previous 18 months, secondly<br />
via a company managing health services provided<br />
through Primary Health Organisations (PHOs)<br />
in the community, and thirdly through a Maori<br />
health provider. From these invitations we received<br />
400 expressions <strong>of</strong> interest. Surveys were<br />
sent out to this group and 341 usable forms were<br />
returned. This reflects a response rate <strong>of</strong> 85.3%<br />
from the expression <strong>of</strong> interest pool. For the clinician<br />
sample, letters <strong>of</strong> invitation and questionnaires<br />
were also sent to GPs and primary health<br />
nurses in the DHB and 89 were returned—77<br />
from nurses and the remainder from GPs.<br />
Materials and procedure<br />
<strong>The</strong> Patient Assessment <strong>of</strong> Chronic Illness Care<br />
(PACIC) 7 was used to measure self-management<br />
support. This 20 item self-report questionnaire<br />
was designed to evaluate five types <strong>of</strong> selfmanagement<br />
support representing five <strong>of</strong> the six<br />
aspects <strong>of</strong> the Chronic Care Model. <strong>The</strong> items<br />
have consequently been developed to provide a<br />
total scale and five subscales which, according to<br />
the authors, are defined as follows: Patient activation<br />
involves actions that solicit patient input and<br />
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involvement in decision-making; Delivery system<br />
design/Decision support includes actions that<br />
organise care and provide information to patients<br />
to enhance their understanding <strong>of</strong> care; Goal<br />
setting/Tailoring means acquiring information for<br />
and setting <strong>of</strong> specific collaborative goals; Problem<br />
solving/Contextual is represented by considering<br />
potential barriers and the patient’s social and<br />
cultural environment in making treatment plans;<br />
and Follow-up/Coordination involves arranging<br />
care that extends and reinforces <strong>of</strong>fice-based<br />
treatment, and making proactive contact with<br />
patients to assess progress and coordinate care. 7<br />
<strong>The</strong> PACIC requires respondents to rate the<br />
frequency with which certain types <strong>of</strong> care are<br />
provided on a 5-point scale ranging from ‘almost<br />
always’ to ‘almost never’, numerically scored as 5<br />
to 1 respectively.<br />
Two sample questions are:<br />
During the last 12 months when receiving care for<br />
my chronic illness, I was…<br />
…helped to make plans for how to get support from<br />
my friends, family or community.<br />
…sure that the health pr<strong>of</strong>essional thought about<br />
my values and my traditions when they recommended<br />
treatments to me.<br />
Scores are averaged to provide a total and subscale<br />
scores within the range <strong>of</strong> 1 to 5. With respect<br />
to internal consistency <strong>of</strong> the scales, Cronbach’s<br />
alphas have been reported to range between 0.77<br />
and 0.90. 7,8<br />
In the current study, participants were asked to<br />
rate two health pr<strong>of</strong>essionals; firstly, their GP<br />
Table 1. Comparison <strong>of</strong> mean PACIC and MPACIC subscale scores<br />
PACIC GP PACIC nurse MPACIC<br />
Patient activation 2.9 3.5 4.3<br />
Delivery system/practice design 3.1 3.7 3.8<br />
Goal setting/tailoring 2.3 3.2 3.8<br />
Problem solving/contextual 2.8 3.5 4.1<br />
Follow-up/coordination 2.6 2.9 3.8<br />
Total scale 2.7 3.3 4.0<br />
or practice nurse (whoever they felt to be most<br />
responsible for their day-to-day chronic illness<br />
care) and, secondly, another health pr<strong>of</strong>essional<br />
who they felt provided care in relation to their<br />
chronic illness/es. <strong>The</strong> PACIC, plus some health<br />
and demographic questions comprised the patient<br />
questionnaire which was posted out with a replypaid<br />
envelope to those who had responded to the<br />
letter <strong>of</strong> invitation. A reminder letter was sent<br />
to those who had not returned the questionnaire<br />
within a month.<br />
<strong>The</strong> health pr<strong>of</strong>essional questionnaire primarily<br />
consisted <strong>of</strong> a modified version <strong>of</strong> the PACIC,<br />
hereafter referred to as the MPACIC. <strong>The</strong> modification<br />
changed the question stem to fit the context<br />
<strong>of</strong> care provided rather than received in order<br />
to amend the questionnaire for use with health<br />
practitioners rather than patients. Questions<br />
about cultural sensitivity were also included.<br />
Further detail is provided elsewhere. 9<br />
Results<br />
<strong>The</strong> patients ranged in age from 23 to 93 with<br />
a mean age <strong>of</strong> 68.2. <strong>The</strong>re were slightly more<br />
men (189, 55.4%) than women; 270 (80.4%) were<br />
NZ European and 49 (14.6%) identified as Maori.<br />
Over half <strong>of</strong> the respondents (176, 58.8%) indicated<br />
they were living on less than $20,000 per<br />
annum. <strong>The</strong> chronic conditions listed were varied<br />
with just over a third <strong>of</strong> the sample (119, 35.2%)<br />
indicating they had only one condition, the other<br />
two-thirds living with two (112, 33.1%) to seven<br />
(20, 0.6%). <strong>The</strong> main conditions experienced,<br />
and the percentage <strong>of</strong> the sample affected were:<br />
cardiac (212, 62.7%), diabetes (136, 40.2%), respiratory<br />
(94, 27.8%) and pain (94, 27.8%). Ratings<br />
<strong>of</strong> the impact <strong>of</strong> their chronic illness on quality<br />
<strong>of</strong> life ranged from 0 to 10, thus representing the<br />
full scale where 0 represented no effect and 10<br />
an extreme effect, with a mean score <strong>of</strong> 6.4 and a<br />
mode <strong>of</strong> 8.0.<br />
Of the 341 patients, 307 (90%) provided ratings<br />
<strong>of</strong> a GP as health provider and 180 (52.8%)<br />
rated a nurse. As a number <strong>of</strong> participants rated<br />
both a nurse and a GP, the ratings could not be<br />
considered independent. <strong>The</strong>refore no inferential<br />
statistics are reported in this paper. <strong>The</strong> mean total<br />
and subscale scores for the patient ratings are<br />
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presented in columns two and three <strong>of</strong> Table 1.<br />
<strong>The</strong> possible range <strong>of</strong> score was 0 to 5 and it can<br />
be seen that the range reported was from 2.3 to<br />
3.7. A comparison reveals that nurses are rated<br />
more highly than GPs on all aspects <strong>of</strong> self-management<br />
support. <strong>The</strong> magnitude <strong>of</strong> the means<br />
shows that, on average, nurses are providing selfmanagement<br />
support sometimes to most <strong>of</strong> the<br />
time whereas GPs are generally not or sometimes<br />
providing it. <strong>The</strong> fourth column provides mean<br />
scores for the health pr<strong>of</strong>essionals’ ratings <strong>of</strong><br />
their own provision <strong>of</strong> self-management support.<br />
<strong>The</strong>y ranged from 3.8 to 4.3 (possible range 0 to<br />
5) and are notably higher than the patient ratings<br />
<strong>of</strong> the support they receive. It is also apparent<br />
from comparing the rank order <strong>of</strong> the subscale<br />
scores that the aspects <strong>of</strong> self-management support<br />
provided by nurses and GPs are similarly<br />
ordered with delivery system design being rated<br />
highest for both practitioner groups and patient<br />
activation second. <strong>The</strong> only difference was the<br />
reversal <strong>of</strong> placings for the two lowest rated<br />
aspects, goal setting and follow-up. A comparison<br />
with the MPACIC scores showed that health pr<strong>of</strong>essionals<br />
considered themselves to be providing<br />
the best support in the area <strong>of</strong> patient activation<br />
with problem solving scoring second. <strong>The</strong> other<br />
three aspects were all equally rated.<br />
One hundred and twenty-two participants<br />
provided ratings <strong>of</strong> both a GP and a nurse and,<br />
within these pairs <strong>of</strong> ratings, mean PACIC scores<br />
were 2.8 and 3.2 respectively. Although the participants<br />
were asked to provide ratings <strong>of</strong> care received<br />
from two health practitioners, not all had<br />
two to rate. To see whether those with two were<br />
better <strong>of</strong>f than those with one, a comparison was<br />
made between the one score <strong>of</strong> those participants<br />
with only one chronic care provider and the best<br />
score <strong>of</strong> those with two. Results showed that the<br />
mean score was 0.3 (on a 5-point scale) higher for<br />
those with two health practitioners, typically a<br />
GP and a nurse.<br />
<strong>The</strong> health practitioners were invited to add<br />
comments to their ratings and many <strong>of</strong> the comments<br />
focussed around the notion that the types<br />
<strong>of</strong> support listed are not all appropriate for every<br />
individual, and neither are they all appropriate to<br />
provide at every meeting. 9 For this reason many<br />
health pr<strong>of</strong>essionals were choosing to provide<br />
self-management support sometimes or mostly<br />
rather than nearly always. Care Plus was cited as<br />
being an ideal way to deliver self-management<br />
support.<br />
Discussion<br />
<strong>The</strong> patient data revealed a variety <strong>of</strong> reasons<br />
why this group required self-management support.<br />
Many were living with more than one<br />
chronic illness, which was having a pronounced<br />
affect on their quality <strong>of</strong> life, in impoverished<br />
circumstances. Pain was identified as being a<br />
problem for nearly a third <strong>of</strong> the participants.<br />
We previously found that patients were keen<br />
to achieve a sense <strong>of</strong> ownership <strong>of</strong> their condition<br />
and expressed a desire to understand, plan<br />
realistically and anticipate the course <strong>of</strong> their<br />
condition. 10 Much <strong>of</strong> this was expressed as a need<br />
to have their personhood rather than their illness<br />
At the heart <strong>of</strong> self-management support is<br />
the nature and quality <strong>of</strong> communication in<br />
clinical encounters and the best use <strong>of</strong> team<br />
members to provide aspects <strong>of</strong> care<br />
as the focus <strong>of</strong> clinical encounters. Literature on<br />
self-management identifies the need for relating<br />
to individuals in terms <strong>of</strong> their personal context<br />
including the particular capacity <strong>of</strong> each individual<br />
to manage changes and demands in their life.<br />
<strong>The</strong> scores on the various aspects <strong>of</strong> self management<br />
support, as identified by the subscale<br />
groupings, show remarkable consistency across<br />
the three sets. It appears that follow-up and goal<br />
setting are the areas <strong>of</strong> self-management support<br />
that are most in need <strong>of</strong> attention within the<br />
current system. At the heart <strong>of</strong> self-management<br />
support is the nature and quality <strong>of</strong> communication<br />
in clinical encounters and the best use <strong>of</strong><br />
team members to provide aspects <strong>of</strong> care. <strong>The</strong><br />
apparent difference between how GPs and nurses<br />
were rated by chronic illness patients in this<br />
study highlights the need for a team approach to<br />
providing self-management support. As noted by<br />
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Wagner, 11 much <strong>of</strong> what is needed is behavioural<br />
counselling, which may be considered outside<br />
the job description <strong>of</strong> most GPs and better suited<br />
to the nurse role in chronic care service delivery.<br />
Thus, if a proactive team-based approach<br />
is utilised, the patient should have access to a<br />
comprehensive range <strong>of</strong> primary health care clinicians<br />
who are well placed to complement the care<br />
provided by GPs and specialists.<br />
Our results suggested that, on average, patients<br />
receiving support from more than one practitioner<br />
rated the care they received more positively<br />
than those with less support. It may well be that<br />
they were being provided with different forms <strong>of</strong><br />
support from different practitioners, thus benefiting<br />
from exposure to a care team.<br />
<strong>The</strong> reported difference between the levels <strong>of</strong><br />
self-management support patients indicated they<br />
…self-management support needs to be<br />
embedded within an ongoing relationship<br />
between patient and health pr<strong>of</strong>essional;<br />
the same approach doesn’t suit everybody<br />
are receiving, and that which health pr<strong>of</strong>essionals<br />
consider themselves to be providing, is interesting.<br />
It may reflect an inconsistency between<br />
patients’ and health practitioners’ knowledge and<br />
beliefs about what constitutes care, and specifically<br />
self-management support. <strong>The</strong> findings<br />
also need to be viewed in light <strong>of</strong> the question<br />
that was being answered. Health practitioners<br />
were rating what they generally do in relation to<br />
chronic illness care; the patients were rating the<br />
self-management support they personally receive.<br />
A number <strong>of</strong> practitioners commented that some<br />
<strong>of</strong> the listed types <strong>of</strong> support were inappropriate<br />
for a number <strong>of</strong> clients or stated that they carried<br />
them out on occasion but not at every visit.<br />
This may be an example <strong>of</strong> Willis’s 12 definition<br />
<strong>of</strong> providing information which, he suggests,<br />
should not just be the transmission <strong>of</strong> facts but<br />
encompass ‘how other people have responded in<br />
a similar situation, what the impact may be on a<br />
patient’s lifestyle, or, based on our knowledge <strong>of</strong><br />
patients derived from being their family doctor,<br />
judging what they may consider appropriate’.<br />
This approach also aligns with the notion that<br />
self-management support needs to be embedded<br />
within an ongoing relationship between patient<br />
and health pr<strong>of</strong>essional; the same approach doesn’t<br />
suit everybody. 13 Enabling patients to incorporate<br />
self-management into their daily routines<br />
requires getting to know them in order to develop<br />
self-management plans collaboratively. 6 Similarly<br />
Willis 12 talked about the need for patients to have<br />
‘true autonomy’ defined as providing information<br />
they want or need, but in a form that they<br />
can understand, thus becoming partners and<br />
enabling them to self-govern. He used a rugby<br />
team analogy to highlight the importance <strong>of</strong> one<br />
person’s autonomy not being allowed to overcome<br />
another’s and this could be applied equally well to<br />
a chronic care team where the successful approach<br />
enables doctors, nurses, other health pr<strong>of</strong>essionals<br />
and patients themselves to exercise their autonomy<br />
both individually and as a team to achieve the<br />
most positive outcome for the patient.<br />
Care Plus was considered by the health pr<strong>of</strong>essionals<br />
sampled to be a useful vehicle for administering<br />
self-management support, primarily<br />
due to the time it made available for individual<br />
consultations. <strong>The</strong> programme was introduced<br />
for people with chronic conditions in July 2004,<br />
with the aims <strong>of</strong> improving chronic care management,<br />
reducing inequalities, improving primary<br />
health care teamwork and reducing service costs<br />
for high need primary care recipients. While<br />
Care Plus was not mentioned by our patient<br />
sample—perhaps because they were unaware <strong>of</strong><br />
their involvement in it—a national review <strong>of</strong> the<br />
Care Plus programme 14 found that patients felt<br />
their care to be better structured, appreciated<br />
the consultation focus on their chronic illness,<br />
had on average accessed four more consultations<br />
per annum than previously, and had mostly<br />
(80%) received a care plan. <strong>The</strong> review identified<br />
a number <strong>of</strong> barriers to the implementation <strong>of</strong><br />
Care Plus; for example remuneration, the need<br />
for extra nurses, and the space and time required,<br />
but concluded that most individuals (pr<strong>of</strong>essionals<br />
and patients) were generally supportive <strong>of</strong><br />
the programme. <strong>The</strong> few comments provided in<br />
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this study concerning Care Plus suggest that it is<br />
well regarded by those implementing it, but the<br />
extent to which it is deployed in the study region<br />
is patchy.<br />
Glasgow et al. 5 quote the adage ‘what gets measured<br />
gets done’ and that was one intention <strong>of</strong><br />
the current study. It was hoped that the process<br />
<strong>of</strong> responding to questions regarding self-management<br />
support would increase awareness <strong>of</strong><br />
what such support involves and encourage health<br />
pr<strong>of</strong>essionals to reflect on, and perhaps even<br />
alter, their behaviour. <strong>The</strong> planned phase two <strong>of</strong><br />
the study will provide the opportunity to assess<br />
developments.<br />
Limitations<br />
Although there may have been some link<br />
between the data sets as some <strong>of</strong> the patients<br />
involved in the study would have been receiving<br />
care from some <strong>of</strong> the health pr<strong>of</strong>essional<br />
participants, patients were not asked to identify<br />
who they were rating by name and doctors and<br />
nurses were not required to identify themselves.<br />
It would be useful in future research to link the<br />
sets <strong>of</strong> ratings in order to identify areas <strong>of</strong> selfmanagement<br />
support where there were apparent<br />
disparities between what health pr<strong>of</strong>essionals<br />
consider themselves to be providing and what<br />
patients feel they are receiving.<br />
8. Rosemann T, Laux G, Droesemeyer S, Gensichen J, Szecsenyi,<br />
J. Evaluation <strong>of</strong> a culturally adapted German version <strong>of</strong> the<br />
Patient Assessment <strong>of</strong> Chronic Illness Care (PACIC 5A) questionnaire<br />
in a sample <strong>of</strong> osteoarthritis patients. J Eval Clin Prac.<br />
2007;13:806–813.<br />
9. Carryer J, Budge C, Hansen C, Gibbs K. Modifying the PACIC<br />
to assess provision <strong>of</strong> chronic illness care: an exploratory study<br />
with primary health care nurses. J Primary Health Care. 2010;<br />
2(2):118–123.<br />
10. Carryer J, Snell H, Perry V, Hunt B, Blakey J. Long term conditions<br />
care in general practice settings: Patient perspectives.<br />
NZ Fam Physician. 2008;35:319–323.<br />
11. Wagner EH. <strong>The</strong> role <strong>of</strong> patient care teams in chronic disease<br />
management. BMJ. 2000;320:569–72.<br />
12. Willis, D. In search <strong>of</strong> true autonomy. J Primary Health Care.<br />
2009;1(2):152–153.<br />
13. Furler J, Walker C, Blackberry I, Dunning T, Sulaiman N,<br />
Dunbar J, Best J, Young D. <strong>The</strong> emotional context <strong>of</strong> selfmanagement<br />
in chronic illness: a qualitative study <strong>of</strong> the role<br />
<strong>of</strong> health pr<strong>of</strong>essional support in the self-management <strong>of</strong> type<br />
2 diabetes. BMC Health Serv Res. 2008;8:214.<br />
14. CBG Health Research. Review <strong>of</strong> the implementation <strong>of</strong> Care<br />
Plus. Wellington: Ministry <strong>of</strong> Health; 2006. [Cited 2009 July<br />
21]. Available from: http://www.moh.govt.nz/moh.nsf/<br />
pagesmh/5567/$File/review-implementation-care-plus.pdf<br />
15. Glasgow RE, Peeples M, Skovlund SE. Where is the patient<br />
in diabetes performance measures? Diabetes Care.<br />
2008;31(5):1046–1050.<br />
References<br />
1. National Health Committee. Meeting the needs <strong>of</strong> people<br />
with chronic conditions. [Internet]. Wellington, <strong>New</strong> <strong>Zealand</strong>:<br />
2007. [Cited 2009 July 22]. Available from: http://www.nhc.<br />
health.govt.nz/moh.nsf/pagescm/666/$File/meeting-needschronic-conditions-feb07.pdf<br />
2. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH.<br />
Collaborative management in chronic illness. Ann Intern Med.<br />
1997;127:1097–1102.<br />
3. Institute <strong>of</strong> Medicine. Priority areas for national action:<br />
transforming health care quality. Washington DC: National<br />
Academies Press; 2003. p 52.<br />
4. Horwitz RI, Horwitz SM. Adherence to treatment and health<br />
outcomes. Arch Intern Med. 1993;153:1863–8.<br />
5. Bodenheimer T, Wagner EH, Grumbach K. Improving<br />
primary care for patients with chronic illness. JAMA.<br />
2002;288(14):1775–1779.<br />
6. Bodenheimer T. A 63-year-old man with multiple cardiovascular<br />
risk factors and poor adherence to treatment plans. JAMA.<br />
2007;298(17):2048–2056.<br />
7. Glasgow R E, Wagner E, Schaefer J, Mahoney L, Reid<br />
R, Greene S. Development and validation <strong>of</strong> the Patient<br />
Assessment <strong>of</strong> Chronic Illness Care (PACIC). Med Care.<br />
2005;43:436–444.<br />
ACKNOWLEDGEMENTS<br />
We wish to thank<br />
the MacColl Institute<br />
for permission to<br />
modify the PACIC.<br />
FUNDING<br />
Thanks to MidCentral DHB<br />
for funding this project.<br />
COMPETING INTERESTS<br />
None declared.<br />
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quaLitative research<br />
Ever decreasing circles: terminal illness,<br />
empowerment and decision-making<br />
Kate Richardson MHealSci, PG Cert, BN; 1 Rod MacLeod PhD, FAChPM; 2 Bridie Kent PhD, BSc(Hons), RN,<br />
FCNA(NZ) 1<br />
1<br />
School <strong>of</strong> Nursing, Deakin<br />
University, Melbourne,<br />
Australia<br />
2<br />
Department <strong>of</strong> <strong>General</strong><br />
Practice and Primary Health<br />
Care, School <strong>of</strong> Population<br />
Health, <strong>The</strong> University<br />
<strong>of</strong> Auckland, Auckland,<br />
<strong>New</strong> <strong>Zealand</strong><br />
ABSTRACT<br />
Introduction: Empowerment is the personal and political processes patients go through to enhance<br />
and restore their sense <strong>of</strong> dignity and self-worth. However, there is much rhetoric surrounding nurses<br />
facilitating patients’ daily choices and enabling empowerment. Furthermore, there is frequently an imbalance<br />
<strong>of</strong> power sharing, with the patient <strong>of</strong>ten obliged to do what the health pr<strong>of</strong>essional wants them to do.<br />
Method: This phenomenological study describes the lived experience <strong>of</strong> patients attending an<br />
outpatient clinic <strong>of</strong> a community hospice. A qualitative study using Max van Manen’s phenomenological<br />
hermeneutic method was conducted to explore <strong>issue</strong>s surrounding empowerment and daily decisionmaking<br />
with terminally ill patients. <strong>The</strong> participants’ stories became a stimulus for learning about the<br />
complexities <strong>of</strong> autonomy and empowerment. It also engendered reflection and analysis <strong>of</strong> <strong>issue</strong>s related<br />
to power and control inequities in current nursing practices.<br />
findings: <strong>The</strong> results revealed not only the themes <strong>of</strong> chaoticum, contracting worlds and capitulation,<br />
but that health pr<strong>of</strong>essionals should be mindful <strong>of</strong> the level <strong>of</strong> control they exert. Within the palliative<br />
care setting they need to become partners in care, enhancing another person’s potential for autonomous<br />
choice.<br />
Conclusion: Empowerment must not be something that simply occurs from within, nor can it be done<br />
by another. Intentional efforts by health pr<strong>of</strong>essionals must enable terminally ill people to be able to stay<br />
enlivened and connected with a modicum <strong>of</strong> autonomy and empowerment over daily decisions, no matter<br />
how mundane or monumental they might be.<br />
KEYWORDS: Phenomenology; empowerment; autonomy; terminal care; decision-making<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):130–135.<br />
CORRESPONDENCE TO:<br />
Kate Richardson<br />
221 Burwood Highway,<br />
Burwood, Victoria<br />
3125, Australia<br />
katerichardson@xtra.co.nz<br />
Introduction<br />
<strong>The</strong>re has been little research conducted exploring<br />
terminally ill patients’ self-empowerment and<br />
decision-making within their day-to-day lives. 1<br />
Anecdotally terminally ill people tend to be treated<br />
as a homogenous group, as though they all suffer<br />
and behave in the same manner. 2,3 <strong>The</strong> end result<br />
is that the therapeutic relationship becomes a ‘one<br />
size fits all’ model, 1,4,5 which can leave the person<br />
and their family members feeling disenfranchised,<br />
frustrated and not listened to. 1 A terminally ill<br />
person’s day-to-day decisions may seem to others<br />
mundane and redundant, but being allowed to<br />
make them can <strong>of</strong>ten enable a person to continue to<br />
feel empowered, autonomous and self-willed. 6<br />
Decision-making by terminally ill adults has been<br />
described as a performance concerning autonomy<br />
that involves a variety <strong>of</strong> players. 7,8 <strong>The</strong> right to be<br />
autonomous and make decisions about their own<br />
lives is a commonly accepted ethical principle. 7<br />
However, pragmatic nursing styles that encourage<br />
‘doing for’ rather than maintaining a presence with<br />
a terminally ill person, tend to disable many autonomous<br />
decision-making abilities and processes. 8<br />
Empowerment is the personal and political processes<br />
patients go through to enhance and restore<br />
their sense <strong>of</strong> dignity and self-worth; 9 however,<br />
there is much rhetoric surrounding nurses facilitating<br />
patients’ daily choices and enabling empow-<br />
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erment. 10,5 Historically nurses have been taught<br />
about the importance <strong>of</strong> autonomy in patients, 11 yet<br />
it is debatable whether consideration <strong>of</strong> empowerment<br />
is truly incorporated into practice. While the<br />
idea <strong>of</strong> empowerment is naturally appealing, its application<br />
becomes weakened because <strong>of</strong> its abstract<br />
ambiguity. 6,4,12,13 Furthermore, there is frequently<br />
an imbalance in power sharing, with the patient<br />
feeling obliged to be humble, in the process left<br />
feeling humiliated and inconsequential. 14,15<br />
This paper reports the findings <strong>of</strong> a qualitative<br />
study with the aim <strong>of</strong> exploring <strong>issue</strong>s <strong>of</strong> empowerment<br />
and daily decision-making from the<br />
perspectives <strong>of</strong> people who are terminally ill.<br />
Method<br />
It was decided that qualitative methods, using<br />
a hermeneutic approach, 15 was the best way to<br />
achieve the aims <strong>of</strong> this study. Such an approach<br />
examines and reveals the language buried within<br />
the meanings <strong>of</strong> words. <strong>The</strong> participants’ stories<br />
allowed glimpses into the lived experience <strong>of</strong> the<br />
world <strong>of</strong> people diagnosed with terminal illness.<br />
Reflections <strong>of</strong> the ‘self’ were revealed along with<br />
the subjective nature <strong>of</strong> integrity, spirituality<br />
and wholeness, thereby enabling the activity <strong>of</strong><br />
phenomenological thinking. 15<br />
Phenomenology is described as ‘being in the moment’,<br />
<strong>of</strong> living the experience with someone else<br />
and discovering something worthy <strong>of</strong> recording. 15<br />
Phenomenology is a style <strong>of</strong> thinking, as well<br />
as a philosophy, and the intention is to describe<br />
or understand a moment in someone’s life by<br />
interpreting recollections. <strong>The</strong> most natural way<br />
<strong>of</strong> doing this is to narrate from lived experience.<br />
15 By being part <strong>of</strong> the narration process, the<br />
researcher refrains from judging and concluding<br />
what is right or wrong, but rather participates in<br />
the story. Phenomenology thus systematically<br />
attempts to uncover, describe and discover the<br />
nature or essence <strong>of</strong> the experience; in this case,<br />
<strong>of</strong> living with a terminal disease. 15<br />
Fourteen participants receiving palliative care<br />
were selected and recruited by a doctor at a community<br />
hospice and invited to participate in an individual<br />
interview between May and June 2005.<br />
Five males and six females agreed to participate in<br />
What gap this fills<br />
What we already know: Decision-making for people nearing the end <strong>of</strong><br />
life is difficult for a number <strong>of</strong> reasons. Despite improvements in communication<br />
and management near the end <strong>of</strong> life, patients and their families <strong>of</strong>ten<br />
feel disempowered, vulnerable and frustrated.<br />
What this study adds: Primary health pr<strong>of</strong>essionals need to work actively<br />
towards ways <strong>of</strong> empowering people who are dying by paying attention as<br />
much to the being aspects <strong>of</strong> care as to the doing aspects. Self-reflection and<br />
positive regard within the therapeutic relationship can enhance the experience<br />
for those who are dying.<br />
the study. Ten were Anglo-European and one was<br />
<strong>of</strong> Polynesian descent. <strong>The</strong> age range was from 48<br />
to 84 years. Cancer was the primary diagnosis for<br />
10 participants, with one having heart disease. All<br />
the participants came from one small geographical<br />
area <strong>of</strong> <strong>New</strong> <strong>Zealand</strong>. Face-to-face interviews were<br />
audiotaped (once consent was gained) and later<br />
transcribed verbatim by the researcher. All <strong>of</strong> the<br />
participants had died by the time the study was<br />
written up. Pseudonyms have been used to protect<br />
the identity <strong>of</strong> the participants.<br />
<strong>The</strong> steps that guide a study undertaken using Van<br />
Manen’s approach are summarised in Table 1. Transcribing<br />
<strong>of</strong> the interviews by the researcher enables<br />
immersion in the transcripts in order to understand<br />
abstraction and develop themes that reveal phenomena<br />
through the narratives <strong>of</strong> lived experience.<br />
A commitment was made to stay close to and intimate<br />
with the original data and this was achieved<br />
through total immersion in the text—reading, listening,<br />
re-reading and reliving the memories <strong>of</strong> the<br />
interview with each <strong>of</strong> the participants. Careful<br />
line-by-line analysis revealed common themes. 15<br />
Ethical approval was gained from the University<br />
<strong>of</strong> Otago Board <strong>of</strong> Graduate Studies, Community<br />
Hospice Ethics Committee, Lower South Regional<br />
Ethics Committee, Ngai Tahu and a member <strong>of</strong><br />
the Chinese community.<br />
Findings<br />
Three key themes were identified from the data.<br />
<strong>The</strong> first relates to participants’ lived space and<br />
was called ‘chaoticum’, as the participants lived<br />
within a chaotic and complex time in their lives. 15<br />
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<strong>The</strong> participants reported that their lives spiralled<br />
out <strong>of</strong> control after being given their diagnosis.<br />
<strong>The</strong> second theme relates to the lived body 15 and<br />
this was called ‘contracting worlds’; participants<br />
spoke <strong>of</strong> forfeiting normality as their worlds<br />
began shrinking around them in ever decreasing<br />
circles. <strong>The</strong> final theme relates to lived time 15 and<br />
was called ‘capitulation’ because the experiences<br />
revealed a time when the participants became<br />
submissive and acknowledged that their lives<br />
were coming to an end.<br />
Chaoticum<br />
<strong>The</strong> lived experience <strong>of</strong> the participants revealed<br />
a world that was, for them, a mixture <strong>of</strong> chaotic<br />
time and chaos. <strong>The</strong>ir worlds were freewheeling<br />
out <strong>of</strong> control, leaving little time to deal with<br />
things. Participants experienced disharmony,<br />
anger, disbelief, chaos and powerlessness, as this<br />
extract from the interview with Jane reveals:<br />
I’ve been given my life sentence; I know I’m going<br />
to die but it is the unknown. Am I going to get<br />
sick, what’s going to happen to me?”<br />
Sage talks about her total disbelief and anger at<br />
the doctor being honest about dying, thus capturing<br />
the conflicting emotions and needs at this<br />
time in her life:<br />
I was angry, I was bloody angry with the doctor<br />
when he told me I was going to die… I didn’t know<br />
where to start with things. <strong>The</strong>re seemed so little<br />
time to fix things you know.<br />
Table 1. Van Manen’s Phenomenology (Adapted from van Manen, 2002 23 )<br />
Two aspects <strong>of</strong> methodology<br />
1. <strong>The</strong> reduction: Bracketing or suspension <strong>of</strong> everyday ‘natural attitude’<br />
2. <strong>The</strong> vocation: Letting things ‘speak’ or be ‘heard’ through text<br />
Six empirical methods<br />
1. Describing experiences<br />
2. Gathering experiences<br />
3. Interviewing experiences<br />
4. Observing experiences<br />
5. Fictional experiences<br />
6. Imaginal experiences<br />
Furthermore, Jessica talks <strong>of</strong> living in a house<br />
that was very chaotic:<br />
It was a sick house. I would just lie on the floor…<br />
it was depressing because I couldn’t do anything<br />
about my life. We lived in a very sick messy chaotic<br />
house all <strong>of</strong> the time.<br />
Another participant, Bruce, appeared upset at the<br />
chaos that he had left for someone else to sort<br />
for him:<br />
<strong>The</strong>re is stuff at the house that someone else will<br />
have to sort because I don’t have the energy. <strong>The</strong>y<br />
will have to sort out the mess because for two<br />
months I haven’t had the energy to fix my life…<br />
Contracting worlds<br />
Participants described the way they had to give<br />
up things in their lives; the forfeitures, losses,<br />
decreasing circles and disempowerment that they<br />
experienced. Not only were their social lives contracting,<br />
but physically they were also suffering<br />
from contractures as their bodies started to change<br />
and shrink from their former self. This is captured<br />
by Virginia who felt very vulnerable and disempowered<br />
when she made trips to the clinician:<br />
I felt terribly disempowered in the hospital setting<br />
by the oncology doctors. Just going for a check up<br />
and I would come out and think God how am I supposed<br />
to keep my hopes up when there was such a<br />
grim sort <strong>of</strong> background, a feeling <strong>of</strong> abandonment<br />
and just the odd comments. I felt so very disempowered…<br />
Apart from hope. I don’t want them to<br />
take that away from me you know.<br />
Connie described how she maintained some semblance<br />
<strong>of</strong> normality as she tried to retain a belief<br />
that her world was not changing, by washing<br />
herself and undertaking other personal care:<br />
I don’t want others doing my personal stuff for me because<br />
that would mean that I was no longer a person…<br />
This is further reflected by Grace who commented:<br />
I got quite bitter for a while. This disease can let<br />
your bodily functions go a bit in front <strong>of</strong> people<br />
and I was disgusted.<br />
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Clearly, these participants resented the way their<br />
bodies were failing and wanted to continue to<br />
care for themselves for as long as possible.<br />
Capitulation<br />
<strong>The</strong> third theme captures the participants’ understanding<br />
that they were only temporally in the<br />
world. Participants found that the closer to death<br />
they got, the more submissive they became until<br />
they finally began to make those final end <strong>of</strong> life<br />
arrangements as reflected in Virginia’s words:<br />
<strong>The</strong>re are days that I feel like I have gone back<br />
several more steps and I have to rely a lot on others<br />
now because I don’t know when my body will give<br />
out. I feel like I have to wait on other people to do<br />
my ‘stuff’ and I feel quite powerless.<br />
Bruce grieves for the loss <strong>of</strong> his past life as he<br />
gave in to his inability to manage for himself:<br />
Two months ago I was still working and now look<br />
at me I am little more than a baby.<br />
Harry was also feeling a sense <strong>of</strong> giving-up when<br />
he commented:<br />
I hated hospital. <strong>The</strong>y (nurses) woke me up every<br />
two hours shining a torch in my eyes. I couldn’t<br />
sleep all week and I am not sure why because I<br />
wasn’t dying. I hated it and I am never going back<br />
because I couldn’t do what I usually do. You are just<br />
stuck there whether you like it or not.<br />
Whilst Jane describes accepting her terminality:<br />
I’ve just dealt with the thought <strong>of</strong> dying. Tomorrow<br />
the funeral director lady is coming. I know I have<br />
got to get some things in order.<br />
Discussion<br />
Individuals make decisions based on personal<br />
strategies and judgments, influenced by biases<br />
and rules, especially when there is an unknown<br />
future ahead. 6 Decision-making, therefore,<br />
is a complex and multifaceted phenomenon.<br />
It is difficult to deconstruct an individual<br />
person’s thoughts, feelings and behaviours and<br />
match them to the different facets <strong>of</strong> decisionmaking.<br />
2 This study has allowed the words <strong>of</strong> a<br />
small number <strong>of</strong> people living with a terminal<br />
illness the chance to describe their lived<br />
experience at a particularly challenging time in<br />
their lives. Each <strong>of</strong> these experiences, and the<br />
subsequent themes that emerged, emphasise<br />
the need for empowerment, especially during<br />
the last period <strong>of</strong> life, since individuals are<br />
more likely to make decisions based on the<br />
availability <strong>of</strong> information, on instances or<br />
recent occurrences. 15<br />
Recent research indicates that terminally ill people<br />
consistently perceive that they have a less active<br />
role in their daily decisions than they desire. 5<br />
Others start making valued judgements for them,<br />
especially health pr<strong>of</strong>essionals, because they are<br />
considered to be too vulnerable, less <strong>of</strong> a person,<br />
thought to have lost the ability to think or too<br />
sick to make choices. Terminally ill adults can<br />
make decisions and do so based on a broad range<br />
<strong>of</strong> factors, such as spirituality, values and beliefs,<br />
that subsequently influence how they respond to<br />
everyday challenges. 1<br />
<strong>The</strong>re has been much criticism concerning<br />
ethical decision-making over recent years 16 as<br />
bioethical discourse has focussed on the ideal,<br />
rather than what actually happens. Many<br />
ethicists believe that only rational or logical decisions<br />
are the right ones, but attention should<br />
also be paid to ‘what genuinely moves people<br />
to act, their motivations and passions, loves and<br />
hates, hopes and fears.’ 16 In this study, this is<br />
supported by Connie’s experiences when she<br />
commented:<br />
I didn’t want people deciding for me right up until I<br />
can no longer talk.<br />
Hunsaker Hawkins 16 suggests that small clinical<br />
aphorism and literary narratives can be a powerful<br />
vehicle for moral reasoning and transporting<br />
you deep into another person’s world for a brief<br />
time. Phenomenology allows both the narrator<br />
and the reader to be transported into the narrator’s<br />
world. 15<br />
This research reminds nurses <strong>of</strong> the importance<br />
<strong>of</strong> reflecting fully on how they can help meet the<br />
wishes <strong>of</strong> a person who is terminally ill. <strong>The</strong>re is<br />
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a need to ask and keep asking whilst also being<br />
prepared to listen.<br />
Each <strong>of</strong> the participants in this study wanted<br />
someone who was not constantly doing but rather<br />
listening or simply being there. This is aptly<br />
captured by Harry when he describes how he insisted<br />
that he keep to his daily schedule because<br />
without that he knew that he would just curl up<br />
and die:<br />
I didn’t want the nurses coming to my house and<br />
doing my washing or chores and I had to keep<br />
telling them this. If I want to walk half way across<br />
town with bags <strong>of</strong> laundry when the weather is<br />
wet then that’s what I want to do. <strong>The</strong>y kept trying<br />
to make me do things on their timetable but I had<br />
other ideas.<br />
When people are given a terminal diagnosis<br />
there is a point in the care continuum when<br />
these people feel abandoned by the biomedical<br />
model along with feeling a sense <strong>of</strong> not<br />
belonging. 17 Such people are different to many<br />
<strong>of</strong> our other patients because there are no<br />
happy endings, no cures or achievable health<br />
outcomes except for the desire and hope for a<br />
perceived good death. This study revealed that<br />
terminally ill patients want nurses to become a<br />
fully-engaged being when entering the therapeutic<br />
relationship, whilst at the same time to<br />
recognise that people who are dying are unique<br />
and unpredictable in terms <strong>of</strong> the connection<br />
and dependency within the nursing/patient<br />
relationship. 17<br />
Empowerment is central to decision-making<br />
and people who are seeking health care need to<br />
be enabled and empowered to make their own<br />
informed choices. 18 Health pr<strong>of</strong>essionals can<br />
never fully understand what the patient is going<br />
through, but they can ease the path by their<br />
own critical self-reflection, listening, intuitive<br />
caring and thought. 19 Illness and disease make<br />
people deviate from their chosen life path and<br />
typically the clinical world has its own customs<br />
and culture that can be difficult to understand.<br />
Throughout the terminal illness journey nurses<br />
should endeavour to enable people to remain<br />
informed and self-empowered. 17 Moral autonomy,<br />
according to Kant, is a combination <strong>of</strong> freedom<br />
and responsibility; a truly autonomous person<br />
cannot be subjected to the will <strong>of</strong> another. 6<br />
<strong>The</strong> findings from this study suggest that health<br />
pr<strong>of</strong>essionals need to think more about power and<br />
control <strong>issue</strong>s and explore how they can become<br />
partners in enhancing another person’s potential<br />
and autonomous choices. 6,8,10 Empowerment<br />
describes the intentional efforts to create a more<br />
equitable relationship and a living within someone<br />
else’s world. 19 How a patient exercises their<br />
empowerment and control depends on individual<br />
engagement, ability and ‘the adoption <strong>of</strong> a personvaluing<br />
approach’. 3<br />
For any moral engagement to work within a particular<br />
given time and space there has to be a comfortable<br />
social and emotional congruence driven<br />
by integrity and honesty. 1,20 Health pr<strong>of</strong>essionals<br />
must not be afraid to enter territory that is uncomfortable<br />
or unknown. <strong>The</strong>re needs to be open, unconditional<br />
positive regard shown towards every<br />
patient for whom we care. Finally, there must be<br />
empathic understanding or ‘sensitive active listening’<br />
not only to the person, but careful listening to<br />
what stories their body can tell us. 21<br />
This is summed up by Connie:<br />
I felt embarrassed and I found it very difficult I<br />
didn’t want other people touching me but when I<br />
got sicker you have to get over that and you can’t<br />
do it for your self so you have to let others do it<br />
for you. But I still don’t want other people making<br />
choices like what I am going to eat. I don’t want<br />
others picking out my food for tea for me.<br />
Limitations <strong>of</strong> this study<br />
<strong>The</strong> most significant and limiting factor was that<br />
most <strong>of</strong> the participants died before their transcripts<br />
could be transcribed and reviewed. This<br />
is a reality in all research where participants have<br />
terminal illness. However their stories are important<br />
and it is the engagement <strong>of</strong> the researcher<br />
with the participant that enables the revelation <strong>of</strong><br />
the essence <strong>of</strong> something. Phenomenology does<br />
not <strong>of</strong>fer the possibility <strong>of</strong> theory that looks at<br />
variables or controls. It does, however, <strong>of</strong>fer the<br />
plausible insights that bring us into contact with<br />
people’s lived experience, in and around us.<br />
134 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
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quaLitative research<br />
Research implications and<br />
recommendations<br />
<strong>The</strong>se findings highlight the need to critically<br />
reflect on practice in a rigorous manner on a daily<br />
basis. <strong>The</strong>y should serve to enlighten health<br />
pr<strong>of</strong>essionals’ internal and external practices and<br />
encourage engagement in self-analysis as truly<br />
caring beings. 22 It is necessary that health pr<strong>of</strong>essionals<br />
actively consider the concept and importance<br />
<strong>of</strong> empowerment. However, more research<br />
needs to be undertaken to understand strategies<br />
related to how empowerment works and the notion<br />
that ‘empowerment is undermined by the<br />
seduction <strong>of</strong> health-discourse so that the patient<br />
ends up wanting what the system wants them<br />
to want’ and who it works for. 10 Further study is<br />
also needed on the effectiveness <strong>of</strong> being instead<br />
<strong>of</strong> doing for our patients.<br />
Conclusion<br />
‘Phenomenology, like poetry, intends to be<br />
silent as it speaks. It wants to be implicit as it<br />
explicates.’ 15 When we enter the world <strong>of</strong> the<br />
patient and actively listen to them, we become<br />
accustomed to their manner <strong>of</strong> speaking, what is<br />
important to them and what individuates them at<br />
this particular point in time. Listening enables us<br />
to get under neath the surface <strong>of</strong> the individual<br />
and their experiences. By using van Manen’s<br />
approach to researching lived experiences, this<br />
study reinforces the importance <strong>of</strong> empowering<br />
those who are terminally ill to remain in control<br />
<strong>of</strong> their day-to-day decisions for as long as possible.<br />
<strong>The</strong> themes reflect key <strong>issue</strong>s that nurses<br />
should reflect on and learn from, so that, when<br />
caring for and working with the terminally ill<br />
patient, this fully engaged being requires different<br />
nursing skills because <strong>of</strong> the unique and<br />
unpredictable psychosocial terms <strong>of</strong> reference<br />
that nurses have to work within.<br />
For each <strong>of</strong> the participants, it was everyday<br />
decisions that concerned them greatly, not the<br />
big, life-changing ones. All <strong>of</strong> the participants<br />
wanted their experiences with a terminal illness<br />
to be their own and to be allowed to die<br />
in their personal way, thus enabling autonomy<br />
and rationality. A positive regard needs to be<br />
revealed before any therapeutic relationship can<br />
ensue. People who are terminally ill are unique<br />
and unpredictable in terms <strong>of</strong> the connection<br />
and dependency within any nursing relationship;<br />
therefore it is imperative that, between the<br />
carer and the cared for, empathic, intuitive, active<br />
listening occurs, resulting in empowerment, feelings<br />
<strong>of</strong> being valued and respected, and enabling<br />
the best possible death.<br />
References<br />
1. Gauthier DM. <strong>The</strong> contextual nature <strong>of</strong> decision-making in a<br />
home hospice setting. [Dissertation]. [Galveston]: University<br />
<strong>of</strong> Texas; 2001.<br />
2. Gilbert T. Nursing: empowerment and the problem <strong>of</strong> power. J<br />
Adv Nurs. 1995;21:865–71.<br />
3. Powers P. Empowerment as treatment and role <strong>of</strong> health<br />
pr<strong>of</strong>essionals. Amer Nurs Standard. 2003;26(3):227–238.<br />
4. Paterson B. Myth <strong>of</strong> empowerment in chronic illness. J Adv<br />
Nurs. 2001;34(5):576–81.<br />
5. Gauthier DM, Swigart VA. <strong>The</strong> contextual nature <strong>of</strong> decisionmaking<br />
near the end <strong>of</strong> life: hospice patients’ perspective.<br />
Amer J Hos Pal Care. 2003;20(2):121–8.<br />
6. Kant I. <strong>The</strong> critique <strong>of</strong> practical reason. Trans. Lewis White<br />
Beck. <strong>New</strong> York: Macmillan; 1788, 1985.<br />
7. Sahlberg-Blom E. Ternestedt M, Johanson J. Patient participation<br />
in decision-making at the end <strong>of</strong> life as seen by a close<br />
relative. Nurs Ethics. 2000;7:296–313.<br />
8. Beauchamp, TL, Childress, JF. Principles <strong>of</strong> biomedical ethics.<br />
4th ed. Oxford: Oxford University Press; 1994.<br />
9. McLean A. Empowerment and the psychiatric consumer/ex<br />
patient movement in the United States: contradictions, crisis<br />
and change. Soc Sci Med. 1995;40(8):1053–1071.<br />
10. Richardson K. Ever decreasing circles: non-curative terminal<br />
illness, empowerment and decision-making: lessons for<br />
nursing practice. A thesis submitted for the degree <strong>of</strong> Master<br />
<strong>of</strong> Health Science at the University <strong>of</strong> Otago, Dunedin, <strong>New</strong><br />
<strong>Zealand</strong>; 2005.<br />
11. Benner P, Wrubel J. <strong>The</strong> primary <strong>of</strong> caring: stress and coping in<br />
health and illness. Menlo Park: Addison-Wesley; 1989.<br />
12. Opie A. ‘Nobody’s asked me for my view’: users’ empowerment<br />
by multidisciplinary health teams. Qual Health Res.<br />
1998;8(2):188–206.<br />
13. Keiffer CH. Citizen empowerment: a developmental perspective.<br />
Prev Human Serv. 1984;3:201–26.<br />
14. Freire P. Pedagogy <strong>of</strong> the oppressed. London: Penguin Books;<br />
1970, 1972.<br />
15. Van Manen M. Researching the lived experience: human<br />
science <strong>of</strong> an action sensitive pedagogy. London: State University<br />
<strong>of</strong> <strong>New</strong> York Press; 1990. p 131.<br />
16. Hunsaker-Hawkins A. Stories and their limits: narrative approach<br />
to bioethics. Lindemann-Nelson H, editor. <strong>New</strong> York:<br />
Routledge; 1997.<br />
17. Dworkin G. <strong>The</strong> theory and practice <strong>of</strong> autonomy. Cambridge:<br />
Cambridge University Press; 1988.<br />
18. MacLeod RD. On reflection: Doctors learning to care for<br />
people who are dying. Soc Sci Med. 2001;52:1717–19.<br />
19. Cumbi SA. <strong>The</strong> integration <strong>of</strong> mind-body-soul and the practice<br />
<strong>of</strong> humanistic nursing. Holi Nurs Practice. 2001;15(3):56–62.<br />
20. Benner P. From novice to expert. California: Addison-Wesley;<br />
1984.<br />
21. Polkinghorne D. Narrative knowing and the human science.<br />
Albany: State University <strong>of</strong> <strong>New</strong> York Press; 1988.<br />
22. Montello M. Narrative competence. Stories and their limits:<br />
narrative approaches to bioethics. Lindemann-Nelson H, editor.<br />
<strong>New</strong> York: Routledge; 1997.<br />
23. Van Manen M. http://www.phenomenologyonline.com/<br />
inquiry/1.html 2002<br />
Acknowledgements<br />
<strong>The</strong> excerpts provided<br />
by the participants<br />
appear in K. Richardson’s<br />
Master <strong>of</strong> Health Science<br />
unpublished thesis,<br />
which is held at the<br />
University <strong>of</strong> Otago and<br />
the Otago Polytechnic.<br />
competing INTERESTs<br />
None declared.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 135
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quaLitative research<br />
Seeing patients first: creating an opportunity<br />
for practice nurse care?<br />
Tim Kenealy MBChB, PhD, FRNZCGP; 1 Barbara Docherty RN, Postgrad DipHlthSc (PHC); 2 Nicolette<br />
Sheridan RN, PhD; 2 Ryan Gao 3<br />
1<br />
Integrated Care Research<br />
Group, South Auckland<br />
Clinical School<br />
2<br />
School <strong>of</strong> Nursing<br />
3<br />
Medical student<br />
Faculty <strong>of</strong> Medical and Health<br />
Sciences, <strong>The</strong> University <strong>of</strong><br />
Auckland, <strong>New</strong> <strong>Zealand</strong><br />
ABSTRACT<br />
introduction: Practice nurses see patients in both a planned (i.e. scheduled appointment) and an<br />
unplanned (i.e. opportunistic) manner. This study aimed to investigate how <strong>of</strong>ten and why <strong>New</strong> <strong>Zealand</strong><br />
practice nurses see patients prior to the general practitioner and whether they organise their care to support<br />
unplanned, opportunistic activity.<br />
Method: National postal survey from a random sample <strong>of</strong> 500 general practices, requesting a response<br />
from one nurse per practice. Semi-structured telephone interviews with a purposeful sample <strong>of</strong><br />
respondents.<br />
FINDINGS: Responses came from 225 nurses (51% <strong>of</strong> practices confirmed to be eligible). Nearly all (92%)<br />
said their work role was the same as that <strong>of</strong> others in their practice. Only 13% <strong>of</strong> nurses routinely saw<br />
patients prior to the doctor, while 24% would choose to do so it they could, and 65% thought it important.<br />
Positive and negative aspects <strong>of</strong> seeing patients first are presented. Constraints included time, their role<br />
assisting practice workflow and perceptions <strong>of</strong> patient expectations. Few organised their work to create<br />
opportunities for lifestyle interventions.<br />
‘I was seldom able<br />
to see an opportunity<br />
until it had ceased<br />
to be one.’<br />
Mark Twain (1835–1910)<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):136–141.<br />
CORRESPONDENCE TO:<br />
Tim Kenealy<br />
Associate Pr<strong>of</strong>essor<br />
South Auckland<br />
Clinical School<br />
Middlemore Hospital<br />
PB 93311, Otahuhu,<br />
Auckland 1640,<br />
<strong>New</strong> <strong>Zealand</strong><br />
t.kenealy@auckland.ac.nz<br />
Conclusion: <strong>The</strong> current working environment <strong>of</strong> practice nurses in <strong>New</strong> <strong>Zealand</strong> does not readily<br />
support them routinely seeing patients before the general practitioner. We suggest this is a lost opportunity<br />
for patient-centred preventive care.<br />
KEYWORDS: Practice nursing roles; opportunistic interventions; work organisation; primary health<br />
care; chronic conditions<br />
Introduction<br />
Practice nurse (PN) work can be considered as<br />
planned and unplanned. Planned work includes<br />
chronic care management clinics and similar ways<br />
<strong>of</strong> organising care to include blocks <strong>of</strong> protected<br />
time to engage with patients in relatively systematic<br />
and prescribed programmes. Unplanned<br />
work includes responding to patient needs as they<br />
present, and proactively taking opportunities<br />
to engage patients on <strong>issue</strong>s which they did not<br />
present. It is this latter, opportunistic work that<br />
interests us in this study.<br />
Identifying and using opportunities effectively<br />
was the principle behind the Brief Opportunistic<br />
Interventions programme developed by author<br />
BD and others at <strong>The</strong> University <strong>of</strong> Auckland. 1<br />
During course feedback <strong>of</strong> this programme, most<br />
nurses stated that the best time to use these<br />
person-centred skills was by seeing the patient<br />
before the general practitioner (GP) (personal<br />
communication B Docherty, 2009). Putting aside<br />
the fact that 23% <strong>of</strong> children and 29% <strong>of</strong> adults<br />
see a PN per year without seeing a GP, 2 these<br />
nurses saw it as problematic that, when patients<br />
saw a GP prior to the PN, the GP <strong>of</strong>ten set the<br />
preventive care agenda prior to any opportunity<br />
for the PN to explore the patient’s agenda. One<br />
logical extension <strong>of</strong> such opportunistic activity<br />
would be for PNs to arrange their work to ensure<br />
that they routinely see every patient, ‘planning’<br />
to create an ‘opportunity’. We therefore sought to<br />
investigate if and when practice nurses can and<br />
do see patients first.<br />
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quaLitative research<br />
Methods<br />
A national postal survey was used to collect<br />
quantitative and qualitative data. Semi-structured<br />
interviews were conducted by telephone with a<br />
purposeful sample <strong>of</strong> survey respondents. Ethics<br />
approval was given by <strong>The</strong> University <strong>of</strong> Auckland<br />
Human Participants Ethics Committee (Reference<br />
number 206/381). In <strong>New</strong> <strong>Zealand</strong>, university<br />
ethics committees can approve studies <strong>of</strong> health<br />
care pr<strong>of</strong>essionals, while the Ministry <strong>of</strong> Health<br />
committees can approve studies with patients.<br />
Participants<br />
A contact list for general practices in <strong>New</strong> <strong>Zealand</strong><br />
was constructed from data held by the Department<br />
<strong>of</strong> <strong>General</strong> Practice and Primary Health<br />
Care and the Immunisation Advisory Service,<br />
both at <strong>The</strong> University <strong>of</strong> Auckland. <strong>The</strong> list contained<br />
1915 organisations presumed to be general<br />
medical practices, from which 500 were randomly<br />
selected using the rand() function in Excel, and<br />
sent one copy <strong>of</strong> the survey questionnaire. We<br />
requested one response from a practice nurse per<br />
practice. <strong>The</strong> sample size was chosen on the basis<br />
<strong>of</strong> available resources, anticipating a response rate<br />
<strong>of</strong> 60%, and was considered more than adequate<br />
for the simple descriptive statistics planned.<br />
Data collection: questionnaire<br />
<strong>The</strong> content <strong>of</strong> the questionnaire was developed<br />
initially based on feedback from nurse training<br />
courses run by author BD and from anecdotes<br />
and experience in primary care by author TK.<br />
Drafts were iteratively tested for content and<br />
face validity with a panel <strong>of</strong> 36 primary health<br />
care nurses.<br />
<strong>The</strong> final questionnaire, which can be found in Appendix<br />
1 in the web version <strong>of</strong> the paper, consisted<br />
<strong>of</strong> 20 closed questions and 11 open questions.<br />
<strong>The</strong> closed questions asked about practice nurse<br />
demographics, pr<strong>of</strong>essional qualifications, and<br />
preferences and practices. <strong>The</strong> open questions gave<br />
practice nurses the opportunity to expand on their<br />
answers and give examples. <strong>The</strong> questionnaires<br />
were tagged with a temporary identification code<br />
to track non-responders. <strong>The</strong> questionnaires were<br />
sent in December 2006, and a follow-up request<br />
was sent to initial non-responders in January 2007.<br />
WHAT GAP THIS FILLS<br />
What we already know: In <strong>New</strong> <strong>Zealand</strong> in 2006/7, 41% <strong>of</strong> adults saw a<br />
practice nurse in the previous 12 months and 85% attended a general practice.<br />
For practice nurses, this is largely for clinical care and planned, structured care.<br />
What this study adds: A minority <strong>of</strong> practice nurses routinely see patients<br />
before they see the doctor, or organise their work to routinely support<br />
unplanned, ‘opportunistic’ person-centred care.<br />
Name and address lists were stored independently<br />
<strong>of</strong> the questionnaires. Respondents were assured<br />
that they would not be identified in any report.<br />
Data collection: interviews<br />
Respondents to the postal questionnaire were<br />
also asked to provide their name and contact<br />
details if they were interested to take part in a<br />
follow-up telephone interview. From this group<br />
we purposefully selected 20 practice nurses to<br />
cover a range <strong>of</strong> age, ethnicity, employment and<br />
geography. <strong>The</strong> guide questions for the interview<br />
were developed following a preliminary analysis<br />
<strong>of</strong> the survey responses, and can be found<br />
in Appendix 2 in the web version <strong>of</strong> the paper.<br />
Questions were intended primarily to confirm<br />
our interpretation <strong>of</strong> the quantitative data. Written<br />
consent was obtained prior to each interview.<br />
<strong>The</strong> interviews lasted from 20 to 35 minutes,<br />
were digitally recorded and transcribed. We <strong>of</strong>fered<br />
interviewees the opportunity to view their<br />
transcript and to receive a copy <strong>of</strong> our report.<br />
Data analysis<br />
Quantitative data were entered and checked in<br />
Excel. Qualitative data from the questionnaires,<br />
together with the interviews, were entered into<br />
NVivo v7.0 for analysis. A general inductive approach<br />
was used for a thematic analysis 3 that was<br />
initially undertaken independently by authors<br />
TK, NS and BD, then confirmed and enriched<br />
by consensus.<br />
Results<br />
Questionnaires<br />
Five hundred questionnaires were sent out. Fiftysix<br />
proved ineligible (24 wrong address, general<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 137
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practice had ceased operating, or the organisation<br />
was not a general practice; and 32 practices had<br />
no practice nurses. <strong>The</strong>re were 225 responses<br />
giving a response rate <strong>of</strong> 225/444 (51%). <strong>The</strong>se<br />
225 individual practice nurses represented 225<br />
practices, with a total <strong>of</strong> 843 practice nurses<br />
and 802 GPs. Ninety-two percent said that their<br />
job was the same as that <strong>of</strong> the other nurses in<br />
the practice, or they were the only nurse in the<br />
practice. Descriptive statistics for respondents are<br />
in Table 1.<br />
Training in lifestyle behaviour change had been<br />
undertaken by 143 practice nurses (64%). Of<br />
these, most indicated condition-specific training<br />
such as for smoking cessation (46), diabetes (44),<br />
asthma (19) or exercise, weight management and<br />
nutrition (29), while only 38 described generic<br />
courses such as Brief Opportunistic Interventions<br />
training. 2<br />
<strong>The</strong> great majority <strong>of</strong> the nurses saw the positives<br />
and negatives <strong>of</strong> seeing patients first in purely<br />
transactional, workflow terms. <strong>The</strong>y could take<br />
very different attitudes to what appeared to be<br />
the same activities:<br />
Don’t believe I’m the slushy to do the observations.<br />
I have my own workload. (#102)<br />
Chance to get to know patients better, catch up<br />
with recalls, bloods etc. sometimes patients tell<br />
PN things they won’t tell GPs. Good interaction<br />
time. (#23)<br />
Responses are summarised in Table 2, which<br />
reflects responses from all the free text questions<br />
in the questionnaire. As in the quotations above,<br />
some <strong>of</strong> the comments contradict each other,<br />
presumably reflecting a variety <strong>of</strong> PN attitudes<br />
and work situations.<br />
When asked when it would be beneficial for<br />
PNs to see the patient first, 147 PNs replied,<br />
most giving several examples. <strong>The</strong> great majority<br />
<strong>of</strong> examples were activities relating to practice<br />
workflow—emergencies, patients arriving<br />
without an appointment or when the GP was<br />
fully booked or running behind time. Thirty<br />
PNs nominated activities that are shaped by<br />
a specific schedule <strong>of</strong> tasks—such as ‘diabetes<br />
checks’, ‘wellness checks’, ‘antenatal visits’, ‘new<br />
patient visits’—that, nevertheless could poten-<br />
Table 1. Describing the 225 practice nurses, one per practice<br />
Summary statistic<br />
Practice nurses per practice, median (range) 3 (1–24)<br />
GPs per practice, median (range) 3 (1–12)<br />
Hours worked by practice nurses, median (inter-quartile range) 32 (24–38)<br />
Age <strong>of</strong> practice nurses, median (inter-quartile range) 48 (43–53)<br />
Years as practice nurse, median (inter-quartile range) 10 (4–15)<br />
Years at current practice, median (inter-quartile range) 5 (2–10)<br />
Ethnicity, n (%) (missing data, 10)<br />
European/other 195 (91)<br />
Maori 14 (7)<br />
Pacific 4 (2)<br />
Asian 2 (1)<br />
Practice nurse has own appointment list 84%<br />
Practice nurse sees, prior to GP, patients with GP appointment<br />
Sees all patients 13%<br />
Would choose to do this if they could 24%<br />
Feels it is important to do this 65%<br />
Feels confident to do this 79%<br />
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tially be used to discuss lifestyle changes in a<br />
patient-centred manner. Seven PNs specifically<br />
noted the opportunity to engage in discussions<br />
and advice around patient lifestyle changes.<br />
Several specifically noted an advantage <strong>of</strong> their<br />
female gender:<br />
Most women are comfortable talking to another<br />
woman about menstrual, sexual, menopause problems.<br />
Some patients feel like they don’t want to<br />
waste doctor’s time so talk to nurse. (#84)<br />
Only two specifically noted their role dealing<br />
with mental health <strong>issue</strong>s:<br />
Depressed, embarrassed elderly woman needing<br />
reassurance. (#332)<br />
Interviews<br />
One hundred and thirty-two nurses indicated<br />
that they were willing to be interviewed, from<br />
which we selected 26. Of these, seven routinely<br />
saw all patients first and nine would choose to<br />
see all patients first if they could. Summary<br />
descriptions <strong>of</strong> the nurses interviewed are in<br />
Table 3.<br />
Perceptions <strong>of</strong> ‘usefulness’ were the principal<br />
drivers <strong>of</strong> whether practice nurses routinely saw<br />
patients prior to the GP.<br />
I can’t really see… practice nurses doing the consultations<br />
first before seeing [the doctor]. All I can do<br />
sometimes is… just take the occupation, height and<br />
weight, when they’re doing some… CVD assessment.<br />
But most <strong>of</strong> the time, there’s not much to do<br />
with them. (#452)<br />
Usefulness was primarily seen as an administrative<br />
role that would contribute to the workflow<br />
<strong>of</strong> the doctors…<br />
It saves the doctors time because we can do blood<br />
pressures weights and take temperatures, get a<br />
basic history before they see them, so they just<br />
need to quickly scan the notes and they’re already<br />
there. (#45)<br />
…and their workflow came secondary to the<br />
doctors’.<br />
Table 2. <strong>The</strong> positives and negatives <strong>of</strong> seeing patients prior to the GP: summary <strong>of</strong><br />
themes from free text in questionnaires<br />
Positives<br />
• Time efficient mostly stated as for GPs, practice and patients, occasionally for PNs<br />
• Continuity <strong>of</strong> care with PN<br />
• Reduction <strong>of</strong> GP workload and stress, all patients do not need to see GP<br />
• Screening, opportunistic education<br />
• Assists GP with essential history prior to GP consultation<br />
• PNs gain experience and educational opportunities<br />
• Increases PN confidence in clinical skills<br />
• Strengthens PN–patient relationships<br />
• Strengthens GP–PN relationship, GP recognises PN skills<br />
• Better care and outcomes for patients<br />
• Autonomy to triage and initiate first aid for emergency patients<br />
• Opportunity to use learned skills, e.g. brief interventions<br />
• Strengthens nursing holistic approach<br />
• More input from PN allows patients to utilise PN more<br />
• Patients more likely to talk to PNs and to be more ‘honest’<br />
• Assist in diagnosis and treatment <strong>of</strong> acute cases<br />
• Perception that PN is less busy than GP<br />
• Improves access for patients when PN service free<br />
• Establishes PN role with patients as independent health pr<strong>of</strong>essional<br />
Negatives<br />
• Patient has right to choose provider (autonomy)<br />
• Patient may want confidentiality or privacy<br />
• Patients may expect to see GP not PN<br />
• Total patient time in practice longer<br />
• Relationship is with the GP not the PN<br />
• Alters GP–patient relationship, PN undermining GP position<br />
• <strong>New</strong> way <strong>of</strong> working for patients, patient resistance<br />
• GP may not want patient to see the PN first<br />
• Patients seen twice and history-taking repeated<br />
• Time constraints, time waster<br />
• PN workload increased, PN already too busy<br />
• No financial reward for PN<br />
• Not cost-effective for practice or patient<br />
• Would reduce consultation time with PN and/or GP<br />
• Increase work hours and paperwork for both PNs and GPs<br />
• Not interesting enough, boring<br />
• PN training inadequate<br />
––<br />
––<br />
––<br />
––<br />
Misdiagnosis could occur<br />
Lack <strong>of</strong> confidence<br />
PN unable to assist in such areas as depression, complicated chronic<br />
management that requires GP input, counselling<br />
In some cases only GP is the suitable provider<br />
• Lack <strong>of</strong> suitable workplace space<br />
• Difficult if PNs working as receptionist<br />
• If only for follow-up…why bother?<br />
PN = practice nurse<br />
GP = general practitioner<br />
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A lot <strong>of</strong> wounds have to be seen by the GP only for<br />
claiming purposes and it’s a waste <strong>of</strong> time because<br />
you need to have the patient sitting around, you’re<br />
waiting for the GP to come in… (#457)<br />
<strong>The</strong> nurses might be ‘useful’ to patients by being<br />
time efficient with administrative <strong>issue</strong>s.<br />
…You’ll be doing some treatment type care for them<br />
and at the same time you’ll take note <strong>of</strong> their other<br />
health <strong>issue</strong>s like recalls and things like that that<br />
they might be due for… (#490)<br />
Nevertheless, there was considerable variation<br />
between nurses in what they saw as useful. Many<br />
saw themselves as never having anything useful<br />
to contribute by seeing patients first, while others<br />
each nominated a small number <strong>of</strong> specific<br />
medically-defined conditions—such as diabetes,<br />
asthma and sexual health—in which they felt<br />
sufficiently skilled and confident to see patients<br />
first. However, the skill list nominated by each<br />
nurse seemed very partial, implying that the<br />
medical conditions <strong>of</strong> the majority <strong>of</strong> patients<br />
could not be ‘matched’ by any one nurse.<br />
<strong>The</strong> nurses who preferred to see all patients<br />
first, however, saw their skills in more generic<br />
terms that were independent <strong>of</strong> specific medical<br />
conditions. <strong>The</strong>se nurses—a minority in both the<br />
questionnaires and interviews—spoke <strong>of</strong> their<br />
role forming and maintaining relationships with<br />
patients, and <strong>of</strong> sensing or seeking opportunities<br />
while performing administrative tasks.<br />
That’s an advantage <strong>of</strong> seeing the patients in the<br />
first place, by doing the weight and by doing the<br />
Table 3. Demographics <strong>of</strong> practice nurses (PNs) interviewed, n=26<br />
Age Median 46, range 32–62<br />
Ethnicity<br />
1 Asian<br />
18 European<br />
6 Maori<br />
1 Pacific<br />
Number <strong>of</strong> PNs in practice Median 3, range 1–12<br />
Type <strong>of</strong> practice<br />
1 Accident and Medical<br />
8 Rural<br />
17 Urban<br />
Years as PN Median 7, range 2–31<br />
Training in lifestyle behaviour change 17<br />
blood pressure and finding out if they’re smokers<br />
those are all the things that we do… we use every<br />
moment we can to educate. (#45)<br />
Most nurses gave a sense <strong>of</strong> being pressured and<br />
controlled by time. Nevertheless, the few nurses<br />
who routinely saw patients first gave a sense <strong>of</strong><br />
multi-tasking and using time, suggesting that<br />
time was the very thing they could <strong>of</strong>fer the<br />
patient that the doctor could not.<br />
We’re able to discuss those <strong>issue</strong>s because we’ve got<br />
more time than the doctors have. (#45)<br />
Frustrations with time pressure seemed more<br />
directed at patients and receptionists than doctors<br />
or the wider health system, and appeared to be<br />
accepted as inevitable.<br />
Nurse perceptions and presumptions about<br />
patient expectations also formed a powerful influence<br />
on whether they saw patients first (or at all).<br />
Nurses mostly took it for granted that patients<br />
<strong>of</strong>ten came specifically to see the doctor—and, by<br />
implication, not the nurse:<br />
I also don’t know how patients would react to seeing<br />
a nurse first if they’ve chosen to make a doctor’s<br />
appointment. (#397)<br />
…that patients had every right to do so:<br />
I feel that we’re taking away patients’ rights to a<br />
certain extent if we chose to do that role automatically.<br />
(#490)<br />
…that patients were entitled to privacy and confidentiality<br />
that might extend to the doctor but not<br />
the nurse:<br />
…<strong>The</strong>y want to wait until the doctor if they feel<br />
it’s something they don’t want to discuss, if they<br />
don’t want me to know they can leave it until<br />
they do see him. (#54)<br />
…and that nurses, doctors and patients probably<br />
share an implicit sense <strong>of</strong> when it was<br />
‘useful’ for the nurse to see the patient first.<br />
However, this may simply be a matter <strong>of</strong> patients,<br />
and nurses, becoming familiar with<br />
a new arrangement.<br />
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I have only one patient who has not wanted to see<br />
the nurse, out <strong>of</strong> all the thousands that we see<br />
there’s probably one guy who would rather just see<br />
the doctor. (#45)<br />
Discussion<br />
Nurses undertook work they considered ‘useful’,<br />
that they considered to be acceptable to patients,<br />
and within limits imposed by time pressure. As<br />
such, only 13% <strong>of</strong> practice nurses routinely saw<br />
all patients before they saw a GP, while 24%<br />
thought it desirable and 65% thought it important.<br />
PNs viewed seeing patients first largely<br />
as an administrative role to assist practice and<br />
GP workflow. A minority took a different view,<br />
seeing patients first because they saw themselves<br />
as <strong>of</strong>fering skills and a relationship that doctors<br />
did not <strong>of</strong>fer. While most nurses acknowledged<br />
that they could become involved in opportunistic<br />
discussions while engaged in clinical care, there<br />
was no sense <strong>of</strong> routinely or proactively creating<br />
such opportunities.<br />
A strength <strong>of</strong> this study is that we surveyed the<br />
<strong>entire</strong> country. <strong>The</strong> fact that 92% <strong>of</strong> respondents<br />
said their job is the same as that <strong>of</strong> the other<br />
nurses in the practice supports our strategy <strong>of</strong><br />
sampling one nurse per practice, as it suggests<br />
that the respondents may be similar to the<br />
nurses not sampled in the same practice. Nevertheless,<br />
our response rate <strong>of</strong> just over half calls<br />
for caution interpreting the results. We have<br />
no data to describe the practices from which we<br />
received no response.<br />
<strong>The</strong> nearest comparative data to our survey is<br />
from a recent evaluation <strong>of</strong> nursing developments<br />
in primary health, which included a national<br />
survey <strong>of</strong> PNs. 4 <strong>The</strong> response rate to their survey<br />
was only 34% and included 384 practice nurses.<br />
This evaluation made it clear that PNs around the<br />
country are increasingly taking up the (planned)<br />
activities involved in structure projects, 5 as was<br />
hoped and expected following <strong>The</strong> <strong>New</strong> <strong>Zealand</strong><br />
Health Strategy 6 and <strong>The</strong> Primary Health Care<br />
Strategy. 7 <strong>The</strong> increase in structured care by PNs<br />
is reflected in the current study, but it also seems<br />
clear from our work that the dedicated time devoted<br />
to structured care, reflected in the number<br />
<strong>of</strong> nurses with their own appointment list, is one<br />
<strong>of</strong> the barriers to PNs taking up unplanned, opportunistic<br />
activities.<br />
Given the perennial problem <strong>of</strong> patients spending<br />
‘too long’ in waiting rooms, we suggest<br />
that PNs routinely seeing patients first is an<br />
opportunity that is largely missed. Seeing<br />
patients first also represents an opportunity<br />
to pr<strong>of</strong>ile PNs, especially given findings that<br />
PNs are frequently anonymous and ‘invisible’<br />
to patients, and that patients can enormously<br />
value a personal pr<strong>of</strong>essional relationship with<br />
a PN. 8 In pr<strong>of</strong>iling PNs, seeing patients first<br />
would help break down one <strong>of</strong> the very barriers<br />
mentioned by our respondents, when they<br />
considered that some patients expect and prefer<br />
to see the doctor.<br />
A seminal paper that shaped the theory <strong>of</strong><br />
general medical practice proposed ‘opportunistic<br />
health promotion’ as one <strong>of</strong> four key dimensions<br />
<strong>of</strong> the ‘exceptional potential’ <strong>of</strong> the GP consultation.<br />
9 We suggest that the same opportunity can<br />
be taken or created within PN care, recognising<br />
that this needs appropriate training and working<br />
conditions that formally acknowledge and support<br />
this role.<br />
References<br />
1. McCormick R. Educating primary care providers about brief<br />
intervention—seven years <strong>of</strong> <strong>New</strong> <strong>Zealand</strong> experience (symposium<br />
abstract). Add Bio. 2005;10:205–18.<br />
2. Ministry <strong>of</strong> Health. A portrait <strong>of</strong> health. Key results <strong>of</strong> the<br />
2006/07 <strong>New</strong> <strong>Zealand</strong> Health Survey. Wellington: Ministry <strong>of</strong><br />
Health; 2008. Available from: http://www.moh.govt.nz/moh.<br />
nsf/indexmh/portrait-<strong>of</strong>-health<br />
3. Ryan GW, Bernard HR. Chapter 29: Data management and<br />
analysis methods. In: Denzin N, Lincoln Y, editors. Handbook<br />
<strong>of</strong> qualitative research. 2nd ed. Thousand Oaks, California:<br />
Sage Publications; 2000. p 769–802.<br />
4. Finlayson M, Sheridan N, Cummings J. Developments in<br />
primary health care nursing 2001–2007. In: Finlayson M,<br />
Sheridan N, Cumming J, editors. Wellington: Ministry <strong>of</strong><br />
Health; 2009. p 1–132.<br />
5. Finlayson M, Sheridan N, Cummings J. Evaluation <strong>of</strong> the implementation<br />
and intermediate outcomes <strong>of</strong> the primary health<br />
care strategy second report: nursing developments in primary<br />
health care 2001–2007. Wellington: Health Services Research<br />
Centre; 2009. p 1–104.<br />
6. King A. <strong>The</strong> <strong>New</strong> <strong>Zealand</strong> health strategy. Wellington: Ministry<br />
<strong>of</strong> Health; 2000. Available from: www.moh.govt.nz/nzhs.html<br />
7. King A. <strong>The</strong> primary health care strategy. Wellington: Ministry<br />
<strong>of</strong> Health; 2001. http://www.moh.govt.nz/moh.nsf/by+unid/<br />
7BAFAD2531E04D92CC2569E600013D04?Open<br />
8. Sheridan N, Kenealy T, Parsons M. Health reality show: regular<br />
celebrities, high stakes. NZ Med J. 2009;122(1301):31–42.<br />
9. Stott N, Davis R. <strong>The</strong> exceptional potential <strong>of</strong> each primary<br />
care consultation. J R Coll Gen Pract. 1979;29(201):201–5.<br />
ACKNOWLEDGEMENTS<br />
We wish to thank the many<br />
nurses who completed<br />
the questionnaires<br />
and interviews.<br />
Funding<br />
Ryan Gao was funded by a<br />
summer studentship from<br />
<strong>The</strong> University <strong>of</strong> Auckland.<br />
COMPETING INTERESTS<br />
None declared.<br />
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What influences practice nurses to<br />
participate in post-registration education?<br />
Anna Richardson MPH, RN; 1 Jeffrey Gage PhD, RN 2<br />
1<br />
School <strong>of</strong> Nursing<br />
and Human Services,<br />
Christchurch Polytechnic<br />
Institute <strong>of</strong> Technology (CPIT),<br />
Christchurch, <strong>New</strong> <strong>Zealand</strong><br />
2<br />
Health Sciences Centre,<br />
University <strong>of</strong> Canterbury,<br />
Christchurch, <strong>New</strong> <strong>Zealand</strong><br />
ABSTRACT<br />
Introduction: <strong>The</strong>re is a need for educated primary health nurses to develop their practice, educational<br />
and career pathways in response to opportunities emerging from the Primary Health Care Strategy<br />
(PHCS). This study aimed to explore the opportunities and constraints encountered by practice nurses<br />
when participating in post-registration education.<br />
Methods: This study used exploratory qualitative design, incorporating focus group interviews with 16<br />
practice nurses employed by Pegasus Health, Christchurch. Qualitative thematic analysis used a general<br />
inductive approach.<br />
Findings: Seven key themes emerged, including motivation to learn, enablers for learning and challenges<br />
to accessing education. Practice nurses also described their changing roles with clients and their<br />
vision for practice nursing in the future.<br />
Conclusion: This study considered accessibility <strong>of</strong> post-registration education for practice nurses<br />
and the extent to which they are embracing these opportunities in order to meet their practice needs.<br />
<strong>The</strong> PHCS states that primary health care nursing is crucial to its implementation. Successful expansion<br />
<strong>of</strong> primary health care nursing roles rests on the development <strong>of</strong> educational qualifications and skills,<br />
as well as career frameworks. It is envisaged that, with strong leadership and research skills resulting<br />
from pr<strong>of</strong>essional development, practice nurses will be more able to reduce health inequalities. Study<br />
findings indicate that practice nurses are rising to the challenge <strong>of</strong> expanding their roles and engaging in<br />
post-registration education. <strong>The</strong>y are more likely to pursue this if constraints are minimised and support<br />
increased. Currently practice nurses make significant contributions to primary health care and have the<br />
potential for an even greater contribution in the future.<br />
KEYWORDS: Nurses; practice nursing; nursing education, post-registration; <strong>New</strong> <strong>Zealand</strong><br />
J PRIMARY HEALTH CARE<br />
2010;2(2):142–149.<br />
CORRESPONDENCE TO:<br />
Anna Richardson<br />
Senior Lecturer, School<br />
<strong>of</strong> Nursing and Human<br />
Services, CPIT<br />
PO Box 540<br />
Christchurch Mail Centre<br />
Christchurch 8140<br />
<strong>New</strong> <strong>Zealand</strong><br />
richardsona@cpit.ac.nz<br />
Introduction<br />
In 2001 the <strong>New</strong> <strong>Zealand</strong> (NZ) Primary Health<br />
Care Strategy (PHCS) was launched. 1 <strong>The</strong> strategy<br />
provided a framework for the health sector<br />
with a focus on population health and addressing<br />
health inequalities <strong>of</strong>fering opportunities<br />
for nurses in primary health care to develop<br />
their practice, educational and career pathways.<br />
<strong>General</strong> practitioners have been employers <strong>of</strong><br />
practice nurses for many years. Working within<br />
a business model has been challenging to nurses<br />
seeking to establish a greater degree <strong>of</strong> autonomy<br />
<strong>of</strong> practice. 2 <strong>The</strong> Ministry <strong>of</strong> Health calls<br />
for governance and leadership opportunities for<br />
practice nurses. Nursing leadership in primary<br />
health care in NZ has had a history <strong>of</strong> being<br />
‘fragmented and devolved to individual primary<br />
health care providers’. 3 However, this situation<br />
has changed over time with District Health<br />
Boards (DHBs) and Primary Health Organisations<br />
(PHOs) recognising the need for nursing<br />
leadership at all levels. <strong>The</strong> Ministry <strong>of</strong> Health<br />
document Investing in Health: Whakatohutia<br />
te Oranga Tangata outlined a comprehensive<br />
framework in which nurses can have a key role<br />
in implementing the Primary Health Care Strat-<br />
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egy. 4 <strong>The</strong> strategy has highlighted opportunities<br />
for nurses to gain advanced nursing practice<br />
qualifications and to develop their roles. Nurses<br />
constitute the largest pr<strong>of</strong>essional group working<br />
in primary health care, yet their potential<br />
roles within the workforce remain unrealised. 5<br />
According to Jones, the Chief Nursing Advisor<br />
to the Ministry <strong>of</strong> Health, the ability <strong>of</strong><br />
practice nurses to communicate with people,<br />
work within the context <strong>of</strong> NZ families and<br />
understand the impact <strong>of</strong> the environment on<br />
their health are highly developed skills. 6 Jones<br />
questions whether practice nurses are equipped<br />
to practise more independently if a family or<br />
individual chose them as their primary health<br />
care pr<strong>of</strong>essional.<br />
<strong>The</strong>re is a critical need for a skilled and educated<br />
workforce to meet the challenging needs<br />
within primary health care. 4 <strong>The</strong> expectations<br />
for primary nursing to develop new roles in<br />
primary health care and to become increasingly<br />
autonomous require access to pr<strong>of</strong>essional<br />
development. Many practice nurses working in<br />
general practices may not wish to become nurse<br />
practitioners nor obtain a clinical postgraduate<br />
qualification, but want to gain the knowledge<br />
required for them to work in their unique role in<br />
the primary health care workforce. 7 This may be<br />
interdisciplinary education with a general practitioner<br />
or a short course with other practice nurse<br />
colleagues. However, Minto sees the future <strong>of</strong><br />
practice nursing as being more mobile, whereby<br />
nurses will visit patients in their homes, be more<br />
educated (most will have postgraduate education)<br />
and better paid. 2<br />
Several constraints to practice nurses’ ongoing<br />
pr<strong>of</strong>essional development are cited in the<br />
literature. First is the need for funding for<br />
pr<strong>of</strong>essional development in primary health care.<br />
Practice nurses have only been able to access<br />
funding from established streams, such as the<br />
Clinical Training Agency (CTA) since 2007. 8<br />
According to Pullon, ‘Primary Health Organisations<br />
have largely not considered practice nurse<br />
pr<strong>of</strong>essional development as their responsibility’.<br />
7 <strong>The</strong> funding shift from DHBs has enabled<br />
them to purchase postgraduate education for both<br />
primary health care nurses and hospital nurses.<br />
Some general practice employers have supported<br />
WHAT GAP THIS FILLS<br />
What we already know: Opportunities for nurses to extend their population<br />
health focus and an increased range <strong>of</strong> services in primary health care<br />
have been clearly identified in the Primary Health Care Strategy. <strong>The</strong>re is<br />
a need for well-educated primary health nurses with developing practice,<br />
educational and career pathways.<br />
What this study adds: This research identifies the constraints and opportunities<br />
experienced by practice nurses in furthering post-registration<br />
education and developing leadership roles in primary health care.<br />
practice nurse pr<strong>of</strong>essional development with<br />
contracts <strong>of</strong> up to five days a year to study; more<br />
<strong>of</strong>ten this study is undertaken in their own<br />
time and at their own cost. A further constraint<br />
in practice nurses obtaining study leave is that<br />
practice locums—<strong>of</strong>ten needed to cover the<br />
positions—can be difficult to find. <strong>The</strong> provision<br />
<strong>of</strong> short courses to acquire clinical skills for practice<br />
nurses may not lead to a qualification, as the<br />
courses may not be linked to the <strong>New</strong> <strong>Zealand</strong><br />
Qualifications Authority framework. 5 Also, the<br />
continual updating <strong>of</strong> specific practising certificates,<br />
such as vaccinators or smear takers, may<br />
lead to practice nurses focussing on these to the<br />
detriment <strong>of</strong> undertaking further pr<strong>of</strong>essional<br />
development.<br />
A growing body <strong>of</strong> literature explores practice<br />
nursing roles in Australia, NZ and the United<br />
Kingdom (UK). 9,10,11,12 Parker et al. 12 and Halcombet<br />
al. 10 note that significant developments have<br />
been made in NZ and the UK to advance primary<br />
health care nursing education and career pathways.<br />
However, in Australia there is no policy<br />
at a national level to prepare nurses for primary<br />
health care, nor a framework for education or<br />
career pathways. In a 2007 Australian survey<br />
the educational needs <strong>of</strong> practice nurses reflected<br />
their current roles, but did not address developing<br />
roles. 13 <strong>The</strong>re has been a call for the development<br />
<strong>of</strong> education and training programmes,<br />
supporting the need for a quality education and<br />
career framework for practice and other nurses in<br />
primary health care. 12,14 Since 2001, the potential<br />
for enhanced roles <strong>of</strong> NZ practice nurses has been<br />
recognised. 12 This includes responding to community<br />
need, developing leadership and models <strong>of</strong><br />
practice, holding governance positions in PHOs,<br />
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and developing a national career pathway for<br />
primary health care nurses.<br />
Methods<br />
An exploratory qualitative research design was<br />
implemented, using focus group interviews. Focus<br />
group interviews were selected for this study<br />
as their interactive nature allows the participants<br />
in a group to comment, explain, disagree,<br />
and share attitudes and experiences, providing<br />
rich perspective in the context in which events<br />
occur. 15,16 Ethical approval was obtained from<br />
Christchurch Polytechnic Institute <strong>of</strong> Technology<br />
and the <strong>New</strong> <strong>Zealand</strong> Health and Disability Ethics<br />
Committee in June 2008.<br />
<strong>The</strong> sample group was practice nurses employed<br />
by general practitioners <strong>of</strong> Pegasus Health Limit-<br />
Kreuger’s tape and note-based approach 18 was<br />
employed for analysis in conjunction with a fourstage<br />
approach guided by Boyatzis. 19<br />
Researchers first listened to the audiotapes then<br />
entered a process <strong>of</strong> reading, listening and summarising<br />
the raw data to identify multiple views<br />
and perceptions <strong>of</strong> participants and to recognise<br />
codable moments. 19 Codes were compared and<br />
examined for their potential to inadvertently reflect<br />
the researchers’ personal values and, finally,<br />
interpreted to contribute to the development <strong>of</strong><br />
knowledge. Finally, key information was identified<br />
and presented in seven themes.<br />
Methodological rigour was achieved through<br />
trustworthiness and authenticity criteria adapted<br />
from the work <strong>of</strong> Lincoln and Guba. 20 <strong>The</strong><br />
research plan was carefully documented, using<br />
In all focus groups, practice nurses identified several challenges to<br />
accessing education courses. <strong>The</strong>se included their employer<br />
supporting only ‘in-house education’, lack <strong>of</strong> assistance to get time<br />
<strong>of</strong>f work if the courses were held during the day, and finding<br />
appropriate courses relevant to practice nursing<br />
ed who had engaged in post-registration education<br />
at graduate (n=10) and postgraduate levels (n=6).<br />
Graduate education included formal learning at<br />
700 level and postgraduate, formal education at<br />
800 level. Practice nurses were selected by a convenience<br />
sampling approach; that is a sample <strong>of</strong><br />
the population that was readily available. Practice<br />
nurses were invited by letter to participate in the<br />
focus groups. To be suitable for inclusion, all practice<br />
nurses were working full-time, currently or<br />
previously engaged in post-registration education<br />
and employed by Pegasus Health (320). 17 Sixteen<br />
participants attended the focus group interviews.<br />
<strong>The</strong> moderator encouraged participant discussion<br />
but avoided leading the group to reinforce existing<br />
assumptions. In addition to the audiotaped<br />
data, notes were taken by the moderator during<br />
the discussions and participants were given opportunity<br />
to clarify their comments and ideas.<br />
the same data collection and analysis techniques<br />
utilised for all three focus groups. Preliminary<br />
results were mailed to participants inviting them<br />
to participate in the analysis by verifying or adding<br />
to the findings.<br />
Findings<br />
Specific demographic information <strong>of</strong> the nurses in<br />
the study is not provided due to ethical considerations<br />
<strong>of</strong> anonymity. However, the 16 participants<br />
were all women, whose ages ranged from 25 to 61<br />
years. Practice nursing experience ranged from<br />
three to five years (for three recently graduated<br />
nurses) and five to 25 years for the other 13 registered<br />
nurses. <strong>The</strong> majority <strong>of</strong> participants identified<br />
as European/Pakeha <strong>New</strong> <strong>Zealand</strong>er.<br />
Seven key themes emerged.<br />
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1. Motivation to learn<br />
In each focus group, all practice nurses talked<br />
about wanting to be better—‘to improve myself<br />
all the time’ to help people and feel efficient.<br />
<strong>The</strong>y wanted to be knowledgeable, using clinical,<br />
evidence-based knowledge to ‘deliver better<br />
practice’. <strong>The</strong> majority <strong>of</strong> participants talked<br />
about the personal satisfaction they gained from<br />
learning. <strong>The</strong>y recognised that ‘knowledge is<br />
power’, which enabled them to improve their<br />
nursing skills to benefit clients while providing<br />
the increased intellectual stimulation that accompanies<br />
learning. Eight participants mentioned the<br />
self-confidence gained by participating in courses.<br />
Seven practice nurses spoke <strong>of</strong> the enjoyment<br />
<strong>of</strong> networking and studying together, especially<br />
for solo practitioners. Developing clinical skills<br />
was important for 14 participants, engaging in<br />
learning that was particularly useful for practice.<br />
Several courses were mentioned: cervical smear<br />
taking, Appetite for Life (healthy eating programme),<br />
preceptorship <strong>of</strong> student nurses, clinical<br />
supervision, along with more formal education<br />
such as the Bachelor <strong>of</strong> Nursing transition programme<br />
and the Graduate Certificate in Nursing<br />
Practice. <strong>The</strong> practice nurses described a strong<br />
commitment to learning—‘I could be addicted<br />
to learning, if it didn’t cost so much and I didn’t<br />
have to complete assignments!’<br />
2. Enablers for learning<br />
Nine practice nurses described being in an atmosphere<br />
that helped motivate them to learn—in<br />
‘like minded groups’. <strong>The</strong>re was agreement in<br />
all focus groups that funding for nurse-related<br />
education that became available in 2007 via the<br />
CTA was ‘a huge barrier to break’ in increasing<br />
the affordability <strong>of</strong> formal study. This meant that<br />
practice nurses could be funded for the full cost<br />
<strong>of</strong> course fees, relief in practice and travel and<br />
accommodation expenses to attend courses, if an<br />
equivalent course was not available locally.<br />
In each focus group all practice nurses spoke<br />
about a difference between practice nurse education<br />
at a clinical level and the courses available at<br />
Christchurch Polytechnic Institute <strong>of</strong> Technology<br />
(CPIT) or university education. ‘It [postgraduate<br />
study] extends you as a registered nurse in the<br />
world’. CPIT graduate courses were described as<br />
being ‘so practical’ and ‘relating to practice nursing<br />
well’. <strong>The</strong> educational credits scheme, where<br />
practice nurses gain credits to access courses as<br />
payment for preceptoring nursing students was<br />
considered very helpful by most participants.<br />
Opportunities for education through Pegasus<br />
Health were mentioned by all focus groups. Full<br />
financial support to attend courses such as the<br />
Child and Adult Health Assessment <strong>of</strong>fered<br />
by CPIT, was a ‘turning point’ in their engagement<br />
in education. <strong>The</strong> funding <strong>of</strong> courses was<br />
described as a ‘massive reason why I have looked<br />
twice’ at child health assessment courses, motivational<br />
learning and diabetes courses. Participants<br />
mentioned the rewards <strong>of</strong>fered by Pegasus Health<br />
to attend group education sessions as enabling<br />
them to engage in study.<br />
3. Challenges to accessing education<br />
In all focus groups, practice nurses identified<br />
several challenges to accessing education courses.<br />
<strong>The</strong>se included their employer supporting only<br />
‘in-house education’, lack <strong>of</strong> assistance to get time<br />
<strong>of</strong>f work if the courses were held during the day,<br />
and finding appropriate courses relevant to practice<br />
nursing. Shortages <strong>of</strong> relieving nurses were<br />
mentioned by most participants as a challenge and<br />
weekend courses made it difficult to maintain the<br />
balance <strong>of</strong> family and work commitments.<br />
Six practice nurses mentioned the ‘steep learning<br />
curve’ <strong>of</strong> getting into academic writing, using a<br />
computer and managing the workload <strong>of</strong> master’s<br />
education. Two practice nurses spoke <strong>of</strong> ‘taking<br />
a sabbatical’ to engage in master’s study. <strong>The</strong>se<br />
challenges did not appear to demotivate the practice<br />
nurses to strive for learning. One mentioned<br />
that ‘being a solo practitioner’ prompted her<br />
personal learning and others were not deterred in<br />
finding appropriate courses, planning and budgeting<br />
for study.<br />
4. Negotiating with the employer<br />
Negotiating study leave with their employer was<br />
mentioned in all three focus groups. This included<br />
coming to agreement that the practice nurses<br />
engage in a course, the funding <strong>of</strong> the course and<br />
being uncomfortable asking for leave when they<br />
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had ‘already done a course that year’. Seven practice<br />
nurses spoke <strong>of</strong> creating some ‘buy in’ from<br />
the employer, so they needed to find courses<br />
which would benefit and were relevant to the<br />
practice. Some practices are run by managers and<br />
two practice nurses had cervical screening funded<br />
when they signed a bond to stay in the practice<br />
for a year following completion. Two practice<br />
nurses spoke <strong>of</strong> being so motivated to learn skills<br />
such as cervical screening that they paid for some<br />
<strong>of</strong> the course fees, with their employer funding<br />
the remainder.<br />
5. Changing clients<br />
All practice nurses described the changing client<br />
as a motivator for them to study. <strong>The</strong>y described<br />
clients in the twenty-first century as ‘well read<br />
and better informed’ and felt they ‘owed it to<br />
their clients’ to provide quality and up-to-date<br />
information. In each focus group practice nurses<br />
stated that clients may not be aware <strong>of</strong> the<br />
potential <strong>of</strong> practice nurses when they come into<br />
the practice and they would like to develop and<br />
market their skills to their client base.<br />
6. <strong>The</strong> changing role <strong>of</strong> the practice nurse<br />
<strong>The</strong>re was consensus that the practice nurse role<br />
had changed so much over the past eight years,<br />
emphasising new opportunities for practice<br />
nurses <strong>of</strong>fered by the PHCS. Changes included<br />
people being ‘put back into the community, with<br />
much more acute care required’ and that practice<br />
nurses are ‘expected to do much more’. This<br />
has motivated nurses to ‘catch up’ (researching<br />
current knowledge while in the workplace) and<br />
‘get involved in CPIT learning’. According to<br />
four participants, the role <strong>of</strong> the practice nurse<br />
has developed in the last 20 years, from being<br />
‘handmaiden’ to becoming ‘colleagues <strong>of</strong> the doctors’.<br />
<strong>The</strong>re was pride in their comments; practice<br />
nurses described themselves as ‘very sharp and go<br />
ahead’. In all focus groups participants spoke <strong>of</strong><br />
special projects that they are involved with such<br />
as ‘Care Plus’, a project for people with chronic<br />
illness and high health needs and ‘Services to<br />
Improve Access’ where the practice nurse and<br />
general practitioner can access funding to assist<br />
clients and families to access health care. <strong>The</strong>se<br />
projects were mentioned in terms <strong>of</strong> practice<br />
nurses becoming more innovative in their approach<br />
to reducing social inequalities. <strong>The</strong>re<br />
was also a change in emphasis in education for<br />
practice nurses, with the need to maintain their<br />
practising certificates through the development <strong>of</strong><br />
pr<strong>of</strong>essional portfolios. Some anticipated the day<br />
when practice nurses might be directly funded in<br />
their workplaces.<br />
7. Vision as a practice nurse/<br />
vision for practice nursing<br />
‘We are so valuable!’ one practice nurse stated,<br />
and there was consensus that practice nurses are<br />
increasingly working independently, alongside<br />
GPs. Ten participants spoke <strong>of</strong> conducting more<br />
nurse consultations, where the ‘nurse owns the<br />
consult’. This growing autonomy was described<br />
as more satisfying and rewarding for practice<br />
nurses—‘we have quite a bit <strong>of</strong> autonomy, depending<br />
on our employer’.<br />
‘Moving up a level’ was also described in terms<br />
<strong>of</strong> engaging in special projects, where the practice<br />
nurses felt they were maximising their skills.<br />
This included mentoring new graduates, running<br />
nurse-led clinics and leading consultations.<br />
Ten practice nurses spoke <strong>of</strong> wanting to lift their<br />
image <strong>of</strong> themselves, to be more confident in<br />
what they can <strong>of</strong>fer and acknowledgement <strong>of</strong> the<br />
income they bring into the practice. <strong>The</strong> manner<br />
in which practice nurses worked was discussed<br />
throughout the focus groups. Ten participants<br />
envisaged the development <strong>of</strong> the primary<br />
health care team, where comprehensive care was<br />
provided. One example included intersectoral collaboration,<br />
with a multidisciplinary health team<br />
in the same building with services such as Work<br />
and Income <strong>New</strong> <strong>Zealand</strong>.<br />
Discussion<br />
<strong>The</strong> 2001 PHCS signalled an increased emphasis<br />
on population health, community involvement,<br />
health promotion and illness prevention, with<br />
primary health care nurses being vital to the<br />
implementation <strong>of</strong> the strategy. 1 Practice nurses<br />
have responded to the challenge with considerable<br />
role development and have been key members<br />
<strong>of</strong> the primary health care team in addressing<br />
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inequality <strong>of</strong> health care and working with<br />
people with chronic disease. 21 According to Rolls,<br />
well-educated nurses can find solutions to health<br />
problems more comprehensively, promptly and efficiently<br />
than others, thus clients are <strong>of</strong>fered the<br />
best possible nursing care. 22 Sibbald et al. found<br />
in a systematic review <strong>of</strong> literature that in the<br />
provision <strong>of</strong> initial consultation and ongoing care<br />
<strong>of</strong> patients, nurses can provide as high a quality<br />
<strong>of</strong> care as general practitioners. 23 In controlled<br />
trials in the UK, practice nurses were shown to<br />
be cost-effective in generating health gains for<br />
patients, particularly in areas <strong>of</strong> screening and<br />
health promotion. 23 <strong>The</strong> focus group interviews<br />
captured participants’ enthusiasm and motivation<br />
for learning, particularly that which will enhance<br />
their clinical skills and health outcomes for<br />
clients and their families.<br />
Participants emphasised their enjoyment <strong>of</strong><br />
their primary health care nursing role, and their<br />
intention to extend their practice within the<br />
general practice interdisciplinary team. Collaborative<br />
practice was identified as a facilitator which<br />
served to extend the practice nurse role, where<br />
the unique role <strong>of</strong> the practice nurse and GP can<br />
be retained and overlaps be identified. 10,11,24,25<br />
Continuing pr<strong>of</strong>essional education is essential<br />
to develop the breadth <strong>of</strong> the practice nurses’<br />
experience and knowledge, to improve levels <strong>of</strong><br />
job satisfaction as well as health outcomes for<br />
consumers <strong>of</strong> primary health care. 24<br />
Participants clearly articulated that the funding<br />
was the key enabler that has assisted them to<br />
engage in post-registration education. <strong>The</strong> cost <strong>of</strong><br />
education can be a significant barrier to improving<br />
nursing education opportunities. Postgraduate<br />
fees for a 30 credit course in 2009 were $1456<br />
and $1935 at the Universities <strong>of</strong> Canterbury and<br />
Otago respectively. 26,27 Accommodation and travel<br />
are additional costs. 22 Pegasus Health has been<br />
proactive in enabling post-registration education<br />
for practice nurses in Christchurch. Pegasus<br />
Health has provided scholarships for practice<br />
nurses to engage in certificate and diploma<br />
courses provided by the Christchurch Polytechnic<br />
Institute <strong>of</strong> Technology.<br />
Several challenges were identified in the focus<br />
group interviews regarding access to postregistration<br />
education. This included discussion<br />
around practice nurses wanting ‘to have a life’,<br />
as well as working and studying. Issues such as<br />
practice nurse career pathways were commented<br />
on. In 2000 the NZ <strong>College</strong> <strong>of</strong> Practice Nurses<br />
developed a career and pr<strong>of</strong>essional development<br />
framework. 28 A uniform, national primary health<br />
care nursing education framework is essential for<br />
the development <strong>of</strong> primary health care nursing<br />
roles. 29 <strong>The</strong>re is no mandatory training, or core<br />
pr<strong>of</strong>essional competencies for practice nurses<br />
in NZ or Australia and the result is ‘unacceptable<br />
variations in the quality <strong>of</strong> practice’ seen<br />
in NZ. 12,24,29 A suggestion from participants was<br />
the establishment <strong>of</strong> an appraisal system for all<br />
practice nurses, to recognise work-related achievements<br />
and highlight pr<strong>of</strong>essional development<br />
goals. <strong>The</strong> Health <strong>Practitioners</strong> Competence Assurance<br />
Act (2003) requires registered nurses to<br />
Participants emphasised their enjoyment <strong>of</strong> their<br />
primary health care nursing role, and their<br />
intention to extend their practice within the<br />
general practice interdisciplinary team<br />
maintain their currency by engaging in ongoing<br />
education, with a minimum <strong>of</strong> 60 hours pr<strong>of</strong>essional<br />
development every three years.<br />
Participants identified negotiating pr<strong>of</strong>essional<br />
development time with their employer as an<br />
<strong>issue</strong>. <strong>The</strong> discussion included practice nurses<br />
gaining support from their employer to embark<br />
on study, agreement about its relevance to the<br />
practice, obtaining funding for upgrading skills<br />
and leave to engage in study. A report <strong>of</strong> nursing<br />
developments in primary health care from 2001<br />
to 2007 found that a majority <strong>of</strong> general practitioners<br />
encouraged practice nurses to increase<br />
their role and 75% reported that practice nurses<br />
had taken on an increased role. 21 <strong>The</strong> Health<br />
Workforce Advisory Committee is concerned<br />
that the general practitioner workforce is in<br />
significant decline in relation to the population<br />
<strong>of</strong> <strong>New</strong> <strong>Zealand</strong>. 30 Thus the expansion <strong>of</strong> the<br />
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practice nurse role could free up general practitioners’<br />
time and be more cost-effective for<br />
the practice. However, it might be necessary to<br />
establish some incentives for practice nurses to<br />
develop their extended roles and continue with<br />
post-registration education. <strong>The</strong>re was consensus<br />
that participants would like financial rewards for<br />
their educational achievements. Nurse leaders in<br />
NZ have suggested that the GP employment <strong>of</strong><br />
nurses should cease, and be replaced by a salaried<br />
model <strong>of</strong> employment by a PHO or DHB. 9 Providing<br />
financial incentives and recognition <strong>of</strong> the<br />
practice nurse’s extended roles has been recommended<br />
by Harrison et al. 31 Twelve participants<br />
spoke <strong>of</strong> wanting to see more acknowledgement<br />
from their GP employers as they felt they ‘have<br />
the qualifications’ but wanted to use their ‘full<br />
Participants’ visions for practice nursing did not<br />
necessarily include obtaining nurse practitioner<br />
status, as they felt that this role required intensive<br />
study and practice and they were not sure if this<br />
was adequately rewarded financially<br />
potential’ in primary health care. All participants<br />
commented on their engagement in nursing innovation<br />
projects, where they have been given<br />
the opportunity to deliver nursing care in new<br />
ways, such as release time to conduct community<br />
or home visits and delivering care for clients and<br />
families with chronic conditions. <strong>The</strong>se new<br />
models <strong>of</strong> care have been cited by participants as<br />
motivators to maintain currency and to engage in<br />
post-registration education.<br />
Participants’ visions for practice nursing did<br />
not necessarily include obtaining nurse practitioner<br />
status, as they felt that this role required<br />
intensive study and practice and they were not<br />
sure if this was adequately rewarded financially.<br />
However, there was a shared vision emerging,<br />
where clients and families were aware <strong>of</strong> and<br />
utilised their potential. Pullon states ‘it is time<br />
practice nurses had due recognition, not only <strong>of</strong><br />
their unique skill set, but also <strong>of</strong> their undis-<br />
puted and essential place in primary care teams<br />
in general practices’. 32 Working collaboratively<br />
in the practice team was valued by participants.<br />
<strong>The</strong> government has proposed the establishment<br />
<strong>of</strong> multidisciplinary, integrated family health<br />
centres that reflect the participants’ vision. 33<br />
Strengths <strong>of</strong> this study<br />
This study involved a review <strong>of</strong> the current literature<br />
on primary health care nursing roles and<br />
post-registration education. <strong>The</strong> 16 participants<br />
provided in-depth understanding <strong>of</strong> the influences<br />
that promoted their engagement in post-registration<br />
education. All participants highlighted<br />
how pr<strong>of</strong>essional development complemented<br />
their clinical expertise, enhancing application <strong>of</strong><br />
theory to practice.<br />
Limitations<br />
<strong>The</strong> qualitative approach <strong>of</strong> the focus group<br />
interviews and the small number <strong>of</strong> participants<br />
prevents generalisations being made to the larger<br />
population <strong>of</strong> practice nurses. Only practice<br />
nurses employed by Pegasus Health were interviewed<br />
and this excluded nurses who work for<br />
other organisations who might have a different<br />
experience <strong>of</strong> accessing post-registration education.<br />
<strong>The</strong> convenience sampling method may have<br />
led to response bias, whereby the group <strong>of</strong> practice<br />
nurses who volunteered for the study may<br />
not have educational experiences representative<br />
<strong>of</strong> the population as a whole. However, the lack<br />
<strong>of</strong> a local practice nurse register precluded other<br />
sampling techniques.<br />
Implications<br />
It is important that practice nurses are supported<br />
to develop their roles in primary health care. This<br />
includes provision <strong>of</strong> educational opportunities<br />
and the development <strong>of</strong> a career pathway and<br />
educational framework. Participants indicated<br />
that Pegasus Health has actively encouraged their<br />
pr<strong>of</strong>essional development and provided opportunities<br />
to overcome barriers to post-registration<br />
education.<br />
Given its qualitative nature, this research could<br />
only explore what influences practice nurses to<br />
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engage in post-registration education, and did<br />
not reflect views <strong>of</strong> practice nurses who are not<br />
interested in further education or improving<br />
their practice skills. Further research on postregistration<br />
education would assist in broadening<br />
the understanding <strong>of</strong> <strong>issue</strong>s for practice nurses<br />
and other primary health care nurses in NZ.<br />
<strong>The</strong> implementation <strong>of</strong> the PHCS has assisted<br />
practice nurses in fostering their role and encouraged<br />
ongoing pr<strong>of</strong>essional development. Practice<br />
nurses already do, and have potential to make an<br />
even greater contribution to primary health care<br />
in the future.<br />
References<br />
1. Ministry <strong>of</strong> Health. <strong>The</strong> primary health care strategy. Wellington:<br />
Ministry <strong>of</strong> Health; 2001.<br />
2. Minto R. <strong>The</strong> future <strong>of</strong> practice nursing. N Z Fam Physician.<br />
2006;33(3):169–172.<br />
3. MacKay BJ. Leadership development: Supporting nursing in<br />
a changing primary health care environment. Nurs Prax N Z.<br />
2006;18(2):18–22.<br />
4. Expert Advisory Group on Primary Health Care Nursing.<br />
Investing in health. Whakatohutia te Orange Tangata. Wellington:<br />
Ministry <strong>of</strong> Health; 2003.<br />
5. McKinlay EM. <strong>New</strong> <strong>Zealand</strong> practice nursing in the<br />
third millennium: Key <strong>issue</strong>s in 2006. NZ Fam Physician<br />
2006;33(3):162–168.<br />
6. Jones M. Practice nursing, some thoughts so far. <strong>The</strong> Practice<br />
Nurse. 2006;6(1):5–6.<br />
7. Pullon S. Toward a culture <strong>of</strong> supporting pr<strong>of</strong>essional development<br />
for primary care pr<strong>of</strong>essionals: A key component <strong>of</strong><br />
successfully implementing the primary health care strategy.<br />
NZ Fam Physician. 2008:31(4):267–270.<br />
8. Ministry <strong>of</strong> Health. Nursing developments in primary health care<br />
2001–2007. A summary. Wellington: Ministry <strong>of</strong> Health; 2009.<br />
9. Hoare KJ, Fairhurst-Winstanley W, Horsburgh M, Cormick R.<br />
Nurse employment in primary care—UK and <strong>New</strong> <strong>Zealand</strong>. NZ<br />
Fam Physician. 2008;35(1):28–31.<br />
10. Halcomb EJ, Davidson PM, Griffiths R, Daly J. Cardiovascular<br />
disease management: Time to advance the practice nurse<br />
role? Health Rev. 2008;32(1):44–55.<br />
11. Halcomb EJ, Davidson PM, Patterson E. Exploring the development<br />
<strong>of</strong> Australian general practice nursing. Where we have<br />
come from and where to from here? Contemporary Nurse.<br />
2007;26(1):145–153.<br />
12. Parker RM, Keleher HM, Francis K, Abdulwadud O. Practice<br />
nursing in Australia: A review <strong>of</strong> education and career pathways.<br />
BMC Nursing. 2009;8(5). Available from: http://www.<br />
biomedcentral.com/1472-6955/8/5.<br />
13. Pascoe T, Hutchinson R, Foley E, Watts I. <strong>The</strong> educational<br />
needs <strong>of</strong> nurses working in Australian general practices. Aus J<br />
<strong>of</strong> Advanced Nursing. 2007;24(3):33–38.<br />
14. Keleher H, Joyce CM, Parker R, Pitterman L. Practice nurses in<br />
Australia: current <strong>issue</strong>s and future directions. Med J <strong>of</strong> Austr.<br />
2007;187(2):108–111.<br />
15. Parahoo K. Nursing research: principles, process and <strong>issue</strong>s.<br />
London: Macmillan; 1997.<br />
16. Curtis E, Redmond R. Focus groups in nursing research. Nurse<br />
Researcher. 2007;14(2):25–37.<br />
17. Maw K, Nursing Facilitator Pegasus Health, Personal communication;<br />
22.9.09.<br />
18. Kreuger RA. Analysing and reporting focus group results.<br />
California: Sage Publications Inc.; 1998.<br />
19. Boyatzis RE. Transforming qualitative information. <strong>The</strong>matic<br />
analysis and code development. California: Sage Publications<br />
Inc.; 1998.<br />
20. Lincoln YS, Guba EG. Naturalistic inquiry. <strong>New</strong>bury Park: CA:<br />
Sage; 1985.<br />
21. Finlayson M, Sheridan N, Cumming J. Nursing developments<br />
in primary health care 2001–2007. Wellington:<br />
Ministry <strong>of</strong> Health. Accessed from: www.moh.govt.nz/<br />
moh.nsf/indexmh/primary-health-care-nursing-developments-2001-2007;<br />
2009.<br />
22. Rolls S. Removing the barriers to nursing education. NZ Nurs J.<br />
2005;10(11):26<br />
23. Sibbald B, Laurant MG, Reeves D. Advanced nurse roles in UK<br />
primary care. Med J <strong>of</strong> Austr. 2006;(185)1:10–12.<br />
24. Mills J, Fitzgerald M. Renegotiating roles as part <strong>of</strong> developing<br />
collaborative practice. Australian nurses in general practice<br />
and cervical screening. J Mulitidisciplinary Health Care.<br />
2008;1:35–43.<br />
25. Daly WM, Carnwell R. Nursing roles and levels <strong>of</strong> practice:<br />
a framework for differentiating between elementary,<br />
specialist and advancing nursing practice. J <strong>of</strong> Clin Nurs.<br />
2003;12(2):158–167.<br />
26. Drayton P, Administrator Health Sciences Centre, Canterbury<br />
University, Personal communication, 18.9.09.<br />
27. Helms R, Administrator Health Sciences Centre, Otago University,<br />
Personal communication, 21.9.09.<br />
28. <strong>New</strong> <strong>Zealand</strong> Nurses Organisation. NZ <strong>College</strong> <strong>of</strong> Practice<br />
Nurses NZNO career and pr<strong>of</strong>essional development framework.<br />
Wellington: NZNO; 2003.<br />
29. Docherty B, Sheridan N, Kenealy T. Painting a new picture<br />
for practice nurses in a capitated environment: who holds the<br />
brush? N Z Med J. 2008;121(1284):11–14.<br />
30. Health Workforce Advisory Committee (HWAC). Fit for<br />
purpose and for practice: a review <strong>of</strong> the medical workforce<br />
in <strong>New</strong> <strong>Zealand</strong>. Consultation document. Wellington:<br />
HWAC; 2005.<br />
31. Harrison S, Dowswell G, Wright J. Practice nurses and clinical<br />
guidelines in a changing primary health care context: an<br />
empirical study. J Adv Nursing. 2002;39:299–307.<br />
32. Pullon S. What is the place <strong>of</strong> general practice within primary<br />
health care—in the Aotearoa <strong>New</strong> <strong>Zealand</strong> context? N Z Fam<br />
Physician. 2008;35(5):301–303.<br />
33. Sheridan S, Finlayson M, Jones M. Position statement: primary<br />
health care nursing. J <strong>of</strong> Prim Health Care. 2009;1(2):95–96.<br />
ACKNOWLEDGEMENTS<br />
We wish to thank the<br />
Director <strong>of</strong> Nursing at<br />
Pegasus Health, Shelley<br />
Frost, Nursing Facilitator,<br />
Kelly Maw and Nursing<br />
Educator, Linda Collier for<br />
supporting this research<br />
project. Thank you to all<br />
the practice nurses who<br />
took time out <strong>of</strong> their<br />
busy lives to contribute<br />
to the focus groups.<br />
Thank you to academic<br />
colleagues who assisted<br />
in the research proposal.<br />
Funding<br />
This study was funded<br />
by the Christchurch<br />
Polytechnic Institute<br />
<strong>of</strong> Technology. Any<br />
views expressed in this<br />
paper are personal to<br />
the authors and are not<br />
necessarily the views <strong>of</strong> the<br />
Christchurch Polytechnic<br />
Institute <strong>of</strong> Technology.<br />
Competing interests<br />
None declared.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 149
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short report<br />
Are unexplained vaginal symptoms<br />
associated with psychosocial distress?<br />
A pilot investigation<br />
Andreas Cohrssen MD; 1 Uzma Aslam MD; 1 Allison Karasz PhD; 2 Matthew A Anderson MD 2<br />
1<br />
Department <strong>of</strong> Family<br />
Medicine, Beth Israel<br />
Hospital, <strong>New</strong>York, <strong>New</strong><br />
York, USA<br />
2<br />
Department <strong>of</strong> Family and<br />
Social Medicine, Montefiore<br />
Medical Center, Bronx, <strong>New</strong><br />
York, USA<br />
ABSTRACT<br />
Aim: Vaginal complaints cannot be definitively diagnosed in approximately one-third <strong>of</strong> women. We<br />
sought to determine if women without a diagnosis had higher levels <strong>of</strong> psychiatric disorders.<br />
Methods: This was an observational study in an urban family practice clinic. Prior to seeing a clinician,<br />
women with vaginal complaints completed the Patient Health Questionnaire (PHQ); symptoms were<br />
measured by the Vaginal Complaints Scale (VCS). Patients were then examined and treated by a family<br />
physician. At one and two weeks’ time patients were contacted by phone regarding symptom resolution<br />
and clinical outcomes.<br />
Results: We enrolled 47 patients; one patient was excluded. A diagnosis was made in 36. Eighteen<br />
had bacterial vaginosis, 16 had candida, three trichomonas, two HSV, one chlamydia; there were eight<br />
dual diagnoses. PHQ diagnoses were slightly less common in women without an identified cause for their<br />
symptoms. We obtained follow-up data from 45 subjects at one week and 34 subjects at two weeks’ time.<br />
At two weeks’ follow-up, 97% <strong>of</strong> subjects had complete resolution or improvement <strong>of</strong> their symptoms.<br />
Symptom improvement was equivalent among women with a diagnosis and those without. We estimate<br />
180 subjects would be needed to detect a clinically meaningful difference in PHQ diagnoses.<br />
Discussion: Our pilot study did not find an association between psychiatric diagnoses made by the<br />
PHQ and unexplained vaginal symptoms. Nearly all patients experienced rapid resolution <strong>of</strong> symptoms irrespective<br />
<strong>of</strong> whether a diagnosis had been made or not. <strong>The</strong>se findings are limited primarily by the small<br />
sample size.<br />
Keywords: Vaginitis; psychosocial stress; symptom resolution<br />
J PRIMARY HEALTH CARE<br />
2010;2(2):150–154.<br />
Correspondence to:<br />
Matthew Anderson<br />
3544 Jerome Ave.<br />
Bronx, NY 10467, USA<br />
bronxdoc@gmail.com<br />
Introduction<br />
Vaginal complaints are common in primary care,<br />
yet comprehensive microbiologic investigations<br />
fail to identify an aetiology in about one-third <strong>of</strong><br />
cases. 1–4 Factors other than known microbes and<br />
dermatological reactions must, therefore, play a<br />
role in the development <strong>of</strong> vaginal complaints.<br />
Since vaginal symptoms can have important<br />
social meanings, 5–8 some investigators have<br />
postulated a role for psychosocial stress in their<br />
genesis. A population-based survey in India<br />
concluded that psychosocial factors were strongly<br />
associated with complaints <strong>of</strong> vaginal discharge,<br />
while reproductive tract infections (RTI) were<br />
not. 8 This may reflect specific cultural ideas in<br />
India concerning leucorrhoea (white vaginal discharge).<br />
7,9 Chronic stress has been linked to vaginal<br />
candidiasis. 10,11 Studies on the role <strong>of</strong> stress in<br />
bacterial vaginosis have been contradictory. 12–14<br />
No study has examined the relationship between<br />
medically unexplained vaginal symptoms and<br />
psychosocial stress. To explore this relationship,<br />
we hypothesised that if unexplained symptoms<br />
resulted from psychosocial factors, then we<br />
would find higher levels <strong>of</strong> depression, somatisation,<br />
anxiety symptoms and psychosocial stress in<br />
patients who did not have an RTI when compared<br />
150 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
ORIGINAL SCIENTIFIC PAPErS<br />
short report<br />
to patients who did have an RTI. In addition, we<br />
evaluated the impact <strong>of</strong> a having made a specific<br />
diagnosis on the resolution <strong>of</strong> vaginal symptoms.<br />
Methods<br />
Subjects<br />
<strong>The</strong> study was conducted at an urban family practice<br />
clinic and residency training site. All women<br />
from 18 to 45 years presenting with vaginal complaints<br />
were eligible. Exclusion criteria included:<br />
fever; known diagnosis <strong>of</strong> gonorrhoea, chlamydia,<br />
or herpes; menstruation; and pregnancy. Women<br />
who had self-treated for vaginal symptoms were<br />
not excluded in order to assure a representative<br />
study population.<br />
Recruitment and consent<br />
Nurses queried all patients regarding their<br />
presenting problems. Patients with any vaginal<br />
complaints were referred to one <strong>of</strong> the authors<br />
(UA). Written informed consent was obtained<br />
from those who wished to participate.<br />
Study protocol<br />
Consenting patients completed a basic demographic<br />
survey, a sexual and contraceptive history,<br />
the Vaginal Complaints Scale (an 18-question survey<br />
designed by the authors) 15 and the depression,<br />
anxiety, somatisation, and stress sections <strong>of</strong> the<br />
self-report Patient Health Questionnaire (PHQ). 16<br />
Study patients were seen by their assigned clinical<br />
providers or by UA. All providers at the clinic<br />
are trained in the diagnosis <strong>of</strong> vaginitis. Resident<br />
physicians only examine patients under direct<br />
supervision <strong>of</strong> attending physicians. A pelvic<br />
examination was performed and a sample <strong>of</strong> the<br />
vaginal fluid obtained. <strong>The</strong> pH was measured, a<br />
whiff test performed, and the sample examined<br />
under a microscope using normal saline and potassium<br />
hydroxide (KOH). All specimens were reviewed<br />
by UA in addition to the primary clinician.<br />
Bacterial vaginosis (BV) was diagnosed using the<br />
Amsel Criteria. If microscopic examination did not<br />
reveal a definitive diagnosis, culture <strong>of</strong> yeast and<br />
T. vaginalis were obtained. Women were tested for<br />
gonorrhoea and chlamydia; physicians were free to<br />
order additional tests at their clinical discretion.<br />
What gap this fills<br />
What we already know: Vaginal complaints are very common in primary<br />
care, but a cause cannot be identified in one-quarter to one-third <strong>of</strong> women.<br />
Some evidence has suggested that psychosocial morbidity may account for<br />
unexplained vaginal symptoms.<br />
What this study adds: In this small pilot study, unexplained symptoms<br />
were not associated with measures <strong>of</strong> psychosocial distress. Most women<br />
experienced prompt relief <strong>of</strong> symptoms regardless <strong>of</strong> whether a diagnosis<br />
had been made or not.<br />
Patients with an identified microbe were treated<br />
by their primary care provider. Patients without<br />
a definitive diagnosis were either treated or not<br />
treated according to their provider’s assessment<br />
(typically based on the severity <strong>of</strong> symptoms or<br />
likelihood <strong>of</strong> disease on the basis <strong>of</strong> the pH or<br />
past history).<br />
Follow-up<br />
UA contacted subjects by phone at both one week<br />
and two weeks after initial presentation regarding<br />
symptom resolution, clinical outcomes, and<br />
any persistent patient concerns. Patients who<br />
remained symptomatic at the two-week follow-up<br />
call were referred for re-evaluation at the clinic.<br />
Infection with trichomonas or candida<br />
Reports indicating an RTI were returned to the<br />
primary care provider who initiated therapy for<br />
the patient and, when applicable, for their sexual<br />
partner(s).<br />
Positive screening for psychosocial <strong>issue</strong>s<br />
Patients with evidence <strong>of</strong> any mental disorder or<br />
family violence were <strong>of</strong>fered referral to a social<br />
worker.<br />
Data analysis<br />
Data was entered into an Access database and analysed<br />
using SPSS for Windows Version 15.0 s<strong>of</strong>tware.<br />
Group differences were evaluated with twotailed<br />
t-tests for independent samples or Fisher’s<br />
exact test. We analysed the vaginal symptom score<br />
using a hierarchical linear regression model with<br />
a random intercept at the individual level. Fixed<br />
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Table 1. Basic demographic data<br />
Age, mean, range<br />
Education<br />
Marital status<br />
Employment<br />
All patients<br />
n=46<br />
29.8<br />
[18–42]<br />
Diagnosis made<br />
n=36<br />
29.9<br />
[20–43]<br />
No diagnosis<br />
n=10<br />
29.6<br />
[18–40]<br />
<strong>College</strong> or advanced degree 31 23 8<br />
High school 11 9 2<br />
No high school 4 4 0<br />
Single 36 27 9<br />
Unwed couple 3 2 1<br />
Married 5 5 0<br />
Separated/divorced 2 2 0<br />
Employed outside home 32 25 7<br />
Student 7 5 2<br />
Not employed outside home 7 6 1<br />
Contraception ‡ OCP/ring 12 10 2<br />
IUD 2 2 0<br />
None 6 6 0<br />
Abstinence 4 1 3<br />
Condoms 18 13 5<br />
Depo-Provera 1 1 0<br />
Sterilisation 1 1 0<br />
No response 2 2 0<br />
Annual income ‡ >$40K–80K 11 8 3<br />
ORIGINAL SCIENTIFIC PAPErS<br />
short report<br />
basis <strong>of</strong> <strong>of</strong>fice tests (pH, microscopy, whiff test).<br />
Four additional diagnoses were made based on<br />
culture: one candida, one chlamydia and two<br />
herpes simplex (HSV). Taking into account both<br />
<strong>of</strong>fice diagnoses and culture, 15 women had BV<br />
alone, 13 women had candida alone, two women<br />
had trichomonas alone and two women had HSV.<br />
Four women had dual diagnoses: two with BV<br />
and candida, one with BV and chlamydia, and<br />
one with trichomonas and candida. No woman<br />
was diagnosed with a non-infectious cause <strong>of</strong><br />
vaginitis (contact dermatitis or allergic reactions).<br />
Ten patients (22%) were undiagnosed.<br />
Psychological distress and diagnosis<br />
Eleven women had diagnoses suggested from<br />
scoring the PHQ survey. Seven women had a<br />
single diagnosis: three had somatisation, two had<br />
minor depression and one each had panic and<br />
anxiety. Three women had dual diagnoses; one<br />
patient each had somatisation associated with either<br />
minor depression, major depression or panic<br />
disorder. One woman was diagnosed with minor<br />
depression, panic disorder, and anxiety. PHQ<br />
diagnoses were not more common in women<br />
without a medical diagnosis (Table 2).<br />
Symptom resolution<br />
We were able to contact 45 patients for follow-up<br />
at one week’s time (one lost to follow-up) and 33<br />
patients at two weeks’ time (13 lost to followup).<br />
At one week 21 (47%) patients had complete<br />
resolution <strong>of</strong> symptoms, 20 (44%) had partial<br />
resolution <strong>of</strong> symptoms and four (9%) reported no<br />
change in symptoms. At two weeks 22 (67%) were<br />
completely better, 10 (30%) were a little better<br />
and only one patient was no better. No patient reported<br />
that symptoms were worse at either time.<br />
Symptoms decreased markedly at the one week<br />
follow-up and decreased further at two weeks;<br />
these differences were statistically significant and<br />
occurred in both the diagnosis and non-diagnosis<br />
group. Differences in clinical resolution and<br />
symptom scores were not statistically different<br />
between the diagnosis and non-diagnosis groups.<br />
Table 2. Diagnoses and association with psychological distress<br />
Diagnosis<br />
Based on PHQ scoring<br />
We considered that three points on the Vaginal<br />
Complaints Scale represented a meaningful clinical<br />
difference. To have 80% power for detecting<br />
a difference <strong>of</strong> three using a two-tailed test with<br />
alpha = 0.05, and a correlation <strong>of</strong> zero between<br />
the baseline and follow-up measure would require<br />
91 people in each group.<br />
Discussion<br />
Women with a<br />
diagnosis (n=36)<br />
In this pilot study we failed to find increased<br />
levels <strong>of</strong> psychosocial distress in women with<br />
undiagnosed vaginal symptoms when compared<br />
to those who did have a diagnosis. Both groups <strong>of</strong><br />
patients experienced prompt symptomatic relief <strong>of</strong><br />
their symptoms. Thus, in terms <strong>of</strong> psychological<br />
distress and symptom resolution, patients in our<br />
study who went undiagnosed seemed indistinguishable<br />
from patients with a medical diagnosis.<br />
Our rate <strong>of</strong> non-diagnosis (22%) compares favourably<br />
to that reported in the medical literature as<br />
do our range <strong>of</strong> diagnoses. Our study is, however,<br />
limited by the small sample size, the convenience<br />
nature <strong>of</strong> the sample, relatively poor follow-up<br />
at two weeks (74%), and the fact that the PHQ is<br />
primarily a screening tool.<br />
<strong>The</strong> simplest explanation <strong>of</strong> our findings is that<br />
women without a medical diagnosis are reacting<br />
appropriately to bodily changes in the same way<br />
as women with an identified cause. This would<br />
suggest that there may be unidentified infectious<br />
pathogens or processes that are causing their<br />
symptoms. Another explanation is that psychosocial<br />
stress is causing them to over-react to normal<br />
bodily functions but that the levels <strong>of</strong> stress are<br />
equivalent to those <strong>of</strong> persons with symptoms<br />
caused by a pathogen. It may be that the PHQ<br />
Women without a<br />
diagnosis (n=10)<br />
Somatisation 5 (14 %) 1 (10%)<br />
Depression<br />
Depressive syndrome 4 (11%) 0<br />
Major depressive disorder 1 (3%) 0<br />
Panic syndrome 3 (8%) 0<br />
Anxiety syndrome 2 (5%) 0<br />
Women with any disorder 10 (24%) 1 (10%)<br />
Note: No significant differences noted in any comparison using Fisher’s exact test<br />
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short report<br />
Table 3. Clinical resolution at one and two weeks’ time post-visit<br />
All women With diagnosis Without diagnosis<br />
Completed interviews<br />
Total symptom score<br />
(mean, SD)<br />
Clinical resolution<br />
@ 1 week<br />
Clinical resolution<br />
@ 2 weeks<br />
At baseline 46 36 10<br />
At one week 45 36 9<br />
At two weeks 34 25 9<br />
Baseline 14.3 (6.4) 15.0 (6.4) 11.6 (5.7)<br />
At one week 5.2 (4.0) 5.8 (4.4) 3.1 (3.2)<br />
At two weeks 2.3 (2.8) 2.3 (2.4) 2.3 (3.8)<br />
Completely better 21 (47%) 17 (47%) 4 (44%)<br />
Somewhat better 20 (44%) 15 (42%) 5 (56%)<br />
Unchanged 4 (9%) 4 (11%) 0<br />
Worse 0 0 0<br />
Completely better 23 (68%) 18 (72%) 5 (56%)<br />
Somewhat better 10 (29%) 6 (24%) 4 (44%)<br />
Unchanged 1 (3%) 1 (4%) 0<br />
Worse 0 0 0<br />
Note: Clinical resolution at one and two weeks not significantly different by Fisher’s exact test. For symptom score see text.<br />
ACKNOWLEDGEMENTs<br />
Dr Clyde Schechter<br />
provided invaluable<br />
assistance with the<br />
statistical analysis<br />
<strong>of</strong> this paper.<br />
FUNDING<br />
Dr Aslam participated<br />
in this project as a<br />
Fellow <strong>of</strong> the <strong>New</strong> York<br />
State Empire Clinical<br />
Research Investigator<br />
Program (ECRIP).<br />
COMPETING INTERESTS<br />
None declared.<br />
test did not measure the psychological processes<br />
that might be responsible for symptoms. It is important<br />
to note that even had we found association<br />
between unexplained vaginal symptoms and<br />
psychological distress at the time <strong>of</strong> presentation<br />
this would not necessarily imply that the distress<br />
caused the symptoms.<br />
Since one-quarter to one-third <strong>of</strong> women in<br />
primary care with vaginal symptoms go undiagnosed,<br />
a better understanding <strong>of</strong> their symptoms<br />
remains an important problem in primary care.<br />
References<br />
1. Schaaf VM, Perez-Stable EJ, Borchardt K. <strong>The</strong> limited value<br />
<strong>of</strong> symptoms and signs in the diagnosis <strong>of</strong> vaginal infections.<br />
Arch Intern Med. 1990;150(9):1929–1933.<br />
2. Berg AO, Heidrich FE, Fihn SD, Bergman JJ, Wood RW,<br />
Stamm WE et al. Establishing the cause <strong>of</strong> genitourinary<br />
symptoms in women in a family practice. Comparison <strong>of</strong><br />
clinical examination and comprehensive microbiology. JAMA.<br />
1984;251(5):620–625.<br />
3. Mayaud P, ka-Gina G, Cornelissen J, Todd J, Kaatano G, West B<br />
et al. Validation <strong>of</strong> a WHO algorithm with risk assessment<br />
for the clinical management <strong>of</strong> vaginal discharge in Mwanza,<br />
Tanzania. Sex Transm Infect. 1998;74 Suppl 1:S77–S84.<br />
4. Bornstein J, Lakovsky Y, Lavi I, Bar-Am A, Abramovici H. <strong>The</strong><br />
classic approach to diagnosis <strong>of</strong> vulvovaginitis: a critical analysis.<br />
Infect Dis Obstet Gynecol. 2001;9(2):105–111.<br />
5. Karasz A, Anderson M. <strong>The</strong> vaginitis monologues: women’s<br />
experiences <strong>of</strong> vaginal complaints in a primary care setting.<br />
Soc Sci Med. 2003;56(5):1013–1021.<br />
6. O’Dowd TC, Parker S, Kelly A. Women’s experiences <strong>of</strong> general<br />
practitioner management <strong>of</strong> their vaginal symptoms. Br J<br />
Gen Pract. 1996;46(408):415–418.<br />
7. Trollope-Kumar K. Cultural and biomedical meanings <strong>of</strong> the<br />
complaint <strong>of</strong> leukorrhea in South Asian women. Trop Med Int<br />
Health. 2001;6(4):260–266.<br />
8. Patel V, Pednekar S, Weiss H, Rodrigues M, Barros P, Nayak B<br />
et al. Why do women complain <strong>of</strong> vaginal discharge? A population<br />
survey <strong>of</strong> infectious and pyschosocial risk factors in a<br />
South Asian community. Int J Epidemiol. 2005;34(4):853–862.<br />
9. Rashid SF. Durbolota (weakness), chinta rog (worry illness),<br />
and poverty: explanations <strong>of</strong> white discharge among married<br />
adolescent women in an urban slum in Dhaka, Bangladesh.<br />
Med Anthropol Q. 2007;21(1):108–132.<br />
10. Ehrstrom S, Kornfeld D, Rylander E. Perceived stress in<br />
women with recurrent vulvovaginal candidiasis. J Psychosom<br />
Obstet Gynaecol. 2007;28(3):169–176.<br />
11. Meyer H, Goettlicher S, Mendling W. Stress as a cause <strong>of</strong><br />
chronic recurrent vulvovaginal candidosis and the effectiveness<br />
<strong>of</strong> the conventional antimycotic therapy. Mycoses.<br />
2006;49(3):202–209.<br />
12. Harville EW, Hatch MC, Zhang J. Perceived life stress<br />
and bacterial vaginosis. J Womens Health (Larchmt).<br />
2005;14(7):627–633.<br />
13. Harville EW, Savitz DA, Dole N, Thorp JM Jr, Herring AH.<br />
Psychological and biological markers <strong>of</strong> stress and bacterial<br />
vaginosis in pregnant women. BJOG. 2007;114(2):216–223.<br />
14. Nansel TR, Riggs MA, Yu KF, Andrews WW, Schwebke JR,<br />
Kleban<strong>of</strong>f MA. <strong>The</strong> association <strong>of</strong> psychosocial stress and bacterial<br />
vaginosis in a longitudinal cohort. Am J Obstet Gynecol.<br />
2006;194(2):381–386.<br />
15. Fletcher J, Cohrssen A, Anderson M, Heinke B, Hendriks E.<br />
Development <strong>of</strong> a vaginal symptom scale. North American Primary<br />
Care Research Group Annual Meeting; Montreal: 2009.<br />
16. Spitzer RL, Kroenke K, Williams JB. Validation and utility <strong>of</strong><br />
a self-report version <strong>of</strong> PRIME-MD: the PHQ primary care<br />
study. Primary Care Evaluation <strong>of</strong> Mental Disorders. Patient<br />
Health Questionnaire. JAMA. 1999;282(18):1737–1744.<br />
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BACK TO BACK<br />
<strong>New</strong> <strong>Zealand</strong> general practice should adopt<br />
population-based screening for attention<br />
deficit hyperactivity disorder (ADHD)<br />
YES<br />
One <strong>of</strong> the advantages <strong>of</strong> having been around in<br />
general practice for more than four decades is the<br />
opportunity to observe the long-term impact <strong>of</strong><br />
a change in thinking in one area <strong>of</strong> medicine and<br />
to ask the question ‘Why do we not deal with<br />
another area according to the same principles?’<br />
For example, in the diagnosis and management <strong>of</strong><br />
diabetes there has been a quiet revolution. When<br />
I first started in general practice we waited until<br />
a diabetic was symptomatic before assessing. <strong>The</strong><br />
usual opportunistic test was to check the urine<br />
for sugar. <strong>The</strong> received wisdom at that time was<br />
that most practices had 1% <strong>of</strong> known diabetes but<br />
that there was another 1% waiting to be detected<br />
if we looked a little harder. At the present time<br />
4% <strong>of</strong> my patients are known to be diabetic but I<br />
am told this is too low. Yes, the rate <strong>of</strong> diabetes<br />
has increased over 40 years because <strong>of</strong> increasing<br />
obesity, but the biggest change is the result<br />
<strong>of</strong> a serious population screening approach with<br />
tougher criteria. All the indications are that<br />
the benefits in patient outcome are substantial<br />
in moving some patients back from the edge <strong>of</strong><br />
diabetes and reducing end organ damage and<br />
therefore mortality.<br />
<strong>The</strong> same could be said <strong>of</strong> the management <strong>of</strong><br />
cardiovascular disease by screening for hypertension<br />
and hypercholesterolaemia, and treating<br />
early. We also have a much more aggressive<br />
approach to smoking cessation and altogether<br />
it is making a difference. No one suggests that<br />
the modern management <strong>of</strong> diabetes and heart<br />
disease is a waste <strong>of</strong> time and money.<br />
An equally strong case can be made for the detection<br />
<strong>of</strong> attention deficit hyperactivity disorder<br />
(ADHD) across the population. <strong>The</strong> generally<br />
agreed rate <strong>of</strong> ADHD in most populations is 5% 1<br />
or more, which translates into at least 200 000<br />
people <strong>of</strong> all ages in <strong>New</strong> <strong>Zealand</strong> (NZ). According<br />
to Pharmac figures, around 25 000 are<br />
currently receiving medication, which is less than<br />
13% <strong>of</strong> the possible total. <strong>The</strong>re may be another<br />
13% in whom a diagnosis <strong>of</strong> ADHD has been<br />
made, but in whom it has been decided by doctors,<br />
patients or families that medication is not<br />
appropriate. If these estimates are roughly correct<br />
there would still be around 74% who are undiagnosed.<br />
Does it matter?<br />
Various studies have found a massive social burden<br />
from ADHD. One claims that 25% <strong>of</strong> those<br />
in jail in the USA have ADHD. Another suggests<br />
that those with ADHD are 22 times more<br />
likely to be incarcerated at some time in life than<br />
Tony Hanne<br />
MB BS MRCS LRCP<br />
Dip Obst FRNZCGP;<br />
general practitioner,<br />
Fowley Lodge,<br />
215 Bleakhouse Road,<br />
Howick, Auckland,<br />
<strong>New</strong> <strong>Zealand</strong><br />
While evidence can help inform best practice, it needs to be placed in context.<br />
<strong>The</strong>re may be no evidence available or applicable for a specific patient with<br />
his or her own set <strong>of</strong> conditions, capabilities, beliefs, expectations and social<br />
circumstances. <strong>The</strong>re are areas <strong>of</strong> uncertainty, ethics and aspects <strong>of</strong> care for which<br />
there is no one right answer. <strong>General</strong> practice is an art as well as a science. Quality<br />
<strong>of</strong> care also lies with the nature <strong>of</strong> the clinical relationship, with communication and<br />
with truly informed decision-making. <strong>The</strong> Back to Back section stimulates<br />
debate, with two pr<strong>of</strong>essionals presenting their opposing views regarding a clinical,<br />
ethical or political <strong>issue</strong>.<br />
Tony Hanne<br />
Ross Lawrenson<br />
BACK TO BACK this <strong>issue</strong>:<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 155
BACK TO BACK<br />
those who do not. 2 <strong>The</strong> rate <strong>of</strong> road accidents was<br />
found to be four times higher in ADHD drivers. 3<br />
Substance abuse is double in ADHD, but reduced<br />
by treatment. 4 Academic underachievement, 5 job<br />
instability, 6 unemployment, relationship breakdowns,<br />
teenage pregnancy, and suicide are all<br />
significantly higher. Rates <strong>of</strong> other psychiatric<br />
illnesses including depression, anxiety, 7 schizophrenia,<br />
and OCD are all higher. A high proportion<br />
<strong>of</strong> Specific Learning Disorders have an underlying<br />
problem <strong>of</strong> ADHD. 8 <strong>The</strong> cost in terms<br />
<strong>of</strong> suffering for the patient and those around<br />
him or her is enormous. <strong>The</strong> financial cost to the<br />
Ministries <strong>of</strong> Education, Social Welfare, Justice,<br />
and Health (with particular reference to ACC)<br />
must be equally substantial. This latter amount<br />
would be many times the cost <strong>of</strong> a greater use <strong>of</strong><br />
medication where needed.<br />
Why then do we not take a wider approach to the<br />
detection <strong>of</strong> ADHD in our practices? <strong>The</strong>re are<br />
various excuses.<br />
1. Isn’t ADHD a new disease?<br />
<strong>The</strong> first good description <strong>of</strong> the condition was<br />
by Dr Alexander Crichton in 1798 and it was<br />
described more fully in 1902 by Dr Joseph Still.<br />
Effective treatment began in 1976. <strong>The</strong> current<br />
name is relatively new, first used in 1980 for<br />
children and in 1994 for adults, but the symptom<br />
complex was clear long before.<br />
2. ADHD is not a real condition, is it?<br />
Positron Emission Tomography first demonstrated<br />
in 1990 the difference in blood flow in key areas<br />
<strong>of</strong> the brain, and this was later shown to reverse<br />
with medication. <strong>The</strong> genetic factors are being<br />
rapidly defined. <strong>The</strong> test <strong>of</strong> variable attention<br />
(TOVA) computer test has 80% specificity and<br />
80% sensitivity. Endless RCTs <strong>of</strong> medication have<br />
shown easily measurable benefits in learning and<br />
behaviour from treatment.<br />
3. Isn’t ADHD a specialist condition?<br />
<strong>The</strong> diagnosis requires a careful history from<br />
the individual, the family and the teacher for<br />
children, and a wider circle for adults. It is a<br />
common problem. <strong>The</strong> management involves the<br />
family and the community and is long-term. <strong>The</strong><br />
medication is simple to titrate and safe. Aren’t<br />
these the very conditions GPs manage best? Only<br />
3% <strong>of</strong> general psychiatric patients are referred to<br />
psychiatrists in the public system. Why should<br />
ADHD be different?<br />
4. Doesn’t ADHD treatment<br />
leads to drug abuse?<br />
Studies have shown, on the contrary, that later<br />
drug abuse is substantially reduced by the early<br />
use <strong>of</strong> medication. <strong>The</strong> proportion <strong>of</strong> those<br />
receiving medication who abuse is less than 5%<br />
if they are strictly managed. Why punish the<br />
other 95%?<br />
5. Can’t ADHD be well-managed<br />
by better parenting, firm teaching,<br />
diet, and counselling?<br />
All <strong>of</strong> these measures may help, but only when<br />
appropriate medication is considered at the same<br />
time. Vast amounts <strong>of</strong> money are spent by desperate<br />
parents on alternative medicines and therapies<br />
for which there is no evidence <strong>of</strong> benefit.<br />
6. Isn’t ADHD only a childhood<br />
condition which they outgrow?<br />
ADHD is recognisable throughout life. About<br />
half <strong>of</strong> ADHD sufferers have adapted sufficiently<br />
by the end <strong>of</strong> the teens, but the other<br />
half need ongoing help.<br />
A population approach to ADHD would inevitably<br />
mean shifting responsibility for basic<br />
assessment and management to general practice.<br />
This, in turn, would necessitate training interested<br />
GPs to be able to undertake this effectively.<br />
9 More complex problems with multiple<br />
psychiatric diagnoses would still need specialist<br />
input. Tools, <strong>of</strong> which there are many, to<br />
assist diagnosis should be reviewed to establish<br />
suitability, effectiveness and reliability. Current<br />
barriers to the decision to prescribe stimulants<br />
would need to be modified. <strong>The</strong> rules<br />
have recently been relaxed to allow GPs to<br />
prescribe Isotretinoin in acne, arguably a more<br />
risky decision. Education <strong>of</strong> teachers, parents,<br />
and social workers would need to be under-<br />
156 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
BACK TO BACK<br />
taken to achieve a more harmonious working<br />
relationship to support ADHD patients. Funding<br />
for GPs with a special interest in this area<br />
to allow sufficient time for thorough assessment<br />
would need to be agreed.<br />
Singapore and South Korea, with similar rates<br />
<strong>of</strong> ADHD to NZ, are developing a population<br />
approach in which GPs are central. <strong>The</strong>y<br />
report that this is working well. What are we<br />
waiting for?<br />
References<br />
1. Barbaresi W, Katusic S, Colligan R et al. How common is attention<br />
deficit/hyperactivity disorder? Towards resolution <strong>of</strong><br />
the controversy: results from a population-based study. Acta<br />
Paediatr Suppl. 2004;93:55–59.<br />
2. Satterfield JH, Schell A. A prospective study <strong>of</strong> hyperactive<br />
boys with conduct problems and normal boys; Adolescent<br />
and adult criminality. J Am Acad Child Adolesc Psychiatry.<br />
1997;36:1726–1735.<br />
3. Barkley RA et al. Motor vehicle driving competencies and risks<br />
in teens and young adults with attention deficit hyperactivity<br />
disorder. Pediatrics. 1996;98(6):1089–95.<br />
4. Wilens TE, Adamson J, Monuteaux MC et al. Effect <strong>of</strong> prior<br />
stimulant treatment for attention deficit/hyperactivity disorder<br />
on subsequent risk for cigarette smoking and alcohol and<br />
drug use disorders in adolescents. Arch Pediatr Adolesc Med.<br />
2008;162:916–21.<br />
5. Barkley RA, Fischer M, Edelbrock CS, Smallish L. <strong>The</strong> adolescent<br />
outcome <strong>of</strong> hyperactive children diagnosed by research<br />
criteria: 1. An 8-year prospective follow-up study. J Am Acad<br />
Child Adolesc Psychiatry. 1990;29:546–557.<br />
6. Murphy K, Barkley RA. Attention deficit hyperactivity disorder<br />
adults: co-morbidities and adaptive impairments. Compr<br />
Psychiatry. 1996:37;393–401.<br />
7. Bowen R, Chavira DA, Bailey K et al. Nature <strong>of</strong> anxiety<br />
comorbid with attention deficit/hyperactivity disorder in<br />
children from a pediatric primary care setting. Psychiatry Res.<br />
2008;157:201–9.<br />
8. Casey JE et al. Learning disorders in children with attention<br />
deficit disorder with and without hyperactivity. Child Neuropsychology.<br />
1996;(2):83–98.<br />
9. Langberg JM, Froehlick TE, Loren REA et al. Assessing<br />
children with ADHD in primary care settings. Expert Rev<br />
Neurother. 2008;8:627–41.<br />
<strong>New</strong> <strong>Zealand</strong> general practice should adopt<br />
population-based screening for attention<br />
deficit hyperactivity disorder (ADHD)<br />
NO<br />
Prevention <strong>of</strong> harm through screening is<br />
naturally a good thing to do—only a wowser<br />
would vote against it. However we work in a<br />
resource-limited system and so have to carefully<br />
consider where we should put our efforts. Over<br />
the years many new screening programmes have<br />
been proposed and then fallen by the wayside.<br />
As far back as 1968 the World Health Organization<br />
promoted a set <strong>of</strong> criteria to be met before a<br />
screening programme is adopted. <strong>The</strong>se include:<br />
Is it a well-defined and important disease? Does<br />
the population want the screening? Do we have<br />
a sensitive and specific test to help differentiate<br />
those at risk? Do we have an effective intervention,<br />
is the screening likely to lead to harm<br />
rather than benefit? Do we have evidence <strong>of</strong><br />
benefit from randomised controlled trials? Do we<br />
have the resources to implement the screening<br />
programme?<br />
So how does screening for attention deficit<br />
hyperactivity disorder (ADHD) stack up against<br />
these criteria? ADHD is a chronic behavioural<br />
disorder characterised by persistent hyperactivity,<br />
impulsivity, and inattention. 1 Its reported<br />
prevalence is greater in boys than girls, decreases<br />
with age and varies from country to country with<br />
the USA reporting as many as one in 20 children<br />
with a diagnosis <strong>of</strong> ADHD. 2 Many young people<br />
with signs <strong>of</strong> ADHD have comorbid conditions<br />
such as depression, conduct disorders, substance<br />
abuse and bipolar disease. 1 It is therefore difficult<br />
to determine what the natural history <strong>of</strong> ADHD<br />
is when many <strong>of</strong> the outcomes can be confounded<br />
by the comorbidities. Whilst we have quite good<br />
data on what happens to children with signs <strong>of</strong><br />
Ross Lawrenson MD,<br />
FRCGP, FFPH, FAFPHM;<br />
Pr<strong>of</strong>essor <strong>of</strong> Primary<br />
Care, Waikato Clinical<br />
School, <strong>The</strong> University <strong>of</strong><br />
Auckland, Auckland, <strong>New</strong><br />
<strong>Zealand</strong>; r.lawrensen@<br />
auckland.ac.nz<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 157
BACK TO BACK<br />
ADHD, 3 the progression and outcomes for adolescents<br />
and adults is less well documented. We do<br />
know that those with attention disorder in childhood<br />
are less likely to achieve academically, and<br />
are more likely to have accidents. <strong>The</strong>re is also<br />
an association with ADHD, conduct disorders in<br />
childhood and later use <strong>of</strong> drugs. 4 Given what<br />
we know about ADHD do we believe there is a<br />
demand for population-based screening in NZ? A<br />
number <strong>of</strong> screening programmes fail because <strong>of</strong><br />
poor uptake. <strong>The</strong> Before Schools Checks includes<br />
a screening test for behavioural problems—and<br />
the uptake to date has been poor. I suspect the<br />
uptake by adolescents and adults would be even<br />
worse. We would certainly need studies to<br />
ascertain the likely uptake before embarking on a<br />
population-based programme.<br />
One danger <strong>of</strong> a screening test is that it may<br />
lead to some patients being incorrectly labelled<br />
rectly labelled as having a condition which may<br />
have lifelong implications.<br />
<strong>The</strong> next key question is: do we have an effective<br />
intervention? Whilst there are good randomised<br />
controlled trials (RCTs) <strong>of</strong> a number<br />
<strong>of</strong> agents (e.g. methylphenidate, amphetamines,<br />
and desipramine) these are generally short-term<br />
studies and the outcomes measured are mainly<br />
reductions in symptom scores. 6 No one has<br />
had the money to show that long-term use <strong>of</strong><br />
methylphenidate has improved intellectual attainment,<br />
reduced driving accidents or helped<br />
with employment—the outcomes that matter.<br />
In the absence <strong>of</strong> long-term RCTs in a screened<br />
population it is unsafe to extrapolate the drug<br />
trials in highly selected populations to propose<br />
effectiveness. Longer term studies have shown<br />
large drop-out rates with older children being less<br />
likely to adhere to treatment. 7 Thus the efficacy<br />
<strong>The</strong> side effects <strong>of</strong> medication for ADHD are well recognised,<br />
but more important is their potential for abuse. Eleven percent<br />
<strong>of</strong> adolescents being treated in the USA reported selling their<br />
medication. Another concern is the harm generated by labelling<br />
a child or adolescent as having ADHD<br />
as having a disorder and subsequently being<br />
unnecessarily or incorrectly treated. <strong>The</strong>re are<br />
a number <strong>of</strong> screening tools for ADHD. Most<br />
are sensitive, but lack specificity. Consequently<br />
a second stage is required where those identified<br />
through screening are then reviewed and a<br />
diagnosis made. For ADHD this should involve<br />
a psychiatrist. It could be argued that general<br />
practitioners (GPs) are competent to accurately<br />
diagnose the condition. Whilst we do not know<br />
NZ GPs’ views on this, a Canadian study suggested<br />
95% <strong>of</strong> GPs would refer patients for a<br />
specialist opinion. 5 I would suspect that most NZ<br />
GPs would want to have an expert opinion—to<br />
ensure there was not a misdiagnosis <strong>of</strong> another<br />
psychiatric condition, to ensure comorbid conditions<br />
had been appropriately picked up, and <strong>of</strong><br />
course to make sure that people were not incor<strong>of</strong><br />
treatment in a screened population is likely to<br />
be much less than that found in short-term RCTs<br />
with selected patients. Is screening likely to<br />
lead to harm as well as benefit? <strong>The</strong> side effects<br />
<strong>of</strong> medication for ADHD are well recognised,<br />
but more important is their potential for abuse.<br />
Eleven percent <strong>of</strong> adolescents being treated in the<br />
USA reported selling their medication. 8 Another<br />
concern is the harm generated by labelling a child<br />
or adolescent as having ADHD.<br />
Finally, do we have the resources to implement<br />
a screening programme? <strong>The</strong> MaGPIe study<br />
noted that GPs felt that managing mental health<br />
problems took more time, the costs were likely to<br />
be subsidised by the practice as patients were not<br />
prepared to pay the full costs, and more training<br />
was needed if recognition <strong>of</strong> mental health<br />
158 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
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problems was to be improved. 9 We should also<br />
recognise that there is a shortage <strong>of</strong> psychiatrists<br />
with expertise in the area and so waiting lists for<br />
assessment and diagnosis are likely to be long. <strong>The</strong><br />
opportunity costs both to GPs and mental health<br />
services are likely to be considerable and would<br />
require a reduction <strong>of</strong> activity in other areas.<br />
Let my review not be construed as saying ADHD<br />
is not important or that GPs should not be<br />
involved in its management. Rather I am saying<br />
that in patients and families who present for help,<br />
proper diagnosis and ongoing long-term support<br />
should be available. But I would suggest that the<br />
greatest utility is achieved by concentrating on<br />
the most severely affected, who have been identified<br />
by parents and teachers as being in need <strong>of</strong><br />
help. This does not mean we should leap into a<br />
screening programme.<br />
In summary, I would argue that ADHD does not<br />
meet the criteria for a screening programme. It<br />
is poorly defined, is frequently associated with<br />
comorbid mental health conditions and the health<br />
impact is not well quantified. Does the population<br />
want the screening? This is not known, but<br />
uptake in children has been poor. Do we have<br />
a sensitive and specific test to help differentiate<br />
those at risk? A variety <strong>of</strong> tests are available,<br />
but different tests are better for different age<br />
groups, they are time-consuming and doctors or<br />
their staff would need training. In the hands <strong>of</strong><br />
experts they are generally sensitive, but followup<br />
diagnosis is required. Do we have an effective<br />
intervention? <strong>The</strong>re are a number <strong>of</strong> medications<br />
that have shown symptom reduction in shortterm<br />
studies, but longer-term drop-out rates<br />
are high and the evidence <strong>of</strong> long-term benefit<br />
for outcomes that matter is poor. Is the screening<br />
likely to lead to harm rather than benefit?<br />
Adverse aspects <strong>of</strong> labelling and diversion <strong>of</strong><br />
drugs into the illicit market are likely to be a<br />
problem. Do we have the resources to implement<br />
the screening programme? <strong>The</strong>re is evidence that<br />
managing mental health problems takes more<br />
time, more training is required and the additional<br />
costs are likely to be borne at least in part by GPs.<br />
References<br />
1. Wolraich ML, Wibelsman CJ, Brown TE et al. Attentiondeficit/hyperactivity<br />
disorder among adolescents: a review <strong>of</strong><br />
the diagnosis, treatment and clinical implications. Pediatrics.<br />
2005;115:1734–1746.<br />
2. Faraone SV, Sergeant J, Gillberg C, Biederman J. <strong>The</strong> worldwide<br />
prevalence <strong>of</strong> ADHD: is it an American condition? World<br />
Psychiatry. 2003:2(2):104–13.<br />
3. Fergusson DM. Lynskey MT. Horwood LJ. Attentional difficulties<br />
in middle childhood and psychosocial outcomes in young<br />
adulthood. J Child Psychol Psychiatry. 1997;38(6):633–44.<br />
4. Fergusson DM. Horwood LJ. Ridder EM. Conduct and attentional<br />
problems in childhood and adolescence and later<br />
substance use, abuse and dependence: results <strong>of</strong> a 25-year<br />
longitudinal study. Drug Alcohol Depend. 2007; 88 Suppl<br />
1:S14–26.<br />
5. Miller AR. Johnston C. Klassen AF. Fine S. Papsdorf M. Family<br />
physicians’ involvement and self-reported comfort and skill in<br />
care <strong>of</strong> children with behavioural and emotional problems: a<br />
population-based survey. BMC Fam Pract. 2005:6(1):12.<br />
6. Brown RT, Amler RW Freeman WS et al. Treatment <strong>of</strong> attention<br />
deficit/hyperactivity disorder: overview <strong>of</strong> the evidence.<br />
Pediatrics. 2005;115:e749–757.<br />
7. Charach A, Ickowicz A, Schachar R. Stimulant treatment over<br />
five years: adherence, effectiveness and adverse effects. J Am<br />
Acad Child Adolesc Psychiatry. 2004;43:559–567.<br />
8. Wilens TE, Gignac M, Swezey A, et al. Characteristics <strong>of</strong><br />
adolescents and young adults with ADHD who divert or<br />
misuse their prescribed medications. J Am Acad Child Adolesc<br />
Psychiatry. 2006;45:408–414.<br />
9. MaGPIe Research Group. <strong>General</strong> practitioners’ perceptions<br />
<strong>of</strong> barriers to their provision <strong>of</strong> mental healthcare: a report on<br />
Mental Health and <strong>General</strong> Practice Investigation (MaGPIe).<br />
N Z Med J. 2005;118(1222):U1654.<br />
Until we have evidence from RCTs conducted<br />
in general practice, the answer to the question<br />
‘Should we screen for ADHD?’ is no.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 159
continuing pr<strong>of</strong>essional development<br />
pearls<br />
cochrane corner<br />
String <strong>of</strong> PEARLS<br />
Practical Evidence About Real Life Situations<br />
PEARLS are succinct summaries <strong>of</strong> Cochrane Systematic Reviews<br />
for primary care practitioners—developed by Pr<strong>of</strong>. Brian McAvoy for<br />
the Cochrane Primary Care Field (www.cochraneprimarycare.org),<br />
<strong>New</strong> <strong>Zealand</strong> Branch <strong>of</strong> the Australasian Cochrane Centre at the<br />
Department <strong>of</strong> <strong>General</strong> Practice and Primary Health Care, University<br />
<strong>of</strong> Auckland (www.auckland.ac.nz/uoa), funded by the <strong>New</strong> <strong>Zealand</strong><br />
Guidelines Group (www.nzgg.org.nz) and published in NZ Doctor<br />
(www.nzdoctor.co.nz.).<br />
Thiazides best first choice for hypertension<br />
Beta-blockers not the best first-line treatment for<br />
hypertension<br />
ACE inhibitors have a modest blood pressure–<br />
lowering effect<br />
Renin inhibitors are effective in lowering blood<br />
pressure<br />
Little evidence <strong>of</strong> benefit from relaxation therapies<br />
for hypertension<br />
Aiming for blood pressure targets lower than<br />
140/90 mmHg may not be <strong>of</strong> benefit<br />
Weight-reducing drugs may be beneficial in<br />
hypertensive patients<br />
Organised systems <strong>of</strong> regular follow-up and review<br />
can improve blood pressure control<br />
Disclaimer: PEARLS are for educational use only and are not meant<br />
to guide clinical activity, nor are they a clinical guideline.<br />
NSAIDs for dysmenorrhoea<br />
Bruce Arroll MBChB, PhD, FRNZCGP; Pr<strong>of</strong>essor <strong>of</strong> <strong>General</strong> Practice<br />
and Primary Health Care, <strong>The</strong> University <strong>of</strong> Auckland, Private Bag 92019,<br />
Auckland, <strong>New</strong> <strong>Zealand</strong>; b.arroll@auckland.ac.nz<br />
<strong>The</strong> problem: Dysmenorrhoea is a common gynaecological<br />
problem consisting <strong>of</strong> painful cramps accompanying menstruation<br />
which, in the absence <strong>of</strong> any underlying abnormality, is<br />
known as primary dysmenorrhoea.<br />
<strong>The</strong> situation: Research has shown that women with<br />
dysmenorrhoea have high levels <strong>of</strong> prostaglandins, hormones<br />
known to cause cramping abdominal pain. Nonsteroidal<br />
anti-inflammatory drugs (NSAIDs) are drugs which act by<br />
blocking prostaglandin production. Pain is usually centred in<br />
the suprapubic area, but may radiate to the back <strong>of</strong> the legs<br />
or lower back, and may be accompanied by other symptoms<br />
such as nausea, diarrhoea, headache and lightheadedness. <strong>The</strong><br />
prevalence estimates vary widely. It was reported by 72% <strong>of</strong><br />
Australian women <strong>of</strong> reproductive age in a recent nationallyrepresentative<br />
sample and caused severe pain in 15% <strong>of</strong> cases.<br />
Other representative samples report rates ranging from 17% to<br />
81%. In addition to the distress associated with dysmenorrhoea,<br />
surveys have shown significant socioeconomic repercussions:<br />
over 35% <strong>of</strong> female high school students report missing school<br />
due to menstrual pain and 15% <strong>of</strong> working.<br />
Clinical bottom line: All NSAIDs are effective for<br />
dysmenorrhoea and there does not seem to be one better than<br />
others. It was not possible to report a numbers needed to treat<br />
from the review, but in one <strong>of</strong> the typical papers it was about<br />
five. <strong>The</strong> review did not suggest when to start taking the<br />
medication, but some <strong>of</strong> the studies advised to start taking the<br />
medication at the onset <strong>of</strong> first cramps.<br />
NSAIDs for dysmenorrhoea<br />
NSAIDs for<br />
dysmenorrhoea<br />
Success Evidence Harms<br />
NNT <strong>of</strong><br />
about 5<br />
Cochrane<br />
review 1<br />
Risk <strong>of</strong> renal injury and<br />
gastric bleeding<br />
NNT = numbers needed to treat for one person to get an improvement<br />
References<br />
1. Marjoribanks J, Proctor M, Farquhar C, Derks RS. Nonsteroidal anti-inflammatory<br />
drugs for dysmenorrhoea. Cochrane Database <strong>of</strong> Systematic Reviews 2010,<br />
Issue 1. Art. No: CD001751. DOI: 10.1002/14651858.CD001751.pub2.<br />
All people residing in <strong>New</strong> <strong>Zealand</strong> have access to the Cochrane Library<br />
via the Ministry website www.moh.govt.nz/cochranelibrary<br />
160 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
continuing pr<strong>of</strong>essional development<br />
charms & harms<br />
Ginkgo<br />
Ginkgo biloba L., also known as fossil tree,<br />
kew tree, maidenhair tree, yin xing (whole plant),<br />
yin xing ye (leaves), bai guo (seeds)<br />
Preparations: <strong>The</strong> leaf is the part used medicinally;<br />
in Traditional Chinese Medicine and<br />
in Japan, the seed is also used, although it contains<br />
some toxic constituents. Extracts <strong>of</strong> ginkgo<br />
leaf are available in several dose forms, including<br />
capsules, tablets and tinctures. Chopped or<br />
powdered forms <strong>of</strong> the dried material are also<br />
available. Several products marketed as dietary<br />
supplements containing ginkgo are available on<br />
the <strong>New</strong> <strong>Zealand</strong> market.<br />
Active constituents: Ginkgo has been<br />
described as having polyvalent action; that is, the<br />
combined activities <strong>of</strong> several constituents are<br />
responsible for its effects. Important constituents<br />
<strong>of</strong> the leaves include the ginkgo flavonoid glycosides<br />
(e.g. glycosides <strong>of</strong> quercetin and kaempferol)<br />
and the terpene lactones (e.g. ginkgolides<br />
A, B and C). Modes <strong>of</strong> action demonstrated in<br />
preclinical studies include cardiovascular and<br />
haemorheological effects, antagonism <strong>of</strong> plateletactivating<br />
factor, antioxidant activity and effects<br />
on concentrations <strong>of</strong> certain neurotransmitters.<br />
Seeds contain ginkgotoxin (4-O-methylpyridoxine)<br />
and ginkgolic acids.<br />
Main uses: Ginkgo leaf and seed have a history<br />
<strong>of</strong> traditional use in China for asthma and the seed<br />
also as an antitussive and expectorant. Contemporary<br />
interest in ginkgo leaf is focussed on its use<br />
in cognitive deficiency and dementia, intermittent<br />
claudication (from peripheral arterial occlusive<br />
disease) and vertigo and tinnitus <strong>of</strong> vascular origin.<br />
It is also used and promoted for cognitive improvement<br />
in healthy individuals.<br />
Evidence for efficacy: Recent Cochrane<br />
systematic reviews are available <strong>of</strong> clinical trials<br />
that assessed the effects <strong>of</strong> standardised ginkgo<br />
leaf preparations in cognitive impairment and dementia,<br />
intermittent claudication, acute ischaemic<br />
stroke, tinnitus and age-related macular degeneration.<br />
<strong>The</strong>se reviews conclude that there is no convincing<br />
evidence available to support the efficacy<br />
<strong>of</strong> the ginkgo preparations tested in cognitive impairment<br />
and dementia, intermittent claudication,<br />
recovery after ischaemic stroke and tinnitus; there<br />
was insufficient research to determine whether<br />
or not ginkgo is efficacious in age-related macular<br />
degeneration. Many trials, particularly older ones,<br />
have methodological limitations.<br />
A Cochrane systematic review <strong>of</strong> trials <strong>of</strong> ginkgo<br />
for cognitive improvement in healthy individuals<br />
is in preparation.<br />
Adverse effects: Typically, Cochrane systematic<br />
reviews <strong>of</strong> (usually small-scale) clinical trials<br />
have not shown any difference between ginkgo and<br />
placebo with respect to the frequency <strong>of</strong> adverse<br />
events, including bleeding episodes. However, spontaneous<br />
reports <strong>of</strong> adverse effects associated with<br />
the use <strong>of</strong> ginkgo preparations have raised concerns<br />
about the risk <strong>of</strong> haemorrhagic reactions, including<br />
intracranial and ocular bleeding. Many <strong>of</strong> these<br />
cases concern individuals who were also taking conventional<br />
antiplatelet and/or anticoagulant agents,<br />
although some concerned use <strong>of</strong> ginkgo only.<br />
A small number <strong>of</strong> drug interaction studies have<br />
indicated that ginkgo leaf extracts generally had no<br />
Joanne Barnes<br />
BPharm, PhD, MRPharmS,<br />
RegPharmNZ, FLS;<br />
Associate Pr<strong>of</strong>essor<br />
in Herbal Medicines,<br />
School <strong>of</strong> Pharmacy, <strong>The</strong><br />
University <strong>of</strong> Auckland,<br />
Auckland, <strong>New</strong> <strong>Zealand</strong><br />
Herbal medicines are a popular health care choice, but few have been tested to contemporary standards.<br />
CHARMS & HARMS summarises the evidence for the potential benefits and possible harms <strong>of</strong> wellknown<br />
herbal medicines.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 161
continuing pr<strong>of</strong>essional development<br />
charms & harms<br />
Summary message<br />
Evidence for the efficacy <strong>of</strong> ginkgo extracts for cognitive impairment and<br />
dementia, intermittent claudication, acute ischaemic stroke, tinnitus and<br />
age-related macular degeneration is unconvincing. Ginkgo preparations<br />
have been associated with haemorrhagic reactions. Health pr<strong>of</strong>essionals<br />
should be aware <strong>of</strong> the possibility <strong>of</strong> (undisclosed) use <strong>of</strong> ginkgo; use <strong>of</strong><br />
ginkgo should be avoided, or at least used only with caution, in patients with<br />
bleeding disorders and those taking conventional anti-platelet or anticoagulant<br />
agents. If using ginkgo, these patients should be advised to be vigilant<br />
for signs <strong>of</strong> bleeding and to seek pr<strong>of</strong>essional help. Suspected adverse drug<br />
reactions should be reported to CARM. As with all herbal medicines, different<br />
ginkgo products vary in their pharmaceutical quality, and the implications<br />
<strong>of</strong> this for efficacy and safety should be considered.<br />
statistically significant effects on antiplatelet effects<br />
and/or pharmacokinetics <strong>of</strong> clopidogrel or ticlopidine,<br />
or on the pharmacokinetics and pharmacodynamics<br />
(INR) <strong>of</strong> warfarin. However, these studies<br />
involved healthy volunteers and the relevance <strong>of</strong><br />
these findings to the clinical setting is unclear.<br />
It is prudent to advise that use <strong>of</strong> ginkgo should be<br />
avoided in patients with bleeding disorders, since it<br />
is unlikely that the benefit–harm balance is favourable<br />
on the basis <strong>of</strong> current evidence. Likewise,<br />
ginkgo should only be used with caution in patients<br />
taking anticoagulant and/or antiplatelet agents.<br />
Some authors advise that the evidence is insufficient<br />
to advise patients taking such medicines to avoid<br />
using ginkgo. If ginkgo is used, patients should be<br />
advised to monitor for bruising and other signs <strong>of</strong><br />
bleeding, and to seek pr<strong>of</strong>essional help if this occurs.<br />
Contact with or ingestion <strong>of</strong> the fruit pulp can<br />
cause severe allergic reactions.<br />
Health pr<strong>of</strong>essionals are reminded to report<br />
suspected adverse reactions associated with all<br />
medicines, including vaccines and complementary<br />
medicines, to the Centre for Adverse Reactions<br />
Monitoring (http://carm.otago.ac.nz).<br />
Drug interactions: See Adverse effects for<br />
information on interactions with antiplatelet/anticoagulant<br />
agents.<br />
Drug interaction studies involving healthy volunteers<br />
who received ginkgo leaf extracts have<br />
indicated that ginkgo induces the metabolism and<br />
lowers concentrations <strong>of</strong> omeprazole; it is unlikely<br />
that the benefit–harm balance for using ginkgo in<br />
patients being treated with omeprazole would be<br />
favourable on the basis <strong>of</strong> current evidence. Similar<br />
studies have shown that ginkgo leaf extracts did<br />
not appear to have clinically relevant pharmacokinetic<br />
interactions with alprazolam, caffeine, chlorzoxazone,<br />
dextromethorphan, dicl<strong>of</strong>enac, digoxin,<br />
donepezil, fex<strong>of</strong>enadine, flurbipr<strong>of</strong>en, midazolam,<br />
propranolol, ritonavir, theophylline or tolbutamide.<br />
<strong>The</strong>re is limited evidence from preclinical studies<br />
that the administration <strong>of</strong> ginkgo and amikacin<br />
may accelerate amikacin-induced ototoxicity, and<br />
that ginkgo may lead to raised concentrations <strong>of</strong><br />
diltiazem and nifedipine and reduced concentrations<br />
<strong>of</strong> nicardipine. <strong>The</strong>re is also some limited<br />
clinical evidence <strong>of</strong> an interaction with nifedipine.<br />
<strong>The</strong>re is a small number <strong>of</strong> isolated case reports <strong>of</strong><br />
breakthrough seizures in patients taking sodium<br />
valproate, with or without phenytoin, in patients<br />
who began taking ginkgo leaf extract or were<br />
taking several products containing ginkgo. Until<br />
further information is available, patients should be<br />
made aware <strong>of</strong> this possible interaction.<br />
Key references<br />
Barnes J, Anderson LA, Phillipson JD. Herbal medicines. 3rd edition.<br />
London: Pharmaceutical Press; 2007.<br />
Birks J, Grimley Evans J. Ginkgo biloba for cognitive impairment<br />
and dementia. Cochrane Database <strong>of</strong> Systematic Reviews<br />
2009, Issue 1. Art. No.: CD003120. DOI: 10.1002/14651858.<br />
CD003120.pub3.<br />
Nicolaï SPA, Kruidenier LM, Bendermacher BLW, Prins MH, Teijink<br />
JAW. Ginkgo biloba for intermittent claudication. Cochrane<br />
Database <strong>of</strong> Systematic Reviews 2009, Issue 2. Art. No.:<br />
CD006888. DOI: 10.1002/14651858.CD006888.pub2.<br />
Zeng X, Liu M, Yang Y, Li Y, Asplund K. Ginkgo biloba for acute<br />
ischaemic stroke. Cochrane Database <strong>of</strong> Systematic Reviews<br />
2005, Issue 4. Art. No.: CD003691. DOI: 10.1002/14651858.<br />
CD003691.pub2.<br />
Hilton MP, Stuart EL. Ginkgo biloba for tinnitus. Cochrane Database<br />
<strong>of</strong> Systematic Reviews 2004, Issue 2. Art. No.: CD003852. DOI:<br />
10.1002/14651858.CD003852.pub2.<br />
Evans JR. Ginkgo biloba extract for age-related macular degeneration.<br />
Cochrane Database <strong>of</strong> Systematic Reviews 1999, Issue 3.<br />
Art. No.: CD001775. DOI: 10.1002/14651858.CD001775.<br />
Lee H, Birks J. Ginkgo biloba for cognitive improvement in<br />
healthy individuals (Protocol). Cochrane Database <strong>of</strong> Systematic<br />
Reviews 2004, Issue 1. Art. No.: CD004671. DOI:<br />
10.1002/14651858.CD004671.<br />
Bent S et al. Spontaneous bleeding associated with ginkgo biloba. A<br />
case report and systematic review <strong>of</strong> the literature. J Gen Intern<br />
Med. 2005;20:657–661.<br />
Williamson EM, Driver S, Baxter K. Stockley’s herbal medicines<br />
interactions. London: Pharmaceutical Press; 2009.<br />
162 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
continuing pr<strong>of</strong>essional development<br />
pounamu<br />
A whanau ora approach to<br />
health care for Maori<br />
Jacquie Kidd PhD, RN; 1 Veronique Gibbons MSc, BSc(Hons), RN; 2 Ross Lawrenson MD, FRCGP, FFPH,<br />
FAFPHM; 2 Wayne Johnstone MA (Hons), BA 3<br />
A<br />
whanau ora approach to health care is<br />
becoming well-established within the<br />
primary health care sector, which means<br />
that we now see many providers, particularly<br />
Maori providers, employing whanau ora workers<br />
who work not just directly with individuals<br />
but with families to help to support individuals<br />
<strong>of</strong>ten with chronic disease or mental health<br />
problems. At the same time a number <strong>of</strong> important<br />
initiatives have emerged including marae<br />
and community-based clinics which emphasise<br />
a positive approach to Maori health, philosophy<br />
and models. However, it is evident that there are<br />
subtle variations in how people and organisations<br />
perceive a whanau ora approach; indeed it is an<br />
approach that is used not only in health but in<br />
education and the social welfare sector. It should<br />
also be acknowledged that there may be local<br />
and iwi-based differences in understanding what<br />
whanau ora is.<br />
<strong>The</strong> term whanau ora was promoted by Mason<br />
Durie 1 as the component <strong>of</strong> good health that<br />
relates to the support from and connection to<br />
the family. Since then the term has been more<br />
widely used to affirm the importance <strong>of</strong> whanau<br />
planning and management <strong>of</strong> their own health<br />
including wairua (spirituality), te ao Maori (the<br />
Maori way <strong>of</strong> living in the world), tikanga (Maori<br />
customs and protocols), self-determination, and<br />
economic and social factors. This broadened view<br />
<strong>of</strong> health is part <strong>of</strong> the government’s Maori policy<br />
document He Korowai Oranga and is defined<br />
as ‘Maori families supported to achieve their<br />
maximum health and wellbeing.’ 2 Ora relates to<br />
well-being or health. When paired with whanau,<br />
the meaning is expanded to suggest the health<br />
and well-being <strong>of</strong> the family within the environment<br />
in which they interact. A more modern<br />
translation <strong>of</strong> whanau represents not only blood<br />
relations but also the relationship through a common<br />
goal or similar interests. 3<br />
Throughout the various District Health Boards,<br />
Maori providers and other health service providers,<br />
whanau ora has been used as a guiding<br />
principle and value, a goal, and in some instances<br />
it has been used to describe a type <strong>of</strong> health<br />
service being delivered to local Maori communities.<br />
While each has varying definitions on what<br />
whanau ora is to their particular region and/<br />
or service, it is clear that the overall goal is to<br />
achieve maximum wellness for the whanau.<br />
When structuring a kaupapa Maori research<br />
project that explores the whanau ora experiences<br />
<strong>of</strong> Maori men who have chronic disease or cancer,<br />
our team <strong>of</strong> Maori and non-Maori clinicians,<br />
academics and health care service managers<br />
concluded that the development <strong>of</strong> a local understanding<br />
<strong>of</strong> whanau ora was required. Bishop, 4<br />
in discussing kaupapa Maori as a preferred<br />
1<br />
<strong>The</strong> University <strong>of</strong> Auckland,<br />
Auckland, <strong>New</strong> <strong>Zealand</strong><br />
2<br />
Waikato Clinical School,<br />
<strong>The</strong> University <strong>of</strong> Auckland<br />
3<br />
Te Puna Oranga (Maori<br />
Health Service), Waikato<br />
District Health Board<br />
Correspondence to:<br />
Jacquie Kidd,<br />
Peter Rothwell Academic<br />
Centre, Waikato Clinical<br />
School, Waikato District<br />
Health Board, PB 3200,<br />
Hamilton, <strong>New</strong> <strong>Zealand</strong><br />
j.kidd@auckland.ac.nz<br />
Pounamu<br />
Maori primary health care treasures<br />
Pounamu (greenstone) is the most precious <strong>of</strong> stone to Maori.<br />
‘Ahakoa he iti, he pounamu’<br />
(Although it is small, it is valuable)<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 163
continuing pr<strong>of</strong>essional development<br />
POUNAMU<br />
methodology, includes the principles <strong>of</strong><br />
whakapapa (genealogy), whanau, te reo<br />
(language), tikanga, rangatiratanga (selfdetermination),<br />
and aroha ki te tangata<br />
(respect, accountability and valuing all<br />
those involved with and affected by<br />
the research). In addition to providing<br />
a sound cultural and ethical basis for<br />
the proposed research, 5 these principles<br />
are congruent with the generic research<br />
aims and form a basis to what Cram 6<br />
describes as talk as data.<br />
To this end, the Oranga Tane project<br />
team sought guidance from Waikato<br />
Kaumatua to determine what a local<br />
definition <strong>of</strong> whanau ora might look<br />
like. This was done through a series <strong>of</strong><br />
hui (meetings) held with local Kaumatua<br />
in each <strong>of</strong> the Tainui iwi areas: Waikato,<br />
Maniapoto, Raukawa and Pare Hauraki.<br />
Hui are an oral and aural medium for<br />
discussing, debating and coming to a<br />
shared understanding about <strong>issue</strong>s, and<br />
have a defined process to follow; this<br />
was undertaken by the Kaumatua for the<br />
research team, Kingi Turner. Kaumatua,<br />
defined as men and women elders who<br />
are guardians <strong>of</strong> genealogy, spirituality<br />
and Maori knowledge, were invited<br />
through their particular marae-based<br />
organisations to attend the hui and respond<br />
to the researchers’ request to ‘tell<br />
us what you understand by the term<br />
whanau ora.’ <strong>The</strong> ensuing discussion was<br />
captured on a whiteboard by a member<br />
<strong>of</strong> the research team who is fluent in te<br />
reo Maori. This ensured that the content<br />
<strong>of</strong> the discussion was accurately recorded<br />
and provided the participants with the<br />
opportunity to correct any misunderstandings<br />
or missed points as an integral<br />
part <strong>of</strong> the hui process.<br />
Although the overall aim <strong>of</strong> the study<br />
is focussed on Maori men, the guidance<br />
that came from Kaumatua encompassed<br />
the whanau as a whole. <strong>The</strong> well-being <strong>of</strong><br />
mokopuna (grandchildren) was a focus,<br />
with many discussions about the importance<br />
for all the whanau to stay healthy<br />
so the children’s well-being could be<br />
assured. Other areas <strong>of</strong> interest included<br />
the importance <strong>of</strong> whanau-based<br />
health education and the importance <strong>of</strong><br />
wairuatanga (spiritual connection) to<br />
health, although the hui also acknowledged<br />
a general reluctance to attend<br />
health screening and early treatment, the<br />
perceived unfriendliness <strong>of</strong> Westernbased<br />
health services, and the difficulties<br />
for some whanau who need to travel to a<br />
main centre to access health services.<br />
<strong>The</strong> <strong>issue</strong> <strong>of</strong> who speaks or acts on<br />
behalf <strong>of</strong> the whanau was also explored,<br />
with some <strong>of</strong> the Kaumatua arguing for<br />
a departure from the traditional gender<br />
separation <strong>of</strong> women’s and men’s health<br />
information. It was proposed that the<br />
whanau as a whole should be aware <strong>of</strong><br />
the health needs <strong>of</strong> their members, and<br />
be prepared to advocate and encourage<br />
self-care for the well-being <strong>of</strong> the wider<br />
whanau. <strong>The</strong>se concerns are common to<br />
international indigenous populations. 7<br />
In addition, wide-ranging discussions<br />
took place about how to connect te ao<br />
Maori, whanau, and health care services<br />
so that whanau ora is achieved. <strong>The</strong> need<br />
for health services to be integrated into<br />
social and economic services was clearly<br />
articulated, and is consistent with national<br />
policy directions. 8<br />
What became clear throughout the hui<br />
is that whanau ora is complex, with<br />
many interconnecting facets. Our findings<br />
indicate that difficulties accessing<br />
primary health care remains an <strong>issue</strong> for<br />
Maori, despite an apparent awareness <strong>of</strong><br />
the need for health screening and early<br />
treatment. It appears that there is a still<br />
unmet need for culturally-appropriate<br />
health care to improve acceptability <strong>of</strong><br />
health care provision. <strong>The</strong> Kaumatua<br />
were emphatic about the need for their<br />
whanau to be engaged with health care<br />
education, which they viewed as being<br />
important for the future health <strong>of</strong> their<br />
mokopuna. <strong>The</strong> value <strong>of</strong> the whanau<br />
ora approach is that the connections<br />
between health care providers, the world<br />
<strong>of</strong> Maori and the people <strong>of</strong> the whanau<br />
are made explicit and measurable. Maori<br />
community health workers provide<br />
general practitioners and others with<br />
the opportunity for such connections to<br />
be made and for improved health care<br />
outcomes for Maori. 9<br />
Overall we have presented in this paper<br />
the beginnings <strong>of</strong> a local whanau ora<br />
definition which is consistent with the<br />
understanding shown in a number <strong>of</strong><br />
studies to have improved access and<br />
health outcomes. We would encourage<br />
primary health care workers to work<br />
with Maori providers and others who<br />
are involved in whanau ora provision<br />
to avail themselves <strong>of</strong> this expertise<br />
in order to improve outcomes for their<br />
Maori patients.<br />
References<br />
1. Durie MH. Whaiora: Maori health development.<br />
Auckland: Oxford University Press; 1994.<br />
2. Ministry <strong>of</strong> Health. He Korowai Oranga: Maori<br />
Health strategy. Wellington, <strong>New</strong> <strong>Zealand</strong>: Ministry<br />
<strong>of</strong> Health; 2002.<br />
3. Smith GH. Whakaoho whanau: new formations<br />
<strong>of</strong> whanau as an innovative intervention into<br />
Maori cultural and educational crises. He Pukenga<br />
Korero. 1995;1(1):18–36.<br />
4. Bishop R. Freeing ourselves from neocolonial domination<br />
in research: a Kaupapa Maori approach<br />
to creating knowledge. In: <strong>The</strong> sage handbook<br />
<strong>of</strong> qualitative research. Denzin NK and Lincoln Y,<br />
editors. Thousand Oaks: Sage; 2005. p 109–138.<br />
5. Smith LT. On tricky ground: researching the native<br />
in the age <strong>of</strong> uncertainty. In: <strong>The</strong> sage handbook<br />
<strong>of</strong> qualitative research. Denzin NK and Lincoln Y,<br />
editors. Thousand Oaks: Sage; 2005. p 85–108.<br />
6. Cram F, et al. Kaupapa Maori research and Pakeha<br />
social science: epistemological tensions in a study<br />
<strong>of</strong> Maori health. Hulili. 2006;3(1):41–68.<br />
7. Mowbray M and the WHO commission on social<br />
determinants <strong>of</strong> health. Social determinants and<br />
Indigenous health: the international experience<br />
and its policy implications. In: International symposium<br />
on the social determinants <strong>of</strong> indigenous<br />
health. Geneva, Adelaide: World Health Organization;<br />
2007.<br />
8. Public Health Advisory Committee. <strong>The</strong> health <strong>of</strong><br />
people and communities. A way forward: public<br />
policy and the economic determinants <strong>of</strong> health.<br />
Wellington, <strong>New</strong> <strong>Zealand</strong>: National Health Committee;<br />
2004.<br />
9. Boulton AF, HH Gifford, Potaka-Osborne M.<br />
Realising Whanau Ora through community action:<br />
the role <strong>of</strong> Maori community health workers.<br />
Education for Health. 2009:22(2).<br />
164 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
ethics<br />
Too much information?<br />
Grant Gillett MBChB, D.Phil (Oxon), FRS NZ, FRACS; Donald Saville-Cook BSc, PGDip.HealSci (Otago), D.E.T.C.C.<br />
A<br />
number <strong>of</strong> recent cases have<br />
raised the <strong>issue</strong> <strong>of</strong> the risks that<br />
are posed both by everyday<br />
medicines and by alternatives to standard<br />
medical interventions, an aspect <strong>of</strong><br />
practice that has been made especially<br />
significant by the recent NZ Medical<br />
Council advice about fringe medicine 1<br />
and from the tendencies in contemporary<br />
medical literature and social policy<br />
to favour what can be referred to as<br />
‘marketing-based medicine’ masquerading<br />
as evidence-based medicine. 2<br />
<strong>The</strong> partial and selective information<br />
provided by the medical establishment<br />
raises questions about how many risks we<br />
should unwittingly run or be allowed to<br />
run by our medical advisors. <strong>The</strong> answer<br />
to this question must, however, be balanced<br />
against two other considerations in<br />
the area <strong>of</strong> information and disclosure.<br />
i. An ordinary consulting doctor,<br />
within the constraints <strong>of</strong> a clinical<br />
practice, cannot be expected to run<br />
through all the potentially relevant<br />
information relating to a condition<br />
and its management as part <strong>of</strong> a<br />
normal consultation with a patient,<br />
although there must be some required<br />
level <strong>of</strong> diligence.<br />
ii. Although the doctor has a legally well-<br />
established duty to answer a patient’s<br />
questions truthfully and to the best<br />
<strong>of</strong> their ability, the patient should not<br />
have to play a macabre game <strong>of</strong> 20<br />
questions to find out about aspects <strong>of</strong><br />
their condition and its treatment that<br />
they might regard as significant.<br />
<strong>The</strong> problem <strong>of</strong> information and what is<br />
required to satisfy rights 5 and 6 <strong>of</strong> the<br />
<strong>New</strong> <strong>Zealand</strong> Code <strong>of</strong> Health and Disability<br />
Services Consumers’ Rights 3 is<br />
made pressing by two possibilities. <strong>The</strong><br />
first is the existence <strong>of</strong> potentially very<br />
serious but systematically downplayed<br />
or concealed side effects from heavily<br />
marketed and promoted medications<br />
(such as statins) and the second is the existence<br />
<strong>of</strong> unorthodox or fringe regimens<br />
for diseases with a standard therapeutic<br />
pr<strong>of</strong>ile (such as psychiatric syndromes or<br />
cardiovascular disease).<br />
A case study<br />
Statin therapy has been associated with<br />
some serious and poorly documented side<br />
effects in that there is a link between not<br />
only myalgia but also rhabdomyolysis<br />
and statins. 4,5 Various reports in sources<br />
ranging from <strong>The</strong> American Journal <strong>of</strong><br />
Medicine to <strong>The</strong> <strong>New</strong> York Times have<br />
listed multiple neuromuscular conditions<br />
associated with statins, although this evidence,<br />
by its very nature, may be underreported<br />
because <strong>of</strong> its varying severity.<br />
A number <strong>of</strong> patients may well not be<br />
told <strong>of</strong> this association and its potentially<br />
life-affecting consequences, despite the<br />
fact that it is alluded to in the drug<br />
information, in part, because <strong>of</strong> the lack<br />
<strong>of</strong> emphasis on this aspect <strong>of</strong> the drugs in<br />
the literature and the widely publicised<br />
prophylactic benefits <strong>of</strong> statins. <strong>The</strong><br />
importance <strong>of</strong> prevention <strong>of</strong> heart attacks<br />
and strokes (and the attendant mortality<br />
and morbidity) makes us very ready to<br />
swallow the industry message (not to say<br />
the pills). <strong>The</strong>refore, even if patients have<br />
a right to know about such problems,<br />
it is not clear to what extent a doctor<br />
should foreground them (despite the clear<br />
warnings on the Medsafe website) nor to<br />
what extent s/he could be the subject <strong>of</strong><br />
complaints that potentially debilitating<br />
side effects were not mentioned. Given<br />
that patients <strong>of</strong>ten take their cue from the<br />
doctor about what is relevant to discuss in<br />
a clinic appointment, the omission could<br />
be serious in certain cases.<br />
<strong>The</strong> second problem is posed by the<br />
recent NZ Medical Council advice in its<br />
Correspondence to:<br />
Grant Gillett<br />
Pr<strong>of</strong>essor <strong>of</strong> Medical Ethics,<br />
Otago Bioethics Centre,<br />
University <strong>of</strong> Otago Medical<br />
School, PO Box 913,<br />
Dunedin, <strong>New</strong> <strong>Zealand</strong><br />
grant.gillett@otago.ac.nz<br />
<strong>The</strong> ethics column explores <strong>issue</strong>s around practising ethically in primary health care<br />
and aims to encourage thoughtfulness about ethical dilemmas that we may face.<br />
THIS ISSUE: Grant Gillett, Pr<strong>of</strong>essor <strong>of</strong> Medical Ethics from Otago, and his colleague,<br />
Donald Saville-Cook, address the <strong>issue</strong> <strong>of</strong> how much information needs to be given<br />
to patients, firstly about serious and potentially life-threatening adverse effects <strong>of</strong><br />
commonly-prescribed medications (such as statins) and, secondly, our duty to raise the<br />
options <strong>of</strong> radical or fringe treatments, and then explain why risk might outweigh benefit.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 165
ethics<br />
Ethics 101 column. 6 <strong>The</strong> tone <strong>of</strong> the piece<br />
is to equate all non-orthodox practices<br />
with quackery or fraud and to dismiss<br />
them out <strong>of</strong> hand. But the idea that our<br />
biomedical theories are fully adequate to<br />
the intractable bestiary <strong>of</strong> ‘medicine in<br />
the (urban) jungle’ is a gross simplification.<br />
In reality, a complex nexus <strong>of</strong> socioeconomic<br />
variables, genetic dispositions,<br />
patterns <strong>of</strong> referral and categorisation,<br />
market-based selection <strong>of</strong> disseminated<br />
medical information, and so on, 2 and the<br />
rise <strong>of</strong> the psycho-neuro-humero-immunological<br />
concepts <strong>of</strong> human health and<br />
disease muddy the waters. 7 What, given<br />
this mish-mash and the lack <strong>of</strong> undistorted<br />
and scientific evidence relating to<br />
wide swathes <strong>of</strong> medical practice such<br />
as primary care, community psychiatry,<br />
and everyday unwellness, ought one to<br />
say and do?<br />
mentioned to patients with OCD or<br />
depression? We seem to be on notice by<br />
the Medical Council <strong>of</strong> NZ that if that<br />
were done they would not regard the<br />
practice as ethical, but the HDC code<br />
Right 6(a) demands <strong>of</strong> providers ‘an<br />
explanation <strong>of</strong> the options available’ 3 (<strong>of</strong><br />
which more anon). Suppose the patient<br />
found prescribed alternatives distressing<br />
or to have unwanted side effects (like<br />
weight gain)? <strong>The</strong> well-intentioned and<br />
patient-centred doctor is likely to be in<br />
a quandary in such a case, particularly<br />
if the patient is one in whom untoward<br />
events might be predicted. One might<br />
want to mention the possibility <strong>of</strong><br />
something a bit ‘fringe’ but what is the<br />
ethical stance to doing so? It seems that<br />
the patient is entitled to a fair representation<br />
<strong>of</strong> current medical opinion and<br />
answer problematic. <strong>The</strong>re obviously<br />
needs to be some kind <strong>of</strong> weighting<br />
<strong>of</strong> advice about risks, but how should<br />
that be done. <strong>The</strong> language <strong>of</strong> material<br />
risk—the kind <strong>of</strong> risk a reasonable person<br />
would take into account in making<br />
a decision—that is <strong>of</strong>ten used does not<br />
tell us how well established those risks<br />
should be. A risk <strong>of</strong> rhabdomyolysis or<br />
polyneuropathy is likely to be material<br />
to anyone even though it is rare,<br />
and common problems like myalgia<br />
are plausibly material in that the kind<br />
<strong>of</strong> group who take statins might find<br />
their physical activity significantly<br />
compromised by such a side effect. But<br />
these may not be foregrounded in the<br />
information available to the average<br />
practitioner, so that the question arises<br />
as to what constitutes due diligence in<br />
<strong>The</strong> problem is intensified when we<br />
consider cases such as the following: an<br />
18-year-old male underwent cognitive<br />
behavioural therapy for severe obsessive<br />
compulsive disorder (OCD) and depression<br />
which had the effect <strong>of</strong> mitigating<br />
it from severe to moderate. He then<br />
underwent an ‘ABAB, (n <strong>of</strong> 1)’ trial <strong>of</strong><br />
a nutritional formula during which ‘his<br />
mood stabilised, his anxiety reduced,<br />
and his obsessions were in remission’. 8<br />
A return to normal diet provoked a relapse<br />
in his symptoms. This single case<br />
study may never be supported by any<br />
‘robust clinical evidence’ considering<br />
patterns <strong>of</strong> research funding, publication<br />
and promulgation in contemporary<br />
medicine, 9 quite apart from the reality<br />
<strong>of</strong> the situation. Nevertheless it is the<br />
kind <strong>of</strong> case behind the major damages<br />
awarded to Truehope as a result <strong>of</strong> a<br />
class 1 withdrawal <strong>of</strong> drugs required by<br />
Health Canada. 10<br />
This is a classical example <strong>of</strong> fringe<br />
medicine (contra the Medical Council<br />
document, 3 rationally and scientifically<br />
reported and assessed) but should<br />
the option it reports be <strong>of</strong>fered or even<br />
Perhaps all that one can say is that the doctor should be a<br />
trustworthy guide and partner in the information sharing<br />
required for effective treatment, a role that is hard to<br />
specify but that is a key element <strong>of</strong> good clinical practice<br />
one should probably position the advice<br />
being given against that framework in<br />
any consultation. 11<br />
A number <strong>of</strong> further questions arise<br />
from these problems about the ethics<br />
<strong>of</strong> medical information and the responsibilities<br />
<strong>of</strong> doctors in their advice to<br />
patients.<br />
To what extent are patients<br />
entitled to information about<br />
risks <strong>of</strong> their treatment?<br />
A number <strong>of</strong> blanket statements state<br />
that a patient is entitled to know <strong>of</strong> any<br />
significant risks associated with a proposed<br />
course <strong>of</strong> treatment (as in Right<br />
6.1(b) <strong>of</strong> the code) but the existence <strong>of</strong><br />
contested or unusual risks makes that<br />
accessing the relevant information, a<br />
problem compounded by the abundance<br />
<strong>of</strong> medical information <strong>of</strong> varying quality<br />
on the Internet.<br />
How should doctors deal with risks<br />
that a patient has found about<br />
from the Internet and other sites?<br />
Here one faces the nightmare scenario<br />
<strong>of</strong> the patient who ‘cannot see the<br />
wood for the trees’. <strong>The</strong>re are in every<br />
practice patients who will make a major<br />
<strong>issue</strong> out <strong>of</strong> a possibility that most<br />
people would not be overly concerned<br />
about to the point where they might<br />
make bad decisions from a faulty appraisal<br />
<strong>of</strong> the evidence available. <strong>The</strong><br />
idea <strong>of</strong> truly patient-centred medicine<br />
takes us a certain way in that the doc-<br />
166 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
ethics<br />
tor should assess the patient and the<br />
ways in which the patient is likely to<br />
distort or misinterpret evidence in the<br />
light <strong>of</strong> idiosyncratic personality factors<br />
so as to form a harmful or prejudicial<br />
opinion about their illness and its management.<br />
But one can imagine pitfalls<br />
aplenty in certain cases. Perhaps all that<br />
one can say is that the doctor should<br />
be a trustworthy guide and partner in<br />
the information sharing required for<br />
effective treatment, a role that is hard<br />
to specify but that is a key element <strong>of</strong><br />
good clinical practice.<br />
What options should a doctor or<br />
health care pr<strong>of</strong>essional provide<br />
the patient with information about?<br />
This question raises the <strong>issue</strong> <strong>of</strong> what<br />
is ‘reasonable medical care’ or ‘a reasonable<br />
body <strong>of</strong> medical opinion’ (both<br />
terms are <strong>of</strong>ten used in disciplinary<br />
hearings). <strong>The</strong> concept becomes difficult<br />
to interpret when there are options<br />
available that may or may not be<br />
regarded as standard treatment in the<br />
context <strong>of</strong> the doctor’s practice. That<br />
problem became pressing in a NZ surgical<br />
case where a patient found out, via<br />
the Internet, about a radical approach<br />
to the treatment <strong>of</strong> brain tumours<br />
and took that option. Subsequently a<br />
complaint was made that he had not<br />
been told <strong>of</strong> the possibility as part <strong>of</strong><br />
his clinical management. <strong>The</strong> Health<br />
and Disability Commissioner’s opinion<br />
was that the advice given to the patient<br />
should have indicated the controversial<br />
possibility <strong>of</strong> more radical treatment<br />
than that which was <strong>of</strong>fered.<br />
It was held that the neurosurgeon should<br />
have taken the time to discuss the option<br />
<strong>of</strong> further surgery. Although it would<br />
not be reasonable to expect him to <strong>of</strong>fer<br />
to perform a procedure that he did not<br />
believe was a viable option, he needed<br />
to raise the option <strong>of</strong> further surgery<br />
(which was available elsewhere in <strong>New</strong><br />
<strong>Zealand</strong> and in Australia) and explain<br />
why he thought the risks outweighed any<br />
potential benefit. <strong>The</strong> surgeon was found<br />
in breach <strong>of</strong> Right 6(1)(b).<br />
<strong>The</strong> more radical surgical option was<br />
commented on by other neurosurgeons<br />
who wrote to the Commissioner in<br />
the following terms: ‘whether or not a<br />
doubtful procedure should be advised<br />
to an anxious patient who will clutch<br />
at any straw is indeed arguable’; ‘Dr [X]<br />
gave advice to the patient and his family<br />
in keeping with standard… opinion’; ‘it<br />
is difficult to see why a surgeon should<br />
apologise for a management plan that<br />
was correct.’ <strong>The</strong>se remarks express what<br />
many feel is sound and sensible when<br />
doctors are giving recommendations to<br />
patients about treatments. Nevertheless,<br />
the finding is in keeping with the<br />
Medical Council recommendation that<br />
a patient is entitled to know how the<br />
advice s/he has received compares with<br />
a range <strong>of</strong> clinical opinion in the area<br />
concerned. This is probably sound advice<br />
also in the light <strong>of</strong> the controversies<br />
surrounding complementary and alternative<br />
medicines (CAM) and ‘fringe’ or<br />
‘natural’ therapies.<br />
Should patients be encouraged<br />
to do their own homework?<br />
<strong>The</strong> ethical response to this question<br />
follows from the arguments above. In<br />
general, a patient should be encouraged<br />
to be an active participant in the<br />
problem-solving partnership that is a<br />
clinical relationship. In that context, a<br />
negotiated mix <strong>of</strong> spontaneous disclosure<br />
(conveying a more or less standard<br />
medical opinion about the patient’s<br />
problem) and a responsive disclosure<br />
(about matters raised by the patient)<br />
is likely to be the best that a wellintentioned<br />
doctor can do. <strong>The</strong> scope <strong>of</strong><br />
information that gets into that conversation<br />
is potentially broad but should<br />
have the effect <strong>of</strong> helping the patient<br />
find his/her way around in the strange<br />
land that is Clinicum 11 with its <strong>of</strong>ten<br />
poorly understood hazards and variably<br />
well-understood therapeutic responses<br />
to those hazards and where a great deal<br />
<strong>of</strong> the guidance that one gets in the<br />
normal course <strong>of</strong> practice is both interested<br />
and promotional.<br />
References<br />
1. Medical Council <strong>of</strong> <strong>New</strong> <strong>Zealand</strong>. Statement on<br />
complementary and alternative medicine. Wellington;<br />
March 2005.<br />
2. Spielmans G, Parry P. From evidence-based medicine<br />
to marketing-based medicine: evidence from<br />
internal industry based documents. J Bioethic Inq.<br />
2010;7(1). In press.<br />
3. NZ Health and Disability Commissioner website.<br />
02 HDC 18414. Accessed 27 Jan 2010.<br />
4. Canadian Adverse Drug Center. <strong>New</strong>sletter.<br />
Statins: rhabdomyolysis and myopathy. Canadian<br />
Adverse Drug Reaction <strong>New</strong>sletter. Toronto; January<br />
2002;12(1).<br />
5. Statins. http://www.medsafe.govt.nz/pr<strong>of</strong>s/puarticles/statinmyop.htm.<br />
Accessed 1 Feb 2010.<br />
6. Medical Council <strong>of</strong> <strong>New</strong> <strong>Zealand</strong>. Ethics 101.<br />
Medical Council <strong>New</strong>s. Wellington; Dec 2009; 48.<br />
p 10–11.<br />
7. Ader R, Cohen N, Felten D. Psychoneuroimmunology:<br />
interactions between the nervous system and<br />
the immune system. Lancet. 1995;345:99–103.<br />
8. Rucklidge J. Successful treatment <strong>of</strong> OCD with a<br />
micronutrient formula following partial response<br />
to cognitive behavioural therapy. J Anxiety Disorders.<br />
2009;23(6):836–840.<br />
9. Elliot C. <strong>The</strong> drug pushers. Atlantic Monthly.<br />
2006;212:2–13.<br />
10. Woodruff C. Health Canada attacks successful<br />
nutritional approach to treating bipolar disorder.<br />
J Clin Psychiatry. 2003;64(3):1.<br />
11. Gillett G. Bioethics in the Clinic Baltimore: Johns<br />
Hopkins University Press; 2009; esp Ch 4.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 167
LETTERS TO THE EDITOR<br />
PSA screening reply<br />
In his Back to Back argument in favour <strong>of</strong> PSA screening,<br />
Robin Smart claims that PSA screening performs<br />
well compared to other screening programmes. 1 He gives a<br />
number needed to screen to save one life <strong>of</strong> 80, and number<br />
needed to treat to save one life <strong>of</strong> two to five. <strong>The</strong> source<br />
for these figures is not given, but they are very different<br />
from the preliminary estimates from the ERSPC study<br />
(which he quotes elsewhere) which found the number<br />
needed to screen over nine years to prevent one death was<br />
1410 and that the number needed to treat to prevent one<br />
death was 48. 2<br />
If men are to make an informed decision about whether<br />
to have a PSA test, then it is important that they are<br />
provided with the best estimates <strong>of</strong> the potential benefits<br />
and harms <strong>of</strong> the test. Smart’s figures give a misleadingly<br />
optimistic impression.<br />
Dr Ben Hudson<br />
References<br />
1. Smart R. <strong>New</strong> <strong>Zealand</strong> should introduce population screening for prostate<br />
cancer using PSA testing: Yes. J Primary Health Care. 2009;1(4):319–20.<br />
2. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer<br />
mortality in a randomized European study. N Engl J Med. 2009 March 18,<br />
2009:NEJMoa0810084.<br />
Cardiovascular disease risk pr<strong>of</strong>ile tools and <strong>New</strong><br />
<strong>Zealand</strong>—absolutely the best way forward<br />
I<br />
n December 2009, the Journal <strong>of</strong> Primary Health Care published<br />
a non–peer reviewed essay about the use <strong>of</strong> cardiovascular<br />
disease (CVD) risk pr<strong>of</strong>ile tools in <strong>New</strong> <strong>Zealand</strong>. 1 <strong>The</strong><br />
authors <strong>of</strong> this essay, Boland and Moriarty, used a crosssection<br />
analysis undertaken by our research group (Bannink<br />
et al. 2006) 2 and an outdated systematic review (Brindle et al.<br />
2006) 3 to argue against the use <strong>of</strong> CVD risk pr<strong>of</strong>ile tools. As<br />
co-authors <strong>of</strong> the Bannink et al. paper we would appreciate the<br />
right <strong>of</strong> response.<br />
Boland and Moriarty are correct that our paper described<br />
the CVD risk factor status <strong>of</strong> the first 18 000 patients pr<strong>of</strong>iled<br />
in routine general practice in <strong>New</strong> <strong>Zealand</strong> using the PRE-<br />
DICT-CVD tool. <strong>The</strong>y also correctly stated that the PREDICT<br />
decision support system is based <strong>entire</strong>ly on evidence-based<br />
guidelines—the updated PREDICT CVD-Diabetes containing<br />
recommendations from the <strong>New</strong> <strong>Zealand</strong> Guidelines for CVD<br />
Risk Assessment and Management and the Management <strong>of</strong><br />
Type 2 Diabetes.<br />
However, the authors <strong>of</strong> the essay inappropriately criticise<br />
this paper as not being able to show evidence <strong>of</strong> effectiveness<br />
<strong>of</strong> CVD risk pr<strong>of</strong>ile tools. <strong>The</strong> Bannink paper was simply a<br />
cross-sectional analysis <strong>of</strong> risk factor pr<strong>of</strong>iles generated opportunistically<br />
in general practice. <strong>The</strong> purpose <strong>of</strong> this first paper<br />
by the PREDICT investigators was to describe the baseline<br />
characteristics <strong>of</strong> a cohort to be used to generate new risk prediction<br />
tools and to demonstrate how a cohort study could be<br />
undertaken in routine primary care practice using a web-based<br />
clinical decision support system (CDSS). This paper never was<br />
nor ever could be a study <strong>of</strong> effectiveness <strong>of</strong> decision support<br />
tools, nor would ever be included in a systematic review <strong>of</strong><br />
the impact <strong>of</strong> CVD risk pr<strong>of</strong>ile tools. It represented the first<br />
stage <strong>of</strong> a large <strong>New</strong> <strong>Zealand</strong> cohort study, the most appropriate<br />
study design for generating risk prediction equations.<br />
<strong>The</strong> Framingham equation used in <strong>New</strong> <strong>Zealand</strong> CVD<br />
risk assessment and management guidelines 4 has long been<br />
acknowledged as having deficiencies leading to over-prediction<br />
<strong>of</strong> risk in low risk populations and under-prediction <strong>of</strong> risk<br />
in high risk populations. 3 In the six years since the publication<br />
<strong>of</strong> Bannink et al., <strong>New</strong> <strong>Zealand</strong> GPs and practice nurses<br />
have produced a cohort <strong>of</strong> over 120 000 participants using the<br />
PREDICT decision support system. By linking the risk pr<strong>of</strong>iles<br />
in this cohort to hospitalisations and deaths, it will be possible<br />
to develop up-to-date risk prediction equations relevant<br />
for all <strong>New</strong> <strong>Zealand</strong>ers and for specific high risk population<br />
subgroups such as those <strong>of</strong> Maori, Pacific and South Asian<br />
ethnicities. Boland and Moriarty raise concerns about possible<br />
missing ethnicity data. As ethnicity is an integral variable in<br />
<strong>New</strong> <strong>Zealand</strong> risk prediction algorithms, it is not possible to<br />
get a risk prediction score using PREDICT without having<br />
complete data entry. Indeed, there is no missing risk assessment<br />
data on anyone in the PREDICT cohort.<br />
Letters may respond to published papers, briefly report original research or case reports, or raise matters <strong>of</strong> interest relevant to<br />
primary health care. <strong>The</strong> best letters are succinct and stimulating. Letters <strong>of</strong> no more than 400 words may be emailed to:<br />
editor@rnzcgp.org.nz. All letters are subject to editing and may be shortened.<br />
168 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
LETTERS TO THE EDITOR<br />
<strong>The</strong> authors develop a debate against the effectiveness <strong>of</strong><br />
CVD risk pr<strong>of</strong>ile tools citing the systematic review by Brindle<br />
et al. published in 2006. <strong>The</strong>y state that ‘…this review found<br />
no conclusive evidence that the use <strong>of</strong> CVD risk pr<strong>of</strong>ile tools<br />
significantly improves patient care.’<br />
<strong>The</strong> review, now out-dated, found that ‘four randomised<br />
controlled trials confined to people with hypertension or<br />
diabetes found no strong evidence that a cardiovascular risk assessment<br />
performed by a clinician improves health outcomes.’<br />
<strong>The</strong> four randomised controlled trials investigated the impact<br />
<strong>of</strong> giving patients a CVD risk score. CVD risk assessment<br />
and management requires a long-term committment to our<br />
patients. It is well-known that one-<strong>of</strong>f advice rarely leads to<br />
persisting changes in patient behaviour. So it is not surprising<br />
that providing a CVD risk assessment at one point in time did<br />
not change patient health outcomes. Furthermore, two <strong>of</strong> the<br />
trials had a CDSS, the others did not. In the two trials using a<br />
CDSS there was very poor uptake <strong>of</strong> the systems by practitioners,<br />
and one was not integrated with the patient’s electronic<br />
medical record—one <strong>of</strong> the most important factors shown to<br />
support uptake and use <strong>of</strong> CDSSs. 5 PREDICT is integrated<br />
into practitioners’ patient management systems, provides decision<br />
support at the time and location <strong>of</strong> decision-making and<br />
generates a comprehensive, personalised set <strong>of</strong> evidence-based<br />
management recommendations, not just a risk score. <strong>The</strong> latter<br />
functionalities have also been shown to be critical independent<br />
predictors <strong>of</strong> improved clinical practice. 5<br />
Furthermore, Boland and Moriarty did not base their argument<br />
on up-to-date evidence <strong>of</strong> the effectiveness <strong>of</strong> CDSS for<br />
CVD. A more relevant systematic review was conducted in<br />
2008. 6 This review identified 42 randomised controlled trials<br />
<strong>of</strong> computerised systems for assessment and management <strong>of</strong><br />
CVD risk or risk factors in primary care. All <strong>of</strong> the older trials<br />
including non–user friendly, non-integrated systems were<br />
included. <strong>The</strong> evidence for the impact <strong>of</strong> CDSS in general has<br />
been moderately favourable in terms <strong>of</strong> improving desired<br />
practice. Of the randomised trials <strong>of</strong> CDSS for assessing or<br />
managing CVD risk, about two-thirds reported improvements<br />
in provider processes (such as improved documentation, increase<br />
in recommended examinations, investigations, providing<br />
advice or management plans) and two-fifths reported some<br />
improvements in intermediate patient outcomes (reduction<br />
in CVD risk, BP or cholesterol levels). Most importantly, no<br />
harms were reported.<br />
We believe that CVD risk pr<strong>of</strong>ile tools incorporated within<br />
general practice management systems have significant potential<br />
to improve the quality <strong>of</strong> patient care in <strong>New</strong> <strong>Zealand</strong>. <strong>The</strong><br />
unique advantage <strong>of</strong>fered by the PREDICT system is its ability<br />
to also provide real-time aggregated reports to individual<br />
practices on their patient care and to generate a cohort study<br />
for developing new risk prediction tools that are based on <strong>New</strong><br />
<strong>Zealand</strong> populations. Moreover we have now integrated into<br />
PREDICT the ‘Your Heart Forecast’ (www.yourheartforecast.<br />
co.nz) tool that we developed in collaboration with the National<br />
Heart Foundation to support and improve risk communication.<br />
This has been well-received by clinical users. Evaluation<br />
to determine whether Your Heart Forecast faciltates patient<br />
understanding <strong>of</strong> a CVD risk score and supports behaviour<br />
change is underway.<br />
We challenge Boland and Moriarty to find both more<br />
appropriate and more up-to-date evidence to support their<br />
arguments.<br />
Sue Wells, Tania Riddell and Rod Jackson<br />
References<br />
1. Boland P, Moriarty H. Cardiovascular disease risk pr<strong>of</strong>ile tools and <strong>New</strong><br />
<strong>Zealand</strong>—the best way forward? J Primary Health Care. 2009;1(4):328–31.<br />
2. Bannink L, Wells S, Broad J, Riddell T, Jackson R. Web-based assessment <strong>of</strong><br />
cardiovascular disease risk in routine primary care practice in <strong>New</strong> <strong>Zealand</strong>: the<br />
first 18,000 patients (PREDICT CVD-1). N Z Med J. 2006;119(1245):U2313.<br />
3. Brindle P, Beswick A, Fahey T, Ebrahim S. Accuracy and impact <strong>of</strong> risk assessment<br />
in the primary prevention <strong>of</strong> cardiovascular disease: a systematic review.<br />
Heart. 2006 Dec;92(12):1752–9.<br />
4. <strong>New</strong> <strong>Zealand</strong> Guideline Group. <strong>The</strong> assessment and management <strong>of</strong> cardiovascular<br />
risk. Wellington: <strong>New</strong> <strong>Zealand</strong>; 2003.<br />
5. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice<br />
using clinical decision support systems: a systematic review <strong>of</strong> trials to identify<br />
features critical to success. BMJ. 2005;330:765–72.<br />
6. Wells S. Getting evidence to and from general practice consultations for cardiovascular<br />
risk management using computerised decision support. PhD thesis.<br />
Auckland: University <strong>of</strong> Auckland; 2008.<br />
COMPETING INTERESTS<br />
PREDICT was developed by a collaboration <strong>of</strong> clinical epidemiologists<br />
at the University <strong>of</strong> Auckland, IT specialists at Enigma Publishing<br />
Ltd (a private provider <strong>of</strong> online health knowledge systems), primary<br />
health care providers, secondary care specialist opinion leaders,<br />
primary health care organisations, non-governmental organisations<br />
(<strong>New</strong> <strong>Zealand</strong> Guidelines Group, National Heart Foundation,<br />
Diabetes <strong>New</strong> <strong>Zealand</strong>, Diabetes Auckland), several district health<br />
boards and the Ministry <strong>of</strong> Health. PREDICT s<strong>of</strong>tware platform<br />
is owned by Enigma Publishing Ltd (PREDICT is a trademark <strong>of</strong><br />
Enigma Publishing Ltd). <strong>The</strong> PREDICT research project has support<br />
by HRC grants 03/183 and 08/121 from the Health Research<br />
Council. TR and SW are co-principal investigators (Maori–non<br />
Maori partnership) and RJ is the supervisory investigator. SW,<br />
TR and RJ have no commercial involvement in PREDICT.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 169
BOOK REVIEW<br />
Interpreting in <strong>New</strong> <strong>Zealand</strong>, the pathway<br />
forward<br />
by Diana Clark and Caroline McGrath<br />
Reviewed by Ben Gray, GP <strong>New</strong>town Union Health Service.<br />
<strong>General</strong> practitioners (GPs) face many risks in<br />
the course <strong>of</strong> an average day. <strong>The</strong>se cluster<br />
alarmingly when a doctor manages a patient<br />
who speaks little or no English. As well as risks<br />
to diagnosis, discussion and treatment, impaired<br />
communication means there are shadows over informed<br />
consent, disclosure <strong>of</strong> previous history, and<br />
how to agree and implement a management plan.<br />
<strong>The</strong> RNZCGP’s practice accreditation document<br />
Aiming For Excellence is almost silent on how to<br />
deal with this problem. Few <strong>of</strong> us have thought<br />
about pr<strong>of</strong>essional and ethical <strong>issue</strong>s as they<br />
might apply to interpreters. <strong>The</strong>y are probably<br />
the only mainstream health pr<strong>of</strong>essional without<br />
an agreed training programme, agreed pr<strong>of</strong>essional<br />
ethics or requirement for registration and<br />
monitoring <strong>of</strong> quality.<br />
<strong>The</strong> Office <strong>of</strong> Ethnic Affairs has produced a book<br />
as a way <strong>of</strong> informing and encouraging debate on<br />
how <strong>New</strong> <strong>Zealand</strong> (NZ) addresses these important<br />
<strong>issue</strong>s and goes forward as a multilingual country.<br />
This book sets out in more than 20 contributions<br />
from NZ and overseas, expertise, insights and<br />
experience in interpreting and related fields. <strong>The</strong><br />
submissions range from the anecdotal (should an<br />
interpreter tell a nurse the patient is a former doctor<br />
from Russia who feels her ear is not being syringed<br />
in the right way?) to ethics, both here and overseas,<br />
to a useful chart setting out the difference between<br />
the activities undertaken by the interpreter and the<br />
translator. <strong>The</strong>re are contributions from educators,<br />
interpreting practitioners and from those with long<br />
experience in the deaf community.<br />
<strong>The</strong> book is not an academic text. It is more <strong>of</strong> a<br />
manual enabling someone who wanted to know<br />
about working with an interpreter to do so and to<br />
be aware <strong>of</strong> some <strong>of</strong> the fish hooks.<br />
Today NZ demographics almost guarantee GPs<br />
will have patients with limited English. Almost a<br />
quarter <strong>of</strong> residents were not born here. Though<br />
many speak English, others don’t. All are entitled<br />
to have access to the services <strong>of</strong>fered by GPs and<br />
management <strong>of</strong> health <strong>issue</strong>s will be a very important<br />
part <strong>of</strong> effective settlement for them all.<br />
In the past, children routinely have been used<br />
as bilingual helpers with no way <strong>of</strong> establishing<br />
the quality <strong>of</strong> their language knowledge nor the<br />
consistency or accuracy <strong>of</strong> their interpretations.<br />
Grim stories <strong>of</strong> serious consequences and misunderstandings<br />
abound, but it seemed there was no<br />
alternative.<br />
If you have felt bewildered, irritated or alarmed<br />
at the challenges and risks inherent in diagnosing<br />
and providing health care to someone who<br />
doesn’t speak English, then this book is for you.<br />
<strong>The</strong>re is a way forward if we can have accurate,<br />
confidential and cost-effective interpreting<br />
because this change will affect all <strong>of</strong> us as our<br />
practices become more multilingual.<br />
Language Line, the telephone service and the<br />
source <strong>of</strong> this book, is available to all NZ doctors<br />
and medical practices through their membership<br />
<strong>of</strong> PHOs or similar organisations. It <strong>of</strong>fers 40<br />
languages—see www.languageline.govt.nz for<br />
more information and to access the book.<br />
Publisher: Steele Roberts, Wellington<br />
Date <strong>of</strong> Publication: 2009<br />
Number <strong>of</strong> pages: 207<br />
170 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
POLICY STATEMENT FOR AUTHORS<br />
Conflict <strong>of</strong> interest in peer-reviewed medical<br />
journals: <strong>The</strong> World Association <strong>of</strong> Medical Editors<br />
(WAME) position on a challenging problem<br />
Lorraine E Ferris 1 and Robert H Fletcher 2<br />
Conflict <strong>of</strong> interest in medical publishing<br />
exists when a participant’s private<br />
interests compete with his or her responsibilities<br />
to the scientific community, readers, and<br />
society. While conflict <strong>of</strong> interest is common,<br />
it reaches the level <strong>of</strong> concern when ‘a reasonable<br />
observer might wonder if the individual’s<br />
behavior or judgment was motivated by his or her<br />
competing interests’. 1 Having a competing interest<br />
does not, in itself, imply wrongdoing. But it<br />
can undermine the credibility <strong>of</strong> research results<br />
and damage public trust in medical journals.<br />
In recent years, the extent <strong>of</strong> conflict <strong>of</strong> interest<br />
in medical journal articles has been increasingly<br />
recognised. Medical journals and the popular<br />
media have published numerous examples <strong>of</strong><br />
competing interests that seemed to have biased<br />
published reports. 2,3,4 Organisations have<br />
expressed concern for the effects <strong>of</strong> conflicts <strong>of</strong><br />
interest on research, 5 publication, 1,6,7 teaching 8<br />
and continuing medical and nursing education. 9<br />
<strong>The</strong> World Association <strong>of</strong> Medical Editors<br />
(WAME) is one <strong>of</strong> the institutions engaged<br />
in this discussion. WAME was established in<br />
1995 10,11 to facilitate worldwide cooperation and<br />
communication among editors <strong>of</strong> peer-reviewed<br />
journals, improve editorial standards, and<br />
promote pr<strong>of</strong>essionalism in medical editing. 12<br />
Membership in WAME is open to all editors <strong>of</strong><br />
peer-reviewed biomedical journals worldwide;<br />
small journals in resource-poor countries are wellrepresented.<br />
As <strong>of</strong> December 2009, WAME had<br />
1595 individual members representing 965 journals<br />
in 92 countries. WAME has broad participation<br />
as there are no dues and WAME activities are<br />
largely carried out through the member list serve<br />
and the member password-protected website.<br />
In March 2009, WAME released an updated policy<br />
statement, Conflict <strong>of</strong> interest in peer-reviewed medical<br />
journals. 1 It details the <strong>issue</strong>s WAME believes<br />
journals should address when establishing their<br />
own policies for conflict <strong>of</strong> interest. <strong>The</strong> editors<br />
<strong>of</strong> this journal thought that the <strong>issue</strong>s were important<br />
enough to share with its readers. A summary<br />
<strong>of</strong> the statement is presented in Table 1 and the<br />
full statement 1 can be found on WAME’s website. 12<br />
How does this statement differ from<br />
earlier conflict-<strong>of</strong>-interest statements?<br />
First, WAME expands the scope <strong>of</strong> competing<br />
interests. Other statements have been concerned<br />
almost exclusively with conflicts <strong>of</strong> interest related<br />
to financial ties to industry—companies that<br />
sell health care products. <strong>The</strong> assumption is that<br />
financial incentives are especially powerful and<br />
are not readily recognised without special efforts<br />
to make them apparent. WAME has extended the<br />
concept <strong>of</strong> financial conflict <strong>of</strong> interest to include<br />
the effects <strong>of</strong> clinical income. For example,<br />
physicians who earn their livelihood by reading<br />
mammograms or performing colonoscopies may<br />
be biased in favour <strong>of</strong> these technologies. WAME<br />
has also included non-financial conflicts <strong>of</strong> interest<br />
(or the appearance <strong>of</strong> one) related to scholarly<br />
commitment: ‘intellectual passion’, (the tendency<br />
to favour positions that one has already espoused<br />
or perhaps even established); personal relationships<br />
(the tendency to judge the works <strong>of</strong> friends/<br />
colleagues or competitors/foes differently because<br />
<strong>of</strong> the relationship); political or religious beliefs<br />
(the tendency to favour or reject positions because<br />
it affirms or challenges one’s political or religious<br />
beliefs); and institutional affiliations (the<br />
tendency to favour or reject results <strong>of</strong> research<br />
because <strong>of</strong> one’s institutional affiliations).<br />
1<br />
Chair, WAME Ethics<br />
Committee, Clinical<br />
Epidemiology Unit,<br />
Sunnybrook Health Sciences<br />
Centre, Toronto, Ontario,<br />
Canada<br />
2<br />
Chair, WAME Policy<br />
Committee, Harvard Medical<br />
School, Boston MA, USA<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 171
POLICY STATEMENT FOR AUTHORS<br />
Second, WAME did not prescribe a universal<br />
standard for when meaningful conflict <strong>of</strong> interest<br />
exists. Rather, it defined and recommended elements<br />
<strong>of</strong> conflict <strong>of</strong> interest policies and encouraged<br />
journals to establish their own standards.<br />
WAME left operational definitions and standards<br />
on the basic <strong>issue</strong>s to member journals, recognising<br />
that journals exist in very different contexts<br />
across the globe, standards for conflict <strong>of</strong> interest<br />
are evolving, and some journals already have<br />
well-established policies and standards. WAME<br />
does not presume to judge which conflicts require<br />
action and what the appropriate action may be,<br />
although its policy does <strong>of</strong>fer factors to consider.<br />
1 Obviously, excessive concern for these and<br />
more comprehensive lists <strong>of</strong> possible competing<br />
interests could paralyse the peer review and<br />
publication process and is not feasible. Editors<br />
must make judgments as to the strength <strong>of</strong> the<br />
conflict, but to do so must have uncensored<br />
information. Similarly, readers need transparency<br />
about conflicts, and therefore editors should<br />
publish with every article all relevant author<br />
disclosures. 1<br />
Third, WAME confirms the seriousness <strong>of</strong><br />
failure to disclose conflict <strong>of</strong> interest by indicating<br />
that editors have a responsibility for investigating<br />
and, if relevant, acting, if competing<br />
interests surface after a manuscript is submitted<br />
Table 1. Summary <strong>of</strong> key elements for peer reviewed medical journal’s conflict <strong>of</strong> interest policies<br />
Element Key aspects Comments<br />
1. Definition and<br />
scope<br />
2. Types <strong>of</strong><br />
competing interests<br />
3. Declaring conflicts<br />
<strong>of</strong> interest<br />
4. Managing conflicts<br />
<strong>of</strong> interest<br />
A clear definition the journal uses as to what<br />
is conflict <strong>of</strong> interest and who is captured in<br />
the definition.<br />
A clear statement <strong>of</strong> examples <strong>of</strong> the types<br />
<strong>of</strong> competing interests (and their definitions)<br />
the journal says must be declared. Should<br />
include the following as examples, but there<br />
could be others:<br />
(a) Financial ties<br />
(b) Academic commitments<br />
(c) Personal relationships<br />
(d) Political or religious beliefs<br />
(e) Institutional affiliations<br />
Clear statements on:<br />
(a) what is to be declared, when and to<br />
whom;<br />
(b) format for declaration;<br />
(c) a journal’s role in asking additional<br />
questions or seeking clarification about<br />
disclosures; and<br />
(d) consequences for failing to disclose<br />
before or after publication.<br />
A clear statement on how conflict <strong>of</strong> interest<br />
will be managed by the journal, including the<br />
position that all relevant conflict <strong>of</strong> interest<br />
disclosures (or the declaration <strong>of</strong> no conflict<br />
<strong>of</strong> interest) will be published with the article<br />
and clarity about what conflict <strong>of</strong> interest<br />
situations will result in a manuscript not<br />
being considered.<br />
Sample definition: Conflict <strong>of</strong> interest<br />
exists when a participant in the publication<br />
process (author, peer reviewer or editor)<br />
has a competing interest that could unduly<br />
influence (or be reasonably seen to do so)<br />
his or her responsibilities in the publication<br />
process (submission <strong>of</strong> manuscripts,<br />
peer review, editorial decisions, and<br />
communication between authors, reviewers<br />
and editors).<br />
<strong>The</strong>re is a need to consider a wide range<br />
<strong>of</strong> competing interests (and a recognition<br />
that they can coexist) which the individual<br />
assesses as to whether they unduly influence<br />
(or be reasonably seen to do so) his or her<br />
responsibilities in the publication process.<br />
Examples and definitions <strong>of</strong> what competing<br />
interests should be declared need to be<br />
articulated with journals moving beyond just<br />
financial conflict <strong>of</strong> interest.<br />
Journals rely on disclosure about the facts<br />
because routine monitoring or investigation<br />
is not possible. This creates a particular<br />
onus on the declarer to report carefully and<br />
comprehensively. It also means that journals<br />
should ask about conflict <strong>of</strong> interest in such<br />
a way that there will be a high likelihood <strong>of</strong><br />
reporting relevant conflict <strong>of</strong> interest.<br />
Journals use various rules about how they<br />
will deal with conflict <strong>of</strong> interest and conflict<br />
<strong>of</strong> interest disclosures and these need to<br />
be made known to all those involved in the<br />
publication process.<br />
172 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
POLICY STATEMENT FOR AUTHORS<br />
or published. <strong>The</strong> intent is that allegations <strong>of</strong> failure<br />
to declare conflicts <strong>of</strong> interest must be taken<br />
seriously by journals.<br />
Finally, WAME has addressed in a single statement<br />
the conflicts <strong>of</strong> interest threatening all<br />
participants in the research and publication continuum,<br />
including authors, peer reviewers, and<br />
editors. Conflicts between editors and journal<br />
owners, which might affect both the accuracy <strong>of</strong><br />
articles and the credibility <strong>of</strong> journals, have been<br />
addressed in another WAME policy statement. 13<br />
What can be done about conflicts<br />
<strong>of</strong> interest in medical journals?<br />
Conflicts <strong>of</strong> interest cannot be eliminated altogether,<br />
but it can be managed so that it has the<br />
smallest possible effects on journal content and<br />
credibility. <strong>The</strong> backbone <strong>of</strong> managing conflicts<br />
<strong>of</strong> interest is full written disclosure; without it,<br />
nothing else is possible. Currently, authors may<br />
not reveal all <strong>of</strong> their competing interests and,<br />
even if they do, journals too <strong>of</strong>ten do not publish<br />
them, 14 so there is plenty <strong>of</strong> room for improvement.<br />
Even so, disclosure alone is an imperfect<br />
remedy; editors still must determine whether a<br />
conflict has sufficient potential to impair an individual’s<br />
objectivity such that the article should<br />
not be published. Even more work may be needed<br />
on reviewers’ and editors competing interests,<br />
given their critical role as gatekeepers for the<br />
medical literature.<br />
No statement will solve the conflict <strong>of</strong> interest<br />
problem, nor will it ever be solved altogether. As<br />
understanding <strong>of</strong> the problem and its management<br />
evolves, journals should be given latitude<br />
to establish their own standards, matching their<br />
policies to the best standards <strong>of</strong> their discipline<br />
and culture. WAME believes journals should<br />
make these policies readily accessible to everyone.<br />
All <strong>of</strong> us—editors, authors, reviewers, and<br />
readers—should be paying more attention to<br />
conflicts <strong>of</strong> interest than we have been. We hope<br />
this statement serves that purpose.<br />
This editorial may appear in other medical and<br />
biomedical journals whose editors are members <strong>of</strong><br />
the World Association <strong>of</strong> Medical Editors (WAME).<br />
References<br />
1 WAME statement on conflict <strong>of</strong> interest in peer-reviewed<br />
medical journals. http://www.wame.org/conflict-<strong>of</strong>-interestin-peer-reviewed-medical-journals<br />
2 Bekelman JE, Li Y, Gross CP. Scope and impact <strong>of</strong> financial conflicts<br />
<strong>of</strong> interest in biomedical research: a systematic review.<br />
JAMA. 2003;289(4);454–65.<br />
3 Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical<br />
industry sponsorship and research outcome and quality:<br />
systematic review. BMJ. 2003;326(7400);1167–1170.<br />
4 Altman LK. For science’s gatekeepers, a credibility gap.<br />
<strong>The</strong> <strong>New</strong> York Times. 2 May 2006. http://www.nytimes.<br />
com/2006/05/02/health/02docs.html?scp=58&sq=conflict+<br />
<strong>of</strong>+interest+%26+medicine&st=nyt<br />
5 Institute <strong>of</strong> Medicine. Conflict <strong>of</strong> interest in medical research,<br />
education, and practice. Washington, DC: National Academies<br />
Press. 2009 (April). http://www.iom.edu/Reports/2009/<br />
Conflict-<strong>of</strong>-Interest-in-Medical-Research-Education-and-<br />
Practice.aspx<br />
6 International Committee <strong>of</strong> Medical Journal Editors (ICMJE)<br />
Uniform requirements for manuscripts submitted to biomedical<br />
journals; ethical considerations in the conduct and reporting<br />
<strong>of</strong> research: conflicts <strong>of</strong> interest. http://www.icmje.org/<br />
ethical-4conflicts.html<br />
7 International Committee <strong>of</strong> Medical Journal Editors (ICMJE)<br />
Uniform format for disclosure <strong>of</strong> competing interests in ICMJE<br />
journals. October 2009. http://www.icmje.org/format.pdf<br />
8 American Association <strong>of</strong> Medical <strong>College</strong>s. Industry funding<br />
<strong>of</strong> medical education: report <strong>of</strong> an AAMC task force.<br />
June 2008.<br />
9 Hager M, Russell S, Fletcher, SW (editors). Continuing education<br />
in the health pr<strong>of</strong>essions: improving healthcare through<br />
lifelong learning. Josiah Macy J Foundation. November 2007.<br />
http://www.josiahmacyfoundation.org/documents/pub_<br />
ContEd_inHealthPr<strong>of</strong>.pdf<br />
10 Squires BP, Fletcher SW. <strong>The</strong> World Association <strong>of</strong> Medical<br />
Editors (WAME): thriving in its first decade. Science Editor.<br />
2005;28(1):13–16.<br />
11 Launching the World Association <strong>of</strong> Medical Editors: report<br />
<strong>of</strong> the conference to promote international cooperation<br />
among medical journal editors. 1995. http://www.wame/org/<br />
Bellagio.htm<br />
12 WAME website. http://www.wame.org<br />
13 WAME policy on the relationship between journal editorsin-chief<br />
and owners (formerly titled Editorial Independence).<br />
http://www.wame/org/resources/policies#independence<br />
14 Bhargava N, Qureshi J, Vakil N. Funding source and conflict<br />
<strong>of</strong> interest disclosures by authors and editors in gastroenterology<br />
specialty journals. American J <strong>of</strong> Gastroenterology.<br />
2007;102(6);1146–1150.<br />
ACKNOWLEDGMENTs<br />
<strong>The</strong> authors wish to thank<br />
the World Association <strong>of</strong><br />
Medical Editors (WAME)<br />
Officers warmly for their<br />
helpful comments on<br />
an earlier version <strong>of</strong> this<br />
editorial. Many thanks to<br />
President Margaret Winker<br />
(USA); Past President<br />
Michael Callaham (USA);<br />
Vice-President John<br />
Overbeke (Netherlands);<br />
Treasurer Tom Lang (USA);<br />
and Secretary Farrokh<br />
Habibzadeh (Iran).<br />
<strong>The</strong> WAME Statement<br />
on Conflict <strong>of</strong> Interest in<br />
Peer-Reviewed Medical<br />
Journals was approved by<br />
the WAME Board in March<br />
2009. Many thanks to the<br />
members <strong>of</strong> the WAME<br />
Ethics Committee and<br />
to the WAME Editorial<br />
Policy Committee for their<br />
insightful and helpful<br />
comments on an earlier<br />
version <strong>of</strong> the statement.<br />
Warm thanks to the<br />
WAME Board for their<br />
input and comments:<br />
Margaret Winker; Michael<br />
Callaham; John Overbeke;<br />
Tom Lang; Farrokh<br />
Habibzadeh; Adamson<br />
Muula (Malawi) and Rob<br />
Siebers (<strong>New</strong> <strong>Zealand</strong>).<br />
COMPETING INTERESTS<br />
As a WAME Director,<br />
Lorraine Ferris did not<br />
participate in the WAME<br />
Board vote to approve the<br />
statement or the vote to<br />
endorse the editorial.<br />
<strong>The</strong> authors have no<br />
conflicts <strong>of</strong> interest<br />
to declare.<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 173
RESEARCH GEMS<br />
Gems <strong>of</strong> <strong>New</strong> <strong>Zealand</strong><br />
Primary Health Care Research<br />
Increase in use <strong>of</strong> cardiovascular<br />
preventive medication<br />
This study measured trends in cardiovascular<br />
preventive medication prescribing<br />
in <strong>New</strong> <strong>Zealand</strong> primary care from 2000<br />
to 2003 using data from the Dunedin<br />
RNZCGP Research Unit database <strong>of</strong><br />
men aged over 44 and women aged over<br />
54 years who consulted a doctor in<br />
2000–2003 in practices supplying electronic<br />
clinical notes. Cardiovascular risk<br />
as calculated by the Framingham-based<br />
risk equation could only be estimated<br />
for one-third <strong>of</strong> the study population<br />
due to missing risk factor information.<br />
<strong>The</strong> treatment <strong>of</strong> all patient groups with<br />
a five-year cardiovascular risk <strong>of</strong> >10%<br />
increased by about 4% per year, and by<br />
3% per year in the five to 10% cardiovascular<br />
risk bracket.<br />
Selak V, Rafter N, Parag V, Tomlin A, Vander<br />
Hoorn S, Dove, S, Rodgers A. Cardiovascular<br />
treatment gaps: closing, but slowly. N Z Med<br />
Journal. 2009;122(1293). Corresponding<br />
author: V. Selak. Email: vanessa.selak@<br />
waitematadhb.govt.nz<br />
Pharmacists’ perceptions <strong>of</strong><br />
roles and accreditation<br />
<strong>The</strong> Ten Year Vision for Pharmacists<br />
outlines the roles pharmacists are expected<br />
to provide now and in the future.<br />
<strong>The</strong> aim <strong>of</strong> this study was to determine<br />
pharmacists’ views on these roles and<br />
the need for accreditation. Findings from<br />
a national postal survey suggest the majority<br />
<strong>of</strong> pharmacists believe they should<br />
continue to undertake traditional clinical<br />
and technical roles. Less than one-third<br />
suggested accreditation for these roles.<br />
<strong>The</strong>re was a positive but more tempered<br />
view regarding the uptake <strong>of</strong> enhanced<br />
or collaborative roles. <strong>The</strong>re was recognition<br />
<strong>of</strong> a need for accreditation suggesting<br />
a cautious optimism about adopting<br />
new services.<br />
Scahill S, Harrison J, Sheridan J. Pharmacy<br />
under the spotlight: <strong>New</strong> <strong>Zealand</strong><br />
pharmacists’ perceptions <strong>of</strong> current and<br />
future roles and the need for accreditation Int<br />
J Pharm Pract. 2010:18;59–62. DOI 10.1211/<br />
ijpp/18.01.0010. Corresponding author:<br />
S. Scahill. Email: s.scahill@auckland.ac.nz<br />
Describing the organisational<br />
culture <strong>of</strong> a selection <strong>of</strong><br />
community pharmacies<br />
This paper outlines the use <strong>of</strong> a predominantly<br />
interpretative mixed methods<br />
technique known as concept mapping<br />
to develop a map which pictorially<br />
represents dimensions <strong>of</strong> organisational<br />
culture. Concept mapping involves the<br />
integration <strong>of</strong> brainstorming techniques<br />
to develop culture statements, along<br />
with robust statistical processes. Eight<br />
cultural dimensions were identified:<br />
leadership and staff management; valuing<br />
each other and the team; free thinking,<br />
fun and open to challenge; trusted<br />
behaviour; customer relations; focus on<br />
external integration; providing systematic<br />
advice and embracing innovation.<br />
<strong>The</strong>se dimensions assist in understanding<br />
factors that influence effectiveness<br />
within community pharmacy.<br />
Scahill S, Harrison J, Carswell P. Describing<br />
the organizational culture <strong>of</strong> a selection <strong>of</strong><br />
community pharmacies using a tool borrowed<br />
from social science. Pharm World Sci.<br />
2010:32;73–80. DOI 10.1007/s11096-009-<br />
9345-5. Corresponding author: S. Scahill.<br />
Email: s.scahill@auckland.ac.nz<br />
How useful are clinical priority<br />
assessment tools?<br />
<strong>The</strong> original aim <strong>of</strong> this research was to<br />
study the use <strong>of</strong> clinical priority assessment<br />
criteria (CPAC) tools. However, in<br />
a sample <strong>of</strong> 47 videotaped consultations<br />
with 15 different surgeons, CPAC tools<br />
were never explicitly used. <strong>The</strong> research<br />
therefore shifted to an investigation <strong>of</strong><br />
interactional factors that might preclude<br />
the use <strong>of</strong> such tools. Our analysis<br />
suggested that decision-making about<br />
operative thresholds is an interactionally<br />
complex matter that does not lend itself<br />
to the rigid following <strong>of</strong> a protocol. It<br />
should be acknowledged that diagnosis<br />
and planning <strong>of</strong> care constitute different<br />
interactional activities to prioritisation<br />
on a waiting list.<br />
Dew K, StubbeM, Macdonald L, Dowell A,<br />
Plumridge E. <strong>The</strong> (non) use <strong>of</strong> prioritisation<br />
protocols by surgeons. Sociology <strong>of</strong> Health<br />
GEMS are short précis <strong>of</strong> original papers published by NZ researchers. For a copy <strong>of</strong> a full paper please<br />
email the corresponding author. Researchers, to have your work included please send a 100<br />
word summary <strong>of</strong> your paper and the full reference details to: editor@rnzcgp.org.nz<br />
174 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE
RESEARCH GEMS<br />
& Illness. 2010;32(4):1–18. DOI 10.1111/<br />
j.1467-9566.2009.01229. Corresponding<br />
author: M. Stubbe. Email: maria.stubbe@<br />
otago.ac.nz<br />
Pharmacists not ready for<br />
increased clinical roles<br />
This paper reports on a 2002 survey <strong>of</strong><br />
general practitioners and community<br />
pharmacists, exploring the perceptions<br />
<strong>of</strong> the role <strong>of</strong> the community pharmacist.<br />
<strong>The</strong>re were significant differences<br />
in the perceptions <strong>of</strong> the role <strong>of</strong><br />
community pharmacists, with general<br />
acceptance <strong>of</strong> technical roles (dispensing,<br />
checking accuracy, counselling on ADRs<br />
and monitoring for compliance) but<br />
less acceptance <strong>of</strong> more clinical patient<br />
care roles. <strong>The</strong> barriers to increased<br />
clinical roles for community pharmacists<br />
included a perceived lack <strong>of</strong> mandate,<br />
legitimacy, adequacy and effectiveness<br />
<strong>of</strong> the roles. <strong>The</strong>re also appeared to be a<br />
lack <strong>of</strong> readiness to change for community<br />
pharmacists.<br />
Bryant L, Coster G, Gamble G, McCormick<br />
R. <strong>General</strong> practitioners’ and pharmacists’<br />
perceptions <strong>of</strong> the role <strong>of</strong> community<br />
pharmacists in delivering clinical services.<br />
Res Soc Admin Pharmacy. 2009;5:299–301.<br />
Corresponding author: L. Bryant.<br />
Email: l.bryant@auckland.ac.nz<br />
Investigating prescription<br />
interventions conducted<br />
by pharmacists<br />
This study investigated the time spent<br />
and the types <strong>of</strong> interventions pharmacists<br />
in Dunedin perform when<br />
dispensing prescription medications.<br />
Interventions related to generic substitution<br />
and legal errors and omissions were<br />
responsible for 50% <strong>of</strong> their time spent.<br />
This could be reduced significantly by<br />
prescribing generically. <strong>The</strong> remaining<br />
50% <strong>of</strong> time spent was on clinical<br />
interventions, however these occurred<br />
at a much lower rate. <strong>The</strong> time spent on<br />
bureaucratic <strong>issue</strong>s may be seen as a significant<br />
barrier for pharmacists providing<br />
clinical services to patients.<br />
Braund R, Furlan HM, George K, Havell<br />
MMA, Murphy JL, West MK. Interventions<br />
performed by <strong>New</strong> <strong>Zealand</strong> community<br />
pharmacists while dispensing prescription<br />
medications. Pharm World Sci. 2010;32:22–<br />
25. Corresponding author: R. Braund.<br />
Email: Rhiannon.braund@otago.ac.nz<br />
Women may be missing out<br />
on preventive drugs<br />
Among 1089 women (40–79 years)<br />
recruited through 17 general practices<br />
to a lifestyle study in the Wellington<br />
region in 2005–2007, 109 (10%) had<br />
a five-year cardiovascular (CVD) risk<br />
>15%. Of these women, only 36% were<br />
taking aspirin, 55% were on blood<br />
pressure–lowering medication, 45%<br />
were taking lipid-lowering medication<br />
and only 17% were taking all three<br />
CVD guidelines–recommended medications.<br />
Our coverage <strong>of</strong> CVD preventive<br />
medications for high-risk women may<br />
be lower than ideal.<br />
Bupha-Intr O, Rose S, Lawton B, Elley<br />
C, Moyes S, Dowell A. Are at-risk <strong>New</strong><br />
<strong>Zealand</strong> women receiving recommended<br />
cardiovascular preventive therapy? N Z<br />
Med J. 2010;123:26–36. Corresponding<br />
Author: B. Lawton. Email: bev.lawton@<br />
otago.ac.nz<br />
Including type 2 diabetes in<br />
cardiovascular risk equations<br />
A new cardiovascular risk equation was<br />
derived from routinely-collected data<br />
on 36 127 patients with type 2 diabetes<br />
assessed through the primary care Get<br />
Checked programme between 2000 and<br />
2006 in <strong>New</strong> <strong>Zealand</strong>. <strong>New</strong> cardiovascular<br />
events or deaths were recorded<br />
2000–2008. Testing the new equation<br />
on 12 626 patients from a geographically-different<br />
area over the same time<br />
showed that the new equation was more<br />
accurate than the currently used equation<br />
for people with diabetes, especially<br />
for Maori, Pacific and Indian populations<br />
and those with poorly controlled diabetes<br />
or renal impairment. <strong>The</strong> currently<br />
used equation <strong>of</strong>ten underestimates<br />
risk for these groups. <strong>The</strong> new equation<br />
could be incorporated into existing risk<br />
assessment tools.<br />
Elley C, Robinson E, Kenealy T, Bramley<br />
D, Drury L. Derivation and Validation <strong>of</strong> a<br />
<strong>New</strong> Cardiovascular Risk Score for People<br />
with Type 2 Diabetes, Diabetes Care;<br />
33 (6) Mar 18. [Epub ahead <strong>of</strong> print].<br />
Corresponding author: R. Elley.<br />
Email: c.elley@auckland.ac.nz<br />
Asking about help is helpful<br />
<strong>The</strong> CHAT (Case-finding and Help Assessment<br />
Tool) is a short validated and<br />
self-administered questionnaire which<br />
detects lifestyle (inactivity, tobacco use,<br />
alcohol and other drug misuse, problem<br />
gambling, abuse, and anger problems)<br />
and mental health <strong>issue</strong>s (depression and<br />
anxiety) in adult primary health care<br />
patients. <strong>The</strong> question asking whether<br />
patients want help (either during this<br />
consultation or later) for each item increases<br />
specificity without compromising<br />
sensitivity and reduces false positives,<br />
allows patients with comorbidities to<br />
prioritise <strong>issue</strong>s they wish to address, indicate<br />
their readiness to change, promote<br />
self-determination, and gives the GP an<br />
indication <strong>of</strong> which topics to pursue.<br />
Goodyear-Smith F, Arroll B, Coupe N.<br />
Asking for help is helpful: validation <strong>of</strong> a<br />
brief lifestyle and mood assessment tool<br />
in primary health care. Annals <strong>of</strong> Family<br />
Medicine. 2009;7:239–244. doi: 10.1370/<br />
afm.962i2009. Corresponding author:<br />
F. Goodyear-Smith. Email: f.goodyear-smith@<br />
auckland.ac.nz<br />
VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 175
about the journal <strong>of</strong> primary health care<br />
<strong>The</strong> Journal <strong>of</strong> Primary Health Care<br />
(JPHC) is a peer-reviewed journal<br />
which has replaced the <strong>New</strong> <strong>Zealand</strong><br />
Family Physician. It is a interdisciplinary<br />
publication aimed at moving research into<br />
primary health care practice and practice into<br />
research. This includes the fields <strong>of</strong> family<br />
practice, primary health care nursing and<br />
community pharmacy as well as areas such<br />
as health care delivery, health promotion,<br />
epidemiology, public health and medical<br />
sociology <strong>of</strong> interest to a primary health care<br />
provider audience.<br />
<strong>The</strong> journal publishes peer-reviewed quantitative<br />
and qualitative original research,<br />
systematic reviews, papers on improving performance<br />
and short reports that are relevant<br />
to its primary health care practitioners. For<br />
the aim, scope, instructions to authors and<br />
templates for publications see www.rnzcgp.<br />
org.nz/journal-<strong>of</strong>-primary-health-care/.<br />
JPHC acts as a knowledge refinery to provide<br />
busy practitioners with up-to-date knowledge<br />
about the latest evidence and best practice.<br />
Continuing pr<strong>of</strong>essional development<br />
includes pithy summaries <strong>of</strong> the latest evidence<br />
such as Cochrane Corner, a String <strong>of</strong><br />
PEARLS (Practical Evidence About Real Life<br />
Situations) and Charms & Harms (evidence <strong>of</strong><br />
effectiveness and safety <strong>of</strong> complementary<br />
and alternative medicines). JPHC includes<br />
Poumanu (treasures <strong>of</strong> Maori wisdom) and<br />
Gems <strong>of</strong> NZ Primary Health Care Research<br />
published at home and internationally.<br />
Evidence can help inform best practice. However<br />
sometimes there is no evidence available<br />
or applicable for a specific patient with his<br />
or her own set <strong>of</strong> conditions, capabilities,<br />
beliefs, expectations and social circumstances.<br />
Evidence needs to be placed in context.<br />
<strong>General</strong> practice is an art as well as a science.<br />
Quality <strong>of</strong> care lies also with the nature <strong>of</strong> the<br />
clinical relationship, with communication and<br />
with truly informed decision-making. JPHC<br />
publishes viewpoints, commentaries and reflections<br />
that explore areas <strong>of</strong> uncertainty on<br />
aspects <strong>of</strong> care for which there is no one right<br />
answer. Debate is stimulated by the Back to<br />
Back section where two pr<strong>of</strong>essionals present<br />
their opposing views on a topic. <strong>The</strong>re is a<br />
regular Ethics column. Letters to the Editor<br />
are welcomed.<br />
While published in <strong>New</strong> <strong>Zealand</strong> by the <strong>Royal</strong><br />
<strong>New</strong> <strong>Zealand</strong> <strong>College</strong> <strong>of</strong> <strong>General</strong> <strong>Practitioners</strong>,<br />
much <strong>of</strong> this research has generic<br />
implications. Our Editorial Board comprises<br />
renowned and active primary care clinicians,<br />
clinical and scientific academics and health<br />
policy experts with both <strong>New</strong> <strong>Zealand</strong> and<br />
international representation.<br />
Editor<br />
Dr Felicity Goodyear-Smith: Pr<strong>of</strong>essor and<br />
Goodfellow Postgraduate Chair, Department<br />
<strong>of</strong> <strong>General</strong> Practice and Primary Health<br />
Care, University <strong>of</strong> Auckland, Auckland, <strong>New</strong><br />
<strong>Zealand</strong>; editor@rnzcgp.org.nz<br />
Deputy Editors<br />
Dr Derelie Mangin: Associate Pr<strong>of</strong>essor,<br />
Department <strong>of</strong> Public Health and <strong>General</strong><br />
Practice, University <strong>of</strong> Otago, Christchurch, NZ<br />
Dr Tony Dowell: Pr<strong>of</strong>essor and Head <strong>of</strong> the<br />
Department <strong>of</strong> Primary Health Care and <strong>General</strong><br />
Practice, Wellington School <strong>of</strong> Medicine,<br />
University <strong>of</strong> Otago, NZ<br />
Editorial Board<br />
Dr Bruce Arroll: Pr<strong>of</strong>essor and Head <strong>of</strong> the<br />
Department <strong>of</strong> <strong>General</strong> Practice & Primary<br />
Health Care, University <strong>of</strong> Auckland, NZ<br />
Dr Jo Barnes: Associate Pr<strong>of</strong>essor <strong>of</strong><br />
Pharmacy, School <strong>of</strong> Pharmacy, University <strong>of</strong><br />
Auckland, NZ<br />
Dr Jenny Carryer: Pr<strong>of</strong>essor <strong>of</strong> Nursing,<br />
School <strong>of</strong> Health and Social Services, Massey<br />
University, Palmerston North, NZ<br />
Dr Peter Crampton: Dean and Head <strong>of</strong><br />
Campus, Wellington School <strong>of</strong> Medicine and<br />
Health Sciences, University <strong>of</strong> Otago, NZ<br />
Ms Eileen McKinlay: Senior Lecturer in<br />
Primary Health Care, Department <strong>of</strong> Primary<br />
Health Care and <strong>General</strong> Practice, University<br />
<strong>of</strong> Otago Wellington, NZ<br />
Dr Barry Parsonson: Psychologist for NZ Ministry<br />
<strong>of</strong> Education and International Consultant,<br />
UNICEF (Georgia) Training Project for Institutional<br />
Staff working with disabled children<br />
Dr Shane Reti: Assistant Pr<strong>of</strong>essor, International<br />
Program Director Clinical Informatics<br />
and CEO <strong>of</strong> Clinical Informatics Industrial<br />
Research, Harvard Medical School, USA<br />
Dr Kurt Stange: Pr<strong>of</strong>essor <strong>of</strong> Family<br />
Medicine, Case Western Reserve University,<br />
Cleveland, OH, USA and Editor, Annals <strong>of</strong><br />
Family Medicine<br />
Dr Colin Tukuitonga: Associate Pr<strong>of</strong>essor<br />
and CEO <strong>of</strong> the Ministry <strong>of</strong> Pacific Island Affairs,<br />
Wellington, NZ<br />
Submissions<br />
Please send all submissions to:<br />
<strong>The</strong> Editor: editor@rnzcgp.org.nz, or to:<br />
<strong>The</strong> Editorial Assistant—Cherylyn Borlase: editorialassistant@rnzcgp.org.nz<br />
accompanied by a covering letter as outlined at:<br />
http://www.rnzcgp.org.nz/journal-<strong>of</strong>-primary-health-care/#cover<br />
Subscription and advertising queries<br />
Cherylyn Borlase, Publications Coordinator<br />
RNZCGP, PO Box 10440, Wellington 6143, <strong>New</strong> <strong>Zealand</strong>; jphcnz@rnzcgp.org.nz<br />
JPHC is printed on uncoated, acid-free paper which meets the archival requirements <strong>of</strong> ANSI/<br />
NISO Z39.48-1992 (Permanence <strong>of</strong> Paper) and is Forest Stewardship Council (FSC)–certified<br />
which meets the highest environmentally responsible standards.<br />
<strong>The</strong> Journal <strong>of</strong> Primary Health Care is the <strong>of</strong>ficial journal <strong>of</strong> the RNZCGP. However, views expressed are not necessarily those <strong>of</strong> the <strong>College</strong>,<br />
the Editor, or the Editorial Board. ©<strong>The</strong> <strong>Royal</strong> <strong>New</strong> <strong>Zealand</strong> <strong>College</strong> <strong>of</strong> <strong>General</strong> <strong>Practitioners</strong> 2010. All Rights Reserved.<br />
176 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE