entire issue - The Royal New Zealand College of General Practitioners

VOLUME 2 • NUMBER 2 • JUNE 2010 

OF PRIMARY HEALTH CARE 

‘The importance of 

prevention of heart 

attacks and strokes… 

makes us very ready 

to swallow the 

industry message 

(not to say the pills)’ 

See Ethics page 165 

Original Scientific Paper 

Aspirin use in primary prevention of 

cardiovascular disease 

See page 92 


Resources GPs use to answer questions 

and for CME 

See page 100 


Self-management support for chronic 

illness 

See page 124 


Practice nurses and postgraduate 

education 

See page 142 

Back to Back 

Should we screen for attention deficit 

hyperactivity disorder? 

See page 155 

Pounamu 

Whanau ora approach to health care 

See page 163

contents 

VOLUME 2 • NUMBER 2 • june 2010 

OF PRIMARY HEALTH CARE 

issn 1172-6164 (Print) 

ISSN 1172-6156 (Online) 

90 Editorials 

From the Editor 

Population and individual health: the two faces of Janus 

Felicity Goodyear-Smith 

92 Original Scientific Papers 

Quantitative Research 

92 Aspirin for primary prevention: yes or no? 

Vanessa Selak, C Raina Elley, Sue Wells, Anthony Rodgers, 

Norman Sharpe 

100 What resources do Auckland general practitioners use for 

answering immediate clinical questions and for lifelong 

learning? 

Zachary Gravatt, Bruce Arroll 

105 Causes of excess hospitalisations among Pacific peoples in 

New Zealand: implications for primary care 

Faafetai Sopoaga, Ken Buckingham, Charlotte Paul 

111 GP practice variation in hospitalisation rates: a study of 

Partnership Health–enrolled patients 

Ross Barnett, Laurence Malcolm 

118 Modifying the PACIC to assess provision of chronic illness 

care: An exploratory study with primary health care nurses 

Jenny Carryer, Claire Budge, Chiquita Hansen, Katherine Gibbs 

124 Providing and receiving self-management support for chronic 

illness: Patients’ and health practitioners’ assessments 

Jenny Carryer, Claire Budge, Chiquita Hansen, Katherine Gibbs 

Qualitative Research 

130 Ever decreasing circles: terminal illness, empowerment and 

decision-making 

Kate Richardson, Rod MacLeod, Bridie Kent 

136 Seeing patients first: creating an opportunity for practice 

nurse care? 

Tim Kenealy, Barbara Docherty, Nicolette Sheridan, Ryan Gao 

142 What influences practice nurses to participate in postregistration 

education? 

Anna Richardson, Jeffrey Gage 

Short Report 

150 Are unexplained vaginal symptoms associated with 

psychosocial distress? A pilot investigation 

Andreas Cohrssen, Uzma Aslam, Allison Karasz, Matthew Anderson 

155 Back to Back 

New Zealand general practice should adopt populationbased 

screening for attention deficit hyperactivity disorder 

(ADHD) 

Yes Tony Hanne; No Ross Lawrenson 

160 Continuing Professional Development 

160 String of PEARLS about hypertension 

160 Cochrane Corner: NSAIDs for dysmenorrhoea 

Bruce Arroll 

161 Charms & Harms: Ginkgo biloba 

Joanne Barnes 

163 Pounamu: A whanau ora approach to health care for Maori 

Jacquie Kidd, Veronique Gibbons, Ross Lawrenson, Wayne Johnstone 

165 Ethics 

Too much information 

Grant Gillett, Donald Saville-Cook 

168 Letters to the Editor 

170 Book Review 

Interpreting in New Zealand, the pathway forward 

—Diana Clark and Caroline McGrath 

Reviewer: Ben Gray 

171 Policy Statement for Authors 

Conflict of interest in peer-reviewed medical journals: The 

World Association of Medical Editors (WAME) position on a 

challenging problem 

Lorraine Ferris, Robert Fletcher 

174 Gems of New Zealand Primary Health Care Research 

176 About the Journal of Primary Health Care 

VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE 89

EDITORIALs 

from the editor 

Population and individual health: 

the two faces of Janus 

Felicity Goodyear- 

Smith MBChB, MGP, 

FRNZCGP, Editor 

Correspondence to: 

Felicity Goodyear-Smith 

Professor and Goodfellow 

Postgraduate Chair, 

Department of General 

Practice and Primary 

Health Care, The 

University of Auckland, 

PB 92019 Auckland, 

New Zealand 

f.goodyear-smith@ 

auckland.ac.nz 

The leading paper in this issue is Selak and 

colleagues’ Aspirin for primary prevention: 

yes or no? 1 New Zealand (NZ) cardiovascular 

disease (CVD) risk guidelines recommend aspirin, 

along with lipid and blood pressure–lowering 

drugs and lifestyle changes, for all people with a 

five-year CVD risk that is 15% or greater. 2 This 

recommendation still stands for secondary prevention 

(patients who have had a previous CVD 

event). However, a recent meta-analysis has cast 

doubt on whether the benefits of aspirin use outweigh 

the potential harms in primary CVD prevention, 

concluding that ‘in primary prevention 

without previous disease, aspirin is of uncertain 

net value’. 3 General practitioners (GPs) therefore 

face a clinical dilemma: should we prescribe aspirin 

(unless contraindicated of course) for primary 

prevention of CVD in at-risk patients? 

Selak et al.’s research gives us the answer. They 

applied evidence-based modelling to the metaanalysis 

data (six randomised controlled trials 

involving 95 456 individuals without prior CVD 

randomised to aspirin or no aspirin) calculating 

the rates of benefit and of harm for men and 

women in 10-year age bands, at different levels 

of CVD risk, both for aspirin alone and also for 

aspirin combined with lipid and blood pressure– 

lowering drugs. 

They found that the benefits of aspirin outweigh 

the harms for both men and women aged up to 80 

years with a five-year CVD risk >15% in primary 

prevention. However, harm may outweigh benefit 

for primary prevention for those over 80 years, 

particularly for men. In men aged 70–79, lipid 

and blood pressure–lowering therapies should be 

considered first and then the patient reassessed as 

to whether aspirin adds an additional net benefit. 

This study is a great example of translational 

research, using the analysis of secondary data 

to answer a clinical question. We can apply the 

evidence to decide whether we should confirm 

or change our practice for optimal health care 

outcomes. Studies such as this, assessing the marginal 

benefits and harms of starting and stopping 

medication, are the way of the future. 

The topic of primary prevention of CVD is also 

touched on in our ethics column. 4 The authors 

discuss the difficult balance that doctors need to 

find between providing patients with information 

on all the possible, but often rare, adverse 

effects of management options, and informing 

patients about every aspect of their condition and 

its treatment that they might consider significant. 

Statins, like aspirin, are used to prevent 

heart attacks and strokes. Statins can cause very 

rare but serious and potentially life-threatening 

events. Most people are able to accept the remote 

risk that something bad may happen, but a few 

may be overly concerned to the point that they 

‘make bad decisions from a faulty appraisal’ 

of the evidence they are given. Ideally in the 

patient-centred approach a GP knows when a 

patient might misinterpret or become unrealistically 

anxious and tailors how much information 

about risks to impart, but the real world is not 

always this simple. 

These two papers demonstrate the potential 

dilemma in practising both population and individual 

care. Like the Roman god Janus, we can 

be perceived as having two heads facing in opposite 

directions. The GP who gives statins and 

aspirin to his or her at-risk patients knows that a 

number are prevented from having a heart attack 

or a stroke, and that treating the practice population 

in this way leads to an overall improvement 

in a number of patients’ quality of life. However 

an individual patient may suffer a severe haemorrhagic 

stroke that can be attributed to taking the 

aspirin, or rhabdomyolysis and renal failure from 

90 VOLUME 2 • NUMBER 2 • JUNE 2010 J OURNAL OF PRIMARY HEALTH CARE

EDITORIALs 

from the editor 

the statin. This is devastating for the person, 

their family and their GP. We may act for the 

greater good, but sometimes individuals will 

suffer harm. 

This theme is continued further in a letter to the 

editor by Wells and colleagues. 5 They challenge 

an essay published in our December 2009 issue 

which argued that using CVD risk profile tools 

does not improve patient care nor outcomes. 6 

Wells et al. agree that merely knowing a patient’s 

risk score and giving one-off advice is unlikely 

to lead to sustained changes in patient behaviour. 

However they provide evidence that integrating 

CVD risk profile tools into practice management 

systems provides immediately available decision 

support and generates ‘a comprehensive, personalised 

set of evidence-based management recommendations’ 

which can significantly improve 

quality of care. 

Indeed, such clinical decision support systems 

help bridge the gap between population and individual 

care, taking best evidence obtained from 

large populations and tailoring management to fit 

a particular patient in the context of his or her 

specific characteristics, risks and needs. 

This issue of the JPHC also includes a study 

exploring the sources that NZ GPs use both for 

lifelong learning and to answer clinical questions 

arising during consultation. 7 Increasingly GPs 

are using web-based tools and resources. This 

research was conducted by Zachary Gravatt as a 

summer studentship 2008–2009. Tragically, Zac 

died last year during his 4th year as a medical 

student, and sadly never saw his work in print. 

Research pertaining to practice nursing is prominent 

this issue. There are two papers on chronic 

illness care, 8,9 another exploring the preventive 

care possibilities from patients seeing the practice 

nurse before the GP, 10 a study of the enablers and 

barriers for practice nurses to advance their professional 

development, 11 and one addressing the 

skills palliative care nurses need to help terminally 

ill people remain in control of their day-to-day 

decisions for as long as possible. 12 There are also 

two studies addressing variation in hospitalisation 

rates, particularly in Maori 13 and in Pacific 

people, 14 and a short report exploring a possible 

association of unexplained vaginal symptoms and 

psychological distress. 15 

In our usual features, two GPs go Back to Back 

on whether there should be population-based 

screening for attention deficit hyperactivity 

disorder, the String of PEARLS is about hypertension, 

Cochrane Corner examines the use of 

NSAIDs for dysmenorrhoea, Charms and Harms 

covers the herbal remedy Ginkgo and Pounamu 

explains the whanau ora approach to health care. 

Again, this issue reflects the diversity that is 

primary health care. 

References 

1. Selak V, Elley R, Wells S, Rodgers A, Sharpe N. Aspirin 

for primary prevention: yes or no? J Primary Health Care. 

2010;2(2):92–9. 

2. New Zealand Guidelines Group. Assessment and management 

of cardiovascular risk: evidence-based best practice guideline. 

Wellington: NZGG; 2003 December. 220 p. 

3. Antithrombotic Trialists C, Baigent C, Blackwell L, et al. Aspirin 

in the primary and secondary prevention of vascular disease: 

collaborative meta-analysis of individual participant data from 

randomised trials. Lancet. 2009 May 30;373(9678):1849–60. 

4. Gillett G, Saville-Cook D. To much information? J Primary 

Health Care. 2010;2(2):165–7. 

5. Wells S, Riddell T, Jackson S. Cardiovascular disease risk profile 

tools and New Zealand—absolutely the best way forward. 

Letter to the Editor. J Primary Health Care. 2010;2(2):168–9. 

6. Boland P, Moriarty H. Cardiovascular disease risk profile tools 

and New Zealand—the best way forward? J Primary Health 

Care. 2009;1(4):328–31. 

7. Gravatt Z, Arroll B. What resources do Auckland general practitioners 

use for answering immediate clinical questions and 

for life-long learning? J Primary Health Care. 2010;2(2):100–4. 

8. Carryer J, Budge C, Hansen C, Gibbs K. Modifying the PACIC 

to assess provision of chronic illness care: an exploratory 

study with primary health care nurses. J Primary Health Care. 

2010;2(2):118–23. 

9. Carryer J, Budge C, Hansen C, Gibbs K. Providing and receiving 

self-management support for chronic illness: patients’ 

and health practitioners’ assessments. J Primary Health Care. 

2010;2(2):124–9. 

10. Kenealy T, Docherty B, Sheridan N, Gao R. Seeing patients 

first: creating an opportunity for practice nurse care? J Primary 

Health Care. 2010;2(2):136–41. 

11. Richardson A, Gage J. What influences practice nurses to 

participate in post-registration education? J Primary Health 

Care. 2010;2(2):142–9. 

12. Richardson K, MacLeod R, Kent B. Ever decreasing circles: 

terminal illness, empowerment and decision-making. J Primary 

Health Care. 2010;2(2):130–5. 

13. Barnett R, Malcolm L. GP practice variation in hospitalisation 

rates–a study of Partnership Health enrolled patients. J 

Primary Health Care. 2010;2(2):111–7. 

14. Sopoaga F, Buckingham K, Paul C. Causes of excess hospitalisations 

among Pacific peoples in New Zealand: implications for 

primary care. J Primary Health Care. 2010;2(2):105–10. 

15. Cohrssen A, Aslam U, Karasz A, Anderson M. Are unexplained 

vaginal symptoms associated with psychosocial 

distress? A pilot investigation. J Primary Health Care. 

2010;2(2):150–4. 


ORIGINAL SCIENTIFIC PAPERS 

quantitative research 

Aspirin for primary prevention: yes or no? 

Vanessa Selak MBChB, MPH (Hons), FAFPHM, FNZCPHM; 1 C Raina Elley MBChB, FRNZCGP, PhD; 2 

Sue Wells MBChB, DipObs, MPH (Hons), PhD, FNZCPHM, RNZCGP; 3 Anthony Rodgers MBChB, DPH, 

FAFPHM, PhD; 4 Norman Sharpe MBChB, MD, DipABIM, DipABCVDis, FRACP, FACC (Medicine) 5 

1 

Clinical Trials Research Unit, 

School of Population Health, 

The University of Auckland, 

Auckland, New Zealand 

2 


Practice and Primary Health 

Care, School of Population 

Health, The University of 

Auckland 

3 

Section of Epidemiology 

and Biostatistics, School 

of Population Health, The 

University of Auckland 

4 

The George Institute for 

International Health, Sydney, 

NSW, Australia 

5 

New Zealand National 

Heart Foundation, Ellerslie, 

Auckland 

ABSTRACT 

Aim: To assess benefit versus harm of aspirin for cardiovascular disease (CVD) primary prevention by 

age group, gender and risk category and to interpret these results in light of current New Zealand CVD 

risk assessment and management guidelines. 

Methods: Rates of benefit (avoided vascular events) and harm (additional major extracranial bleeds) 

for each gender and age group were calculated from data from the six randomised controlled trials included 

in the Anti-Thrombotic Trialists’ (ATT) Collaboration meta-analysis. These rates were applied to CVD 

risk categories to calculate the net benefit or net harm likely to occur from the use of aspirin in primary 

prevention of CVD as monotherapy and when added to lipid and blood pressure–lowering therapies. 

Results: Benefits of aspirin monotherapy outweigh the harms for both men and women aged up to 

80 years with calculated five-year CVD risk >15% in primary prevention. Harm may outweigh benefit for 

primary prevention for those over 80 years. For men 70–79 years the benefit of aspirin in primary prevention 

is marginal when added to lipid and blood pressure–lowering therapies. 

Discussion: The recent ATT Collaboration meta-analysis has raised doubts about the relative safety 

of aspirin in primary prevention of CVD. However, modelling by risk category and age group suggests 

that current guidelines are justified in recommending aspirin for primary prevention of CVD in those with 

five-year CVD risk ≥15% up to the age of 80 years. For men 70–79, consider lipid and blood pressure– 

lowering therapies first then reassess whether aspirin adds additional net benefit. 

KEYWORDS: Aspirin; primary prevention; cardiovascular disease; cardiovascular risk 

J PRIMARY HEALTH CARE 

2010;2(2):92–99. 

CORRESPONDENCE TO: 

Vanessa Selak 

Clinical Trials Research 

Unit, The University 

of Auckland, PB 92019 

Auckland Mail Centre, 


v.selak@ctru.auckland.ac.nz 

Introduction 

Cardiovascular disease (CVD) is New Zealand’s 

biggest killer and leading cause of loss of 

healthy life years. 1 Current New Zealand (NZ) 

CVD risk assessment and management guidelines 

recommend that CVD preventive management 

decisions are based on an individual’s 

five-year absolute CVD risk. 2 All people with 

a five-year CVD risk 15% or greater should be 

considered for aspirin, lipid-lowering and blood 

pressure–lowering therapies (unless there are 

contraindications), in addition to lifestyle interventions, 

as necessary to reduce their absolute 

risk. This recommendation was made on the 

basis that the combination of aspirin, lipidlowering 

and blood pressure–lowering therapies 

is estimated to reduce CVD risk by at least 55% 

with a much lower risk of harm. 3 While the 

role of aspirin in the management of people 

with a prior CVD event remains undisputed, 

the recently published Anti-Thrombotic Trialists’ 

(ATT) Collaboration meta-analysis has 

raised doubts about the relative safety of aspirin 

in the primary prevention of CVD. 4 We sought 

to model benefit versus harm of aspirin for 

CVD primary prevention for age group, gender 

and risk categories using data from the ATT 

Collaboration meta-analysis and to interpret 

these results in light of current NZ CVD risk 

assessment and management guidelines. 


ORIGINAL SCIENTIFIC PAPErS 

The effect of adding aspirin to a regime of lipid 

and blood pressure–lowering therapy among 

those with five-year CVD risk >15% was assessed 

for each sex / age category. The benefit of lipidlowering 

therapy (statin) and blood pressure– 

lowering therapy was estimated from recent 

meta-analyses of randomised controlled trials. 7,8 

Proportional reductions in the risk of coronary 

and cerebro vascular events associated with treatquantitative 

research 

Methods 

Design 

Evidence-based modelling of benefit and harm of 

aspirin for primary prevention of CVD. 

Population 

This analysis used results from the ATT Collaboration 

meta-analysis, which included 95 456 

individuals without prior CVD who had been 

randomised to aspirin or no aspirin in six 

randomised controlled trials of at least 1000 nondiabetic 

participants each with at least two years 

of scheduled treatment. 4 

Analysis 

Expected CVD events 

The expected number of CVD events based on 

five-year CVD risk for a hypothetical population 

of 1000 people was calculated. For example, 

for a hypothetical cohort of 1000 people at 1% 

five-year CVD risk, 10 CVD events would be expected. 

The CVD outcomes included in Framingham-based 

prediction models (such as those used 

in NZ) are myocardial infarction, angina, stroke, 

transient ischaemia, congestive heart failure, peripheral 

vascular disease and CVD-related death. 5 

Benefit 

Rates of benefit (avoided vascular events) with aspirin 

were calculated by applying the proportional 

reduction in serious vascular events observed in 

the ATT Collaboration meta-analysis (12%, 99% 

confidence interval 6–18%) to the number of CVD 

events expected to be avoided in five years. This 

reduction was applied to progressively increasing 

five-year CVD risk groups (from 1% to 20%) for 

hypothetical populations of 1000 people who were 

also stratified by gender and 10-year age bands: 

50–59, 60–69, 70–79 and 80–89 years. Vascular 

events in the meta-analysis were defined as myocardial 

infarction, stroke (haemorrhagic or other), 

or death from a vascular cause (coronary heart disease 

death, stroke death, or other vascular death— 

including sudden death, death from pulmonary 

embolism, and death from any haemorrhage). 

WHAT GAP THIS FILLS 

What we already know: The benefits of aspirin outweigh the risks in 

people with a history of cardiovascular disease. 

What this study adds: The benefits of aspirin outweigh the risks in primary 

prevention of CVD in those with five-year CVD risk >15%, up to the age 

of 80 years, although in men 70–79 consider lipid and blood pressure–lowering 

therapies first then reassess whether aspirin adds additional net benefit. 

Harm 

Rates of harm (i.e. the difference between rates 

of non-fatal major extracranial bleeds in the 

aspirin and control groups) were provided by the 

ATT Collaboration meta-analysis for men and 

women aged 50–59 years (0.2% and 0.1%, respectively). 

Non-fatal major extracranial bleeds were 

mainly gastrointestinal and usually defined as a 

bleed requiring transfusion. Rates of harm were 

estimated for other age groups (60–69, 70–79 

and 80–89 years) by multiplying the rate for 

those aged 50–59 years by the rate ratio associated 

with age (per decade) identified by the ATT 

Collaboration meta-analysis for each additional 

decade (2.15, 95% confidence interval 1.93–2.39). 

Haemorrhagic stroke and fatal extracranial 

haemorrhage were included in vascular events 

(see above). 

Aspirin monotherapy 

Rates of benefit and harm were compared in 

CVD risk / sex / age categories to assess the net 

benefit or net harm likely from the use of aspirin 

in primary prevention of CVD and depicted in 

table format. 6 

Adding aspirin to lipid and blood pressure– 

lowering therapy 




ment in people without a history of CVD were 

combined using the ratio of these events from 

the ATT Collaboration meta-analysis to produce a 

proportional reduction in the risk of CVD events. 

Rates of harm from the most serious adverse 

events associated with statins (rhabdomyolysis) 

and antihypertensives (adverse events serious 

enough to warrant discontinuation of antihypertensive 

therapy) were also estimated from metaanalyses 

of randomised controlled trials. 9,10 

Results 

Aspirin monotherapy 

The benefits of aspirin are estimated to exceed 

the harms at least fourfold among men 60–69 

years and women 70–79 who have a calculated 

five-year CVD risk >15% in primary prevention 

(see Table 1). In people one decade older (men 

70–79 and women 80–89) with the same CVD 

risk, the number of vascular events avoided by 

aspirin are still close to twice the harms. From 

the age of 80 years the harms of aspirin are likely 

to outweigh the benefits in primary prevention 

among men with five-year CVD risk at or just 

over 15%. 

Adding aspirin to lipid and blood pressure– 

lowering therapy 

For people with a five-year CVD risk of 15%, 

statin and antihypertensive therapy are estimated 

to reduce absolute CVD risk by 6.6% (relative 

risk reduction (RRR) of 26% and 24% for statin 

and antihypertensive therapy respectively applied 

in a stepwise fashion to produce an overall RRR 

of 44%) and increase absolute risk of serious side 

effects by 0.15% over a five-year period (see Figure 

1). The balance of benefits and risks varies by 

sex and age when aspirin is added to the regime. 

Aspirin is estimated to reduce absolute CVD risk 

by a further 1% (12% RRR), but absolute risk of 

additional serious side effects (extracranial bleeding) 

is estimated to increase by 0.20% in men 

aged 50–59 years, 0.43% in men 60–69, 0.92% in 

men 70–79 and 1.99% in men 80–89. Absolute 

risk of additional serious side effects is estimated 

to increase by 0.10% in women aged 50–59 years, 

0.22% in women 60–69, 0.46% in women 70–79 

and 0.99% in women 80–89 (see Figure 2). 

Discussion 

This analysis found that the benefits of aspirin 

monotherapy outweigh the harms for both men 

and women aged up to 80 years with five-year CVD 

risk >15% in primary prevention. However, harm 

may outweigh benefit for primary prevention for 

those over 80 years, particularly for men. The proportional 

reduction in CVD risk is greater and the 

risk of serious adverse events is lower with statin 

and antihypertensive therapies than with aspirin. 

For men 70–79 years the benefit of aspirin in primary 

prevention is marginal when added to lipid 

and blood pressure–lowering therapies. Therefore, 

current New Zealand CVD risk assessment and 

management guidelines are justified in recommending 

aspirin for primary prevention of CVD in 

those with five-year CVD risk ≥15%, up to the age 

of 80 years, although in men 70–79, lipid and blood 

pressure–lowering therapies should be considered 

first and additional net benefit of aspirin assessed. 

This analysis used the most recently published 

meta-analysis of randomised controlled trials 

of aspirin for the primary prevention of CVD 

to model the benefit and harm of aspirin. 4 The 

proportional reduction of CVD (and increase in 

haemorrhagic stroke) with aspirin was assumed 

to be constant across sex and age groups. Aspirin 

has been shown to reduce CVD primarily 

by reducing myocardial infarctions in men and 

ischaemic strokes in women. 11 Modelling could 

be improved by updating the ATT Collaboration 

with more recent trials, 12 obtaining nationally 

representative data to provide more up-to-date 

and generalisable estimates for rates of serious 

adverse events and assessing the treatment effect 

of aspirin by sex and age groups. 

There are differences in the way outcomes are 

defined that should be considered when interpreting 

results. Firstly, haemorrhagic strokes and 

fatal extracranial bleeds were included in the 

ATT Collaboration’s estimate of the proportional 

reduction in serious vascular events. This may 

explain why their estimate of the benefit of aspirin 

was lower than those previously reported. 2 

Secondly, the number of estimated CVD events 

and those avoided may be slightly overestimated 

by the NZ CVD risk assessment and management 

guidelines, which use the Framingham 

equation, because while the ATT Collaboration 




Table 1. Estimated vascular events avoided and estimated additional extracranial bleeds associated with using aspirin for five years in hypothetical 

cohorts of 1000 people 

Estimated vascular events avoided † in 5 years, ‡ n 

5-year 

risk of 

CVD 

event 

CVD 

events 

expected, 

*n 

Age 

50–59 

years 

Age 

60–69 

years 

Men 

Age 

70–79 

years 

Age 

80–89 

years 

Age 

50–59 

years 

Age 

60–69 

years 

Women 

Age 

70–79 

years 

Age 

80–89 

years 

1% 10 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 

2% 20 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 

3% 30 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 

4% 40 4.8 4.8 4.8 4.8 4.8 4.8 4.8 4.8 

5% 50 6 6 6 6 6 6 6 6 

6% 60 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 

7% 70 8.4 8.4 8.4 8.4 8.4 8.4 8.4 8.4 

8% 80 9.6 9.6 9.6 9.6 9.6 9.6 9.6 9.6 

9% 90 10.8 10.8 10.8 10.8 10.8 10.8 10.8 10.8 

10% 100 12 12 12 12 12 12 12 12 

11% 110 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 

12% 120 14.4 14.4 14.4 14.4 14.4 14.4 14.4 14.4 

13% 130 15.6 15.6 15.6 15.6 15.6 15.6 15.6 15.6 

14% 140 16.8 16.8 16.8 16.8 16.8 16.8 16.8 16.8 

15% 150 18 18 18 18 18 18 18 18 

16% 160 19.2 19.2 19.2 19.2 19.2 19.2 19.2 19.2 

17% 170 20.4 20.4 20.4 20.4 20.4 20.4 20.4 20.4 

18% 180 21.6 21.6 21.6 21.6 21.6 21.6 21.6 21.6 

19% 190 22.8 22.8 22.8 22.8 22.8 22.8 22.8 22.8 

20% 200 24 24 24 24 24 24 24 24 

Estimated additional non-fatal extracranial bleeds § in 5 years, n 

2.0 4.3 9.2 19.9 1.0 2.2 4.6 9.9 

Areas shaded light grey indicate combinations of five-year CVD risk, sex and age for which the estimated number of additional extracranial bleeds are greater than or equal 

to the estimated number of vascular events avoided 6 

* Based on Framingham equation, i.e. including myocardial infarction, angina, stroke, transient ischaemia, congestive heart failure, peripheral vascular disease and CVDrelated 

death 5 

† 

Vascular events avoided defined as myocardial infarction, stroke (ischaemic, haemorrhagic or other), or vascular death (coronary heart disease death, stroke death, or 

other vascular death [which includes sudden death, death from pulmonary embolism, and death from any haemorrhage]) 4 

‡ 

Assuming 12% proportional net reduction in vascular events 4 

§ 

Calculated from number of excess non-fatal gastrointestinal or other extracranial bleeds (usually defined as a bleed requiring a transfusion) among those aged 50–59 

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 

counted in vascular events (see above). 4 




Figure 1. Cardiovascular events and serious side effects with addition of aspirin* to a regime of statin † and 

antihypertensive therapy ‡ over a five-year period in men with calculated five-year CVD risk >15% 

* Assuming 12% proportional reduction in CVD events with aspirin 4 

† 

Assuming 26% proportional reduction in CVD events with statin 7 

‡ 

Assuming 24% proportional reduction in CVD events with antihypertensive 8 

§ 

Assuming 0.05% rhabdomyolysis with statins, 0.1% experience adverse events serious enough to warrant discontinuation of antihypertensive 

therapy (as demonstrated with thiazides and ACE [angiotensin converting enzyme] inhibitors) 9 and extracranial bleeds as 

outlined in Table 1 




Figure 2. Cardiovascular events and serious side effects with addition of aspirin* to a regime of statin † and 

antihypertensive therapy ‡ over a five-year period in women with calculated five-year CVD risk >15% 

* Assuming 12% proportional reduction in CVD events with aspirin 4 

† 

Assuming 26% proportional reduction in CVD events with statin 7 

‡ 

Assuming 24% proportional reduction in CVD events with antihypertensive 8 

§ 

Assuming 0.05% rhabdomyolysis with statins, 0.1% experience adverse events serious enough to warrant discontinuation of antihypertensive 

therapy (as demonstrated with thiazides and ACE [angiotensin converting enzyme] inhibitors) 9 and extracranial bleeds as 

outlined in Table 1 




meta-analysis included only serious events 

such as myocardial infarction, stroke and death 

from CVD (or haemorrhage), the Framingham 

equation includes ‘softer’ CVD events such 

as angina, transient ischaemia and peripheral 

vascular disease. 5 

New Zealand CVD risk management guidelines 

use an adjusted Framingham equation. 2 Certain 

groups (on the basis of family history, ethnicity, 

diabetes status) are moved up one risk category 

(5%) during risk assessment and people with 

isolated high blood pressure or high cholesterol 

are categorised as being at >15% five-year CVD 

risk. The implications of this adjustment to the 

absolute benefit likely from medications such 

as aspirin in people who have been ‘upgraded’ 

are not fully known, but there is no obvious 

reason to believe that the benefit gained would 

be different. However, one study has suggested 

that the risk assessment strategy currently used 

in New Zealand for ethnicity adjustment may 

be over-estimating risk, 13 while another suggests 

that for people who have diabetes with 

microalbuminuria, the Framingham equation 

underestimates risk substantially, and still underestimates 

risk with current adjustments. 14 

The ATT Collaboration found that the main 

risk factors for coronary disease were also risk 

factors for bleeding associated with aspirin. 4 

Whilst our analysis accounted for the risk 

factors with the greatest effect on bleeds (age 

and male sex), diabetes, smoking, mean blood 

pressure and body mass index have not been 

adjusted for. 

On the other hand, the ATT Collaboration 

meta-analysis is likely to overestimate current 

gastrointestinal bleeding rates with aspirin. 

There has been an increase in the use of triple 

eradication therapy (for H. Pylori) and proton 

pump inhibitors, along with a reduction in the 

use of non-steroidal anti-inflammatory agents. 

Further, while efforts were made to balance the 

severity of benefit and harm events, side effects 

of comparable severity to ischaemic stroke or a 

coronary heart disease event are very rare. 

Our findings and recommendations are broadly 

consistent with, and if anything more conservative 

than, British and United States (US) guidelines. 

British guidelines advise that the benefit 

of aspirin in primary prevention outweighs 

harm in people aged over 50 years and with 

10-year CVD risk >20% (equivalent to five-year 

CVD risk >10% 15 ). 16 US guidelines recommend 

that aspirin is offered to men 45–79 years and 

women 55–79 years when the potential benefit 

(reduction in myocardial infarction (MI) in men 

and ischaemic stroke in women) outweighs the 

potential harm of an increase in gastrointestinal 

haemorrhage. 6 They estimate that the number 

of MIs prevented is closely balanced to the 

number of serious bleeding events when 10-year 

coronary heart disease risk is 4% for men 45–69, 

9% for men 60–69 and 12% for men 70–79 years 

(equivalent to five-year CVD risk 3, 6.75 and 

9%, respectively 15 ) . For women, the number of 

ischaemic strokes prevented is estimated to be 

closely balanced to the number of serious bleeding 

events when 10-year stroke risk is 3% for 

women 55–59, 8% for women 60–69 and 11% for 

women 70–79 years. 

The proportional reduction with aspirin in the 

ATT Collaboration meta-analysis is comparable 

across ‘primary’ and ‘secondary’ prevention settings 

in cause-specific outcomes: major coronary 

events (Rate Ratio 0.82 in primary prevention 

vs 0.80 in secondary prevention), ischaemic 

stroke (0.86 vs 0.78) and serious vascular event 

(0.88 vs 0.81), 4 which questions the rationale for 

dichotimising CVD prevention. It is more likely 

that CVD risk and benefit from aspirin are on a 

continuum. 

In conclusion, the findings of this analysis 

reinforce the importance of basing preventive 

management decisions on CVD risk. CVD risk 

assessment is recommended prior to commencing 

aspirin, lipid-lowering and blood pressure– 

lowering therapy, and management decisions 

should generally be made on the basis of this 

assessment, according to current guidelines. 

From these analyses, aspirin should still be 

considered for primary prevention of CVD 

in those with five-year CVD risk >15%, up to 

the age of 80 years, although in men 70–79 

consider lipid and blood pressure–lowering 

therapies first and then reassess whether aspirin 

adds additional net benefit. 




References 

1. World Health Organization. Global burden of disease. Death 

and DALY estimates for 2004 by cause for WHO member 

states. Geneva: World Health Organization; 2009. 

2. New Zealand Guidelines Group. New Zealand cardiovacsular 

guidelines handbook: a summary resource for primary care 

practitioners. 2nd ed. Wellington: New Zealand Guidelines 

Group; 2009. 

3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease 

by more than 80%. BMJ. 2003;326:1419–24. 

4. Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the 

primary and secondary prevention of vascular disease: collaborative 

meta-analysis of individual participant data from 

randomised trials. Lancet. 2009;373:1849–60. 

5. Anderson KM, Odell PM, Wilson PWF, Kannel WB. Cardiovascular 

disease risk profiles. Am Heart J. 1990;121:293–8. 

6. U.S. Preventive Services Task Force. Aspirin for the prevention 

of cardiovascular disease: U.S. Preventive Services Task Force 

Recommendation Statement. Ann Int Med. 2009;150:396–404. 

7. Brugts JJ, Yetgin T, Hoeks SE, Gotto AM, Shepherd J, Westendorp 

RGJ, et al. The benefits of statins in people without 

established cardiovascular disease but with cardiovascular risk 

factors: meta analysis of randomised controlled trials. BMJ. 

2009;228:b2376. 

8. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering 

drugs in the prevention of cardiovascular disease: meta-analysis 

of 147 randomised trials in the context of expectations from 

prospective epidemiological studies. BMJ. 2009;228:b1665. 

9. Law MR, Wald NJ, Morris JK, Jordan RE. Value of low dose 

combination treatment with blood pressure lowering drugs: 

analysis of 354 ranomised trials. BMJ. 2003;326:1427–34. 

10. Law MR, Wald NJ, Rudnicka AR. Quantifying effect of statins 

on low density lipoprotein cholesterol, ischaemic heart disease, 

and stroke: systematic reivew and meta-analysis. BMJ. 

2003;326:1423–9. 

11. Berger JS, Roncaglioni MC, Avanzini F, Pangrazzi I, Tognoni G, 

Brown DL. Aspirin for the primary prevention of cardiovascular 

events in women and men. JAMA. 2006;295(3):306–13. 

12. Belch J, MacCuish A, Campbell I, Cobbe S, Taylor R, Prescott 

R, et al. The prevention of progression of arterial disease 

and diabetes (POPADAD) trial: factorial randomised placebo 

controlled trial of aspirin and antioxidants in patients with 

diabetes and asymptomatic peripheral arterial disease. BMJ. 

2008;337:a1840. 

13. Riddell T, Wells S, Jackson R, Lee A-W, Crengle S, Bramley D, 

et al. Performance of Framingham cardiovascular risk scores 

by ethnic groups in New Zealand: PREDICT CVD-10. N Z Med 

J. 2010;123(1309). 

14. Elley CR, Robinson E, Kenealy T, Bramley D, Drury PL. 

Derivation and validation of a new cardiovascular risk score 

for people with type 2 diabetes: the New Zealand Diabetes 

Cohort Study (DCS). Diabetes Care. 2010;33(6). 

15. New Zealand Guidelines Group. Evidence-based best practice 

guideline. The assessment and management of cardiovascular 

risk. New Zealand Guidelines Group; 2003. 

16. British Hypertension Society. Statement on the use of aspirin. 

Fact File 01/2010, 2010. 

ACKNOWLEDGEMENTS 

Colin Baigent provided 

helpful comments 

during the preparation 

of this article. 

Funding 

Vanessa Selak is the 

recipient of a National 

Heart Foundation 

Research Fellowship. 

COMPETING INTERESTS 

VS, CE and AR are 

undertaking research into 

a cardiovascular polypill 

that includes aspirin, 

but have no financial 

interest in this product. 




What resources do Auckland general 

practitioners use for answering immediate 

clinical questions and for lifelong learning? 

Zachary BH Gravatt; 1 Bruce Arroll MBChB, PhD, FNZCPHM, FRNZCGP 2 

1 

Medical student 

(posthumous publication) 

2 



Care, Faculty of Medical 

and Health Sciences, The 



ABSTRACT 

INTRODUCTION: General practitioners need to search for evidence to remain up-to-date with knowledge 

and to answer clinical questions that arise during consultations. In the past their main sources of 

information have been via colleagues and books. 

Aim: To determine the resources Auckland GPs use to answer clinical questions and to maintain lifelong 

learning. 

Methods: One hundred questionnaires were mailed to Auckland GPs. There were 33 replies (33% 

response rate). From this sample 10 were chosen at random and all agreed to be interviewed (100% 

response rate). 

Results: All participants were using Internet resources to obtain answers to clinical questions. Colleagues 

were also important for answering immediate questions, but not for future requirements. There 

is possibly less use of paper book resources. The websites were used to obtain knowledge now and for 

future need, while paper books were only used for answering immediate questions. 

Discussion: The use of websites may be increasing in general practice for both immediate knowledge 

requirements and for lifelong learning. Colleagues are still a source of answers to immediate clinical questions, 

but textbooks may be less used. Empiric data are needed to monitor changes in answering clinical 

questions and the issue of lifelong learning requires more research. 

KEYWORDS: Education, medical, continuing; family practice; information management; information 

storage and retrieval; medical informatics; Internet 


2010;2(2):100–104. 


Bruce Arroll 

Professor and Head of 


Practice and Primary 

Health Care, Elaine Gurr 

Chair in General Practice, 

Faculty of Medicine and 

Health Science, The 


PB 92019 Auckland 


b.arroll@auckland.ac.nz 

Introduction 

For medicine to continue to be respected as a 

profession, evidence-based decision-making is 

required where this is possible. This in turn 

depends on physicians being able to understand 

how and why they make decisions. 1 In particular, 

evidence-based decision-making requires a ‘conscientious, 

explicit and judicious use of current 

best evidence in making decisions about the care 

of individual patients’. 2 It is this definition that 

underpins evidence-based medicine (EBM). By applying 

such a definition it becomes apparent that 

physicians’ knowledge following formal graduation 

will not remain current throughout their 

careers unless they develop skills enabling them 

to participate in lifelong learning (LLL). 3 

General practitioners (GPs) are likely to search 

for evidence for two primary reasons. The first 

is to keep up-to-date with new information 4 

and modern clinical opinion. This style of LLL 

and continuing medical education (CME) relies 

considerably on individuals’ own awareness of 

strengths and weaknesses in their knowledge. 5 

It has been suggested that GPs have imperfect 

abilities to judge their own learning requirements 

and external assessment is one proposed 

solution to this. 6,7 Currently GPs believe CME 




is advantageous and can lead to patient benefits. 8 

The literature suggests GPs may be somewhat 

misguided in this belief, because CME sessions 

only occasionally change health outcomes or 

result in professional development. 9,10 This might 

result from a preponderance of poor quality CME 

activities with low levels of effectiveness. 11 

The second reason GPs might search for evidence 

is to answer questions generated by patients. 4 

However this can be an arduous and problematic 

task due to the time and effort required to navigate 

the large and ever-expanding wealth of medical 

information available. 4 Consequently, GPs may be 

unable to answer reliably 70% of clinical questions 

for which they have sought answers. 4 For certain 

questions electronic textbooks such as DynaMed, 

MDConsult and UpToDate might prove to be 

a reasonable resource for this problem. 12 These 

electronic textbooks are comprehensive, reasonably 

evidence-based where such information is 

available, and can give answers to common clinical 

questions in a few minutes of searching. 

Previous research exploring the ways New 

Zealand GPs answer patient questions has been 

reported. This demonstrated that, although the 

majority of GPs had access to computers, they 

were not the most frequently used source for 

answering patient questions. 13 Instead, answers 

are most likely to be sought from books, followed 

by colleagues. 13 These patient questions were 

most likely to focus on issues related to treatment 

or diagnosis. 13 

On the issue of information sources used to 

find answers to clinical questions, interesting 

differences arise between GPs and specialists. 4,14 

A 2005 New Zealand survey found that New 

Zealand GPs want information that is presented 

concisely, clearly, timely, attractively and is 

‘owned’ and trusted by them. 16 GPs are unlikely 

to seek original research articles, but instead 

opt to conduct Internet searches. Specialists, 

however, are more likely to search the literature 

and journals or enter into correspondence with 

colleagues. 16 Family medicine residents who are 

trained in EBM are unlikely to perform evidencebased 

searches at the point of care, but instead 

use sources that allow them access to answers 

swiftly and conveniently. 4,16 


What we already know: GPs used colleagues and books in the past to 

answer immediate clinical questions. There is no recent overview of how 

general practitioners acquire clinical information and keep up-to-date. 

What this study adds: Colleagues are still a common source of information, 

but it appears that paper books are being replaced with electronic resources. 

Websites are used both to answer clinical questions and to facilitate 

lifelong learning. 

The aim of this study was to determine the resources 

used by GPs for lifelong learning and to 

retrieve answers to clinical questions as they arise 

during a consultation. 

Methods 

One hundred questionnaires were mailed to a 

random selection of Auckland GPs using the 

Department of General Practice and Primary 

Health Care (Auckland University) database of 

Auckland GPs. This database is regularly updated. 

The questionnaire asked about sources of 

information (such as websites, books, colleagues, 

email), how often they were used and how often 

an ‘answer’ was found. There were 33 replies 

(33% response rate). It was considered that the 

responders were likely to be interested GPs keen 

on lifelong learning. 

From this sample 10 were chosen at random 

and all agreed to be interviewed (100% response 

rate). The interview was conducted by 

telephone and notes were taken rather than an 

audio-recording. The interviewer had the GP’s 

answers to the original questionnaire to guide 

the GP through the interview. These interviews 

were conducted between December 2008 and 

February 2009. 

The GPs were asked which sources of information 

they used for particular enquiries; specifically, 

websites, online text, journals (electronic or 

paper), paper books, colleagues, audits, prescribing 

sources and email feeds. For each answer 

the GP was asked for the name of the source, if 

payment was required, if it was a source accessed 

when needed (a ‘pull’ resource) or information 

that is sent to them routinely (a ‘push’ resource), 




Table 1. Demographics of interviewed general practitioners 

Number of years since graduation 

Median years since graduation 

how often they got an answer to their question 

and whether this source was for a question now 

or for future reference. 

The study had ethics approval from The University 

of Auckland Human Participants Ethics 

Committee (Reference number 2008/427). 

The GPs’ responses are described and their resources 

listed in categories. 

Results 

17–35 years 

26 years 

Fellow of the RNZCGP 9/10 (90%) 

Male 5/10 (50%) 

Overseas-trained 5/10 (50%) 

Self-assessed electronic skills 

0=poor; 10=excellent 

Range 4.5–10 

Median 7.5 

The demographics of the 10 GPs interviewed 

indicate that they were senior members of the 

profession, all but one were Fellows of the College 

with a median of 26 years since graduation. 

There were equal numbers of male and female 

and of NZ- and overseas-trained respondents. 

While there was a range in their self-assessed 

electronic skills, they generally judged these 

positively (Table 1). 

The sources they used are shown in Table 2. All 

accessed websites for information when needed 

(a ‘pull’ resource) both for immediate clinical 

questions and for future reference, and 50% used 

websites daily. Other resources commonly used 

when information was needed at the point of 

care were paper books, MIMS catalogues and GP 

and specialist colleagues, whereas journals were 

used for updating knowledge. In general, they 

were more satisfied with the answers to their 

questions from Internet resources and colleagues 

than from books. 

The resources they used are in Table 3. A wide 

range of websites are listed, including medical 

e-learning sites, literature databases, e-texts, 

general search engines and topic-specific sites. 

Relatively few paper textbooks are listed. 

Discussion 

This study shows that all the participants were 

using the Internet both to seek information for 

questions requiring an answer now and for future 

learning. Half were using it daily. Colleagues and 

paper-based sources were only used daily by one 

of the participants and only used for immediate 

clinical questions. 

This may represent a change in information seeking 

when compared with another Auckland-based 

study in 2002 where computers were rarely used 

to answer clinical questions. Colleagues including 

Table 2. Details of use of sources 

Source Use at all Use daily Pull* Free to use Now/future † 

Websites 10/10 5/10 10/10 Majority 10/10 both 

Online textbook 2/10 0/10 2/10 1/10 1/10 now 

Journals 

(paper and electronic) 

8/10 

Range (each issue 

to 1/year) 

6/10 8/10 7/10 future 

Paper book 8/10 1/10 7/10 4/10 7/10 now 

MIMS ‡ 7/10 5/10 6/10 5/10 5/10 now 

GP colleagues 7/10 1/10 7/10 7/10 7/10 now 

Specialist colleagues 6/10 0/10 6/10 6/10 6/10 now 

Pharmacist colleagues 2/10 0/10 2/10 2/10 2/10 now 

* Pull: information accessed when needed, v. push: a resource sent routinely to a clinician 

† 

Whether resource for answering clinical questions now or for future learning 

‡ 

Only source of prescribing used (at the time, every GP in New Zealand was given a free copy from the publisher) 




Table 3. Resources used by the 10 GPs 

Websites (‘pull’) 

Routine emails (‘push’) 

Journals (electronic or paper) 

and publications 

Paper books 

Colleagues 

Australian Menopause Society 

British Medical Journal Learning 

CDC travel medicine 

Cochrane reviews 

Dermnet 

Dilworth audiology 

e-medicine 

Everybody 

FamilyDoctor 

FpNotebook.com 

Goodfellow Club 

Google 

Google scholar 

Isabelhealthcare.com 

MD consult 

From PHOs 

From DHBs 

From MOH 

From hospital specialists 

ePulse (RNZCGP) 

Research reviews via email 

Wonca journal alerts 

Am J Clinical Nutrition 

Am J Medicine 

Australian Family Physician 

British Medical Journal 

BPAC Best Practice 

Casebook (Medical Protection Society) 

Consumer 

Evidence Based Medicine 

JAMA 

New Zealand Doctor 

New Zealand Family Physician 

New Zealand Medical Journal 

Clinical Evidence 

(BMJ) 

A Handbook for 

the Interpretation 

of Laboratory Tests 

(Diagnostic Medlab) 

Fitzpatrick’s 

Dermatology in 

General Medicine 

Grant's Atlas of 

Anatomy 

Immunisation 

Handbook (Ministry 

of Health) 

The Merck Manual 

Murtagh’s General 

Practice 

Diabetic nurse 

Laboratory 

specialist 

GP 

Hospital specialist 

Pharmacist 

Peer group 

Med Media patient info 

Medscape 

New Zealand guidelines 

Patient.co.uk 

P.E.A.R.L. 

(cochraneprimarycare.org) 

Pharmac 

Procare 

Pubmed 

RACGP online CME-CPD 

Real age 

RNZCGP 

SearchMedica 


Wikipedia 

GPs, specialists and pharmacists were still common 

sources of information. 13 The use of journal 

articles or searching for literature other than 

through search engines was rare. We were also 

surprised at the wide range of websites used and 

the fact that some were using web resources daily 

and some less often. 

A strength of this study is that each of the 10 

GPs was able to be interviewed in some depth 

about their information approaches. A limitation 

is that they are a self-selected group of highly 

motivated learners who probably represent one 

end of a spectrum of GPs and are not representative 

of all GPs. However, the study intended to 

interview such a group to see what innovations 

are possible in the primary care setting. It was 

not possible to do an in-depth interview on a 

wide range of GPs with the resources available to 

the study. 

In the words of McConaghy we agree that 

‘clinicians must learn the techniques and skills 

to focus on finding, evaluating and using 





Thank you to the GPs who 

participated in the project. 

relevant and valid information at the point 

of care. Clinicians also need sources for rapid 

retrieval of this information to integrate it into 

their daily practice and their careers of lifelong 

learning.’ 4 The GPs in our sample certainly 

have ‘sources for rapid retrieval’ and are using 

‘relevant’ information; they are probably also 

getting ‘valid’ information, given the resources 

they have nominated. 

Web resources have the potential to provide 

both immediate answers to clinical questions 

and contribute to lifelong learning. The possible 

change from textbooks to web resources has the 

additional advantages of providing clinicians 

with up-to-date information which is not possible 

with paper textbooks. Future research is needed 

and perhaps it would be worthwhile repeating 

the study of 2002 to see how answering clinical 

questions may have changed. 13 The issue of lifelong 

learning (knowledge for the future) needs 

more research. 

References 

1. Glasziou P. Why is evidence-based medicine important? Evid 

Based Med. 2006 ;11(5):133–5. 

2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson 

WS. Evidence based medicine: what it is and what it isn’t. 

BMJ. 1996;312:71–2. 

3. Miller SH, Thompson JN, Mazmanian PE, Aparicio A, Davis 

DA, Spivey BE, et al. Continuing medical education, professional 

development, and requirements for medical licensure: a 

white paper of the Conjoint Committee on Continuing Medical 

Education. J Contin Educ Health Prof. 2008;28(2):95–8. 

4. McConaghy JR. Evolving medical knowledge: moving toward 

efficiently answering questions and keeping current. Prim 

Care. 2006;33(4):831–7. 

5. Duffy FD, Holmboe ES. Self-assessment in lifelong learning 

and improving performance in practice: physician know 

thyself. JAMA. 2006;296(9):1137. 

6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe 

KE, Perrier L. Accuracy of physician self-assessment compared 

with observed measures of competence: a systematic review. 

JAMA. 2006;296(9):1094. 

7. Tracey J, Arroll B, Barham P, Richmond D. The validity of 

general practitioners’ self assessment of knowledge: cross 

sectional study. BMJ.1997:1426–8. 

8. Campion-Smith C, Smith H, White P, Baker E, Baker R, Holloway 

I. Learners’ experience of continuing medical education 

events: a qualitative study of GP principals in Dorset. Br J Gen 

Pract. 1998;48(434):1590. 

9. Treweek S, Flottorp S, Fretheim A, Havelsrud K, Kristoffersen 

DT, Oxman A, et al. What do general practitioners 

do to keep themselves up to date? Tidsskr Nor Laegeforen. 

2005;125(3):304–6. 

10. Davis D, O’Brien MAT, Freemantle N, Wolf FM, Mazmanian 

P, Taylor-Vaisey A. Impact of formal continuing medical 

education: do conferences, workshops, rounds, and 

other traditional continuing education activities change 

physician behavior or health care outcomes? JAMA. 

1999;282(9):867–74. 

11. Bloom BS. Effects of continuing medical education on 

improving physician clinical care and patient health: a review 

of systematic reviews. Int J Technol Assess Health Care. 

2005;21(03):380–5. 

12. Goodyear-Smith F, Kerse N, Warren J, Arroll B. Evaluation of 

e-textbooks. DynaMed, MD Consult and UpToDate. Aust Fam 

Phys. 2008;37(10):878. 

13. Arroll B, Pandit S, Kerins D, Tracey J, Kerse N. Use of information 

sources among New Zealand family physicians with high 

access to computers. J Fam Pract. 2002;51(8):706. 

14. Bennett NL, Casebeer LL, Kristofco R, Collins BC. Family 

physicians’ information seeking behaviors: a survey comparison 

with other specialties. BMC Med Inform Decis Mak. 

2005;5:9. 

15. Dovey SM, Fraser TJ, Tilyard MW, Ross SJ, Baldwin KE, Kane 

D. ‘Really simple, summary, bang! That’s what I need.’ –Clinical 

information needs of New Zealand general practitioners 

and the resources they use to meet them. N Z Fam Physician. 

2006;33(1):18. 

16. Ramos K, Linscheld R, Schafer S. Real-time informationseeking 

behavior of residency physicians. Fam Med. 

2003;35(4):257–60. 

Funding 

This project was funded 

by a summer studentship 

in the Faculty of Medicine 

and Health Science, The 

University of Auckland. 


None declared. 

Zac Gravatt conducted research through a summer studentship in the Department of General Practice 

and Primary Health Care at the end of his 2nd medical school year. He was such a popular and good 

researcher that he was welcomed back for a second summer studentship at the end of 3rd year. This 

paper is the result of his second studentship. In July 2009, halfway through his 4th medical school year, 

Zac died suddenly and tragically of meningococcal C septicaemia. We would like to honour the great 

doctor and researcher Zac could have been should he have survived. 




Causes of excess hospitalisations among 

Pacific peoples in New Zealand: implications 

for primary care 

Faafetai Sopoaga MBChB, FRNZCGP, FAFPHM; Ken Buckingham PhD (Aberdeen), MSc (York), BSc (Bath); 

Charlotte Paul MBChB, PhD, FAFPHM 

ABSTRACT 

introduction: Pacific people suffer disproportionately poorer health and reduced life expectancy at 

birth compared to the total New Zealand population. 

Department of Preventive 

and Social Medicine, 

University of Otago, 


Aim: To assess causes of excess morbidity in the Pacific population, and identify lesser known or previously 

unknown causes which require further investigation. 

Methods: We obtained public hospital discharge data from July 2000 to December 2002. The population 

data were from the 2001 Census. Standardised discharge ratios were calculated to compare Pacific 

peoples with the total New Zealand population. 

Results: Pacific peoples were six times more likely to have a diagnosis of cardiomyopathy and gout, 

and four to five times of rheumatic fever, gastric ulcer, systemic lupus erythematosus (SLE), and diabetes. 

Respiratory diseases, skin abscesses, heart failure, cataracts, cerebral infarction and chronic renal failure 

were also significant causes of excess morbidity. Unexpected causes of excess morbidity included candidiasis, 

excess vomiting in pregnancy (hyperemesis gravidarum) and pterygium. 

discussion: The magnitude of established causes of excess morbidity among Pacific peoples were 

similar to our findings. Other causes of excess morbidity are less widely known, or are identified here for 

the first time. These are systemic lupus erythematosus, hyperemesis gravidarum, cardiomyopathy, gastric 

ulcer, candidiasis and pterygium. The findings draw attention to specific causes of excess morbidity in Pacific 

communities where effective interventions are available in primary care, and where further research 

may identify preventive or curative interventions. 

KEYWORDS: Pacific peoples; primary care; hyperemesis gravidarum; morbidity; hospitalizations 

Introduction 

The Pacific population makes up approximately 

7% of the total New Zealand population from 

the 2006 Census. 1 Pacific people suffer disproportionately 

from poorer health and, in 2001, 

their life expectancy at birth was five years less 

compared to the total New Zealand population. 2,3 

The focus of many health intervention programmes 

is on addressing this disparity in health 

status. To decrease disparities it is important to 

understand the range of health problems which 

disproportionately affect Pacific peoples. Some of 

these problems have already been identified from 

mortality and health survey data. 2–5 Nevertheless, 

there is limited information published on the 

occurrence of chronic conditions among Pacific 

peoples in New Zealand. 

This study was carried out as part of a health 

needs analysis for Pacific peoples commissioned by 

the Ministry of Health. Our aim was to determine 

the specific causes of hospital admissions which 

are significantly elevated in the Pacific population. 

This will provide information that may assist early 

diagnosis and treatment in primary care, and may 

result in better outcomes for Pacific peoples. 


2010;2(2):105–110. 


Faafetai Sopoaga 

Department of Preventive 

and Social Medicine, 

University of Otago 

PO Box 913, Dunedin 


tai.ventura@otago.ac.nz 




Methods 

We undertook a systematic examination of public 

hospital discharge diagnoses (as a measure of 

morbidity) to determine which conditions are 

relatively important causes of morbidity among 

Pacific peoples compared to the total population 

in New Zealand. The results presented are 

for those who were admitted to hospital only. 

Patients who were seen at the emergency department 

and discharged were excluded. 

The hospital activity data used in this study were 

obtained from the New Zealand Health Information 

Service of the Ministry of Health, and relate 

to public hospital discharges for the period July 

2000 to December 2002. The population data 

were derived from Statistics New Zealand census 

data for 2001. Discharge diagnoses were coded to 

International Classification of Diseases (ICD) 10. 

‘Pacific peoples’ included anyone who reported 

sole Pacific Island ethnicity or Pacific Island ethnicity 

as well as another ethnic group or groups 

from hospital discharges. 

Standardised discharge ratios (SDRs) were 

calculated using the rate of discharges per capita 

by age group for the total population, applied to 

the age structure of the Pacific population. This 

provides an estimate of the expected number of 

discharges that the Pacific population would have 

had, given its own population structure, but with 

discharge rates equal to those in the population 

at large. Effectively we adjust for the younger age 

structure of the Pacific population. The expected 

number of discharges for Pacific people formed 

the denominator, and the observed number of 

discharges the numerator. SDRs higher than one 

thus imply higher standardised discharges among 

Pacific peoples compared to the total population. 

Further adjustment were made to the expected 

number of discharges to allow for the different 

fertility pattern of Pacific peoples. For those conditions 

that relate to pregnancies and births, we 

multiplied the expected number of hospitalisations 

by the relative birth rate for Pacific peoples 

compared to the population as a whole. 

Given the relatively small number of hospitalisation 

events, the frequency of occurrence in the 

two population groups can differ by chance. Confidence 

is usually represented statistically by confidence 

intervals (CIs); these intervals show the 

range of values in which we can be 95% confident 

that the ‘true’ value lies. The CIs for the SDRs 

were calculated using an algorithm described by 

Byar. 6 This algorithm makes allowances for the 

lower confidence we can place on estimates from 

smaller samples. Because the SDRs are distributed 

non-normally, we applied a log transformation 

before calculating the standardised distance from 

the mean in terms of the number of CIs. The 

method is effectively a measure of our certainty 

that the disease differs from the population 

standard, and might be thought of as equivalent 

to a ‘z’ score. The ICD-10 diagnoses where the 

standardised distance from the mean was in the 

top 5% of values are presented. 

Permission for access to data was granted from 

the Ministry of Health. 

Results 

During the study period July 2000 to December 

2002, there were 2 831 789 discharges from 

all public hospitals in New Zealand. Of these, 

99 476 (3.5%) were identified as Pacific peoples. 

The number of people responding to the ethnicity 

question in the 2001 Census was 3 586 731 

(96%), and 231 801 (6.2 %) identified themselves 

as Pacific peoples. The apparent lower proportion 

admitted to hospital is because of differences in 

the age structure of the Pacific population compared 

to the total population. 

Table 1 shows the 24 discharge diagnoses which 

were most elevated for Pacific peoples; that is, the 

top 5% of values. Pacific peoples were around two 

to six times more likely to be discharged from 

hospital with these conditions. More specifically, 

Pacific peoples were six times more likely to have 

a diagnosis of cardiomyopathy and gout, and four 

to five times more likely to have rheumatic fever, 

gastric ulcer, systemic lupus erythematosus (SLE), 

diabetes and its associated complications. Respiratory 

diseases were also a significant cause of 

excess morbidity with discharges for bronchiectasis 

nearly five times, and pneumonia at least two 

times more in comparison. Skin abscesses, heart 

failure, cataracts, cerebral infarction and chronic 




renal failure were at least twice as likely to be 

discharge diagnoses. There were some unexpected 

findings also, where Pacific peoples were five 

times more likely to have candidiasis, and ‘other 

disorders of the conjunctiva’ and two times more 

likely to have hyperemesis gravidarum compared 

to the total New Zealand population, after adjustment 

for fertility rates. When looking at the 

four-character ICD code for candidiasis, 90% of 

Pacific cases were due to either cheilitis (candidiasis 

of the mouth) or enteritis. The four-character 

ICD code for other disorders of the conjunctiva 

showed 97% of cases were pterygium. Of the six 


What we already know: The main known causes of excess morbidity 

amongst Pacific peoples in New Zealand are respiratory and cardiovascular 

diseases, diabetes, gout, skin infections, rheumatic fever, and their associated 

complications. 

What this study adds: Causes of excess morbidity among Pacific people 

that are less well known, or reported here for the first time, are: cardiomyopathy, 

systemic lupus erythematosus, hyperemesis gravidarum, gastric ulcer, 

candidiasis, and pterygium. Early diagnosis and treatment of these conditions 

in primary care will reduce morbidity. 

Table 1. Public hospital discharges for Pacific peoples compared to the total population in New Zealand, July 2000 to December 2002 

Description 

3 digit 

ICD-10 

codes 

Standardised Discharge 

Ratio (age and fertility 

adjusted) 

Lower 

confidence 

limits 

Upper 

confidence 

limits 

Standardised 

distance from 

the mean 

N* 

Pneumonia, organism unspecified J18 2.35 2.27 2.43 12.91 3532 

Non–insulin-dependent diabetes E11 4.54 4.25 4.83 11.88 964 

Cardiomyopathy I42 6.26 5.65 6.91 9.11 389 

Gout M10 6.39 5.74 7.10 8.74 350 

Cutaneous abscess, furuncle and carbuncle L02 2.36 2.24 2.48 8.62 1571 

Acute bronchiolitis J21 1.83 1.76 1.90 7.94 2674 

Bronchiectasis J47 4.63 4.20 5.09 7.93 422 

Care involving dialysis Z49 5.67 5.02 6.39 7.19 272 

Heart failure I50 2.62 2.44 2.81 6.89 801 

Other disorders of conjunctiva H11 5.29 4.63 6.03 6.30 227 

Hyperemesis gravidarum O21 1.98 1.87 2.10 6.07 1230 

Other cataract H26 2.64 2.42 2.87 5.71 544 

Senile cataract H25 3.01 2.71 3.34 5.23 355 

Acute lower respiratory infection, 

unspecified 

J22 1.98 1.85 2.12 5.00 835 

Gastric ulcer K25 3.90 3.36 4.50 4.65 186 

Cellulitis L03 1.62 1.53 1.71 4.53 1377 

Other chronic obstructive pulmonary 

disease 

J44 1.88 1.76 2.02 4.51 793 

Asthma J45 1.46 1.39 1.52 4.36 2099 

Rheumatic fever I01 5.52 4.51 6.68 4.36 105 

Systemic lupus erythematosus (SLE) M32 3.87 3.28 4.54 4.14 150 

Diabetes mellitus in pregnancy O24 2.39 2.14 2.66 4.04 339 

Candidiasis B37 4.72 3.84 5.73 3.88 101 

Cerebral infarction I63 2.28 2.05 2.54 3.82 338 

Chronic renal failure N18 2.49 2.20 2.81 3.75 267 

* Number of hospital discharges for Pacific people. 




most common diagnoses, pneumonia, acute bronchiolitis 

and asthma each resulted in over 2000 

admissions during this period. Skin infections, 

cellulitis, and hyperemesis gravidarum each were 

a cause of over 1000 admissions. 

Discussion 

Our results provide a description of the illnesses 

causing hospital admissions which most clearly 

affect Pacific peoples disproportionately compared 

to the total New Zealand population. Some of 

these causes of morbidity were consistent with 

what is already known; however, there were also 

some unexpected findings. The cut-off of the top 

5% was arbitrary, but chosen in order to include 

only differences which we were confident were 

not chance findings. Moreover, by taking the 

top 5% of conditions we satisfy the Bonferroni 

correction for multiple sampling (to allow for the 

possibility that some significant results would 

Public hospital discharge data, despite the 

limitations discussed, are a good measure 

of morbidity amongst Pacific peoples 

occur purely by chance when considering a large 

number of statistics). A number of conditions 

which are known to be higher amongst Pacific 

peoples were below this cut-off. 2 For example, 

meningococcal infection (SDR 2.11), gastric 

cancer (SDR 2.98), and tuberculosis (SDR 3.57). 

Many of the illnesses resulting in admissions 

for Pacific peoples in this study can either be 

prevented, their severity reduced, or complications 

delayed, through effective primary care 

interventions. 

There were some limitations in our study. It was 

a snapshot of morbidity and does not offer any 

information about trends over time. ICD discharge 

diagnosis coding will contain errors, but 

these could not account for large differences. The 

results show admissions not people. If Pacific people 

have a higher number of re-admissions than 

the total population, this could account for some 

of the excess. Because of potential differences in 

knowledge, access to services, and referrals for 

treatment, it may be that SDRs for Pacific peoples 

are higher (or lower) on average, for reasons that 

are unrelated to levels of morbidity. The most 

extreme SDRs, however, are likely to indicate 

conditions within the Pacific community that 

are associated with the highest levels of excess 

morbidity. Ethnicity data collection has improved 

since 1995 and there are changes in how ethnicity 

data are now collected. However, there are 

persisting issues with the recording of ethnicity 

in New Zealand with underenumeration of Maori 

and Pacific peoples. 7–8 This means the elevated 

rates observed may be an underestimation. On the 

other hand, the definition of Pacific ethnicity in 

the hospitalisation data and the census differ (the 

former prioritised Pacific, the latter prioritised 

Maori). This could lead to an overestimation of 

the elevated rates in Pacific people, but any effect 

will be very small. Private hospital data were not 

included. If Pacific peoples use private hospitals 

less, this may result in an overestimation of the 

elevated rates. This is likely to be a minor problem 

for the conditions examined, as most of these 

are treated in public hospitals for everyone. 

The strengths of this study include the large 

number of admissions, hence the statistical 

power. Public hospital discharge data, despite 

the limitations discussed, are a good measure of 

morbidity amongst Pacific peoples. 

Our results, compared to other published data, 

showed similar or higher excess rates for respiratory 

diseases, heart failure, rheumatic fever, 

cerebral infarction (stroke), and diabetes and 

other related conditions. For instance, the annual 

hospitalisation rate for pneumonia in Pacific children 

in Auckland was twice as high, while the 

national incidence of bronchiectasis was at least 

10 times higher compared to Europeans. 9,10 The 

prevalence of diabetes in the Pacific population, 

at 23.5%, was higher compared to all other ethnic 

groups. 11 Pacific mortality from heart failure and 

stroke was at least double compared to the total 

population. 2 Cardiomyopathy was six times more 

common among Pacific peoples in our study, 

but there appears to be no previous research on 

this. We found that a whole range of respiratory 

illnesses were significantly more common among 

Pacific people. In terms of burden of disease (total 

numbers), respiratory diseases were the most 




important. Many of these illnesses are influenced 

by socioeconomic and environmental conditions. 

We found Pacific peoples were at least six times 

more likely to have a diagnosis of gout, and four 

times more likely to have gastric ulcer. Research 

into the aetiology of gout in Pacific people had 

identified a potential genetic link, which may 

act in conjunction with diet and obesity. 12,13 

Indigenous Fijians had a higher prevalence of 

gastric ulcers diagnosed by endoscopic examination 

than Fijian Indians. 14 Risk factors for gastric 

ulcers included helicobacter pylori (H.pylori) 

infection, non-steroidal anti-inflammatory drugs 

and smoking. 15–16 H.pylori IgG seropositivity 

has been shown to be highest in Pacific peoples 

compared to either Maori or people of European 

ethnicity. 17 Antibiotic treatment is effective for 

H.pylori eradication. 

We found Pacific peoples were at least 1.5 times 

more likely to have a diagnosis of cellulitis, and 

five times more likely to have rheumatic fever 

compared to the total New Zealand population. 

Cellulitis is caused by either Group A streptococcus 

or staphylococcus aureus. 18 A complication of 

Group A streptococcus infection is acute rheumatic 

fever. Skin infections are more common 

among Pacific children. 3 High rates of rheumatic 

fever are linked to socioeconomic conditions, and 

consistent with previous findings for Maori and 

Pacific peoples. 2,19 Improved socioeconomic conditions 

and access to early diagnosis and treatment 

can reduce the development of complications. 

Most pregnant women experience some degree 

of nausea and vomiting. Previous research based 

on a review of medical notes found the incidence 

of hyperemesis gravidarum in Pacific Island 

women was higher compared to either Maori or 

Europeans. 20,21 We found Pacific women to be 

two times more likely to be hospitalised because 

of hyperemesis gravidarum compared to the total 

New Zealand population, and this accounted for 

a high burden of disease (over 1000 admissions 

in 2.5 years). Recent research showed a consistent 

association between hyperemesis gravidarum and 

H.pylori, with relief of symptoms after antibiotic 

treatment for H.pylori. 22,23 Given the higher 

prevalence of H.pylori this is a plausible cause of 

hyperemesis gravidarum among Pacific women, 

although psychosocial factors and disorders of 

thyroid function are also possible causes. 23 We 

could find no evidence that any clinical trial of 

treatment of H.pylori in women with hyperemesis 

gravidarum has been undertaken. 

Candida is a commensal found in the mouth, 

stool and vagina. 18 Invasive candidiasis is a serious 

problem in diabetic patients. 24 Our results 

showed Pacific peoples were nearly five times 

more likely to be discharged with a diagnosis of 

candida enteritis and cheilitis, compared to the 

total New Zealand population. There has been no 

previous research on ethnic differences in susceptibility 

to candidiasis in New Zealand. Research 

is required to find out why Pacific peoples appear 

to be more susceptible. 

The prevalence of SLE is known to vary among 

people of different ethnic groups. 25–29 A review 

of medical notes in New Zealand in the 1980s 

showed a major difference in prevalence when 

comparing people of European ethnicity and Polynesians. 

30 The Polynesian ethnic group included 

Maori and Pacific peoples. Polynesians were 3.5 

times more likely to have SLE compared to the 

European population in New Zealand. Age standardised 

comparative mortality rates were also 

higher. Our findings are similar, with Pacific peoples 

four times more likely to have SLE compared 

to the total New Zealand population. It would 

be helpful to look at Maori and Pacific peoples 

separately, to provide clarity about morbidity and 

mortality from SLE in these ethnic groups. 

Pterygium is a ‘wedge-shaped fibrovascular 

growth of conjunctiva that extends onto the 

cornea’. 18 The prevalence is higher in countries 

nearer the equator, and appears to be associated 

with sun exposure. 31–32 We did not have information 

about the country of birth for Pacific peoples 

in this study. It is possible that the higher prevalence 

of cases seen is due to Pacific peoples from 

the Pacific Islands now living in New Zealand. 

This association does not appear to have been 

documented previously. 

Conclusion 

The established causes of excess morbidity 

among Pacific people—respiratory and cardio- 





We wish to acknowledge 

Dr Lianne Parkin, and 

Professor Phillip Hill for 

peer review comments, 

and Shiva Nair (medical 

student) who was 

involved in the initial 

aspects of the research. 

FUNDING 

This study was supported 

by funds from the Ministry 

of Health, Dunedin Office. 



vascular diseases, diabetes, gout, skin infections 

and their associated complications—were all 

considerably more common discharge diagnoses 

compared with the total population in this 

analysis. These disorders are already the focus of 

attention, and it is important for primary health 

care professionals to continue working collaboratively 

with Pacific communities to improve 

health in these areas. 

Other causes of excess morbidity in Pacific peoples 

are less widely known, or are identified here 

for the first time. These are cardiomyopathy, SLE, 

hyperemesis gravidarum, gastric ulcer, candidiasis 

and pterygium. The clinical implications 

are that improved knowledge amongst general 

practitioners of the excess risk of these conditions 

in Pacific peoples will lead to earlier diagnosis, 

treatment and improved outcomes. Further research 

is required to establish the cause of excess 

hyperemesis gravidarum in the Pacific population 

and the potential for treatment. 

Although a main focus on the broader socioeconomic 

determinants of health is appropriate in 

order to improve the health of Pacific peoples, it 

is important also to attend to specific causes of 

morbidity where effective interventions are available, 

and where further research may identify 

preventive or curative interventions. 

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Koiora Roa: the health of New Zealanders. Wellington; 1999. 

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2002/2003 New Zealand Health Survey. Wellington; 2004. 

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6. Rothman KJ, Boice JD, Jr. Epidemiologic analysis with a programmable 

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7. Callister P, Didham R, Pooter D, Blakely T. Measuring ethnicity 

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9. Twiss J, Metclafe R, Edwards E, Byrnes C. New Zealand 

national incidence of brochiectasis ‘too high’ for a developed 

country. Arch Dis Child. 2005;90:737–40. 

10. Grant CC, Scragg D, Tan D, et al. Hospitalisation for pneumonia 

in children in Auckland, New Zealand. J Paediatr Child 

Health. 1998;34:355–9. 

11. Sundborn G, Metcalf P, Scragg R et al. Ethnic differences 

in the prevalence of new and known diabetes, impaired 

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from: http://www.nzma.org.nz/journal/120-1257/2607/ 

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12. Simmonds HA, McBride MB, Hatfield PJ, et al. Polynesian 

women are also at risk for hyperuricaemia and gout because 

of a genetic defect in renal urate handling. Br J Rheumatol. 

1994;33:932–7. 

13. Gibson T, Waterworth R, Hatfield P, et al. Hyperuricaemia, 

gout and kidney function in New Zealand Maori men. Br J 

Rheumatol. 1984;23:276–82. 

14. Scobie BA, Beg F, Oldmeadows M. Peptic diseases compared 

endoscopically in indigenous Fijians and Indians. NZ Med J. 

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15. Sung J, Russell RI, Nyeomans, et al. Non steroidal antiinflammatory 

drug toxicity in the upper gastrointestinal tract. 

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16. Kanto I, Nomura AM, Stemmermann GN, Chyou PH. A 

prospective study of gastric and duodenal ulcer and its 

relation to smoking, alcohol, and diet. Am J Epidemiol. 

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17. Fraser AG, Scragg R, Metclaff P, et al. Prevalence of Helicobacter 

pylori in different ethnic groups in New Zealand 

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18. Fauci A, Braunwald E, Kasper D, Hauser S, Longo D, Jameson 

J, Loscalzo J, editors. Harrison’s principles of internal medicine. 

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c1991[1990 printing]. ISBN : 0070708908 (1-vol.ed). 

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20. Jordan V, MacDonald J, Crichton S, et al. The incidence of 

hyperemesis gravidarum is increased among Pacific Islanders 

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gravidarum, a literature review. Hum Reprod Update. 

2005;11:527–39. 

24. Heald AH, O’Halloran DJ, Richards K, et al. Fungal infection 

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2001;18:567–72. 

25. Siegel M, Lee SL. The epidemiology of systemic lupus erythematosus. 

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1999;128:280–7. 




GP practice variation in hospitalisation rates: 

a study of Partnership Health–enrolled patients 

Ross Barnett MA, PhD; 1 Laurence Malcolm MD, FRCPE 2 

ABSTRACT 

Aim: This project aims to provide information to support the planning and implementation of strategies 

to reduce hospitalisation. It examines variations in hospital discharge rates between practice populations 

and the use of special general practice access funding. 

1 

Department of Geography, 

University of Canterbury, 

Christchurch, New Zealand 

2 

Aotearoa Health, Lyttelton, 


Methods: Practice enrolment data for 345 254 patients enrolled with 102 Partnership Health Primary 

Health Organisation (PHO) general practices were sent to New Zealand Health Information Service. Data 

linked to the patient National Health Index (NHI) relating to hospital discharges were attached to the 

practice enrolment data for the two years ending June 2007 and returned to the researchers with the NHI 

numbers encrypted. Total discharges were 127 426.The data were analysed for rates of hospital discharges 

for different population groups and by general practice. 

Results: There is a substantial variation in hospital discharge rates between general practices, but this 

is only partly accounted for by practice population characteristics. Furthermore while there is a strong 

social gradient in European admissions, this is much less true for Maori. There was also a wide variation 

between practices in the uptake of High Use Health Cards, special funding for frequent attenders at general 

practices and ‘Care Plus’ funding for patients with chronic conditions. Practice deprivation, ethnicity 

and age only explained a minor part of this variation. 

Discussion: The high rate of unexplained practice variation in chronic care management and hospitalisation 

rates, especially for Maori, is of concern. Further investigation of the causes of such variability is 

needed as a first step in reducing hospitalisation. 

KEYWORDS: Hospitalization; ethnic groups; data collection 

Introduction 

Reduction of hospital admissions through greater 

intensity of care in primary health care has been 

strongly emphasised in many countries, including 

New Zealand. The evidence from the experience 

of Kaiser Permanente, a large United States 

Health Maintenance Organisation, is that hospital 

admissions can be halved through appropriate 

use of the primary care sector. 1 A key factor in 

this strategy is the organisational integration of 

primary and secondary care such as is now being 

addressed by District Health Boards (DHBs). 

Canterbury DHB, in conjunction with the 

primary care sector in Christchurch including 

Pegasus Health, have sought to reduce demand 

upon emergency department and hospital services 

through primary care alternatives. Attention has 

now shifted to what has being hailed as the 

‘Canterbury Initiative’. 2 General practitioners 

and specialists are working together to develop 

and implement mutually acceptable solutions 

to common problems. One aim is to reduce 

unnecessary demands on hospital-based care, 

including admissions. 

Despite the importance of reducing hospital 

admissions, there has been little research examining 

variations in hospital admission rates between 

general practices. While studies of medical prac- 


2010;2(2):111–117. 


Laurence Malcolm 

Professor Emeritus 

University of Otago, 

Consultant Aotearoa Health 

Lyttelton RD 1, Canterbury, 


lm@cyberxpress.co.nz 




tice variation are well documented in primary 

and secondary care, both in New Zealand 3–6 and 

elsewhere, 7–8 there has been little research that 

has specifically examined links between the two. 

That which has been conducted suggests that 

sociodemographic characteristics of practices explained 

most of the variation in overall admission 

rates and that the general practice characteristics 

considered added very little. 9–10 

If variation in admission rates cannot be accounted 

for by differences in patient morbidity, 

then questions arise regarding equity of access to 

hospital care, appropriateness of hospital referrals 

and admissions and the effectiveness of primary 

care. Given the recent emergence of Primary 

Health Organisations (PHOs) in New Zealand, 

While studies of medical practice variation are 

well documented in primary and secondary 

care, both in New Zealand and elsewhere, 

there has been little research that has 

specifically examined links between the two 

with their increased focus on equity issues in 

health policy, 11 it is imperative that research 

investigates such variations. 

This study is part of a larger set of studies examining 

relationships between primary and secondary 

care in Partnership Health general practices. 

These include studies of the quality of PHO data 

compared with hospital data, 12 of hospital general 

practice/hospital data on cardiological services 

especially related to Maori, 13 and of ambulatory 

sensitive hospitalisations. 14 

With such considerations in mind, this paper has 

three main objectives: 

• To examine the extent of the variation in hospital 

discharge rates between general practices. 

• To determine the extent to which this variation 

can be explained by patient characteristics, 

in particular deprivation and ethnicity. 

• To determine the extent to which special 

access funding is associated with 

practice need characteristics and increased 

risks of hospitalisation. 

Methods 

The study is based on patient enrolment data 

provided by Partnership Health, which represents 

approximately 75% of the Canterbury district 

population and is the largest PHO in New 

Zealand, with an enrolled population of 345 254 

in 2007 including 19 712 Maori and 6974 Pacific 

people. It has over 100 general practices based in 

Christchurch and Selwyn. 15 It has a broadly-based 

governance structure with strong representation 

from community groups including Maori and 

Pacific people. 

Partnership Health, in conjunction with Pegasus 

Health, has established a comprehensive practicebased 

database of its enrolled patients. The 

almost complete recording of patients’ National 

Health Index (NHI) numbers is a key part of this 

database and enables linkages to be researched between 

this database and hospital discharges from 

data held by the New Zealand Health Information 

Service (NZHIS). 

Enrolment data for Partnership Health were 

provided by Pegasus Health. This included the 

NHI numbers for all patients enrolled to which 

was attached data relating to practice of enrolment, 

date of birth, gender, ethnicity, deprivation 

scores, High Use Health Cards (HUHCs)—a 

subsidy related to need for high use of general 

practice consultations—and Care Plus—a subsidy 

for patients with chronic conditions. The date of 

the data set was October 2007. 

The data were sent directly to the NZHIS by 

Pegasus Health. The NHI was used to link 

the Partnership Health enrolment data to the 

National Minimum Data Set (NMDS) for all 

hospital discharges totalling 127 246 for those 

enrolled for the 2½ years ending 30 June 2007. 

The data added to the Partnership Health data set 

included ethnicity, and all the other variables associated 

with a hospital discharge including date 

of admission and discharge and diagnosis. The 

linked data from NZHIS was returned to the re- 




searchers with the NHIs encrypted. The NMDS 

data analysed were based upon the discharges of 

all patients enrolled with Partnership Health over 

the two years ending 30 June 2007. 

In addition to calculating annual admission rates 

for age, gender, ethnicity, deprivation (meshblock 

domicile), HUHCs and Care Plus, crude annual 

rates were calculated for each general practice. 

These are defined as the total number of admissions 

for each general practice per year per 1000 

patients registered at that practice. Rates were 

calculated for all 102 practices for which data 

were available. 

The association between admission rates and 

possible explanatory factors was investigated 

via stepwise multiple regression analysis. The 

analyses of admission rates were undertaken as 

follows: First, controls were made for practice 

variations in age and sex by entering these into 

the model followed by other practice population 

variables, including deprivation, percentage 

Maori, percentage Pacific and percentage Asian 

patients. Second, the same process was then repeated 

using age/sex and other practice characteristics. 

The latter included practice size (number 

of enrolled patients), average number of patients 

per GP and the proportion of practice populations 

enrolled in Care Plus and with HUHCs. Third, 

all practice characteristics were included in the 

final model. Separate analyses were conducted for 

total, European and Maori patients. 

For the analyses predicting practice variations 

in the take-up of Care Plus, and in the use of 

HUHCs, all variables were included in stepwise 

models, for total, European and Maori patients. 

The analyses were conducted with SPSS for Windows 

Version 15. 

Results 

Practice variations in discharge rates 

Figure 1 indicates extensive variation in crude 

discharge rates between practices. Crude discharge 

rates/1000 ranged from a low of 74/1000 

to 353/1000 around the mean of 184/1000 

(SD=38.0). The important question is, thus, to 

what extent can this variation be explained by 


What we already know: Despite the improving quality of general practice 

enrolment data, very little analysis has been undertaken to explore the 

use of the data in linking primary and secondary care utilisation. 

What this study adds: A new approach to analysis using the National 

Health Index numbers to link general practice data with other data sources, 

including national data on deprivation and ethnicity, demonstrates how primary 

health organisation data can reliably contribute to a district database. 

Figure 1. Annualised discharge rates for GP practices 

variation in practice populations or by other practice 

characteristics? 

Table 1 presents the results of the stepwise 

regression models containing age and other 

practice population characteristics. Three practice 

population characteristics emerged as significant 

predictors of total discharges: mean deprivation, 

Maori ethnicity and the percentage of Asian 

patients, the presence of whom tended to reduce 

admission rates. Similar results were obtained for 

European but not for Maori patients. Here both 

predictors were different and the cumulative R 2 

was much lower than for the other two models 

(0.271 vs 0.558 and 0.583). Also it is interesting 

that European discharge rates were higher in 

practices with a higher proportion of Maori (even 

after accounting for deprivation) and Maori rates 




Table 1. Stepwise regression models for total discharge rates 

Factors included in model Coefficient P-value R 2 Cumulative R 2 

Total patients 

% patients 0–4 4.64 0.001 

% patients 65 and over 1.64 0.001 

Males per 100 females 0.03 0.799 0.092 0.092 

Mean deprivation 11.86 0.001 0.382 0.474 

% Maori 2.66 0.001 0.067 0.541 

% Asian -1.25 0.003 0.042 0.583 

European 

% patients 0–4 6.16 0.001 


Males per 100 females -0.09 0.931 0.088 0.088 


% Maori 1.84 0.006 0.036 0.558 

Maori 

% patients 0–4 2.25 0.027 


Males per 100 females -0.07 0.615 0.014 0.014 


% European 1.01 0.005 0.040 0.240 

% Pacific 1.52 0.047 0.031 0.271 

Table 2. Hospital discharge rates for Partnership Health enrolled patients by Care Plus and 

High Use Health Cards 

Standardised discharge rate 

95% confidence limit 

Care Plus 511 (499.7–522.3) 

No Care Plus 177 (175.3–178.7) 

Ratio 2.9 

HUHC 701 (665–736) 

No HUHC 168 (166.3–169.7) 

Ratio 4.2 

were also high in practices with more European 

and Pacific patients, although the effect of these 

factors was small compared to the effects of deprivation. 

Nevertheless, what is important is that 

ethnic mix had effects independent of deprivation 

in all three models. 

While there was a significant relationship, after 

controlling for age and sex, between the proportion 

of patients enrolled in Care Plus and 

hospitalisation rates, the effect disappeared when 

further controls were made for deprivation and 

other practice population characteristics. 

Practice variations in enrolment in Care Plus 

Partnership Health patients enrolled in Care 

Plus and with HUHCs have much higher 

discharge rates than those without, with the 

former being 2.9 times more likely to experience 

a hospital episode and the latter 4.2 times 

(Table 2). However, the question arises as to the 

extent to which GP practices vary in the extent 

to which they have developed chronic patient 

care programmes, like Care Plus, compared to 

HUHCs which is a subsidy approach tied to the 

number of GP visits. 

Even more so than for discharge rates, Figure 2 

indicates a considerable variation between 

practices in patient enrolment in Care Plus. Just 

over half of the Partnership Health practices had 

enrolment rates of less than 1%, while 12 practices 

had rates of enrolment over 5% and seven of 

these were over 10%. 

Of the practice population and other characteristics, 

only the former help predict practice variations 

in Care Plus enrolment. For all patients, 

the percentage of Maori and the percentage aged 

75 years and over are the main predictors. This 

is also true for European patients, while for 

Maori only the percentage of Maori in a practice 

emerged as a significant predictor. Other variables, 

such as practice size, were not significant. 

For HUHCs the results (not shown) are similar, 

with older patients and deprivation being the 

main predictors in all three models (R 2 of 0.251, 

0.313 and 0.124 respectively). 

Discussion 

There are two important findings of this 

research. First, the study confirms substantial 

variations in discharge rates between general 

practices in the Partnership Health PHO, with 

the highest rates more than double those of the 

lowest. The mean admission rate of 184 per 1000 

is almost identical to that reported by an English 

study. 9 Thus, while the level of practice variation 

in the current study is not unexpected, it is important 

because of the need to better understand 




the reasons for such differences. There is no 

universal standard on what constitutes a normal 

range of practice variation in admission rates, but 

clearly in an era of fiscal constraints and limits 

on the ability of hospitals to provide patient care, 

increasing our understanding of patient pathways 

to hospital and the role of GPs as ‘gatekeepers’ 

would seem to be a high priority. 

Figure 2. Practice variations in enrolment in Care Plus 

While, as in other studies, 9–10 practice population 

characteristics were found to be the most significant 

factors explaining practice differences in 

discharge rates, these factors explained only 63% 

of the variation in total discharge rates, 58% of 

the variation in European rates, but only 26% of 

the variation in Maori rates. Other measures of 

primary care service provision, such as practice, 

were insignificant. Substantial variation therefore 

remained. 

The most likely explanation, as suggested by 

the numerous studies of medical practice variation, 

which is ubiquitous in the health sector, is 

general practitioner variability in the assessment 

and treatment of patients. Variations in clinical 

decision-making could occur for a variety of 

reasons, including uncertainty in diagnoses, 14 

which is associated with higher rates of investigations 

and follow-up and increased chances of 

referral to hospital. 15 Pressure from patients, 16 GP 

relationships with local specialists 9 or patterns 

of social exclusion in primary care have also 

been suggested as contributory factors. With 

respect to the latter, overseas research indicates 

that the quality of care, especially in terms of 

consultation time, is less in more disadvantaged 

practices. 17–18 While GP utilisation rates for 

deprived groups have increased in recent years, 11 

if social and ethnic variation exists in the quality 

of treatment provided to patients by GPs, 

then unmet need is likely to result in increased 

hospitalisation. This may well be one factor 

leading to relatively high rates of hospitalisation 

among Maori attending less deprived practices 

and why there was a lack of any clear relationship 

between practice deprivation and Maori 

hospitalisation rates. 

The second important finding of this research 

is the independent and often divergent effect of 

ethnicity on hospitalisation rates. While Maori 

had the highest rates of admission, these were 

Table 3. Stepwise regression models for enrolment in Care Plus 

Factors included in model Unstandardised coefficient Beta P-value Cumulative R 2 

Total patients 

% Maori 0.24 0.33 0.001 0.079 

% 75 years and over 0.22 0.29 0.003 0.159 

European 

% 75 years and over 0.29 0.39 0.001 0.132 

% Maori 0.27 0.31 0.001 0.226 

Maori 

% Maori 0.28 0.36 0.001 0.129 




inadequately explained by social demographic 

characteristics—in particular, deprivation. By 

contrast, after controlling for age, sex and 

deprivation, practices with larger Asian populations 

had much lower rates of hospitalisation. 

These ethnic differences cannot be attributed to 

deprivation, but rather likely reflect the influence 

of other factors such as cultural variations 

in individual lifestyles, differences in dietary 

behaviour—the latter perhaps reflecting the 

length of residence of Asian immigrant groups in 

New Zealand (the ‘migrant’ effect). Better access 

to primary care on the part of Asian patients may 

also be a contributory factor. 

The third important finding is that the uptake 

of Care Plus is relatively incomplete and highly 

variable between practices. These variations were 

only partly accounted for by age and ethnicity, 

but most of the practice variation in enrolment 

was unexplained by practice population characteristics. 

This is an important finding given 

In light of these findings, we suggest that there 

are three areas in particular where further 

research is necessary. First, with respect to local 

practice variations in admissions, it would be 

desirable to undertake a more in-depth study of 

GP referral decisions in high and low income 

practices. Increased understanding of the referral 

process and the organisational environments 

affecting GPs’ ‘gatekeeping’ role would seem to 

be a high priority, especially given some research 

showing that a relatively high proportion of 

referrals may be inappropriate. 20 A start has been 

made in this regard by examining patterns of 

avoidable hospitalisation, 21 since this factor has 

been used extensively as an indicator of access 

to, and the overall effectiveness of, primary 

health care. 

Second, particular attention is needed to address 

ethnic variations in admission rates between 

practices and particularly why there is little of 

a social gradient in Maori rates of hospitalisa- 

Increased understanding of the referral process and the organisational 

environments affecting GPs’ ‘gatekeeping’ role would seem to be a 

high priority, especially given some research showing that a relatively 

high proportion of referrals may be inappropriate 

the high hospitalisation rates of Care Plus (and 

HUHC) patients. For example, a previous study 

based in Christchurch South Health Centre 19 

showed that the 8.6% of patients with an HUHC 

generated 31.5% of discharges, 42.4% of bed days 

and had a longer average length of stay. Identifying 

such patients and ensuring that appropriate, 

more intensive, care is provided may be a 

strategy to significantly reduce their impact upon 

hospital services. 

Finally, GP practices with higher rates of enrolment 

in Care Plus did not have lower rates of 

hospitalisation. This may be due to improved 

monitoring of conditions and a greater likelihood 

of arranged admissions among a group of 

patients who previously were less likely to access 

primary care. 

tion. Thirdly, with respect to Care Plus, further 

work is needed to assess why patient enrolment 

in this programme has been so low and 

why so much variation occurs across individual 

practices. Also, given the cross-sectional nature 

of this study, it was not possible to assess the 

longer-term implications of Care Plus on hospitalisation 

rates. 

This study suggests that GP practices exhibit 

considerable variation in patterns of hospital 

admission and that practice population characteristics 

are particularly important in explaining 

this. Nevertheless, some of the variation can also 

be attributed to other practice characteristics, in 

particular the availability of special need funding 

designed to limit hospitalisation rates among 

older and more deprived patients. 




In the light of these results, and in view of 

the recent development of PHO performance 

measures, 15 we suggest that particular attention 

is needed to address variation between practices, 

especially in terms of ethnic differences in admission 

rates and in the uptake of access funding 

which appears to be inequitable. 

We suggest that health services research, while it 

has studied either primary or secondary care, has 

largely ignored the interface between these two 

sectors. In view of the development of integrated 

and managed care models of primary health care 

in many countries over the last decade, 11 this 

is an important omission in such studies and 

one that needs to be rectified if we are to have 

a fuller understanding of spatial and temporal 

trends in hospitalisation. 

13. Malcolm L, Barnett R. Utilization of inpatient cardiology 

services including by Maori: a study of hospital discharges for 

patients enrolled with Partnership Health practices for the two 

years ending June 2007. N Z Med J. In press. 

14. Barnett R, Malcolm L. Practice and ethnic variations in avoidable 

hospital admission rates in Christchurch, New Zealand. 

Health & Place. 2010;16:199–208. 

15. Partnership Health. Partnership Health Annual Report. 

Christchurch: Partnership Health; 2008. 

16. Wyke S, Campbell G and Maciver S. Provision of, and patient 

satisfaction with, primary care services in a relatively affluent 

area and a relatively deprived area of Glasgow. Br J Gen Pract. 

1992;42:271–75. 

17. Furler JS. The inverse care law revisited: impact of 

disadvantaged location on accessing longer GP consultation 

times. Med J Aust. 2002;177:80–83. 

18. Malcolm L, Wright L, Carson S. Integrating primary and secondary 

care: the case of Christchurch South Health Centre. 

N Z Med J. 2000;113:514–7. 

19. Ministry of Health. Review of the Implementation of Care Plus. 

Wellington 2006. 

References 

1. Feachem R, Sekhri N, White K. Getting more for their dollar: 

a comparison of the NHS with California’s Kaiser Permanente. 

BMJ. 2002;324:135–43. 

2. New Zealand Doctor. Canterbury’s Hot Initiative.1 July 

2009:17. www. nzdoctor.co.nz 

3. Davis P, Gribben B, Lay-Yee R, Scott A. How much variation 

in clinical activity is there between general practitioners? A 

multi-level analysis of decision-making in primary care. Jour 

Health Serv Res Policy. 2002;7:202–208. 

4. Davis P, Gribben B, Scott A, Lay-Yee R. The ‘supply’ hypothesis 

and medical practice variation in primary care: testing 

economic and clinical models of inter-practitioner variation. 

Soc Sci Med. 1999;50:407–418. 

5. Love T, Dowell AC, Salmond C, Crampton P. Quality indicators 

and variation in primary care: modelling GP referral patterns. 

Fam Pract. 2004;21:160–165. 

6. Brown L, Barnett JR. Influence of bed supply and health care 

organisation on regional and local patterns of diabetes related 

hospitalisation. Soc Sci Med. 1992;35:1157–1170. 

7. Verstappen W, Riet GT, Van der Weijden T, Hermsen J, Grol 

R. Variation in requests for imaging investigations by general 

practitioners: a multi-level analysis. Jour Health Serv Res 

Policy. 2005;10:25–30. 

8. Wilkin D, Smith A. Explaining variation in general practitioner 

referrals to hospital. Fam Pract. 1987;4:160–169. 

9. Reid FDA, Cook DG, Majeed A. Explaining variation in hospital 

admission rates between general practices: cross sectional 

study. BMJ. 1999;319:98–103. 

10. Saxena S, George J, Barber J, Fitzpatrick J, Majeed A. Association 

of population and practice factors with potentially 

avoidable admission rates for chronic diseases in London: 

cross sectional analysis. Jour Royal Soc Med. 2006;99:81–89. 

11. Barnett JR, Barnett P. Reinventing primary care: the New 

Zealand case compared. In: Crooks, VA and Andrews, GJ 

(editors). Primary health care: people, practice, place. London: 

Ashgate; 2008. p 149–165. 

12. Malcolm L, Barnett R. General practice records can provide 

a more reliable data base for district health services analysis 

than national hospital data: analysis of Partnership Health 

general practice data. Submitted for publication. 


The authors are grateful 

to Pegasus Health and 

NZHIS for the supply of 

hospitalisation data linked 

to PHO practice records. 

FUNDING 

The authors are grateful to 

Partnership Health PHO for 

the funding of this study. 






Modifying the PACIC to assess provision of 

chronic illness care: An exploratory study with 

primary health care nurses 

Jenny Carryer RN, PhD, FCNA (NZ), MNZM; 1 Claire Budge PhD; 2 Chiquita Hansen RN, MPhil (Nursing); 2 

Katherine Gibbs RN, MMS 2 

1 

Massey University, 

Palmerston North, 


2 

MidCentral DHB, 



ABSTRACT 

Introduction: In line with Wagner’s Chronic Care Model, the Patient Assessment of Chronic Illness 

Care (PACIC) has been developed to evaluate chronic illness care delivery from the patient's perspective. 

Modification of the instrument to assess the same aspects of care delivery from the health practitioner’s 

perspective would enable individual practitioners to evaluate their own provision of self-management 

support, and would also enable a more direct comparison between care provided and care received 

within the chronic illness context. 

Aim: To explore the potential of a modified PACIC instrument to assess individual health practitioners’ 

delivery of care to chronic illness patients with a sample of primary health care nurses. 

Methods: Seventy-seven primary care nurses completed the modified PACIC, reworded to ask about 

care provision rather than receipt of care. An additional seven cultural sensitivity items were included, as 

were questions about the suitability of the types of chronic illness care and who should be providing the 

care. 

Results: The modified PACIC items appear to be appropriate for use with health practitioners. Agreement 

that the types of care described in the PACIC should be provided was almost unanimous, and the 

predominant view was that self-management support should be provided by both nurses and doctors. 

Mean scale scores were higher than those generally reported from studies using the PACIC. 

Discussion: The results of this first evaluation of a modified PACIC suggest that the original items 

plus the cultural sensitivity items can be used to assess self-management support by individual health 

practitioners. 

KEYWORDS: Chronic illness; self-management; primary health care, nurses 


2010;2(2):118–123. 


Jenny Carryer 

Professor of Nursing, 

School of Health 

and Social Services, 


PB 11222 Palmerston 

North, New Zealand 

J.B.Carryer@massey.ac.nz 

Introduction 

The Chronic Care Model (CCM) developed by 

Wagner and colleagues at the MacColl Institute 

1,2 has received considerable attention in 

recent years as a suitable framework for delivery 

of primary care to people living with chronic 

illness, and has been promoted in a range of 

countries such as Australia, 3 England, 4 Scotland 

5 and New Zealand. 6 The model consists of 

six components (community resources, health 

organisation, self-management support, delivery 

system design, decision support, and clinical 

information systems) which together encompass 

the health care provider, patient and community 

interactions necessary for planned chronic illness 

care. Two instruments have been developed to 

measure the application of the Chronic Care 

Model in practice: the Assessment of Chronic 

Illness Care (ACIC) 7 designed to be used with 

teams of care providers, and the Patient Assessment 

of Chronic Illness Care (PACIC) 8 developed 

for patients. 




Project outline 

As part of a larger scale study of chronic illness 

care provision and experience, we wanted to evaluate 

chronic care provision from the perspective 

of health care providers in one District Health 

Board (DHB) region of New Zealand. Recent 

changes in the health care system have seen the 

establishment of chronic care teams consisting of 

general practitioners (GPs), practice nurses, specialist 

nurses and allied health practitioners such 

as dieticians, podiatrists, physiotherapists etc. 

working within Primary Health Organisations 

(PHOs). Our longitudinal study aims to evaluate 

the development of these teams. However, 

as the teams are only just being established, we 

also wanted to explore care provision from the 

perspective of individual practitioners and needed 

a suitable evaluation tool. While the ACIC is 

generally considered appropriate for assessing 

provision of care, we decided to use a modified 

version of the PACIC instead. There were two 

rationales for this decision. Firstly, the ACIC was 

not considered to be the best tool for individual 

practitioners to use as it is designed to be completed 

as a result of discussion amongst a chronic 

care team—thus representing a team opinion. 

Secondly, we were interested in the possibility 

of obtaining responses that could be directly 

compared to those generated by the PACIC, thus 

contrasting practitioners’ and patients’ views on 

the same dimensions of care. Consequently we 

obtained permission from the MacColl Institute 

to modify the PACIC to suit our purposes. 

The Patient Assessment of 

Chronic Illness Care (PACIC) 

In developing the PACIC, Glasgow and colleagues 

tested 46 items, originally generated by 

chronic illness care experts, with 130 patients. 8 

Twenty items were retained because they 

demonstrated adequate variability, were easily 

understood by patients and best represented 

the underlying constructs of the Chronic Care 

Model. In a study of 283 people with one or more 

chronic illnesses, they provided a psychometric 

evaluation of the PACIC. The measure was presented 

as having an overall score, calculated by 

averaging across scores on all 20 items, with good 

internal consistency represented by a Cronbach’s 

alpha of 0.93. Glasgow et al. 8 also divided the 


What we already know: The PACIC instrument has been designed to 

assess how well elements of Wagner’s Chronic Care Model are being met by 

practitioners providing chronic illness care. The instrument enables people 

living with chronic illness to rate the care they receive. 

What this study adds: This exploratory study proposes a modification 

and extension of the PACIC so that it can be applied to the provision of care 

and can be completed by an individual health practitioner. The extra items 

allow for the assessment of the appropriateness of chronic illness care for 

people of different ethnicities. 

items into groups of three to five, resulting in 

five a priori scales based on key components of 

the CCM named Patient activation (items 1–3), 

Delivery system design/Decision support (items 

4–6), Goal setting/Tailoring (items 7–11), Problemsolving/Contextual 

(items 12–15) and Follow-up/ 

Coordination (items 16–20). These represented 

five of the six CCM components. The sixth was 

not exemplified as the authors felt that patients 

would be unable to report on clinical information 

systems or health care organisation. They 

conducted a confirmatory factor analysis to evaluate 

the goodness of fit of the items to the scale 

structure and reported it to be moderate. Item 16 

was described as having a relatively poor fit but, 

as contact following a visit was considered to be 

essential, it was left in the measure. 

Since then, McIntosh 9 examined the factor 

structure using the items from four of the PACIC 

subscales with a general population, aiming to 

measure their experiences with the health care 

system. He concluded that the data better fitted a 

two-factor model which he labelled Whole Person 

Care and Coordination of Care. He acknowledged 

that the lack of consistency between his and 

Glasgow’s findings may have resulted from the 

sampling differences, but the other measures 

he tested retained their structure despite being 

applied to a general sample. Other authors 11 have 

also raised questions about the factor structure 

of the PACIC. While their principal components 

analysis suggested the existence of five factors, 

the items were distributed differently to how the 

original authors proposed. 

Previous modifications of the PACIC have 

included an extension of the measure to develop 




the PACIC 5As version, 10 and translations into 

different languages. The 5As extension was based 

on the 5A model of behavioural change (assess, 

advise, agree, assist and arrange) and involved the 

addition of six items which, in combination with 

subsets of the original 20, enabled the assessment 

of practitioners’ counselling aimed at improving 

patients’ self-management. In addition there have 

been translations into Spanish, 12 Dutch 11 and 

German 13 for use with different patient populations, 

but no previous attempts have been made 

to use the tool with health care providers. 

The aim of this exploratory project was to evaluate 

a new version of the PACIC, the focus being 

on content validation of the modification to see 

whether it is appropriate to apply the same items 

from the perspective of health practitioners 

rather than patients, as was originally intended. 

This included collecting participants’ views on 

the items included in the measure and finding 

out who they thought should be providing 

chronic illness care. For this project, the modification 

process involved rewording the PACIC 

items so that they could be used to evaluate care 

provided to chronic illness patients, rather than 

care received by them as the measure was originally 

intended. The new version is referred to as 

the modified PACIC (MPACIC). 

Methods 

Sample 

Using a list of regional primary care nurses held 

by the DHB, a questionnaire, plus an information 

sheet and a reply paid envelope, was posted to 

241 primary health nurses in the DHB region. A 

reminder letter was sent two weeks later. Seventy-seven 

(32%) questionnaires were returned. This 

study received ethical approval from the Central 

Ethics Committee. 

Materials 

The questionnaire consisted of a modified version 

of the PACIC. In modifying the original 

instrument, the content of the questions was left 

the same but the question stem was changed to 

read ‘when caring for a person with a chronic 

illness, how often do you…’ and each question 

was altered to fit the care provision context. An 

example of the item modification is as follows: 

Original wording: 

During the last six months, when receiving care for 

my chronic illness I was asked for my ideas when 

we made a treatment plan. 

Modified wording: 

When caring for a person with a chronic illness, 

how often do you ask for their ideas when making a 

treatment plan? 

The response options remained unchanged as 

‘almost always’, ‘most of the time’, ‘sometimes’, 

‘generally not’ and ‘almost never’, numerically 

scored as 5 to 1 respectively. The items are listed 

in the appendix in the web version of this paper. 

As well as altering the focus from care receipt to 

care provision, a section containing seven new 

items was added to address cultural sensitivity in 

care provision. Maori have poorer health status 

than non-Maori, regardless of income, educational 

and socioeconomic level 14 and the Ministry of 

Health is committed to addressing health disparities 

following three Treaty of Waitangi (Te Tiriti 

o Waitangi) principles: partnership, participation 

and protection. 15 The seven cultural sensitivity 

items added to the MPACIC were developed 

by Maori nurses in discussion with the project 

advisory team. The items, following the stem, are 

presented below: 

When caring for a person with chronic illness, how 

often do you… 

appropriately involve the whanau/family in 

• 

the care and management of their condition? 

gather information or feedback from 

• 

whanau/family members? 

educate the whanau/family on prevention of 

• 

the chronic condition where appropriate? 

screen the whanau/family where ap- 

• 

propriate—including risk factors? 

alter or modify your care due to their ethnicity? 

• 

offer another culturally appropriate service if 

• 

there is one available? 

ask them if there are cultural or ethnic issues 

• 

that you need to be aware of? 




Two extra questions were added to each of the 

MPACIC items enquiring about whether the type 

of care outlined in the item should be provided 

(yes or no) and, if so, by whom (GP, nurse or 

both). The first was done partly as a validation of 

the content of the PACIC since if the respondents 

did not see some type of care as being important 

they would presumably not be providing 

it. The second addition was included in order to 

explore the ‘division of labour’ notion of a team 

approach to chronic illness care. It was thought 

that views may differ on who was responsible for 

providing certain types of care, with a possible 

consequence being that some types were being 

neglected as different types of health practitioners 

thought somebody else was, or should be, 

taking responsibility. 

Data analysis 

Responses were entered into SPSS for Windows 

Version 15.0 and analyses included examination 

of item distributions, total scale means, and interitem 

correlations. 

Results 

MPACIC (20 items) 

Examination of the item frequencies showed 

that most items had either a normal or negatively 

skewed distribution, suggesting that most 

nurses rated their chronic illness care neutrally 

or positively. This picture was borne out by the 

mean item scores which ranged (out of a possible 

score of 5) from 3.42 for ‘provide a written list 

of things they should do to improve their health’ 

to 4.52 for ‘consider their values and traditions 

when recommending treatments’. The mean total 

PACIC scores ranged from 2.3 to 4.9 out of a possible 

5, with a mean score of 3.99. This equates to 

care being provided most of the time on average. 

There were very little missing data and what 

was missing resulted from a range of people not 

answering an item rather than one or two people 

not responding to several items. 

Pearson’s correlations between items ranged 

from 0.02 to 0.70 with the majority of correlations 

being in the low moderate range (mean 

r=0.34). Cronbach’s alpha for the total scale was 

0.91 and although this would not improve if any 

individual items were removed, examination of 

the corrected item-total and squared multiple 

correlations suggested that items 16 and 18 were 

contributing less to the total scale than the other 

items. Both of these items demonstrated limited 

variability and were more weakly correlated with 

the other items. 

The seven new items received mean scores 

between 3.53 and 3.92, and correlations between 

items ranged from 0.15 to 0.73. The most 

strongly correlated items were the first two, 

both relating to involvement of family/whanau 

in chronic illness management. Despite the correlation 

being relatively strong, the distributions 

were different, and the pattern of correlations 

with other cultural sensitivity items, while being 

in the same strength range, were not identical. 

When these seven new items were combined 

with the other 20 MPACIC items, the range 

of scale scores was similar, ranging from 2.33 

to 4.85 with a mean score of 3.94. Cronbach’s 

alpha for the extended scale was 0.93. One of 

these new items (number 5) had a relatively low 

corrected item-total correlation when compared 

to the other items and again displayed slightly 

more limited variability. 

As this was an exploratory project, space was provided 

for respondents to supplement their ratings 

with any comments or feedback they wanted to 

provide. The strongest message arising from the 

additional comments was that the care provided 

needed to be suited to the individual concerned, 

for example ‘this is done when appropriate, it 

depends on where the person is on their health 

journey at that time’. Similarly, a number of comments 

related to things being done sometimes 

but not at every appointment, for example ‘(this) 

may not be done at every consultation but is an 

integral part of ongoing care’. 

Appropriateness of care 

As stated earlier, two additional questions were 

tagged onto the PACIC items; whether the care 

should be provided for people with a chronic 

illness and, if so, by whom. The agreement that 

the types of care itemised should be provided was 

almost unanimous, with 15 of the 20 original 




items and four of the seven new items receiving 

100% support. The lowest support was provided 

for the screening of whanau/family where appropriate, 

but only two respondents (2.2%) disagreed 

that this should be provided. 

In terms of who should be providing chronic 

illness care ‘both GPs and nurses’ was the 

predominant response. All but one of the items 

(number 16) received this response from at least 

50 (72.5%) of the nurses; 29 (32.6%) felt that it 

was the responsibility of both GPs and nurses 

to contact people after a visit to see how things 

were going, but 44 (49.4%) considered this to be 

for nurses rather than GPs to carry out. In general, 

support for the itemised types of care being 

specifically part of the nurse’s role ranged from 

1.4% to 60.3% (one to 53 respondents). Support 

for types of care being specifically part of the 

whether the types of self-management care covered 

by its items are being provided by nurses 

for the people with chronic illness whom they 

see in primary practice. 

From the MPACIC total score it was clear that 

the nurses in this study perceived themselves as 

providing a better level of care than the patients 

in previous studies have indicated that they are 

receiving. The mean score was higher than those 

found with the PACIC in research with patients 

with various chronic conditions, 8 with diabetes 

10,16,17 or with osteoarthritis. 13 

The importance of providing health care that is 

appropriate and sensitive to patients’ ethnicity 

through the cultural competence of practitioners 

is widely documented as a way of decreasing 

inequalities in health care and reducing health 

The Chronic Care Model promotes provision of chronic illness care 

that requires a transformation of the health care system in order to 

provide proactive care aimed at keeping people healthy rather than 

acute, reactive care provided once symptoms have taken hold and 

people are no longer managing 

GP’s role ranged from 0% to 4.5% (zero to four 

respondents) with the highest support indicated 

for the screening of family/whanau being part 

of the GP role, although another four (4.5%) felt 

it should be performed by nurses and 81 (91.0%) 

by both. 

Discussion 

The Chronic Care Model promotes provision 

of chronic illness care that requires a transformation 

of the health care system in order to 

provide proactive care aimed at keeping people 

healthy rather than acute, reactive care provided 

once symptoms have taken hold and people are 

no longer managing. The ACIC and PACIC 

instruments have been designed with patient 

self-management as a primary focus and this 

study has adapted the PACIC in order to assess 

disparities. 18–19 The additional seven items designed 

to address cultural sensitivity in chronic 

illness care appeared to work well and may add 

a useful dimension to measurement in this area 

where people of various ethnicities are part of the 

patient population. 

This paper has considered the individual items of 

the MPACIC and has combined them as an overall 

scale. Subscale scores are reported in a separate 

paper. 20 Future work with a larger sample should 

be conducted to enable analysis of the potential 

factor structure of the items. Inclusion of other 

primary care practitioners such as general practitioners 

would also be advisable. 

The results of this first application of a modified 

PACIC suggest that the items can be used to 

assess chronic illness care provision by individual 




health practitioners, and that the content of the 

items was considered an appropriate part of both 

nurses’ and general practitioners’ roles. Due to 

the small number of respondents we were unable 

to examine any underlying structure of the 

items and further work with a larger sample is 

needed with respect to this. The modified instrument 

may add useful information to that gained 

from application of the PACIC and ACIC when 

evaluating care provision for people living with 

chronic illness and could enable a comparison between 

the care practitioners consider themselves 

to be providing and that which patients report 

they are receiving. 

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6. Rea H, Kenealy T, Wellingham J, Moffitt A, Sinclair G, McAuley 

S, et al. Chronic care management evolves towards integrated 

care in Counties Manukau, New Zealand [Viewpoint]. 

NZ Med J. 2007;120(1252):2489. 

7. Bonomi AE, Glasgow RE, Wagner EH, Von Korff M. Assessment 

of chronic illness care (ACIC): a practical tool for quality 

improvement. HSR. 2001;37:791–820. 

8. Glasgow RE, Wagner E, Schaefer J, Mahoney L, Reid R, 

Greene S. Development and validation of the Patient 

Assessment of Chronic Illness Care (PACIC). Med Care. 

2005;43:436–444. 

9. McIntosh CN. Examining the factorial validity of selected 

modules for the Canadian Survey of Experiences with Primary 

Health Care. Working Paper. Statistics Canada; 2008. [Cited 

2009 July 22]. Available from: http://dsp-psd.pwgsc.gc.ca/ 

collection_2008/statcan/82-622-X/82-622-XIE2008001.pdf 

10. Glasgow RE, Whitesdies H, Nelson CC, King DK. Use of 

the Patient Assessment of Chronic Illness Care (PACIC) 

with diabetic patients: relationship to patient characteristics, 

receipt of care, and self-management. Diab Care. 

2005;28(11):2655–2661. 

11. Wensing M, van Lieshout J, Jung HP, Hermsen J, Rosemann 

T. The Patient Assessment Chronic Illness Care (PACIC) 

questionnaire in The Netherlands: a validation study in rural 

general practice. BMC Health Serv Research. 2008;8:182. 

12. Aragones A, Schaefer EW, Stevens D, Gourevitch M N, Glasgow 

R E and Shaha NR. Validation of the Spanish translation 

of the Patient Assessment of Chronic Illness Care (PACIC) 

Survey. Prev Chronic Dis. 2008;5(4):A113. 

13. Rosemann T, Laux G, Droesemeyer S, Gensichen J, Szecsenyi 

J. Evaluation of a culturally adapted German version of the 

Patient Assessment of Chronic Illness Care (PACIC 5A) 

questionnaire in a sample of osteoarthritis patients. J Eval Clin 

Pract. 2007;13(5):806–13. 

14. Howden-Chapman P and Tobias M. Social inequalities in health: 

New Zealand 1999. Wellington: Ministry of Health; 2000. 

15. Ministry of Health. Improving Maori health: a guide for 

Primary Health Organisations. Wellington, NZ; 2004. [Cited 

2009 July 30]. Available from: http://www.moh.govt.nz 

16. Glasgow RE, Whitesides H, Nelson CC, King D K. Use of 

the Patient Assessment of Chronic Illness Care (PACIC) 

with diabetic patients: relationship to patient characteristics, 

receipt of care, and self-management. Diab Care. 

2005;28(11):2655–2661. 

17. Szecsenyi J, Rosemann T, Joos S, Peters-Klimm F, Miksch 

A. German diabetes disease management programs are appropriate 

for restructuring care according to the Chronic Care 

Model: an evaluation with the Patient Assessment of Chronic 

Illness Care instrument. Diab Care. 2008;31(6):1150–1154. 

18. Fisher TL, Burnet DL, Huang ES, Chin MH, Kagney KA. 

Cultural leverage: interventions using culture to narrow 

racial disparities in health care. Med Care Res Rev. 

2007;64:243S–282S 

19. Paez KA, Allen JK, Carson KA, Cooper LA. Provider and 

clinical cultural competence in a primary care setting. Soc Sci 

Med. 2008;66(5):1204–1216. 

20. Carryer J, Budge C, Hansen C, Gibbs K. Providing and receiving 

self-management support for chronic illness: Patients’ and 

health practitioners’ assessments. JPHC. 2010; 2(2):124–129. 


We wish to thank the 

MacColl Institute for 

permission to modify 

the PACIC. We also 

thank Dr John Spicer 

for his advice during the 

writing of this paper. 

FUNDING 

We thank the 

MidCentral DHB for 

funding this project. 






Providing and receiving self-management 

support for chronic illness: Patients’ and 

health practitioners’ assessments 

Jenny Carryer RN, PhD, FCNA (NZ), MNZM; 1 Claire Budge PhD; 2 Chiquita Hansen RN, MPhil (Nursing); 2 

Katherine Gibbs RN, MMS 2 

1 




2 

MidCentral DHB, 



ABSTRACT 

Introduction: Providing care for people with chronic illness is a major issue for health practitioners 

around the world, especially as populations age. Encouraging self-management is beneficial in terms of 

relieving the burden on the health system and promoting better health and adherence to medication and 

advice amongst this group. 

Aim: To measure the level of self-management support being provided to and received by people living 

with chronic illness in a District Health Board (DHB) region. 

Methods: Self-report questionnaires (PACIC) were completed by 341 people living with chronic illness 

to measure the self-management support they receive from general practitioners and nurses. A modified 

version of the PACIC was used with 12 GPs and 77 primary health nurses in the same region to assess the 

provision of self-management support. 

Results: Patients’ assessments suggest that they are receiving intermittent self-management support 

for their chronic illness. A comparison of ratings of different health practitioners revealed that nurses 

were reported to be providing support more consistently than GPs. The health practitioners rated themselves 

as providing self-management support more often than the patients reported receiving it. Many 

clinicians also suggested that not all forms of support are appropriate for everyone, suggesting the need 

to tailor support to the individual. 

Discussion: Chronic illness support needs to be considered within the context of the individual and to 

be embedded in an ongoing relationship between the person and the provider. Findings highlight the benefits 

of a multidisciplinary team approach to self-management support and education in chronic illness care. 

KEYWORDS: Chronic disease; self care; primary health care; primary nursing care; physicians, family 


2010;2(2):124–129. 

Correspondence to 

Jenny Carryer 

Professor of Nursing, 

School of Health 

and Social Services, 


PB 11222 Palmerston 

North, New Zealand 

J.B.Carryer@massey.ac.nz 

Introduction 

Chronic conditions have been identified by 

the World Health Organization as the twentyfirst 

century health care challenge due to the 

escalating incidence and the social and economic 

costs which accompany them. In 2006 

the NZ National Health Committee presented 

a report to the Minister of Health which 

outlined chronic conditions as a major driver 

for inequalities and an area where there were 

significant opportunities to review and revise 

the nature of service provision. 1 In line with 

international literature, a key component of 

that advice was a move towards increasing the 

capacity of people with chronic illness to better 

understand and manage their own conditions. 

This has become variously known as 

self-management or self-care support. 




Self-management has been defined as: 

1) engaging in activities that promote health, build 

physiologic reserve and prevent adverse sequelae; 2) 

interacting with health care providers and adhering 

to recommended treatment protocols; 3) monitoring 

physical and emotional status and making 

appropriate management decisions on the basis of 

the results of self-monitoring; and 4) managing the 

effects of illness on the patient’s ability to function 

in important roles and on emotions, self-esteem and 

relationships with others. 2 

This suggests the need for self-management support 

from health professionals, defined as ‘the 

systematic provision of education and supportive 

interventions to increase patients’ skills and confidence 

in managing their health problems, including 

regular assessment of progress and problems, 

goal setting, and problem-solving support’. 3 

The need for self-management is twofold; firstly, 

engaging patients in the decisions and management 

of their condition(s) results in better 

adherence to medication, more positive health 

behaviours and better outcomes, even when 

treatment has proved ineffective, 4 and, secondly, 

self-management can reduce the strain on the 

health system of coping with the increasing 

level of chronic illness in the population. Selfmanagement 

is a core dimension of the Chronic 

Care Model 5 which is widely accepted in the US 

and around the world. Bodenheimer 6 suggests 

that the provision of self-management support 

requires a team approach to: giving information; 

teaching disease-specific skills; negotiating health 

behaviour change; providing training in problemsolving 

skills; assisting with the emotional impact 

of having a chronic disease; providing regular 

and sustained follow-up and encouraging active 

participation in the management of the disease. 

The aim of this study was to measure the level of 

self-management support being provided for and 

received by people living with chronic illness in 

the MidCentral DHB region. Here we report on 

the completed first phase of a two-phase study. 

Phase one will be replicated 15 months later to 

assess naturally occurring developments in recognition 

that this is an area of ongoing learning and 

development for primary health care services. 


What we already know: Facilitating self-management is an important 

aspect of chronic illness care, both to decrease demands on the health 

system and to improve patient outcomes. Previous research has explored the 

support provided by health practitioners, but little consideration has been 

given to how the impact of that support might differ when provided by health 

practitioners from different disciplines. 

What this study adds: This study shows that nurses are perceived to 

provide more self-care support than GPs. A multidisciplinary team approach 

to the provision of chronic illness care is likely to best meet the needs of individuals 

living with chronic illness. 

Methods 

Sample 

In this study, two sets of data were collected; one 

from people living with one or more chronic illness/es, 

the other from general practitioners (GPs) 

and primary health nurses providing chronic 

illness care. The patient sample was recruited by 

sending letters of invitation; firstly to all who 

had attended any ambulatory chronic illness 

clinic during the previous 18 months, secondly 

via a company managing health services provided 

through Primary Health Organisations (PHOs) 

in the community, and thirdly through a Maori 

health provider. From these invitations we received 

400 expressions of interest. Surveys were 

sent out to this group and 341 usable forms were 

returned. This reflects a response rate of 85.3% 

from the expression of interest pool. For the clinician 

sample, letters of invitation and questionnaires 

were also sent to GPs and primary health 

nurses in the DHB and 89 were returned—77 

from nurses and the remainder from GPs. 

Materials and procedure 

The Patient Assessment of Chronic Illness Care 

(PACIC) 7 was used to measure self-management 

support. This 20 item self-report questionnaire 

was designed to evaluate five types of selfmanagement 

support representing five of the six 

aspects of the Chronic Care Model. The items 

have consequently been developed to provide a 

total scale and five subscales which, according to 

the authors, are defined as follows: Patient activation 

involves actions that solicit patient input and 




involvement in decision-making; Delivery system 

design/Decision support includes actions that 

organise care and provide information to patients 

to enhance their understanding of care; Goal 

setting/Tailoring means acquiring information for 

and setting of specific collaborative goals; Problem 

solving/Contextual is represented by considering 

potential barriers and the patient’s social and 

cultural environment in making treatment plans; 

and Follow-up/Coordination involves arranging 

care that extends and reinforces office-based 

treatment, and making proactive contact with 

patients to assess progress and coordinate care. 7 

The PACIC requires respondents to rate the 

frequency with which certain types of care are 

provided on a 5-point scale ranging from ‘almost 

always’ to ‘almost never’, numerically scored as 5 

to 1 respectively. 

Two sample questions are: 

During the last 12 months when receiving care for 

my chronic illness, I was… 

…helped to make plans for how to get support from 

my friends, family or community. 

…sure that the health professional thought about 

my values and my traditions when they recommended 

treatments to me. 

Scores are averaged to provide a total and subscale 

scores within the range of 1 to 5. With respect 

to internal consistency of the scales, Cronbach’s 

alphas have been reported to range between 0.77 

and 0.90. 7,8 

In the current study, participants were asked to 

rate two health professionals; firstly, their GP 

Table 1. Comparison of mean PACIC and MPACIC subscale scores 

PACIC GP PACIC nurse MPACIC 

Patient activation 2.9 3.5 4.3 

Delivery system/practice design 3.1 3.7 3.8 

Goal setting/tailoring 2.3 3.2 3.8 

Problem solving/contextual 2.8 3.5 4.1 

Follow-up/coordination 2.6 2.9 3.8 

Total scale 2.7 3.3 4.0 

or practice nurse (whoever they felt to be most 

responsible for their day-to-day chronic illness 

care) and, secondly, another health professional 

who they felt provided care in relation to their 

chronic illness/es. The PACIC, plus some health 

and demographic questions comprised the patient 

questionnaire which was posted out with a replypaid 

envelope to those who had responded to the 

letter of invitation. A reminder letter was sent 

to those who had not returned the questionnaire 

within a month. 

The health professional questionnaire primarily 

consisted of a modified version of the PACIC, 

hereafter referred to as the MPACIC. The modification 

changed the question stem to fit the context 

of care provided rather than received in order 

to amend the questionnaire for use with health 

practitioners rather than patients. Questions 

about cultural sensitivity were also included. 

Further detail is provided elsewhere. 9 

Results 

The patients ranged in age from 23 to 93 with 

a mean age of 68.2. There were slightly more 

men (189, 55.4%) than women; 270 (80.4%) were 

NZ European and 49 (14.6%) identified as Maori. 

Over half of the respondents (176, 58.8%) indicated 

they were living on less than $20,000 per 

annum. The chronic conditions listed were varied 

with just over a third of the sample (119, 35.2%) 

indicating they had only one condition, the other 

two-thirds living with two (112, 33.1%) to seven 

(20, 0.6%). The main conditions experienced, 

and the percentage of the sample affected were: 

cardiac (212, 62.7%), diabetes (136, 40.2%), respiratory 

(94, 27.8%) and pain (94, 27.8%). Ratings 

of the impact of their chronic illness on quality 

of life ranged from 0 to 10, thus representing the 

full scale where 0 represented no effect and 10 

an extreme effect, with a mean score of 6.4 and a 

mode of 8.0. 

Of the 341 patients, 307 (90%) provided ratings 

of a GP as health provider and 180 (52.8%) 

rated a nurse. As a number of participants rated 

both a nurse and a GP, the ratings could not be 

considered independent. Therefore no inferential 

statistics are reported in this paper. The mean total 

and subscale scores for the patient ratings are 




presented in columns two and three of Table 1. 

The possible range of score was 0 to 5 and it can 

be seen that the range reported was from 2.3 to 

3.7. A comparison reveals that nurses are rated 

more highly than GPs on all aspects of self-management 

support. The magnitude of the means 

shows that, on average, nurses are providing selfmanagement 

support sometimes to most of the 

time whereas GPs are generally not or sometimes 

providing it. The fourth column provides mean 

scores for the health professionals’ ratings of 

their own provision of self-management support. 

They ranged from 3.8 to 4.3 (possible range 0 to 

5) and are notably higher than the patient ratings 

of the support they receive. It is also apparent 

from comparing the rank order of the subscale 

scores that the aspects of self-management support 

provided by nurses and GPs are similarly 

ordered with delivery system design being rated 

highest for both practitioner groups and patient 

activation second. The only difference was the 

reversal of placings for the two lowest rated 

aspects, goal setting and follow-up. A comparison 

with the MPACIC scores showed that health professionals 

considered themselves to be providing 

the best support in the area of patient activation 

with problem solving scoring second. The other 

three aspects were all equally rated. 

One hundred and twenty-two participants 

provided ratings of both a GP and a nurse and, 

within these pairs of ratings, mean PACIC scores 

were 2.8 and 3.2 respectively. Although the participants 

were asked to provide ratings of care received 

from two health practitioners, not all had 

two to rate. To see whether those with two were 

better off than those with one, a comparison was 

made between the one score of those participants 

with only one chronic care provider and the best 

score of those with two. Results showed that the 

mean score was 0.3 (on a 5-point scale) higher for 

those with two health practitioners, typically a 

GP and a nurse. 

The health practitioners were invited to add 

comments to their ratings and many of the comments 

focussed around the notion that the types 

of support listed are not all appropriate for every 

individual, and neither are they all appropriate to 

provide at every meeting. 9 For this reason many 

health professionals were choosing to provide 

self-management support sometimes or mostly 

rather than nearly always. Care Plus was cited as 

being an ideal way to deliver self-management 

support. 

Discussion 

The patient data revealed a variety of reasons 

why this group required self-management support. 

Many were living with more than one 

chronic illness, which was having a pronounced 

affect on their quality of life, in impoverished 

circumstances. Pain was identified as being a 

problem for nearly a third of the participants. 

We previously found that patients were keen 

to achieve a sense of ownership of their condition 

and expressed a desire to understand, plan 

realistically and anticipate the course of their 

condition. 10 Much of this was expressed as a need 

to have their personhood rather than their illness 

At the heart of self-management support is 

the nature and quality of communication in 

clinical encounters and the best use of team 

members to provide aspects of care 

as the focus of clinical encounters. Literature on 

self-management identifies the need for relating 

to individuals in terms of their personal context 

including the particular capacity of each individual 

to manage changes and demands in their life. 

The scores on the various aspects of self management 

support, as identified by the subscale 

groupings, show remarkable consistency across 

the three sets. It appears that follow-up and goal 

setting are the areas of self-management support 

that are most in need of attention within the 

current system. At the heart of self-management 

support is the nature and quality of communication 

in clinical encounters and the best use of 

team members to provide aspects of care. The 

apparent difference between how GPs and nurses 

were rated by chronic illness patients in this 

study highlights the need for a team approach to 

providing self-management support. As noted by 




Wagner, 11 much of what is needed is behavioural 

counselling, which may be considered outside 

the job description of most GPs and better suited 

to the nurse role in chronic care service delivery. 

Thus, if a proactive team-based approach 

is utilised, the patient should have access to a 

comprehensive range of primary health care clinicians 

who are well placed to complement the care 

provided by GPs and specialists. 

Our results suggested that, on average, patients 

receiving support from more than one practitioner 

rated the care they received more positively 

than those with less support. It may well be that 

they were being provided with different forms of 

support from different practitioners, thus benefiting 

from exposure to a care team. 

The reported difference between the levels of 

self-management support patients indicated they 

…self-management support needs to be 

embedded within an ongoing relationship 

between patient and health professional; 

the same approach doesn’t suit everybody 

are receiving, and that which health professionals 

consider themselves to be providing, is interesting. 

It may reflect an inconsistency between 

patients’ and health practitioners’ knowledge and 

beliefs about what constitutes care, and specifically 

self-management support. The findings 

also need to be viewed in light of the question 

that was being answered. Health practitioners 

were rating what they generally do in relation to 

chronic illness care; the patients were rating the 

self-management support they personally receive. 

A number of practitioners commented that some 

of the listed types of support were inappropriate 

for a number of clients or stated that they carried 

them out on occasion but not at every visit. 

This may be an example of Willis’s 12 definition 

of providing information which, he suggests, 

should not just be the transmission of facts but 

encompass ‘how other people have responded in 

a similar situation, what the impact may be on a 

patient’s lifestyle, or, based on our knowledge of 

patients derived from being their family doctor, 

judging what they may consider appropriate’. 

This approach also aligns with the notion that 

self-management support needs to be embedded 

within an ongoing relationship between patient 

and health professional; the same approach doesn’t 

suit everybody. 13 Enabling patients to incorporate 

self-management into their daily routines 

requires getting to know them in order to develop 

self-management plans collaboratively. 6 Similarly 

Willis 12 talked about the need for patients to have 

‘true autonomy’ defined as providing information 

they want or need, but in a form that they 

can understand, thus becoming partners and 

enabling them to self-govern. He used a rugby 

team analogy to highlight the importance of one 

person’s autonomy not being allowed to overcome 

another’s and this could be applied equally well to 

a chronic care team where the successful approach 

enables doctors, nurses, other health professionals 

and patients themselves to exercise their autonomy 

both individually and as a team to achieve the 

most positive outcome for the patient. 

Care Plus was considered by the health professionals 

sampled to be a useful vehicle for administering 

self-management support, primarily 

due to the time it made available for individual 

consultations. The programme was introduced 

for people with chronic conditions in July 2004, 

with the aims of improving chronic care management, 

reducing inequalities, improving primary 

health care teamwork and reducing service costs 

for high need primary care recipients. While 

Care Plus was not mentioned by our patient 

sample—perhaps because they were unaware of 

their involvement in it—a national review of the 

Care Plus programme 14 found that patients felt 

their care to be better structured, appreciated 

the consultation focus on their chronic illness, 

had on average accessed four more consultations 

per annum than previously, and had mostly 

(80%) received a care plan. The review identified 

a number of barriers to the implementation of 

Care Plus; for example remuneration, the need 

for extra nurses, and the space and time required, 

but concluded that most individuals (professionals 

and patients) were generally supportive of 

the programme. The few comments provided in 




this study concerning Care Plus suggest that it is 

well regarded by those implementing it, but the 

extent to which it is deployed in the study region 

is patchy. 

Glasgow et al. 5 quote the adage ‘what gets measured 

gets done’ and that was one intention of 

the current study. It was hoped that the process 

of responding to questions regarding self-management 

support would increase awareness of 

what such support involves and encourage health 

professionals to reflect on, and perhaps even 

alter, their behaviour. The planned phase two of 

the study will provide the opportunity to assess 

developments. 

Limitations 

Although there may have been some link 

between the data sets as some of the patients 

involved in the study would have been receiving 

care from some of the health professional 

participants, patients were not asked to identify 

who they were rating by name and doctors and 

nurses were not required to identify themselves. 

It would be useful in future research to link the 

sets of ratings in order to identify areas of selfmanagement 

support where there were apparent 

disparities between what health professionals 

consider themselves to be providing and what 

patients feel they are receiving. 

8. Rosemann T, Laux G, Droesemeyer S, Gensichen J, Szecsenyi, 

J. Evaluation of a culturally adapted German version of the 

Patient Assessment of Chronic Illness Care (PACIC 5A) questionnaire 

in a sample of osteoarthritis patients. J Eval Clin Prac. 

2007;13:806–813. 

9. Carryer J, Budge C, Hansen C, Gibbs K. Modifying the PACIC 

to assess provision of chronic illness care: an exploratory study 

with primary health care nurses. J Primary Health Care. 2010; 

2(2):118–123. 

10. Carryer J, Snell H, Perry V, Hunt B, Blakey J. Long term conditions 

care in general practice settings: Patient perspectives. 

NZ Fam Physician. 2008;35:319–323. 

11. Wagner EH. The role of patient care teams in chronic disease 

management. BMJ. 2000;320:569–72. 

12. Willis, D. In search of true autonomy. J Primary Health Care. 

2009;1(2):152–153. 

13. Furler J, Walker C, Blackberry I, Dunning T, Sulaiman N, 

Dunbar J, Best J, Young D. The emotional context of selfmanagement 

in chronic illness: a qualitative study of the role 

of health professional support in the self-management of type 

2 diabetes. BMC Health Serv Res. 2008;8:214. 

14. CBG Health Research. Review of the implementation of Care 

Plus. Wellington: Ministry of Health; 2006. [Cited 2009 July 

21]. Available from: http://www.moh.govt.nz/moh.nsf/ 

pagesmh/5567/$File/review-implementation-care-plus.pdf 

15. Glasgow RE, Peeples M, Skovlund SE. Where is the patient 

in diabetes performance measures? Diabetes Care. 

2008;31(5):1046–1050. 

References 

1. National Health Committee. Meeting the needs of people 

with chronic conditions. [Internet]. Wellington, New Zealand: 

2007. [Cited 2009 July 22]. Available from: http://www.nhc. 

health.govt.nz/moh.nsf/pagescm/666/$File/meeting-needschronic-conditions-feb07.pdf 

2. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. 

Collaborative management in chronic illness. Ann Intern Med. 

1997;127:1097–1102. 

3. Institute of Medicine. Priority areas for national action: 

transforming health care quality. Washington DC: National 

Academies Press; 2003. p 52. 

4. Horwitz RI, Horwitz SM. Adherence to treatment and health 

outcomes. Arch Intern Med. 1993;153:1863–8. 

5. Bodenheimer T, Wagner EH, Grumbach K. Improving 

primary care for patients with chronic illness. JAMA. 

2002;288(14):1775–1779. 

6. Bodenheimer T. A 63-year-old man with multiple cardiovascular 

risk factors and poor adherence to treatment plans. JAMA. 

2007;298(17):2048–2056. 

7. Glasgow R E, Wagner E, Schaefer J, Mahoney L, Reid 

R, Greene S. Development and validation of the Patient 

Assessment of Chronic Illness Care (PACIC). Med Care. 

2005;43:436–444. 


We wish to thank 

the MacColl Institute 

for permission to 

modify the PACIC. 

FUNDING 

Thanks to MidCentral DHB 

for funding this project. 





quaLitative research 

Ever decreasing circles: terminal illness, 

empowerment and decision-making 

Kate Richardson MHealSci, PG Cert, BN; 1 Rod MacLeod PhD, FAChPM; 2 Bridie Kent PhD, BSc(Hons), RN, 

FCNA(NZ) 1 

1 

School of Nursing, Deakin 

University, Melbourne, 

Australia 

2 



Care, School of Population 

Health, The University 

of Auckland, Auckland, 


ABSTRACT 

Introduction: Empowerment is the personal and political processes patients go through to enhance 

and restore their sense of dignity and self-worth. However, there is much rhetoric surrounding nurses 

facilitating patients’ daily choices and enabling empowerment. Furthermore, there is frequently an imbalance 

of power sharing, with the patient often obliged to do what the health professional wants them to do. 

Method: This phenomenological study describes the lived experience of patients attending an 

outpatient clinic of a community hospice. A qualitative study using Max van Manen’s phenomenological 

hermeneutic method was conducted to explore issues surrounding empowerment and daily decisionmaking 

with terminally ill patients. The participants’ stories became a stimulus for learning about the 

complexities of autonomy and empowerment. It also engendered reflection and analysis of issues related 

to power and control inequities in current nursing practices. 

findings: The results revealed not only the themes of chaoticum, contracting worlds and capitulation, 

but that health professionals should be mindful of the level of control they exert. Within the palliative 

care setting they need to become partners in care, enhancing another person’s potential for autonomous 

choice. 

Conclusion: Empowerment must not be something that simply occurs from within, nor can it be done 

by another. Intentional efforts by health professionals must enable terminally ill people to be able to stay 

enlivened and connected with a modicum of autonomy and empowerment over daily decisions, no matter 

how mundane or monumental they might be. 

KEYWORDS: Phenomenology; empowerment; autonomy; terminal care; decision-making 


2010;2(2):130–135. 


Kate Richardson 

221 Burwood Highway, 

Burwood, Victoria 

3125, Australia 

katerichardson@xtra.co.nz 

Introduction 

There has been little research conducted exploring 

terminally ill patients’ self-empowerment and 

decision-making within their day-to-day lives. 1 

Anecdotally terminally ill people tend to be treated 

as a homogenous group, as though they all suffer 

and behave in the same manner. 2,3 The end result 

is that the therapeutic relationship becomes a ‘one 

size fits all’ model, 1,4,5 which can leave the person 

and their family members feeling disenfranchised, 

frustrated and not listened to. 1 A terminally ill 

person’s day-to-day decisions may seem to others 

mundane and redundant, but being allowed to 

make them can often enable a person to continue to 

feel empowered, autonomous and self-willed. 6 

Decision-making by terminally ill adults has been 

described as a performance concerning autonomy 

that involves a variety of players. 7,8 The right to be 

autonomous and make decisions about their own 

lives is a commonly accepted ethical principle. 7 

However, pragmatic nursing styles that encourage 

‘doing for’ rather than maintaining a presence with 

a terminally ill person, tend to disable many autonomous 

decision-making abilities and processes. 8 

Empowerment is the personal and political processes 

patients go through to enhance and restore 

their sense of dignity and self-worth; 9 however, 

there is much rhetoric surrounding nurses facilitating 

patients’ daily choices and enabling empow- 




erment. 10,5 Historically nurses have been taught 

about the importance of autonomy in patients, 11 yet 

it is debatable whether consideration of empowerment 

is truly incorporated into practice. While the 

idea of empowerment is naturally appealing, its application 

becomes weakened because of its abstract 

ambiguity. 6,4,12,13 Furthermore, there is frequently 

an imbalance in power sharing, with the patient 

feeling obliged to be humble, in the process left 

feeling humiliated and inconsequential. 14,15 

This paper reports the findings of a qualitative 

study with the aim of exploring issues of empowerment 

and daily decision-making from the 

perspectives of people who are terminally ill. 

Method 

It was decided that qualitative methods, using 

a hermeneutic approach, 15 was the best way to 

achieve the aims of this study. Such an approach 

examines and reveals the language buried within 

the meanings of words. The participants’ stories 

allowed glimpses into the lived experience of the 

world of people diagnosed with terminal illness. 

Reflections of the ‘self’ were revealed along with 

the subjective nature of integrity, spirituality 

and wholeness, thereby enabling the activity of 

phenomenological thinking. 15 

Phenomenology is described as ‘being in the moment’, 

of living the experience with someone else 

and discovering something worthy of recording. 15 

Phenomenology is a style of thinking, as well 

as a philosophy, and the intention is to describe 

or understand a moment in someone’s life by 

interpreting recollections. The most natural way 

of doing this is to narrate from lived experience. 

15 By being part of the narration process, the 

researcher refrains from judging and concluding 

what is right or wrong, but rather participates in 

the story. Phenomenology thus systematically 

attempts to uncover, describe and discover the 

nature or essence of the experience; in this case, 

of living with a terminal disease. 15 

Fourteen participants receiving palliative care 

were selected and recruited by a doctor at a community 

hospice and invited to participate in an individual 

interview between May and June 2005. 

Five males and six females agreed to participate in 

What gap this fills 

What we already know: Decision-making for people nearing the end of 

life is difficult for a number of reasons. Despite improvements in communication 

and management near the end of life, patients and their families often 

feel disempowered, vulnerable and frustrated. 

What this study adds: Primary health professionals need to work actively 

towards ways of empowering people who are dying by paying attention as 

much to the being aspects of care as to the doing aspects. Self-reflection and 

positive regard within the therapeutic relationship can enhance the experience 

for those who are dying. 

the study. Ten were Anglo-European and one was 

of Polynesian descent. The age range was from 48 

to 84 years. Cancer was the primary diagnosis for 

10 participants, with one having heart disease. All 

the participants came from one small geographical 

area of New Zealand. Face-to-face interviews were 

audiotaped (once consent was gained) and later 

transcribed verbatim by the researcher. All of the 

participants had died by the time the study was 

written up. Pseudonyms have been used to protect 

the identity of the participants. 

The steps that guide a study undertaken using Van 

Manen’s approach are summarised in Table 1. Transcribing 

of the interviews by the researcher enables 

immersion in the transcripts in order to understand 

abstraction and develop themes that reveal phenomena 

through the narratives of lived experience. 

A commitment was made to stay close to and intimate 

with the original data and this was achieved 

through total immersion in the text—reading, listening, 

re-reading and reliving the memories of the 

interview with each of the participants. Careful 

line-by-line analysis revealed common themes. 15 

Ethical approval was gained from the University 

of Otago Board of Graduate Studies, Community 

Hospice Ethics Committee, Lower South Regional 

Ethics Committee, Ngai Tahu and a member of 

the Chinese community. 

Findings 

Three key themes were identified from the data. 

The first relates to participants’ lived space and 

was called ‘chaoticum’, as the participants lived 

within a chaotic and complex time in their lives. 15 




The participants reported that their lives spiralled 

out of control after being given their diagnosis. 

The second theme relates to the lived body 15 and 

this was called ‘contracting worlds’; participants 

spoke of forfeiting normality as their worlds 

began shrinking around them in ever decreasing 

circles. The final theme relates to lived time 15 and 

was called ‘capitulation’ because the experiences 

revealed a time when the participants became 

submissive and acknowledged that their lives 

were coming to an end. 

Chaoticum 

The lived experience of the participants revealed 

a world that was, for them, a mixture of chaotic 

time and chaos. Their worlds were freewheeling 

out of control, leaving little time to deal with 

things. Participants experienced disharmony, 

anger, disbelief, chaos and powerlessness, as this 

extract from the interview with Jane reveals: 

I’ve been given my life sentence; I know I’m going 

to die but it is the unknown. Am I going to get 

sick, what’s going to happen to me?” 

Sage talks about her total disbelief and anger at 

the doctor being honest about dying, thus capturing 

the conflicting emotions and needs at this 

time in her life: 

I was angry, I was bloody angry with the doctor 

when he told me I was going to die… I didn’t know 

where to start with things. There seemed so little 

time to fix things you know. 

Table 1. Van Manen’s Phenomenology (Adapted from van Manen, 2002 23 ) 

Two aspects of methodology 

1. The reduction: Bracketing or suspension of everyday ‘natural attitude’ 

2. The vocation: Letting things ‘speak’ or be ‘heard’ through text 

Six empirical methods 

1. Describing experiences 

2. Gathering experiences 

3. Interviewing experiences 

4. Observing experiences 

5. Fictional experiences 

6. Imaginal experiences 

Furthermore, Jessica talks of living in a house 

that was very chaotic: 

It was a sick house. I would just lie on the floor… 

it was depressing because I couldn’t do anything 

about my life. We lived in a very sick messy chaotic 

house all of the time. 

Another participant, Bruce, appeared upset at the 

chaos that he had left for someone else to sort 

for him: 

There is stuff at the house that someone else will 

have to sort because I don’t have the energy. They 

will have to sort out the mess because for two 

months I haven’t had the energy to fix my life… 

Contracting worlds 

Participants described the way they had to give 

up things in their lives; the forfeitures, losses, 

decreasing circles and disempowerment that they 

experienced. Not only were their social lives contracting, 

but physically they were also suffering 

from contractures as their bodies started to change 

and shrink from their former self. This is captured 

by Virginia who felt very vulnerable and disempowered 

when she made trips to the clinician: 

I felt terribly disempowered in the hospital setting 

by the oncology doctors. Just going for a check up 

and I would come out and think God how am I supposed 

to keep my hopes up when there was such a 

grim sort of background, a feeling of abandonment 

and just the odd comments. I felt so very disempowered… 

Apart from hope. I don’t want them to 

take that away from me you know. 

Connie described how she maintained some semblance 

of normality as she tried to retain a belief 

that her world was not changing, by washing 

herself and undertaking other personal care: 

I don’t want others doing my personal stuff for me because 

that would mean that I was no longer a person… 

This is further reflected by Grace who commented: 

I got quite bitter for a while. This disease can let 

your bodily functions go a bit in front of people 

and I was disgusted. 




Clearly, these participants resented the way their 

bodies were failing and wanted to continue to 

care for themselves for as long as possible. 

Capitulation 

The third theme captures the participants’ understanding 

that they were only temporally in the 

world. Participants found that the closer to death 

they got, the more submissive they became until 

they finally began to make those final end of life 

arrangements as reflected in Virginia’s words: 

There are days that I feel like I have gone back 

several more steps and I have to rely a lot on others 

now because I don’t know when my body will give 

out. I feel like I have to wait on other people to do 

my ‘stuff’ and I feel quite powerless. 

Bruce grieves for the loss of his past life as he 

gave in to his inability to manage for himself: 

Two months ago I was still working and now look 

at me I am little more than a baby. 

Harry was also feeling a sense of giving-up when 

he commented: 

I hated hospital. They (nurses) woke me up every 

two hours shining a torch in my eyes. I couldn’t 

sleep all week and I am not sure why because I 

wasn’t dying. I hated it and I am never going back 

because I couldn’t do what I usually do. You are just 

stuck there whether you like it or not. 

Whilst Jane describes accepting her terminality: 

I’ve just dealt with the thought of dying. Tomorrow 

the funeral director lady is coming. I know I have 

got to get some things in order. 

Discussion 

Individuals make decisions based on personal 

strategies and judgments, influenced by biases 

and rules, especially when there is an unknown 

future ahead. 6 Decision-making, therefore, 

is a complex and multifaceted phenomenon. 

It is difficult to deconstruct an individual 

person’s thoughts, feelings and behaviours and 

match them to the different facets of decisionmaking. 

2 This study has allowed the words of a 

small number of people living with a terminal 

illness the chance to describe their lived 

experience at a particularly challenging time in 

their lives. Each of these experiences, and the 

subsequent themes that emerged, emphasise 

the need for empowerment, especially during 

the last period of life, since individuals are 

more likely to make decisions based on the 

availability of information, on instances or 

recent occurrences. 15 

Recent research indicates that terminally ill people 

consistently perceive that they have a less active 

role in their daily decisions than they desire. 5 

Others start making valued judgements for them, 

especially health professionals, because they are 

considered to be too vulnerable, less of a person, 

thought to have lost the ability to think or too 

sick to make choices. Terminally ill adults can 

make decisions and do so based on a broad range 

of factors, such as spirituality, values and beliefs, 

that subsequently influence how they respond to 

everyday challenges. 1 

There has been much criticism concerning 

ethical decision-making over recent years 16 as 

bioethical discourse has focussed on the ideal, 

rather than what actually happens. Many 

ethicists believe that only rational or logical decisions 

are the right ones, but attention should 

also be paid to ‘what genuinely moves people 

to act, their motivations and passions, loves and 

hates, hopes and fears.’ 16 In this study, this is 

supported by Connie’s experiences when she 

commented: 

I didn’t want people deciding for me right up until I 

can no longer talk. 

Hunsaker Hawkins 16 suggests that small clinical 

aphorism and literary narratives can be a powerful 

vehicle for moral reasoning and transporting 

you deep into another person’s world for a brief 

time. Phenomenology allows both the narrator 

and the reader to be transported into the narrator’s 

world. 15 

This research reminds nurses of the importance 

of reflecting fully on how they can help meet the 

wishes of a person who is terminally ill. There is 




a need to ask and keep asking whilst also being 

prepared to listen. 

Each of the participants in this study wanted 

someone who was not constantly doing but rather 

listening or simply being there. This is aptly 

captured by Harry when he describes how he insisted 

that he keep to his daily schedule because 

without that he knew that he would just curl up 

and die: 

I didn’t want the nurses coming to my house and 

doing my washing or chores and I had to keep 

telling them this. If I want to walk half way across 

town with bags of laundry when the weather is 

wet then that’s what I want to do. They kept trying 

to make me do things on their timetable but I had 

other ideas. 

When people are given a terminal diagnosis 

there is a point in the care continuum when 

these people feel abandoned by the biomedical 

model along with feeling a sense of not 

belonging. 17 Such people are different to many 

of our other patients because there are no 

happy endings, no cures or achievable health 

outcomes except for the desire and hope for a 

perceived good death. This study revealed that 

terminally ill patients want nurses to become a 

fully-engaged being when entering the therapeutic 

relationship, whilst at the same time to 

recognise that people who are dying are unique 

and unpredictable in terms of the connection 

and dependency within the nursing/patient 

relationship. 17 

Empowerment is central to decision-making 

and people who are seeking health care need to 

be enabled and empowered to make their own 

informed choices. 18 Health professionals can 

never fully understand what the patient is going 

through, but they can ease the path by their 

own critical self-reflection, listening, intuitive 

caring and thought. 19 Illness and disease make 

people deviate from their chosen life path and 

typically the clinical world has its own customs 

and culture that can be difficult to understand. 

Throughout the terminal illness journey nurses 

should endeavour to enable people to remain 

informed and self-empowered. 17 Moral autonomy, 

according to Kant, is a combination of freedom 

and responsibility; a truly autonomous person 

cannot be subjected to the will of another. 6 

The findings from this study suggest that health 

professionals need to think more about power and 

control issues and explore how they can become 

partners in enhancing another person’s potential 

and autonomous choices. 6,8,10 Empowerment 

describes the intentional efforts to create a more 

equitable relationship and a living within someone 

else’s world. 19 How a patient exercises their 

empowerment and control depends on individual 

engagement, ability and ‘the adoption of a personvaluing 

approach’. 3 

For any moral engagement to work within a particular 

given time and space there has to be a comfortable 

social and emotional congruence driven 

by integrity and honesty. 1,20 Health professionals 

must not be afraid to enter territory that is uncomfortable 

or unknown. There needs to be open, unconditional 

positive regard shown towards every 

patient for whom we care. Finally, there must be 

empathic understanding or ‘sensitive active listening’ 

not only to the person, but careful listening to 

what stories their body can tell us. 21 

This is summed up by Connie: 

I felt embarrassed and I found it very difficult I 

didn’t want other people touching me but when I 

got sicker you have to get over that and you can’t 

do it for your self so you have to let others do it 

for you. But I still don’t want other people making 

choices like what I am going to eat. I don’t want 

others picking out my food for tea for me. 

Limitations of this study 

The most significant and limiting factor was that 

most of the participants died before their transcripts 

could be transcribed and reviewed. This 

is a reality in all research where participants have 

terminal illness. However their stories are important 

and it is the engagement of the researcher 

with the participant that enables the revelation of 

the essence of something. Phenomenology does 

not offer the possibility of theory that looks at 

variables or controls. It does, however, offer the 

plausible insights that bring us into contact with 

people’s lived experience, in and around us. 




Research implications and 

recommendations 

These findings highlight the need to critically 

reflect on practice in a rigorous manner on a daily 

basis. They should serve to enlighten health 

professionals’ internal and external practices and 

encourage engagement in self-analysis as truly 

caring beings. 22 It is necessary that health professionals 

actively consider the concept and importance 

of empowerment. However, more research 

needs to be undertaken to understand strategies 

related to how empowerment works and the notion 

that ‘empowerment is undermined by the 

seduction of health-discourse so that the patient 

ends up wanting what the system wants them 

to want’ and who it works for. 10 Further study is 

also needed on the effectiveness of being instead 

of doing for our patients. 

Conclusion 

‘Phenomenology, like poetry, intends to be 

silent as it speaks. It wants to be implicit as it 

explicates.’ 15 When we enter the world of the 

patient and actively listen to them, we become 

accustomed to their manner of speaking, what is 

important to them and what individuates them at 

this particular point in time. Listening enables us 

to get under neath the surface of the individual 

and their experiences. By using van Manen’s 

approach to researching lived experiences, this 

study reinforces the importance of empowering 

those who are terminally ill to remain in control 

of their day-to-day decisions for as long as possible. 

The themes reflect key issues that nurses 

should reflect on and learn from, so that, when 

caring for and working with the terminally ill 

patient, this fully engaged being requires different 

nursing skills because of the unique and 

unpredictable psychosocial terms of reference 

that nurses have to work within. 

For each of the participants, it was everyday 

decisions that concerned them greatly, not the 

big, life-changing ones. All of the participants 

wanted their experiences with a terminal illness 

to be their own and to be allowed to die 

in their personal way, thus enabling autonomy 

and rationality. A positive regard needs to be 

revealed before any therapeutic relationship can 

ensue. People who are terminally ill are unique 

and unpredictable in terms of the connection 

and dependency within any nursing relationship; 

therefore it is imperative that, between the 

carer and the cared for, empathic, intuitive, active 

listening occurs, resulting in empowerment, feelings 

of being valued and respected, and enabling 

the best possible death. 

References 

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home hospice setting. [Dissertation]. [Galveston]: University 

of Texas; 2001. 

2. Gilbert T. Nursing: empowerment and the problem of power. J 

Adv Nurs. 1995;21:865–71. 

3. Powers P. Empowerment as treatment and role of health 

professionals. Amer Nurs Standard. 2003;26(3):227–238. 

4. Paterson B. Myth of empowerment in chronic illness. J Adv 

Nurs. 2001;34(5):576–81. 

5. Gauthier DM, Swigart VA. The contextual nature of decisionmaking 

near the end of life: hospice patients’ perspective. 

Amer J Hos Pal Care. 2003;20(2):121–8. 

6. Kant I. The critique of practical reason. Trans. Lewis White 

Beck. New York: Macmillan; 1788, 1985. 

7. Sahlberg-Blom E. Ternestedt M, Johanson J. Patient participation 

in decision-making at the end of life as seen by a close 

relative. Nurs Ethics. 2000;7:296–313. 

8. Beauchamp, TL, Childress, JF. Principles of biomedical ethics. 

4th ed. Oxford: Oxford University Press; 1994. 

9. McLean A. Empowerment and the psychiatric consumer/ex 

patient movement in the United States: contradictions, crisis 

and change. Soc Sci Med. 1995;40(8):1053–1071. 

10. Richardson K. Ever decreasing circles: non-curative terminal 

illness, empowerment and decision-making: lessons for 

nursing practice. A thesis submitted for the degree of Master 

of Health Science at the University of Otago, Dunedin, New 

Zealand; 2005. 

11. Benner P, Wrubel J. The primary of caring: stress and coping in 

health and illness. Menlo Park: Addison-Wesley; 1989. 

12. Opie A. ‘Nobody’s asked me for my view’: users’ empowerment 

by multidisciplinary health teams. Qual Health Res. 

1998;8(2):188–206. 

13. Keiffer CH. Citizen empowerment: a developmental perspective. 

Prev Human Serv. 1984;3:201–26. 

14. Freire P. Pedagogy of the oppressed. London: Penguin Books; 

1970, 1972. 

15. Van Manen M. Researching the lived experience: human 

science of an action sensitive pedagogy. London: State University 

of New York Press; 1990. p 131. 

16. Hunsaker-Hawkins A. Stories and their limits: narrative approach 

to bioethics. Lindemann-Nelson H, editor. New York: 

Routledge; 1997. 

17. Dworkin G. The theory and practice of autonomy. Cambridge: 

Cambridge University Press; 1988. 

18. MacLeod RD. On reflection: Doctors learning to care for 

people who are dying. Soc Sci Med. 2001;52:1717–19. 

19. Cumbi SA. The integration of mind-body-soul and the practice 

of humanistic nursing. Holi Nurs Practice. 2001;15(3):56–62. 

20. Benner P. From novice to expert. California: Addison-Wesley; 

1984. 

21. Polkinghorne D. Narrative knowing and the human science. 

Albany: State University of New York Press; 1988. 

22. Montello M. Narrative competence. Stories and their limits: 

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inquiry/1.html 2002 

Acknowledgements 

The excerpts provided 

by the participants 

appear in K. Richardson’s 

Master of Health Science 

unpublished thesis, 

which is held at the 

University of Otago and 

the Otago Polytechnic. 

competing INTERESTs 





Seeing patients first: creating an opportunity 

for practice nurse care? 

Tim Kenealy MBChB, PhD, FRNZCGP; 1 Barbara Docherty RN, Postgrad DipHlthSc (PHC); 2 Nicolette 

Sheridan RN, PhD; 2 Ryan Gao 3 

1 

Integrated Care Research 

Group, South Auckland 

Clinical School 

2 

School of Nursing 

3 

Medical student 

Faculty of Medical and Health 

Sciences, The University of 


ABSTRACT 

introduction: Practice nurses see patients in both a planned (i.e. scheduled appointment) and an 

unplanned (i.e. opportunistic) manner. This study aimed to investigate how often and why New Zealand 

practice nurses see patients prior to the general practitioner and whether they organise their care to support 

unplanned, opportunistic activity. 

Method: National postal survey from a random sample of 500 general practices, requesting a response 

from one nurse per practice. Semi-structured telephone interviews with a purposeful sample of 

respondents. 

FINDINGS: Responses came from 225 nurses (51% of practices confirmed to be eligible). Nearly all (92%) 

said their work role was the same as that of others in their practice. Only 13% of nurses routinely saw 

patients prior to the doctor, while 24% would choose to do so it they could, and 65% thought it important. 

Positive and negative aspects of seeing patients first are presented. Constraints included time, their role 

assisting practice workflow and perceptions of patient expectations. Few organised their work to create 

opportunities for lifestyle interventions. 

‘I was seldom able 

to see an opportunity 

until it had ceased 

to be one.’ 

Mark Twain (1835–1910) 


2010;2(2):136–141. 


Tim Kenealy 

Associate Professor 

South Auckland 

Clinical School 

Middlemore Hospital 

PB 93311, Otahuhu, 

Auckland 1640, 


t.kenealy@auckland.ac.nz 

Conclusion: The current working environment of practice nurses in New Zealand does not readily 

support them routinely seeing patients before the general practitioner. We suggest this is a lost opportunity 

for patient-centred preventive care. 

KEYWORDS: Practice nursing roles; opportunistic interventions; work organisation; primary health 

care; chronic conditions 

Introduction 

Practice nurse (PN) work can be considered as 

planned and unplanned. Planned work includes 

chronic care management clinics and similar ways 

of organising care to include blocks of protected 

time to engage with patients in relatively systematic 

and prescribed programmes. Unplanned 

work includes responding to patient needs as they 

present, and proactively taking opportunities 

to engage patients on issues which they did not 

present. It is this latter, opportunistic work that 

interests us in this study. 

Identifying and using opportunities effectively 

was the principle behind the Brief Opportunistic 

Interventions programme developed by author 

BD and others at The University of Auckland. 1 

During course feedback of this programme, most 

nurses stated that the best time to use these 

person-centred skills was by seeing the patient 

before the general practitioner (GP) (personal 

communication B Docherty, 2009). Putting aside 

the fact that 23% of children and 29% of adults 

see a PN per year without seeing a GP, 2 these 

nurses saw it as problematic that, when patients 

saw a GP prior to the PN, the GP often set the 

preventive care agenda prior to any opportunity 

for the PN to explore the patient’s agenda. One 

logical extension of such opportunistic activity 

would be for PNs to arrange their work to ensure 

that they routinely see every patient, ‘planning’ 

to create an ‘opportunity’. We therefore sought to 

investigate if and when practice nurses can and 

do see patients first. 




Methods 

A national postal survey was used to collect 

quantitative and qualitative data. Semi-structured 

interviews were conducted by telephone with a 

purposeful sample of survey respondents. Ethics 

approval was given by The University of Auckland 

Human Participants Ethics Committee (Reference 

number 206/381). In New Zealand, university 

ethics committees can approve studies of health 

care professionals, while the Ministry of Health 

committees can approve studies with patients. 

Participants 

A contact list for general practices in New Zealand 

was constructed from data held by the Department 

of General Practice and Primary Health 

Care and the Immunisation Advisory Service, 

both at The University of Auckland. The list contained 

1915 organisations presumed to be general 

medical practices, from which 500 were randomly 

selected using the rand() function in Excel, and 

sent one copy of the survey questionnaire. We 

requested one response from a practice nurse per 

practice. The sample size was chosen on the basis 

of available resources, anticipating a response rate 

of 60%, and was considered more than adequate 

for the simple descriptive statistics planned. 

Data collection: questionnaire 

The content of the questionnaire was developed 

initially based on feedback from nurse training 

courses run by author BD and from anecdotes 

and experience in primary care by author TK. 

Drafts were iteratively tested for content and 

face validity with a panel of 36 primary health 

care nurses. 

The final questionnaire, which can be found in Appendix 

1 in the web version of the paper, consisted 

of 20 closed questions and 11 open questions. 

The closed questions asked about practice nurse 

demographics, professional qualifications, and 

preferences and practices. The open questions gave 

practice nurses the opportunity to expand on their 

answers and give examples. The questionnaires 

were tagged with a temporary identification code 

to track non-responders. The questionnaires were 

sent in December 2006, and a follow-up request 

was sent to initial non-responders in January 2007. 


What we already know: In New Zealand in 2006/7, 41% of adults saw a 

practice nurse in the previous 12 months and 85% attended a general practice. 

For practice nurses, this is largely for clinical care and planned, structured care. 

What this study adds: A minority of practice nurses routinely see patients 

before they see the doctor, or organise their work to routinely support 

unplanned, ‘opportunistic’ person-centred care. 

Name and address lists were stored independently 

of the questionnaires. Respondents were assured 

that they would not be identified in any report. 

Data collection: interviews 

Respondents to the postal questionnaire were 

also asked to provide their name and contact 

details if they were interested to take part in a 

follow-up telephone interview. From this group 

we purposefully selected 20 practice nurses to 

cover a range of age, ethnicity, employment and 

geography. The guide questions for the interview 

were developed following a preliminary analysis 

of the survey responses, and can be found 

in Appendix 2 in the web version of the paper. 

Questions were intended primarily to confirm 

our interpretation of the quantitative data. Written 

consent was obtained prior to each interview. 

The interviews lasted from 20 to 35 minutes, 

were digitally recorded and transcribed. We offered 

interviewees the opportunity to view their 

transcript and to receive a copy of our report. 

Data analysis 

Quantitative data were entered and checked in 

Excel. Qualitative data from the questionnaires, 

together with the interviews, were entered into 

NVivo v7.0 for analysis. A general inductive approach 

was used for a thematic analysis 3 that was 

initially undertaken independently by authors 

TK, NS and BD, then confirmed and enriched 

by consensus. 

Results 

Questionnaires 

Five hundred questionnaires were sent out. Fiftysix 

proved ineligible (24 wrong address, general 




practice had ceased operating, or the organisation 

was not a general practice; and 32 practices had 

no practice nurses. There were 225 responses 

giving a response rate of 225/444 (51%). These 

225 individual practice nurses represented 225 

practices, with a total of 843 practice nurses 

and 802 GPs. Ninety-two percent said that their 

job was the same as that of the other nurses in 

the practice, or they were the only nurse in the 

practice. Descriptive statistics for respondents are 

in Table 1. 

Training in lifestyle behaviour change had been 

undertaken by 143 practice nurses (64%). Of 

these, most indicated condition-specific training 

such as for smoking cessation (46), diabetes (44), 

asthma (19) or exercise, weight management and 

nutrition (29), while only 38 described generic 

courses such as Brief Opportunistic Interventions 

training. 2 

The great majority of the nurses saw the positives 

and negatives of seeing patients first in purely 

transactional, workflow terms. They could take 

very different attitudes to what appeared to be 

the same activities: 

Don’t believe I’m the slushy to do the observations. 

I have my own workload. (#102) 

Chance to get to know patients better, catch up 

with recalls, bloods etc. sometimes patients tell 

PN things they won’t tell GPs. Good interaction 

time. (#23) 

Responses are summarised in Table 2, which 

reflects responses from all the free text questions 

in the questionnaire. As in the quotations above, 

some of the comments contradict each other, 

presumably reflecting a variety of PN attitudes 

and work situations. 

When asked when it would be beneficial for 

PNs to see the patient first, 147 PNs replied, 

most giving several examples. The great majority 

of examples were activities relating to practice 

workflow—emergencies, patients arriving 

without an appointment or when the GP was 

fully booked or running behind time. Thirty 

PNs nominated activities that are shaped by 

a specific schedule of tasks—such as ‘diabetes 

checks’, ‘wellness checks’, ‘antenatal visits’, ‘new 

patient visits’—that, nevertheless could poten- 

Table 1. Describing the 225 practice nurses, one per practice 

Summary statistic 

Practice nurses per practice, median (range) 3 (1–24) 

GPs per practice, median (range) 3 (1–12) 

Hours worked by practice nurses, median (inter-quartile range) 32 (24–38) 

Age of practice nurses, median (inter-quartile range) 48 (43–53) 

Years as practice nurse, median (inter-quartile range) 10 (4–15) 

Years at current practice, median (inter-quartile range) 5 (2–10) 

Ethnicity, n (%) (missing data, 10) 

European/other 195 (91) 

Maori 14 (7) 

Pacific 4 (2) 

Asian 2 (1) 

Practice nurse has own appointment list 84% 

Practice nurse sees, prior to GP, patients with GP appointment 

Sees all patients 13% 

Would choose to do this if they could 24% 

Feels it is important to do this 65% 

Feels confident to do this 79% 




tially be used to discuss lifestyle changes in a 

patient-centred manner. Seven PNs specifically 

noted the opportunity to engage in discussions 

and advice around patient lifestyle changes. 

Several specifically noted an advantage of their 

female gender: 

Most women are comfortable talking to another 

woman about menstrual, sexual, menopause problems. 

Some patients feel like they don’t want to 

waste doctor’s time so talk to nurse. (#84) 

Only two specifically noted their role dealing 

with mental health issues: 

Depressed, embarrassed elderly woman needing 

reassurance. (#332) 

Interviews 

One hundred and thirty-two nurses indicated 

that they were willing to be interviewed, from 

which we selected 26. Of these, seven routinely 

saw all patients first and nine would choose to 

see all patients first if they could. Summary 

descriptions of the nurses interviewed are in 

Table 3. 

Perceptions of ‘usefulness’ were the principal 

drivers of whether practice nurses routinely saw 

patients prior to the GP. 

I can’t really see… practice nurses doing the consultations 

first before seeing [the doctor]. All I can do 

sometimes is… just take the occupation, height and 

weight, when they’re doing some… CVD assessment. 

But most of the time, there’s not much to do 

with them. (#452) 

Usefulness was primarily seen as an administrative 

role that would contribute to the workflow 

of the doctors… 

It saves the doctors time because we can do blood 

pressures weights and take temperatures, get a 

basic history before they see them, so they just 

need to quickly scan the notes and they’re already 

there. (#45) 

…and their workflow came secondary to the 

doctors’. 

Table 2. The positives and negatives of seeing patients prior to the GP: summary of 

themes from free text in questionnaires 

Positives 

• Time efficient mostly stated as for GPs, practice and patients, occasionally for PNs 

• Continuity of care with PN 

• Reduction of GP workload and stress, all patients do not need to see GP 

• Screening, opportunistic education 

• Assists GP with essential history prior to GP consultation 

• PNs gain experience and educational opportunities 

• Increases PN confidence in clinical skills 

• Strengthens PN–patient relationships 

• Strengthens GP–PN relationship, GP recognises PN skills 

• Better care and outcomes for patients 

• Autonomy to triage and initiate first aid for emergency patients 

• Opportunity to use learned skills, e.g. brief interventions 

• Strengthens nursing holistic approach 

• More input from PN allows patients to utilise PN more 

• Patients more likely to talk to PNs and to be more ‘honest’ 

• Assist in diagnosis and treatment of acute cases 

• Perception that PN is less busy than GP 

• Improves access for patients when PN service free 

• Establishes PN role with patients as independent health professional 

Negatives 

• Patient has right to choose provider (autonomy) 

• Patient may want confidentiality or privacy 

• Patients may expect to see GP not PN 

• Total patient time in practice longer 

• Relationship is with the GP not the PN 

• Alters GP–patient relationship, PN undermining GP position 

• New way of working for patients, patient resistance 

• GP may not want patient to see the PN first 

• Patients seen twice and history-taking repeated 

• Time constraints, time waster 

• PN workload increased, PN already too busy 

• No financial reward for PN 

• Not cost-effective for practice or patient 

• Would reduce consultation time with PN and/or GP 

• Increase work hours and paperwork for both PNs and GPs 

• Not interesting enough, boring 

• PN training inadequate 

–– 

–– 

–– 

–– 

Misdiagnosis could occur 

Lack of confidence 

PN unable to assist in such areas as depression, complicated chronic 

management that requires GP input, counselling 

In some cases only GP is the suitable provider 

• Lack of suitable workplace space 

• Difficult if PNs working as receptionist 

• If only for follow-up…why bother? 

PN = practice nurse 

GP = general practitioner 




A lot of wounds have to be seen by the GP only for 

claiming purposes and it’s a waste of time because 

you need to have the patient sitting around, you’re 

waiting for the GP to come in… (#457) 

The nurses might be ‘useful’ to patients by being 

time efficient with administrative issues. 

…You’ll be doing some treatment type care for them 

and at the same time you’ll take note of their other 

health issues like recalls and things like that that 

they might be due for… (#490) 

Nevertheless, there was considerable variation 

between nurses in what they saw as useful. Many 

saw themselves as never having anything useful 

to contribute by seeing patients first, while others 

each nominated a small number of specific 

medically-defined conditions—such as diabetes, 

asthma and sexual health—in which they felt 

sufficiently skilled and confident to see patients 

first. However, the skill list nominated by each 

nurse seemed very partial, implying that the 

medical conditions of the majority of patients 

could not be ‘matched’ by any one nurse. 

The nurses who preferred to see all patients 

first, however, saw their skills in more generic 

terms that were independent of specific medical 

conditions. These nurses—a minority in both the 

questionnaires and interviews—spoke of their 

role forming and maintaining relationships with 

patients, and of sensing or seeking opportunities 

while performing administrative tasks. 

That’s an advantage of seeing the patients in the 

first place, by doing the weight and by doing the 

Table 3. Demographics of practice nurses (PNs) interviewed, n=26 

Age Median 46, range 32–62 

Ethnicity 

1 Asian 

18 European 

6 Maori 

1 Pacific 

Number of PNs in practice Median 3, range 1–12 

Type of practice 

1 Accident and Medical 

8 Rural 

17 Urban 

Years as PN Median 7, range 2–31 

Training in lifestyle behaviour change 17 

blood pressure and finding out if they’re smokers 

those are all the things that we do… we use every 

moment we can to educate. (#45) 

Most nurses gave a sense of being pressured and 

controlled by time. Nevertheless, the few nurses 

who routinely saw patients first gave a sense of 

multi-tasking and using time, suggesting that 

time was the very thing they could offer the 

patient that the doctor could not. 

We’re able to discuss those issues because we’ve got 

more time than the doctors have. (#45) 

Frustrations with time pressure seemed more 

directed at patients and receptionists than doctors 

or the wider health system, and appeared to be 

accepted as inevitable. 

Nurse perceptions and presumptions about 

patient expectations also formed a powerful influence 

on whether they saw patients first (or at all). 

Nurses mostly took it for granted that patients 

often came specifically to see the doctor—and, by 

implication, not the nurse: 

I also don’t know how patients would react to seeing 

a nurse first if they’ve chosen to make a doctor’s 

appointment. (#397) 

…that patients had every right to do so: 

I feel that we’re taking away patients’ rights to a 

certain extent if we chose to do that role automatically. 

(#490) 

…that patients were entitled to privacy and confidentiality 

that might extend to the doctor but not 

the nurse: 

…They want to wait until the doctor if they feel 

it’s something they don’t want to discuss, if they 

don’t want me to know they can leave it until 

they do see him. (#54) 

…and that nurses, doctors and patients probably 

share an implicit sense of when it was 

‘useful’ for the nurse to see the patient first. 

However, this may simply be a matter of patients, 

and nurses, becoming familiar with 

a new arrangement. 




I have only one patient who has not wanted to see 

the nurse, out of all the thousands that we see 

there’s probably one guy who would rather just see 

the doctor. (#45) 

Discussion 

Nurses undertook work they considered ‘useful’, 

that they considered to be acceptable to patients, 

and within limits imposed by time pressure. As 

such, only 13% of practice nurses routinely saw 

all patients before they saw a GP, while 24% 

thought it desirable and 65% thought it important. 

PNs viewed seeing patients first largely 

as an administrative role to assist practice and 

GP workflow. A minority took a different view, 

seeing patients first because they saw themselves 

as offering skills and a relationship that doctors 

did not offer. While most nurses acknowledged 

that they could become involved in opportunistic 

discussions while engaged in clinical care, there 

was no sense of routinely or proactively creating 

such opportunities. 

A strength of this study is that we surveyed the 

entire country. The fact that 92% of respondents 

said their job is the same as that of the other 

nurses in the practice supports our strategy of 

sampling one nurse per practice, as it suggests 

that the respondents may be similar to the 

nurses not sampled in the same practice. Nevertheless, 

our response rate of just over half calls 

for caution interpreting the results. We have 

no data to describe the practices from which we 

received no response. 

The nearest comparative data to our survey is 

from a recent evaluation of nursing developments 

in primary health, which included a national 

survey of PNs. 4 The response rate to their survey 

was only 34% and included 384 practice nurses. 

This evaluation made it clear that PNs around the 

country are increasingly taking up the (planned) 

activities involved in structure projects, 5 as was 

hoped and expected following The New Zealand 

Health Strategy 6 and The Primary Health Care 

Strategy. 7 The increase in structured care by PNs 

is reflected in the current study, but it also seems 

clear from our work that the dedicated time devoted 

to structured care, reflected in the number 

of nurses with their own appointment list, is one 

of the barriers to PNs taking up unplanned, opportunistic 

activities. 

Given the perennial problem of patients spending 

‘too long’ in waiting rooms, we suggest 

that PNs routinely seeing patients first is an 

opportunity that is largely missed. Seeing 

patients first also represents an opportunity 

to profile PNs, especially given findings that 

PNs are frequently anonymous and ‘invisible’ 

to patients, and that patients can enormously 

value a personal professional relationship with 

a PN. 8 In profiling PNs, seeing patients first 

would help break down one of the very barriers 

mentioned by our respondents, when they 

considered that some patients expect and prefer 

to see the doctor. 

A seminal paper that shaped the theory of 

general medical practice proposed ‘opportunistic 

health promotion’ as one of four key dimensions 

of the ‘exceptional potential’ of the GP consultation. 

9 We suggest that the same opportunity can 

be taken or created within PN care, recognising 

that this needs appropriate training and working 

conditions that formally acknowledge and support 

this role. 

References 

1. McCormick R. Educating primary care providers about brief 

intervention—seven years of New Zealand experience (symposium 

abstract). Add Bio. 2005;10:205–18. 

2. Ministry of Health. A portrait of health. Key results of the 

2006/07 New Zealand Health Survey. Wellington: Ministry of 

Health; 2008. Available from: http://www.moh.govt.nz/moh. 

nsf/indexmh/portrait-of-health 

3. Ryan GW, Bernard HR. Chapter 29: Data management and 

analysis methods. In: Denzin N, Lincoln Y, editors. Handbook 

of qualitative research. 2nd ed. Thousand Oaks, California: 

Sage Publications; 2000. p 769–802. 

4. Finlayson M, Sheridan N, Cummings J. Developments in 

primary health care nursing 2001–2007. In: Finlayson M, 

Sheridan N, Cumming J, editors. Wellington: Ministry of 

Health; 2009. p 1–132. 

5. Finlayson M, Sheridan N, Cummings J. Evaluation of the implementation 

and intermediate outcomes of the primary health 

care strategy second report: nursing developments in primary 

health care 2001–2007. Wellington: Health Services Research 

Centre; 2009. p 1–104. 

6. King A. The New Zealand health strategy. Wellington: Ministry 

of Health; 2000. Available from: www.moh.govt.nz/nzhs.html 

7. King A. The primary health care strategy. Wellington: Ministry 

of Health; 2001. http://www.moh.govt.nz/moh.nsf/by+unid/ 

7BAFAD2531E04D92CC2569E600013D04?Open 

8. Sheridan N, Kenealy T, Parsons M. Health reality show: regular 

celebrities, high stakes. NZ Med J. 2009;122(1301):31–42. 

9. Stott N, Davis R. The exceptional potential of each primary 

care consultation. J R Coll Gen Pract. 1979;29(201):201–5. 


We wish to thank the many 

nurses who completed 

the questionnaires 

and interviews. 

Funding 

Ryan Gao was funded by a 

summer studentship from 

The University of Auckland. 






What influences practice nurses to 

participate in post-registration education? 

Anna Richardson MPH, RN; 1 Jeffrey Gage PhD, RN 2 

1 

School of Nursing 

and Human Services, 

Christchurch Polytechnic 

Institute of Technology (CPIT), 


2 

Health Sciences Centre, 

University of Canterbury, 


ABSTRACT 

Introduction: There is a need for educated primary health nurses to develop their practice, educational 

and career pathways in response to opportunities emerging from the Primary Health Care Strategy 

(PHCS). This study aimed to explore the opportunities and constraints encountered by practice nurses 

when participating in post-registration education. 

Methods: This study used exploratory qualitative design, incorporating focus group interviews with 16 

practice nurses employed by Pegasus Health, Christchurch. Qualitative thematic analysis used a general 

inductive approach. 

Findings: Seven key themes emerged, including motivation to learn, enablers for learning and challenges 

to accessing education. Practice nurses also described their changing roles with clients and their 

vision for practice nursing in the future. 

Conclusion: This study considered accessibility of post-registration education for practice nurses 

and the extent to which they are embracing these opportunities in order to meet their practice needs. 

The PHCS states that primary health care nursing is crucial to its implementation. Successful expansion 

of primary health care nursing roles rests on the development of educational qualifications and skills, 

as well as career frameworks. It is envisaged that, with strong leadership and research skills resulting 

from professional development, practice nurses will be more able to reduce health inequalities. Study 

findings indicate that practice nurses are rising to the challenge of expanding their roles and engaging in 

post-registration education. They are more likely to pursue this if constraints are minimised and support 

increased. Currently practice nurses make significant contributions to primary health care and have the 

potential for an even greater contribution in the future. 

KEYWORDS: Nurses; practice nursing; nursing education, post-registration; New Zealand 


2010;2(2):142–149. 


Anna Richardson 

Senior Lecturer, School 

of Nursing and Human 

Services, CPIT 

PO Box 540 

Christchurch Mail Centre 

Christchurch 8140 


richardsona@cpit.ac.nz 

Introduction 

In 2001 the New Zealand (NZ) Primary Health 

Care Strategy (PHCS) was launched. 1 The strategy 

provided a framework for the health sector 

with a focus on population health and addressing 

health inequalities offering opportunities 

for nurses in primary health care to develop 

their practice, educational and career pathways. 

General practitioners have been employers of 

practice nurses for many years. Working within 

a business model has been challenging to nurses 

seeking to establish a greater degree of autonomy 

of practice. 2 The Ministry of Health calls 

for governance and leadership opportunities for 

practice nurses. Nursing leadership in primary 

health care in NZ has had a history of being 

‘fragmented and devolved to individual primary 

health care providers’. 3 However, this situation 

has changed over time with District Health 

Boards (DHBs) and Primary Health Organisations 

(PHOs) recognising the need for nursing 

leadership at all levels. The Ministry of Health 

document Investing in Health: Whakatohutia 

te Oranga Tangata outlined a comprehensive 

framework in which nurses can have a key role 

in implementing the Primary Health Care Strat- 




egy. 4 The strategy has highlighted opportunities 

for nurses to gain advanced nursing practice 

qualifications and to develop their roles. Nurses 

constitute the largest professional group working 

in primary health care, yet their potential 

roles within the workforce remain unrealised. 5 

According to Jones, the Chief Nursing Advisor 

to the Ministry of Health, the ability of 

practice nurses to communicate with people, 

work within the context of NZ families and 

understand the impact of the environment on 

their health are highly developed skills. 6 Jones 

questions whether practice nurses are equipped 

to practise more independently if a family or 

individual chose them as their primary health 

care professional. 

There is a critical need for a skilled and educated 

workforce to meet the challenging needs 

within primary health care. 4 The expectations 

for primary nursing to develop new roles in 

primary health care and to become increasingly 

autonomous require access to professional 

development. Many practice nurses working in 

general practices may not wish to become nurse 

practitioners nor obtain a clinical postgraduate 

qualification, but want to gain the knowledge 

required for them to work in their unique role in 

the primary health care workforce. 7 This may be 

interdisciplinary education with a general practitioner 

or a short course with other practice nurse 

colleagues. However, Minto sees the future of 

practice nursing as being more mobile, whereby 

nurses will visit patients in their homes, be more 

educated (most will have postgraduate education) 

and better paid. 2 

Several constraints to practice nurses’ ongoing 

professional development are cited in the 

literature. First is the need for funding for 

professional development in primary health care. 

Practice nurses have only been able to access 

funding from established streams, such as the 

Clinical Training Agency (CTA) since 2007. 8 

According to Pullon, ‘Primary Health Organisations 

have largely not considered practice nurse 

professional development as their responsibility’. 

7 The funding shift from DHBs has enabled 

them to purchase postgraduate education for both 

primary health care nurses and hospital nurses. 

Some general practice employers have supported 


What we already know: Opportunities for nurses to extend their population 

health focus and an increased range of services in primary health care 

have been clearly identified in the Primary Health Care Strategy. There is 

a need for well-educated primary health nurses with developing practice, 

educational and career pathways. 

What this study adds: This research identifies the constraints and opportunities 

experienced by practice nurses in furthering post-registration 

education and developing leadership roles in primary health care. 

practice nurse professional development with 

contracts of up to five days a year to study; more 

often this study is undertaken in their own 

time and at their own cost. A further constraint 

in practice nurses obtaining study leave is that 

practice locums—often needed to cover the 

positions—can be difficult to find. The provision 

of short courses to acquire clinical skills for practice 

nurses may not lead to a qualification, as the 

courses may not be linked to the New Zealand 

Qualifications Authority framework. 5 Also, the 

continual updating of specific practising certificates, 

such as vaccinators or smear takers, may 

lead to practice nurses focussing on these to the 

detriment of undertaking further professional 

development. 

A growing body of literature explores practice 

nursing roles in Australia, NZ and the United 

Kingdom (UK). 9,10,11,12 Parker et al. 12 and Halcombet 

al. 10 note that significant developments have 

been made in NZ and the UK to advance primary 

health care nursing education and career pathways. 

However, in Australia there is no policy 

at a national level to prepare nurses for primary 

health care, nor a framework for education or 

career pathways. In a 2007 Australian survey 

the educational needs of practice nurses reflected 

their current roles, but did not address developing 

roles. 13 There has been a call for the development 

of education and training programmes, 

supporting the need for a quality education and 

career framework for practice and other nurses in 

primary health care. 12,14 Since 2001, the potential 

for enhanced roles of NZ practice nurses has been 

recognised. 12 This includes responding to community 

need, developing leadership and models of 

practice, holding governance positions in PHOs, 




and developing a national career pathway for 

primary health care nurses. 

Methods 

An exploratory qualitative research design was 

implemented, using focus group interviews. Focus 

group interviews were selected for this study 

as their interactive nature allows the participants 

in a group to comment, explain, disagree, 

and share attitudes and experiences, providing 

rich perspective in the context in which events 

occur. 15,16 Ethical approval was obtained from 

Christchurch Polytechnic Institute of Technology 

and the New Zealand Health and Disability Ethics 

Committee in June 2008. 

The sample group was practice nurses employed 

by general practitioners of Pegasus Health Limit- 

Kreuger’s tape and note-based approach 18 was 

employed for analysis in conjunction with a fourstage 

approach guided by Boyatzis. 19 

Researchers first listened to the audiotapes then 

entered a process of reading, listening and summarising 

the raw data to identify multiple views 

and perceptions of participants and to recognise 

codable moments. 19 Codes were compared and 

examined for their potential to inadvertently reflect 

the researchers’ personal values and, finally, 

interpreted to contribute to the development of 

knowledge. Finally, key information was identified 

and presented in seven themes. 

Methodological rigour was achieved through 

trustworthiness and authenticity criteria adapted 

from the work of Lincoln and Guba. 20 The 

research plan was carefully documented, using 

In all focus groups, practice nurses identified several challenges to 

accessing education courses. These included their employer 

supporting only ‘in-house education’, lack of assistance to get time 

off work if the courses were held during the day, and finding 

appropriate courses relevant to practice nursing 

ed who had engaged in post-registration education 

at graduate (n=10) and postgraduate levels (n=6). 

Graduate education included formal learning at 

700 level and postgraduate, formal education at 

800 level. Practice nurses were selected by a convenience 

sampling approach; that is a sample of 

the population that was readily available. Practice 

nurses were invited by letter to participate in the 

focus groups. To be suitable for inclusion, all practice 

nurses were working full-time, currently or 

previously engaged in post-registration education 

and employed by Pegasus Health (320). 17 Sixteen 

participants attended the focus group interviews. 

The moderator encouraged participant discussion 

but avoided leading the group to reinforce existing 

assumptions. In addition to the audiotaped 

data, notes were taken by the moderator during 

the discussions and participants were given opportunity 

to clarify their comments and ideas. 

the same data collection and analysis techniques 

utilised for all three focus groups. Preliminary 

results were mailed to participants inviting them 

to participate in the analysis by verifying or adding 

to the findings. 

Findings 

Specific demographic information of the nurses in 

the study is not provided due to ethical considerations 

of anonymity. However, the 16 participants 

were all women, whose ages ranged from 25 to 61 

years. Practice nursing experience ranged from 

three to five years (for three recently graduated 

nurses) and five to 25 years for the other 13 registered 

nurses. The majority of participants identified 

as European/Pakeha New Zealander. 

Seven key themes emerged. 




1. Motivation to learn 

In each focus group, all practice nurses talked 

about wanting to be better—‘to improve myself 

all the time’ to help people and feel efficient. 

They wanted to be knowledgeable, using clinical, 

evidence-based knowledge to ‘deliver better 

practice’. The majority of participants talked 

about the personal satisfaction they gained from 

learning. They recognised that ‘knowledge is 

power’, which enabled them to improve their 

nursing skills to benefit clients while providing 

the increased intellectual stimulation that accompanies 

learning. Eight participants mentioned the 

self-confidence gained by participating in courses. 

Seven practice nurses spoke of the enjoyment 

of networking and studying together, especially 

for solo practitioners. Developing clinical skills 

was important for 14 participants, engaging in 

learning that was particularly useful for practice. 

Several courses were mentioned: cervical smear 

taking, Appetite for Life (healthy eating programme), 

preceptorship of student nurses, clinical 

supervision, along with more formal education 

such as the Bachelor of Nursing transition programme 

and the Graduate Certificate in Nursing 

Practice. The practice nurses described a strong 

commitment to learning—‘I could be addicted 

to learning, if it didn’t cost so much and I didn’t 

have to complete assignments!’ 

2. Enablers for learning 

Nine practice nurses described being in an atmosphere 

that helped motivate them to learn—in 

‘like minded groups’. There was agreement in 

all focus groups that funding for nurse-related 

education that became available in 2007 via the 

CTA was ‘a huge barrier to break’ in increasing 

the affordability of formal study. This meant that 

practice nurses could be funded for the full cost 

of course fees, relief in practice and travel and 

accommodation expenses to attend courses, if an 

equivalent course was not available locally. 

In each focus group all practice nurses spoke 

about a difference between practice nurse education 

at a clinical level and the courses available at 

Christchurch Polytechnic Institute of Technology 

(CPIT) or university education. ‘It [postgraduate 

study] extends you as a registered nurse in the 

world’. CPIT graduate courses were described as 

being ‘so practical’ and ‘relating to practice nursing 

well’. The educational credits scheme, where 

practice nurses gain credits to access courses as 

payment for preceptoring nursing students was 

considered very helpful by most participants. 

Opportunities for education through Pegasus 

Health were mentioned by all focus groups. Full 

financial support to attend courses such as the 

Child and Adult Health Assessment offered 

by CPIT, was a ‘turning point’ in their engagement 

in education. The funding of courses was 

described as a ‘massive reason why I have looked 

twice’ at child health assessment courses, motivational 

learning and diabetes courses. Participants 

mentioned the rewards offered by Pegasus Health 

to attend group education sessions as enabling 

them to engage in study. 

3. Challenges to accessing education 

In all focus groups, practice nurses identified 

several challenges to accessing education courses. 

These included their employer supporting only 

‘in-house education’, lack of assistance to get time 

off work if the courses were held during the day, 

and finding appropriate courses relevant to practice 

nursing. Shortages of relieving nurses were 

mentioned by most participants as a challenge and 

weekend courses made it difficult to maintain the 

balance of family and work commitments. 

Six practice nurses mentioned the ‘steep learning 

curve’ of getting into academic writing, using a 

computer and managing the workload of master’s 

education. Two practice nurses spoke of ‘taking 

a sabbatical’ to engage in master’s study. These 

challenges did not appear to demotivate the practice 

nurses to strive for learning. One mentioned 

that ‘being a solo practitioner’ prompted her 

personal learning and others were not deterred in 

finding appropriate courses, planning and budgeting 

for study. 

4. Negotiating with the employer 

Negotiating study leave with their employer was 

mentioned in all three focus groups. This included 

coming to agreement that the practice nurses 

engage in a course, the funding of the course and 

being uncomfortable asking for leave when they 




had ‘already done a course that year’. Seven practice 

nurses spoke of creating some ‘buy in’ from 

the employer, so they needed to find courses 

which would benefit and were relevant to the 

practice. Some practices are run by managers and 

two practice nurses had cervical screening funded 

when they signed a bond to stay in the practice 

for a year following completion. Two practice 

nurses spoke of being so motivated to learn skills 

such as cervical screening that they paid for some 

of the course fees, with their employer funding 

the remainder. 

5. Changing clients 

All practice nurses described the changing client 

as a motivator for them to study. They described 

clients in the twenty-first century as ‘well read 

and better informed’ and felt they ‘owed it to 

their clients’ to provide quality and up-to-date 

information. In each focus group practice nurses 

stated that clients may not be aware of the 

potential of practice nurses when they come into 

the practice and they would like to develop and 

market their skills to their client base. 

6. The changing role of the practice nurse 

There was consensus that the practice nurse role 

had changed so much over the past eight years, 

emphasising new opportunities for practice 

nurses offered by the PHCS. Changes included 

people being ‘put back into the community, with 

much more acute care required’ and that practice 

nurses are ‘expected to do much more’. This 

has motivated nurses to ‘catch up’ (researching 

current knowledge while in the workplace) and 

‘get involved in CPIT learning’. According to 

four participants, the role of the practice nurse 

has developed in the last 20 years, from being 

‘handmaiden’ to becoming ‘colleagues of the doctors’. 

There was pride in their comments; practice 

nurses described themselves as ‘very sharp and go 

ahead’. In all focus groups participants spoke of 

special projects that they are involved with such 

as ‘Care Plus’, a project for people with chronic 

illness and high health needs and ‘Services to 

Improve Access’ where the practice nurse and 

general practitioner can access funding to assist 

clients and families to access health care. These 

projects were mentioned in terms of practice 

nurses becoming more innovative in their approach 

to reducing social inequalities. There 

was also a change in emphasis in education for 

practice nurses, with the need to maintain their 

practising certificates through the development of 

professional portfolios. Some anticipated the day 

when practice nurses might be directly funded in 

their workplaces. 

7. Vision as a practice nurse/ 

vision for practice nursing 

‘We are so valuable!’ one practice nurse stated, 

and there was consensus that practice nurses are 

increasingly working independently, alongside 

GPs. Ten participants spoke of conducting more 

nurse consultations, where the ‘nurse owns the 

consult’. This growing autonomy was described 

as more satisfying and rewarding for practice 

nurses—‘we have quite a bit of autonomy, depending 

on our employer’. 

‘Moving up a level’ was also described in terms 

of engaging in special projects, where the practice 

nurses felt they were maximising their skills. 

This included mentoring new graduates, running 

nurse-led clinics and leading consultations. 

Ten practice nurses spoke of wanting to lift their 

image of themselves, to be more confident in 

what they can offer and acknowledgement of the 

income they bring into the practice. The manner 

in which practice nurses worked was discussed 

throughout the focus groups. Ten participants 

envisaged the development of the primary 

health care team, where comprehensive care was 

provided. One example included intersectoral collaboration, 

with a multidisciplinary health team 

in the same building with services such as Work 

and Income New Zealand. 

Discussion 

The 2001 PHCS signalled an increased emphasis 

on population health, community involvement, 

health promotion and illness prevention, with 

primary health care nurses being vital to the 

implementation of the strategy. 1 Practice nurses 

have responded to the challenge with considerable 

role development and have been key members 

of the primary health care team in addressing 




inequality of health care and working with 

people with chronic disease. 21 According to Rolls, 

well-educated nurses can find solutions to health 

problems more comprehensively, promptly and efficiently 

than others, thus clients are offered the 

best possible nursing care. 22 Sibbald et al. found 

in a systematic review of literature that in the 

provision of initial consultation and ongoing care 

of patients, nurses can provide as high a quality 

of care as general practitioners. 23 In controlled 

trials in the UK, practice nurses were shown to 

be cost-effective in generating health gains for 

patients, particularly in areas of screening and 

health promotion. 23 The focus group interviews 

captured participants’ enthusiasm and motivation 

for learning, particularly that which will enhance 

their clinical skills and health outcomes for 

clients and their families. 

Participants emphasised their enjoyment of 

their primary health care nursing role, and their 

intention to extend their practice within the 

general practice interdisciplinary team. Collaborative 

practice was identified as a facilitator which 

served to extend the practice nurse role, where 

the unique role of the practice nurse and GP can 

be retained and overlaps be identified. 10,11,24,25 

Continuing professional education is essential 

to develop the breadth of the practice nurses’ 

experience and knowledge, to improve levels of 

job satisfaction as well as health outcomes for 

consumers of primary health care. 24 

Participants clearly articulated that the funding 

was the key enabler that has assisted them to 

engage in post-registration education. The cost of 

education can be a significant barrier to improving 

nursing education opportunities. Postgraduate 

fees for a 30 credit course in 2009 were $1456 

and $1935 at the Universities of Canterbury and 

Otago respectively. 26,27 Accommodation and travel 

are additional costs. 22 Pegasus Health has been 

proactive in enabling post-registration education 

for practice nurses in Christchurch. Pegasus 

Health has provided scholarships for practice 

nurses to engage in certificate and diploma 

courses provided by the Christchurch Polytechnic 

Institute of Technology. 

Several challenges were identified in the focus 

group interviews regarding access to postregistration 

education. This included discussion 

around practice nurses wanting ‘to have a life’, 

as well as working and studying. Issues such as 

practice nurse career pathways were commented 

on. In 2000 the NZ College of Practice Nurses 

developed a career and professional development 

framework. 28 A uniform, national primary health 

care nursing education framework is essential for 

the development of primary health care nursing 

roles. 29 There is no mandatory training, or core 

professional competencies for practice nurses 

in NZ or Australia and the result is ‘unacceptable 

variations in the quality of practice’ seen 

in NZ. 12,24,29 A suggestion from participants was 

the establishment of an appraisal system for all 

practice nurses, to recognise work-related achievements 

and highlight professional development 

goals. The Health Practitioners Competence Assurance 

Act (2003) requires registered nurses to 

Participants emphasised their enjoyment of their 

primary health care nursing role, and their 

intention to extend their practice within the 

general practice interdisciplinary team 

maintain their currency by engaging in ongoing 

education, with a minimum of 60 hours professional 

development every three years. 

Participants identified negotiating professional 

development time with their employer as an 

issue. The discussion included practice nurses 

gaining support from their employer to embark 

on study, agreement about its relevance to the 

practice, obtaining funding for upgrading skills 

and leave to engage in study. A report of nursing 

developments in primary health care from 2001 

to 2007 found that a majority of general practitioners 

encouraged practice nurses to increase 

their role and 75% reported that practice nurses 

had taken on an increased role. 21 The Health 

Workforce Advisory Committee is concerned 

that the general practitioner workforce is in 

significant decline in relation to the population 

of New Zealand. 30 Thus the expansion of the 




practice nurse role could free up general practitioners’ 

time and be more cost-effective for 

the practice. However, it might be necessary to 

establish some incentives for practice nurses to 

develop their extended roles and continue with 

post-registration education. There was consensus 

that participants would like financial rewards for 

their educational achievements. Nurse leaders in 

NZ have suggested that the GP employment of 

nurses should cease, and be replaced by a salaried 

model of employment by a PHO or DHB. 9 Providing 

financial incentives and recognition of the 

practice nurse’s extended roles has been recommended 

by Harrison et al. 31 Twelve participants 

spoke of wanting to see more acknowledgement 

from their GP employers as they felt they ‘have 

the qualifications’ but wanted to use their ‘full 

Participants’ visions for practice nursing did not 

necessarily include obtaining nurse practitioner 

status, as they felt that this role required intensive 

study and practice and they were not sure if this 

was adequately rewarded financially 

potential’ in primary health care. All participants 

commented on their engagement in nursing innovation 

projects, where they have been given 

the opportunity to deliver nursing care in new 

ways, such as release time to conduct community 

or home visits and delivering care for clients and 

families with chronic conditions. These new 

models of care have been cited by participants as 

motivators to maintain currency and to engage in 

post-registration education. 

Participants’ visions for practice nursing did 

not necessarily include obtaining nurse practitioner 

status, as they felt that this role required 

intensive study and practice and they were not 

sure if this was adequately rewarded financially. 

However, there was a shared vision emerging, 

where clients and families were aware of and 

utilised their potential. Pullon states ‘it is time 

practice nurses had due recognition, not only of 

their unique skill set, but also of their undis- 

puted and essential place in primary care teams 

in general practices’. 32 Working collaboratively 

in the practice team was valued by participants. 

The government has proposed the establishment 

of multidisciplinary, integrated family health 

centres that reflect the participants’ vision. 33 

Strengths of this study 

This study involved a review of the current literature 

on primary health care nursing roles and 

post-registration education. The 16 participants 

provided in-depth understanding of the influences 

that promoted their engagement in post-registration 

education. All participants highlighted 

how professional development complemented 

their clinical expertise, enhancing application of 

theory to practice. 

Limitations 

The qualitative approach of the focus group 

interviews and the small number of participants 

prevents generalisations being made to the larger 

population of practice nurses. Only practice 

nurses employed by Pegasus Health were interviewed 

and this excluded nurses who work for 

other organisations who might have a different 

experience of accessing post-registration education. 

The convenience sampling method may have 

led to response bias, whereby the group of practice 

nurses who volunteered for the study may 

not have educational experiences representative 

of the population as a whole. However, the lack 

of a local practice nurse register precluded other 

sampling techniques. 

Implications 

It is important that practice nurses are supported 

to develop their roles in primary health care. This 

includes provision of educational opportunities 

and the development of a career pathway and 

educational framework. Participants indicated 

that Pegasus Health has actively encouraged their 

professional development and provided opportunities 

to overcome barriers to post-registration 

education. 

Given its qualitative nature, this research could 

only explore what influences practice nurses to 




engage in post-registration education, and did 

not reflect views of practice nurses who are not 

interested in further education or improving 

their practice skills. Further research on postregistration 

education would assist in broadening 

the understanding of issues for practice nurses 

and other primary health care nurses in NZ. 

The implementation of the PHCS has assisted 

practice nurses in fostering their role and encouraged 

ongoing professional development. Practice 

nurses already do, and have potential to make an 

even greater contribution to primary health care 

in the future. 

References 

1. Ministry of Health. The primary health care strategy. Wellington: 

Ministry of Health; 2001. 

2. Minto R. The future of practice nursing. N Z Fam Physician. 

2006;33(3):169–172. 

3. MacKay BJ. Leadership development: Supporting nursing in 

a changing primary health care environment. Nurs Prax N Z. 

2006;18(2):18–22. 

4. Expert Advisory Group on Primary Health Care Nursing. 

Investing in health. Whakatohutia te Orange Tangata. Wellington: 

Ministry of Health; 2003. 

5. McKinlay EM. New Zealand practice nursing in the 

third millennium: Key issues in 2006. NZ Fam Physician 

2006;33(3):162–168. 

6. Jones M. Practice nursing, some thoughts so far. The Practice 

Nurse. 2006;6(1):5–6. 

7. Pullon S. Toward a culture of supporting professional development 

for primary care professionals: A key component of 

successfully implementing the primary health care strategy. 

NZ Fam Physician. 2008:31(4):267–270. 

8. Ministry of Health. Nursing developments in primary health care 

2001–2007. A summary. Wellington: Ministry of Health; 2009. 

9. Hoare KJ, Fairhurst-Winstanley W, Horsburgh M, Cormick R. 

Nurse employment in primary care—UK and New Zealand. NZ 

Fam Physician. 2008;35(1):28–31. 

10. Halcomb EJ, Davidson PM, Griffiths R, Daly J. Cardiovascular 

disease management: Time to advance the practice nurse 

role? Health Rev. 2008;32(1):44–55. 

11. Halcomb EJ, Davidson PM, Patterson E. Exploring the development 

of Australian general practice nursing. Where we have 

come from and where to from here? Contemporary Nurse. 

2007;26(1):145–153. 

12. Parker RM, Keleher HM, Francis K, Abdulwadud O. Practice 

nursing in Australia: A review of education and career pathways. 

BMC Nursing. 2009;8(5). Available from: http://www. 

biomedcentral.com/1472-6955/8/5. 

13. Pascoe T, Hutchinson R, Foley E, Watts I. The educational 

needs of nurses working in Australian general practices. Aus J 

of Advanced Nursing. 2007;24(3):33–38. 

14. Keleher H, Joyce CM, Parker R, Pitterman L. Practice nurses in 

Australia: current issues and future directions. Med J of Austr. 

2007;187(2):108–111. 

15. Parahoo K. Nursing research: principles, process and issues. 

London: Macmillan; 1997. 

16. Curtis E, Redmond R. Focus groups in nursing research. Nurse 

Researcher. 2007;14(2):25–37. 

17. Maw K, Nursing Facilitator Pegasus Health, Personal communication; 

22.9.09. 

18. Kreuger RA. Analysing and reporting focus group results. 

California: Sage Publications Inc.; 1998. 

19. Boyatzis RE. Transforming qualitative information. Thematic 

analysis and code development. California: Sage Publications 

Inc.; 1998. 

20. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: CA: 

Sage; 1985. 

21. Finlayson M, Sheridan N, Cumming J. Nursing developments 

in primary health care 2001–2007. Wellington: 

Ministry of Health. Accessed from: www.moh.govt.nz/ 

moh.nsf/indexmh/primary-health-care-nursing-developments-2001-2007; 

2009. 

22. Rolls S. Removing the barriers to nursing education. NZ Nurs J. 

2005;10(11):26 

23. Sibbald B, Laurant MG, Reeves D. Advanced nurse roles in UK 

primary care. Med J of Austr. 2006;(185)1:10–12. 

24. Mills J, Fitzgerald M. Renegotiating roles as part of developing 

collaborative practice. Australian nurses in general practice 

and cervical screening. J Mulitidisciplinary Health Care. 

2008;1:35–43. 

25. Daly WM, Carnwell R. Nursing roles and levels of practice: 

a framework for differentiating between elementary, 

specialist and advancing nursing practice. J of Clin Nurs. 

2003;12(2):158–167. 

26. Drayton P, Administrator Health Sciences Centre, Canterbury 

University, Personal communication, 18.9.09. 

27. Helms R, Administrator Health Sciences Centre, Otago University, 

Personal communication, 21.9.09. 

28. New Zealand Nurses Organisation. NZ College of Practice 

Nurses NZNO career and professional development framework. 

Wellington: NZNO; 2003. 

29. Docherty B, Sheridan N, Kenealy T. Painting a new picture 

for practice nurses in a capitated environment: who holds the 

brush? N Z Med J. 2008;121(1284):11–14. 

30. Health Workforce Advisory Committee (HWAC). Fit for 

purpose and for practice: a review of the medical workforce 

in New Zealand. Consultation document. Wellington: 

HWAC; 2005. 

31. Harrison S, Dowswell G, Wright J. Practice nurses and clinical 

guidelines in a changing primary health care context: an 

empirical study. J Adv Nursing. 2002;39:299–307. 

32. Pullon S. What is the place of general practice within primary 

health care—in the Aotearoa New Zealand context? N Z Fam 

Physician. 2008;35(5):301–303. 

33. Sheridan S, Finlayson M, Jones M. Position statement: primary 

health care nursing. J of Prim Health Care. 2009;1(2):95–96. 


We wish to thank the 

Director of Nursing at 

Pegasus Health, Shelley 

Frost, Nursing Facilitator, 

Kelly Maw and Nursing 

Educator, Linda Collier for 

supporting this research 

project. Thank you to all 

the practice nurses who 

took time out of their 

busy lives to contribute 

to the focus groups. 

Thank you to academic 

colleagues who assisted 

in the research proposal. 

Funding 

This study was funded 

by the Christchurch 

Polytechnic Institute 

of Technology. Any 

views expressed in this 

paper are personal to 

the authors and are not 

necessarily the views of the 

Christchurch Polytechnic 

Institute of Technology. 

Competing interests 




short report 

Are unexplained vaginal symptoms 

associated with psychosocial distress? 

A pilot investigation 

Andreas Cohrssen MD; 1 Uzma Aslam MD; 1 Allison Karasz PhD; 2 Matthew A Anderson MD 2 

1 

Department of Family 

Medicine, Beth Israel 

Hospital, NewYork, New 

York, USA 

2 

Department of Family and 

Social Medicine, Montefiore 

Medical Center, Bronx, New 

York, USA 

ABSTRACT 

Aim: Vaginal complaints cannot be definitively diagnosed in approximately one-third of women. We 

sought to determine if women without a diagnosis had higher levels of psychiatric disorders. 

Methods: This was an observational study in an urban family practice clinic. Prior to seeing a clinician, 

women with vaginal complaints completed the Patient Health Questionnaire (PHQ); symptoms were 

measured by the Vaginal Complaints Scale (VCS). Patients were then examined and treated by a family 

physician. At one and two weeks’ time patients were contacted by phone regarding symptom resolution 

and clinical outcomes. 

Results: We enrolled 47 patients; one patient was excluded. A diagnosis was made in 36. Eighteen 

had bacterial vaginosis, 16 had candida, three trichomonas, two HSV, one chlamydia; there were eight 

dual diagnoses. PHQ diagnoses were slightly less common in women without an identified cause for their 

symptoms. We obtained follow-up data from 45 subjects at one week and 34 subjects at two weeks’ time. 

At two weeks’ follow-up, 97% of subjects had complete resolution or improvement of their symptoms. 

Symptom improvement was equivalent among women with a diagnosis and those without. We estimate 

180 subjects would be needed to detect a clinically meaningful difference in PHQ diagnoses. 

Discussion: Our pilot study did not find an association between psychiatric diagnoses made by the 

PHQ and unexplained vaginal symptoms. Nearly all patients experienced rapid resolution of symptoms irrespective 

of whether a diagnosis had been made or not. These findings are limited primarily by the small 

sample size. 

Keywords: Vaginitis; psychosocial stress; symptom resolution 


2010;2(2):150–154. 


Matthew Anderson 

3544 Jerome Ave. 

Bronx, NY 10467, USA 

bronxdoc@gmail.com 

Introduction 

Vaginal complaints are common in primary care, 

yet comprehensive microbiologic investigations 

fail to identify an aetiology in about one-third of 

cases. 1–4 Factors other than known microbes and 

dermatological reactions must, therefore, play a 

role in the development of vaginal complaints. 

Since vaginal symptoms can have important 

social meanings, 5–8 some investigators have 

postulated a role for psychosocial stress in their 

genesis. A population-based survey in India 

concluded that psychosocial factors were strongly 

associated with complaints of vaginal discharge, 

while reproductive tract infections (RTI) were 

not. 8 This may reflect specific cultural ideas in 

India concerning leucorrhoea (white vaginal discharge). 

7,9 Chronic stress has been linked to vaginal 

candidiasis. 10,11 Studies on the role of stress in 

bacterial vaginosis have been contradictory. 12–14 

No study has examined the relationship between 

medically unexplained vaginal symptoms and 

psychosocial stress. To explore this relationship, 

we hypothesised that if unexplained symptoms 

resulted from psychosocial factors, then we 

would find higher levels of depression, somatisation, 

anxiety symptoms and psychosocial stress in 

patients who did not have an RTI when compared 



short report 

to patients who did have an RTI. In addition, we 

evaluated the impact of a having made a specific 

diagnosis on the resolution of vaginal symptoms. 

Methods 

Subjects 

The study was conducted at an urban family practice 

clinic and residency training site. All women 

from 18 to 45 years presenting with vaginal complaints 

were eligible. Exclusion criteria included: 

fever; known diagnosis of gonorrhoea, chlamydia, 

or herpes; menstruation; and pregnancy. Women 

who had self-treated for vaginal symptoms were 

not excluded in order to assure a representative 

study population. 

Recruitment and consent 

Nurses queried all patients regarding their 

presenting problems. Patients with any vaginal 

complaints were referred to one of the authors 

(UA). Written informed consent was obtained 

from those who wished to participate. 

Study protocol 

Consenting patients completed a basic demographic 

survey, a sexual and contraceptive history, 

the Vaginal Complaints Scale (an 18-question survey 

designed by the authors) 15 and the depression, 

anxiety, somatisation, and stress sections of the 

self-report Patient Health Questionnaire (PHQ). 16 

Study patients were seen by their assigned clinical 

providers or by UA. All providers at the clinic 

are trained in the diagnosis of vaginitis. Resident 

physicians only examine patients under direct 

supervision of attending physicians. A pelvic 

examination was performed and a sample of the 

vaginal fluid obtained. The pH was measured, a 

whiff test performed, and the sample examined 

under a microscope using normal saline and potassium 

hydroxide (KOH). All specimens were reviewed 

by UA in addition to the primary clinician. 

Bacterial vaginosis (BV) was diagnosed using the 

Amsel Criteria. If microscopic examination did not 

reveal a definitive diagnosis, culture of yeast and 

T. vaginalis were obtained. Women were tested for 

gonorrhoea and chlamydia; physicians were free to 

order additional tests at their clinical discretion. 

What gap this fills 

What we already know: Vaginal complaints are very common in primary 

care, but a cause cannot be identified in one-quarter to one-third of women. 

Some evidence has suggested that psychosocial morbidity may account for 

unexplained vaginal symptoms. 

What this study adds: In this small pilot study, unexplained symptoms 

were not associated with measures of psychosocial distress. Most women 

experienced prompt relief of symptoms regardless of whether a diagnosis 

had been made or not. 

Patients with an identified microbe were treated 

by their primary care provider. Patients without 

a definitive diagnosis were either treated or not 

treated according to their provider’s assessment 

(typically based on the severity of symptoms or 

likelihood of disease on the basis of the pH or 

past history). 

Follow-up 

UA contacted subjects by phone at both one week 

and two weeks after initial presentation regarding 

symptom resolution, clinical outcomes, and 

any persistent patient concerns. Patients who 

remained symptomatic at the two-week follow-up 

call were referred for re-evaluation at the clinic. 

Infection with trichomonas or candida 

Reports indicating an RTI were returned to the 

primary care provider who initiated therapy for 

the patient and, when applicable, for their sexual 

partner(s). 

Positive screening for psychosocial issues 

Patients with evidence of any mental disorder or 

family violence were offered referral to a social 

worker. 

Data analysis 

Data was entered into an Access database and analysed 

using SPSS for Windows Version 15.0 software. 

Group differences were evaluated with twotailed 

t-tests for independent samples or Fisher’s 

exact test. We analysed the vaginal symptom score 

using a hierarchical linear regression model with 

a random intercept at the individual level. Fixed 



short report 

Table 1. Basic demographic data 

Age, mean, range 

Education 

Marital status 

Employment 

All patients 

n=46 

29.8 

[18–42] 

Diagnosis made 

n=36 

29.9 

[20–43] 

No diagnosis 

n=10 

29.6 

[18–40] 

College or advanced degree 31 23 8 

High school 11 9 2 

No high school 4 4 0 

Single 36 27 9 

Unwed couple 3 2 1 

Married 5 5 0 

Separated/divorced 2 2 0 

Employed outside home 32 25 7 

Student 7 5 2 

Not employed outside home 7 6 1 

Contraception ‡ OCP/ring 12 10 2 

IUD 2 2 0 

None 6 6 0 

Abstinence 4 1 3 

Condoms 18 13 5 

Depo-Provera 1 1 0 

Sterilisation 1 1 0 

No response 2 2 0 

Annual income ‡ >$40K–80K 11 8 3 


short report 

basis of office tests (pH, microscopy, whiff test). 

Four additional diagnoses were made based on 

culture: one candida, one chlamydia and two 

herpes simplex (HSV). Taking into account both 

office diagnoses and culture, 15 women had BV 

alone, 13 women had candida alone, two women 

had trichomonas alone and two women had HSV. 

Four women had dual diagnoses: two with BV 

and candida, one with BV and chlamydia, and 

one with trichomonas and candida. No woman 

was diagnosed with a non-infectious cause of 

vaginitis (contact dermatitis or allergic reactions). 

Ten patients (22%) were undiagnosed. 

Psychological distress and diagnosis 

Eleven women had diagnoses suggested from 

scoring the PHQ survey. Seven women had a 

single diagnosis: three had somatisation, two had 

minor depression and one each had panic and 

anxiety. Three women had dual diagnoses; one 

patient each had somatisation associated with either 

minor depression, major depression or panic 

disorder. One woman was diagnosed with minor 

depression, panic disorder, and anxiety. PHQ 

diagnoses were not more common in women 

without a medical diagnosis (Table 2). 

Symptom resolution 

We were able to contact 45 patients for follow-up 

at one week’s time (one lost to follow-up) and 33 

patients at two weeks’ time (13 lost to followup). 

At one week 21 (47%) patients had complete 

resolution of symptoms, 20 (44%) had partial 

resolution of symptoms and four (9%) reported no 

change in symptoms. At two weeks 22 (67%) were 

completely better, 10 (30%) were a little better 

and only one patient was no better. No patient reported 

that symptoms were worse at either time. 

Symptoms decreased markedly at the one week 

follow-up and decreased further at two weeks; 

these differences were statistically significant and 

occurred in both the diagnosis and non-diagnosis 

group. Differences in clinical resolution and 

symptom scores were not statistically different 

between the diagnosis and non-diagnosis groups. 

Table 2. Diagnoses and association with psychological distress 

Diagnosis 

Based on PHQ scoring 

We considered that three points on the Vaginal 

Complaints Scale represented a meaningful clinical 

difference. To have 80% power for detecting 

a difference of three using a two-tailed test with 

alpha = 0.05, and a correlation of zero between 

the baseline and follow-up measure would require 

91 people in each group. 

Discussion 

Women with a 

diagnosis (n=36) 

In this pilot study we failed to find increased 

levels of psychosocial distress in women with 

undiagnosed vaginal symptoms when compared 

to those who did have a diagnosis. Both groups of 

patients experienced prompt symptomatic relief of 

their symptoms. Thus, in terms of psychological 

distress and symptom resolution, patients in our 

study who went undiagnosed seemed indistinguishable 

from patients with a medical diagnosis. 

Our rate of non-diagnosis (22%) compares favourably 

to that reported in the medical literature as 

do our range of diagnoses. Our study is, however, 

limited by the small sample size, the convenience 

nature of the sample, relatively poor follow-up 

at two weeks (74%), and the fact that the PHQ is 

primarily a screening tool. 

The simplest explanation of our findings is that 

women without a medical diagnosis are reacting 

appropriately to bodily changes in the same way 

as women with an identified cause. This would 

suggest that there may be unidentified infectious 

pathogens or processes that are causing their 

symptoms. Another explanation is that psychosocial 

stress is causing them to over-react to normal 

bodily functions but that the levels of stress are 

equivalent to those of persons with symptoms 

caused by a pathogen. It may be that the PHQ 

Women without a 

diagnosis (n=10) 

Somatisation 5 (14 %) 1 (10%) 

Depression 

Depressive syndrome 4 (11%) 0 

Major depressive disorder 1 (3%) 0 

Panic syndrome 3 (8%) 0 

Anxiety syndrome 2 (5%) 0 

Women with any disorder 10 (24%) 1 (10%) 

Note: No significant differences noted in any comparison using Fisher’s exact test 



short report 

Table 3. Clinical resolution at one and two weeks’ time post-visit 

All women With diagnosis Without diagnosis 

Completed interviews 

Total symptom score 

(mean, SD) 

Clinical resolution 

@ 1 week 

Clinical resolution 

@ 2 weeks 

At baseline 46 36 10 

At one week 45 36 9 

At two weeks 34 25 9 

Baseline 14.3 (6.4) 15.0 (6.4) 11.6 (5.7) 

At one week 5.2 (4.0) 5.8 (4.4) 3.1 (3.2) 

At two weeks 2.3 (2.8) 2.3 (2.4) 2.3 (3.8) 

Completely better 21 (47%) 17 (47%) 4 (44%) 

Somewhat better 20 (44%) 15 (42%) 5 (56%) 

Unchanged 4 (9%) 4 (11%) 0 

Worse 0 0 0 

Completely better 23 (68%) 18 (72%) 5 (56%) 

Somewhat better 10 (29%) 6 (24%) 4 (44%) 

Unchanged 1 (3%) 1 (4%) 0 

Worse 0 0 0 

Note: Clinical resolution at one and two weeks not significantly different by Fisher’s exact test. For symptom score see text. 

ACKNOWLEDGEMENTs 

Dr Clyde Schechter 

provided invaluable 

assistance with the 

statistical analysis 

of this paper. 

FUNDING 

Dr Aslam participated 

in this project as a 

Fellow of the New York 

State Empire Clinical 

Research Investigator 

Program (ECRIP). 



test did not measure the psychological processes 

that might be responsible for symptoms. It is important 

to note that even had we found association 

between unexplained vaginal symptoms and 

psychological distress at the time of presentation 

this would not necessarily imply that the distress 

caused the symptoms. 

Since one-quarter to one-third of women in 

primary care with vaginal symptoms go undiagnosed, 

a better understanding of their symptoms 

remains an important problem in primary care. 

References 

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of symptoms and signs in the diagnosis of vaginal infections. 

Arch Intern Med. 1990;150(9):1929–1933. 

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Stamm WE et al. Establishing the cause of genitourinary 

symptoms in women in a family practice. Comparison of 

clinical examination and comprehensive microbiology. JAMA. 

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3. Mayaud P, ka-Gina G, Cornelissen J, Todd J, Kaatano G, West B 

et al. Validation of a WHO algorithm with risk assessment 

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classic approach to diagnosis of vulvovaginitis: a critical analysis. 

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5. Karasz A, Anderson M. The vaginitis monologues: women’s 

experiences of vaginal complaints in a primary care setting. 

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6. O’Dowd TC, Parker S, Kelly A. Women’s experiences of general 

practitioner management of their vaginal symptoms. Br J 

Gen Pract. 1996;46(408):415–418. 

7. Trollope-Kumar K. Cultural and biomedical meanings of the 

complaint of leukorrhea in South Asian women. Trop Med Int 

Health. 2001;6(4):260–266. 

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et al. Why do women complain of vaginal discharge? A population 

survey of infectious and pyschosocial risk factors in a 

South Asian community. Int J Epidemiol. 2005;34(4):853–862. 

9. Rashid SF. Durbolota (weakness), chinta rog (worry illness), 

and poverty: explanations of white discharge among married 

adolescent women in an urban slum in Dhaka, Bangladesh. 

Med Anthropol Q. 2007;21(1):108–132. 

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women with recurrent vulvovaginal candidiasis. J Psychosom 

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2006;194(2):381–386. 

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Development of a vaginal symptom scale. North American Primary 

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Health Questionnaire. JAMA. 1999;282(18):1737–1744. 


BACK TO BACK 

New Zealand general practice should adopt 

population-based screening for attention 

deficit hyperactivity disorder (ADHD) 

YES 

One of the advantages of having been around in 

general practice for more than four decades is the 

opportunity to observe the long-term impact of 

a change in thinking in one area of medicine and 

to ask the question ‘Why do we not deal with 

another area according to the same principles?’ 

For example, in the diagnosis and management of 

diabetes there has been a quiet revolution. When 

I first started in general practice we waited until 

a diabetic was symptomatic before assessing. The 

usual opportunistic test was to check the urine 

for sugar. The received wisdom at that time was 

that most practices had 1% of known diabetes but 

that there was another 1% waiting to be detected 

if we looked a little harder. At the present time 

4% of my patients are known to be diabetic but I 

am told this is too low. Yes, the rate of diabetes 

has increased over 40 years because of increasing 

obesity, but the biggest change is the result 

of a serious population screening approach with 

tougher criteria. All the indications are that 

the benefits in patient outcome are substantial 

in moving some patients back from the edge of 

diabetes and reducing end organ damage and 

therefore mortality. 

The same could be said of the management of 

cardiovascular disease by screening for hypertension 

and hypercholesterolaemia, and treating 

early. We also have a much more aggressive 

approach to smoking cessation and altogether 

it is making a difference. No one suggests that 

the modern management of diabetes and heart 

disease is a waste of time and money. 

An equally strong case can be made for the detection 

of attention deficit hyperactivity disorder 

(ADHD) across the population. The generally 

agreed rate of ADHD in most populations is 5% 1 

or more, which translates into at least 200 000 

people of all ages in New Zealand (NZ). According 

to Pharmac figures, around 25 000 are 

currently receiving medication, which is less than 

13% of the possible total. There may be another 

13% in whom a diagnosis of ADHD has been 

made, but in whom it has been decided by doctors, 

patients or families that medication is not 

appropriate. If these estimates are roughly correct 

there would still be around 74% who are undiagnosed. 

Does it matter? 

Various studies have found a massive social burden 

from ADHD. One claims that 25% of those 

in jail in the USA have ADHD. Another suggests 

that those with ADHD are 22 times more 

likely to be incarcerated at some time in life than 

Tony Hanne 

MB BS MRCS LRCP 

Dip Obst FRNZCGP; 

general practitioner, 

Fowley Lodge, 

215 Bleakhouse Road, 

Howick, Auckland, 


While evidence can help inform best practice, it needs to be placed in context. 

There may be no evidence available or applicable for a specific patient with 

his or her own set of conditions, capabilities, beliefs, expectations and social 

circumstances. There are areas of uncertainty, ethics and aspects of care for which 

there is no one right answer. General practice is an art as well as a science. Quality 

of care also lies with the nature of the clinical relationship, with communication and 

with truly informed decision-making. The Back to Back section stimulates 

debate, with two professionals presenting their opposing views regarding a clinical, 

ethical or political issue. 

Tony Hanne 

Ross Lawrenson 

BACK TO BACK this issue: 


BACK TO BACK 

those who do not. 2 The rate of road accidents was 

found to be four times higher in ADHD drivers. 3 

Substance abuse is double in ADHD, but reduced 

by treatment. 4 Academic underachievement, 5 job 

instability, 6 unemployment, relationship breakdowns, 

teenage pregnancy, and suicide are all 

significantly higher. Rates of other psychiatric 

illnesses including depression, anxiety, 7 schizophrenia, 

and OCD are all higher. A high proportion 

of Specific Learning Disorders have an underlying 

problem of ADHD. 8 The cost in terms 

of suffering for the patient and those around 

him or her is enormous. The financial cost to the 

Ministries of Education, Social Welfare, Justice, 

and Health (with particular reference to ACC) 

must be equally substantial. This latter amount 

would be many times the cost of a greater use of 

medication where needed. 

Why then do we not take a wider approach to the 

detection of ADHD in our practices? There are 

various excuses. 

1. Isn’t ADHD a new disease? 

The first good description of the condition was 

by Dr Alexander Crichton in 1798 and it was 

described more fully in 1902 by Dr Joseph Still. 

Effective treatment began in 1976. The current 

name is relatively new, first used in 1980 for 

children and in 1994 for adults, but the symptom 

complex was clear long before. 

2. ADHD is not a real condition, is it? 

Positron Emission Tomography first demonstrated 

in 1990 the difference in blood flow in key areas 

of the brain, and this was later shown to reverse 

with medication. The genetic factors are being 

rapidly defined. The test of variable attention 

(TOVA) computer test has 80% specificity and 

80% sensitivity. Endless RCTs of medication have 

shown easily measurable benefits in learning and 

behaviour from treatment. 

3. Isn’t ADHD a specialist condition? 

The diagnosis requires a careful history from 

the individual, the family and the teacher for 

children, and a wider circle for adults. It is a 

common problem. The management involves the 

family and the community and is long-term. The 

medication is simple to titrate and safe. Aren’t 

these the very conditions GPs manage best? Only 

3% of general psychiatric patients are referred to 

psychiatrists in the public system. Why should 

ADHD be different? 

4. Doesn’t ADHD treatment 

leads to drug abuse? 

Studies have shown, on the contrary, that later 

drug abuse is substantially reduced by the early 

use of medication. The proportion of those 

receiving medication who abuse is less than 5% 

if they are strictly managed. Why punish the 

other 95%? 

5. Can’t ADHD be well-managed 

by better parenting, firm teaching, 

diet, and counselling? 

All of these measures may help, but only when 

appropriate medication is considered at the same 

time. Vast amounts of money are spent by desperate 

parents on alternative medicines and therapies 

for which there is no evidence of benefit. 

6. Isn’t ADHD only a childhood 

condition which they outgrow? 

ADHD is recognisable throughout life. About 

half of ADHD sufferers have adapted sufficiently 

by the end of the teens, but the other 

half need ongoing help. 

A population approach to ADHD would inevitably 

mean shifting responsibility for basic 

assessment and management to general practice. 

This, in turn, would necessitate training interested 

GPs to be able to undertake this effectively. 

9 More complex problems with multiple 

psychiatric diagnoses would still need specialist 

input. Tools, of which there are many, to 

assist diagnosis should be reviewed to establish 

suitability, effectiveness and reliability. Current 

barriers to the decision to prescribe stimulants 

would need to be modified. The rules 

have recently been relaxed to allow GPs to 

prescribe Isotretinoin in acne, arguably a more 

risky decision. Education of teachers, parents, 

and social workers would need to be under- 


BACK TO BACK 

taken to achieve a more harmonious working 

relationship to support ADHD patients. Funding 

for GPs with a special interest in this area 

to allow sufficient time for thorough assessment 

would need to be agreed. 

Singapore and South Korea, with similar rates 

of ADHD to NZ, are developing a population 

approach in which GPs are central. They 

report that this is working well. What are we 

waiting for? 

References 

1. Barbaresi W, Katusic S, Colligan R et al. How common is attention 

deficit/hyperactivity disorder? Towards resolution of 

the controversy: results from a population-based study. Acta 

Paediatr Suppl. 2004;93:55–59. 

2. Satterfield JH, Schell A. A prospective study of hyperactive 

boys with conduct problems and normal boys; Adolescent 

and adult criminality. J Am Acad Child Adolesc Psychiatry. 

1997;36:1726–1735. 

3. Barkley RA et al. Motor vehicle driving competencies and risks 

in teens and young adults with attention deficit hyperactivity 

disorder. Pediatrics. 1996;98(6):1089–95. 

4. Wilens TE, Adamson J, Monuteaux MC et al. Effect of prior 

stimulant treatment for attention deficit/hyperactivity disorder 

on subsequent risk for cigarette smoking and alcohol and 

drug use disorders in adolescents. Arch Pediatr Adolesc Med. 

2008;162:916–21. 

5. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent 

outcome of hyperactive children diagnosed by research 

criteria: 1. An 8-year prospective follow-up study. J Am Acad 

Child Adolesc Psychiatry. 1990;29:546–557. 

6. Murphy K, Barkley RA. Attention deficit hyperactivity disorder 

adults: co-morbidities and adaptive impairments. Compr 

Psychiatry. 1996:37;393–401. 

7. Bowen R, Chavira DA, Bailey K et al. Nature of anxiety 

comorbid with attention deficit/hyperactivity disorder in 

children from a pediatric primary care setting. Psychiatry Res. 

2008;157:201–9. 

8. Casey JE et al. Learning disorders in children with attention 

deficit disorder with and without hyperactivity. Child Neuropsychology. 

1996;(2):83–98. 

9. Langberg JM, Froehlick TE, Loren REA et al. Assessing 

children with ADHD in primary care settings. Expert Rev 

Neurother. 2008;8:627–41. 

New Zealand general practice should adopt 

population-based screening for attention 

deficit hyperactivity disorder (ADHD) 

NO 

Prevention of harm through screening is 

naturally a good thing to do—only a wowser 

would vote against it. However we work in a 

resource-limited system and so have to carefully 

consider where we should put our efforts. Over 

the years many new screening programmes have 

been proposed and then fallen by the wayside. 

As far back as 1968 the World Health Organization 

promoted a set of criteria to be met before a 

screening programme is adopted. These include: 

Is it a well-defined and important disease? Does 

the population want the screening? Do we have 

a sensitive and specific test to help differentiate 

those at risk? Do we have an effective intervention, 

is the screening likely to lead to harm 

rather than benefit? Do we have evidence of 

benefit from randomised controlled trials? Do we 

have the resources to implement the screening 

programme? 

So how does screening for attention deficit 

hyperactivity disorder (ADHD) stack up against 

these criteria? ADHD is a chronic behavioural 

disorder characterised by persistent hyperactivity, 

impulsivity, and inattention. 1 Its reported 

prevalence is greater in boys than girls, decreases 

with age and varies from country to country with 

the USA reporting as many as one in 20 children 

with a diagnosis of ADHD. 2 Many young people 

with signs of ADHD have comorbid conditions 

such as depression, conduct disorders, substance 

abuse and bipolar disease. 1 It is therefore difficult 

to determine what the natural history of ADHD 

is when many of the outcomes can be confounded 

by the comorbidities. Whilst we have quite good 

data on what happens to children with signs of 

Ross Lawrenson MD, 

FRCGP, FFPH, FAFPHM; 

Professor of Primary 

Care, Waikato Clinical 

School, The University of 

Auckland, Auckland, New 

Zealand; r.lawrensen@ 



BACK TO BACK 

ADHD, 3 the progression and outcomes for adolescents 

and adults is less well documented. We do 

know that those with attention disorder in childhood 

are less likely to achieve academically, and 

are more likely to have accidents. There is also 

an association with ADHD, conduct disorders in 

childhood and later use of drugs. 4 Given what 

we know about ADHD do we believe there is a 

demand for population-based screening in NZ? A 

number of screening programmes fail because of 

poor uptake. The Before Schools Checks includes 

a screening test for behavioural problems—and 

the uptake to date has been poor. I suspect the 

uptake by adolescents and adults would be even 

worse. We would certainly need studies to 

ascertain the likely uptake before embarking on a 

population-based programme. 

One danger of a screening test is that it may 

lead to some patients being incorrectly labelled 

rectly labelled as having a condition which may 

have lifelong implications. 

The next key question is: do we have an effective 

intervention? Whilst there are good randomised 

controlled trials (RCTs) of a number 

of agents (e.g. methylphenidate, amphetamines, 

and desipramine) these are generally short-term 

studies and the outcomes measured are mainly 

reductions in symptom scores. 6 No one has 

had the money to show that long-term use of 

methylphenidate has improved intellectual attainment, 

reduced driving accidents or helped 

with employment—the outcomes that matter. 

In the absence of long-term RCTs in a screened 

population it is unsafe to extrapolate the drug 

trials in highly selected populations to propose 

effectiveness. Longer term studies have shown 

large drop-out rates with older children being less 

likely to adhere to treatment. 7 Thus the efficacy 

The side effects of medication for ADHD are well recognised, 

but more important is their potential for abuse. Eleven percent 

of adolescents being treated in the USA reported selling their 

medication. Another concern is the harm generated by labelling 

a child or adolescent as having ADHD 

as having a disorder and subsequently being 

unnecessarily or incorrectly treated. There are 

a number of screening tools for ADHD. Most 

are sensitive, but lack specificity. Consequently 

a second stage is required where those identified 

through screening are then reviewed and a 

diagnosis made. For ADHD this should involve 

a psychiatrist. It could be argued that general 

practitioners (GPs) are competent to accurately 

diagnose the condition. Whilst we do not know 

NZ GPs’ views on this, a Canadian study suggested 

95% of GPs would refer patients for a 

specialist opinion. 5 I would suspect that most NZ 

GPs would want to have an expert opinion—to 

ensure there was not a misdiagnosis of another 

psychiatric condition, to ensure comorbid conditions 

had been appropriately picked up, and of 

course to make sure that people were not incorof 

treatment in a screened population is likely to 

be much less than that found in short-term RCTs 

with selected patients. Is screening likely to 

lead to harm as well as benefit? The side effects 

of medication for ADHD are well recognised, 

but more important is their potential for abuse. 

Eleven percent of adolescents being treated in the 

USA reported selling their medication. 8 Another 

concern is the harm generated by labelling a child 

or adolescent as having ADHD. 

Finally, do we have the resources to implement 

a screening programme? The MaGPIe study 

noted that GPs felt that managing mental health 

problems took more time, the costs were likely to 

be subsidised by the practice as patients were not 

prepared to pay the full costs, and more training 

was needed if recognition of mental health 


BACK TO BACK 

problems was to be improved. 9 We should also 

recognise that there is a shortage of psychiatrists 

with expertise in the area and so waiting lists for 

assessment and diagnosis are likely to be long. The 

opportunity costs both to GPs and mental health 

services are likely to be considerable and would 

require a reduction of activity in other areas. 

Let my review not be construed as saying ADHD 

is not important or that GPs should not be 

involved in its management. Rather I am saying 

that in patients and families who present for help, 

proper diagnosis and ongoing long-term support 

should be available. But I would suggest that the 

greatest utility is achieved by concentrating on 

the most severely affected, who have been identified 

by parents and teachers as being in need of 

help. This does not mean we should leap into a 

screening programme. 

In summary, I would argue that ADHD does not 

meet the criteria for a screening programme. It 

is poorly defined, is frequently associated with 

comorbid mental health conditions and the health 

impact is not well quantified. Does the population 

want the screening? This is not known, but 

uptake in children has been poor. Do we have 

a sensitive and specific test to help differentiate 

those at risk? A variety of tests are available, 

but different tests are better for different age 

groups, they are time-consuming and doctors or 

their staff would need training. In the hands of 

experts they are generally sensitive, but followup 

diagnosis is required. Do we have an effective 

intervention? There are a number of medications 

that have shown symptom reduction in shortterm 

studies, but longer-term drop-out rates 

are high and the evidence of long-term benefit 

for outcomes that matter is poor. Is the screening 

likely to lead to harm rather than benefit? 

Adverse aspects of labelling and diversion of 

drugs into the illicit market are likely to be a 

problem. Do we have the resources to implement 

the screening programme? There is evidence that 

managing mental health problems takes more 

time, more training is required and the additional 

costs are likely to be borne at least in part by GPs. 

References 

1. Wolraich ML, Wibelsman CJ, Brown TE et al. Attentiondeficit/hyperactivity 

disorder among adolescents: a review of 

the diagnosis, treatment and clinical implications. Pediatrics. 

2005;115:1734–1746. 

2. Faraone SV, Sergeant J, Gillberg C, Biederman J. The worldwide 

prevalence of ADHD: is it an American condition? World 

Psychiatry. 2003:2(2):104–13. 

3. Fergusson DM. Lynskey MT. Horwood LJ. Attentional difficulties 

in middle childhood and psychosocial outcomes in young 

adulthood. J Child Psychol Psychiatry. 1997;38(6):633–44. 

4. Fergusson DM. Horwood LJ. Ridder EM. Conduct and attentional 

problems in childhood and adolescence and later 

substance use, abuse and dependence: results of a 25-year 

longitudinal study. Drug Alcohol Depend. 2007; 88 Suppl 

1:S14–26. 

5. Miller AR. Johnston C. Klassen AF. Fine S. Papsdorf M. Family 

physicians’ involvement and self-reported comfort and skill in 

care of children with behavioural and emotional problems: a 

population-based survey. BMC Fam Pract. 2005:6(1):12. 

6. Brown RT, Amler RW Freeman WS et al. Treatment of attention 

deficit/hyperactivity disorder: overview of the evidence. 

Pediatrics. 2005;115:e749–757. 

7. Charach A, Ickowicz A, Schachar R. Stimulant treatment over 

five years: adherence, effectiveness and adverse effects. J Am 

Acad Child Adolesc Psychiatry. 2004;43:559–567. 

8. Wilens TE, Gignac M, Swezey A, et al. Characteristics of 

adolescents and young adults with ADHD who divert or 

misuse their prescribed medications. J Am Acad Child Adolesc 

Psychiatry. 2006;45:408–414. 

9. MaGPIe Research Group. General practitioners’ perceptions 

of barriers to their provision of mental healthcare: a report on 

Mental Health and General Practice Investigation (MaGPIe). 

N Z Med J. 2005;118(1222):U1654. 

Until we have evidence from RCTs conducted 

in general practice, the answer to the question 

‘Should we screen for ADHD?’ is no. 


continuing professional development 

pearls 

cochrane corner 

String of PEARLS 

Practical Evidence About Real Life Situations 

PEARLS are succinct summaries of Cochrane Systematic Reviews 

for primary care practitioners—developed by Prof. Brian McAvoy for 

the Cochrane Primary Care Field (www.cochraneprimarycare.org), 

New Zealand Branch of the Australasian Cochrane Centre at the 

Department of General Practice and Primary Health Care, University 

of Auckland (www.auckland.ac.nz/uoa), funded by the New Zealand 

Guidelines Group (www.nzgg.org.nz) and published in NZ Doctor 

(www.nzdoctor.co.nz.). 

Thiazides best first choice for hypertension 

Beta-blockers not the best first-line treatment for 

hypertension 

ACE inhibitors have a modest blood pressure– 

lowering effect 

Renin inhibitors are effective in lowering blood 

pressure 

Little evidence of benefit from relaxation therapies 

for hypertension 

Aiming for blood pressure targets lower than 

140/90 mmHg may not be of benefit 

Weight-reducing drugs may be beneficial in 

hypertensive patients 

Organised systems of regular follow-up and review 

can improve blood pressure control 

Disclaimer: PEARLS are for educational use only and are not meant 

to guide clinical activity, nor are they a clinical guideline. 

NSAIDs for dysmenorrhoea 

Bruce Arroll MBChB, PhD, FRNZCGP; Professor of General Practice 

and Primary Health Care, The University of Auckland, Private Bag 92019, 

Auckland, New Zealand; b.arroll@auckland.ac.nz 

The problem: Dysmenorrhoea is a common gynaecological 

problem consisting of painful cramps accompanying menstruation 

which, in the absence of any underlying abnormality, is 

known as primary dysmenorrhoea. 

The situation: Research has shown that women with 

dysmenorrhoea have high levels of prostaglandins, hormones 

known to cause cramping abdominal pain. Nonsteroidal 

anti-inflammatory drugs (NSAIDs) are drugs which act by 

blocking prostaglandin production. Pain is usually centred in 

the suprapubic area, but may radiate to the back of the legs 

or lower back, and may be accompanied by other symptoms 

such as nausea, diarrhoea, headache and lightheadedness. The 

prevalence estimates vary widely. It was reported by 72% of 

Australian women of reproductive age in a recent nationallyrepresentative 

sample and caused severe pain in 15% of cases. 

Other representative samples report rates ranging from 17% to 

81%. In addition to the distress associated with dysmenorrhoea, 

surveys have shown significant socioeconomic repercussions: 

over 35% of female high school students report missing school 

due to menstrual pain and 15% of working. 

Clinical bottom line: All NSAIDs are effective for 

dysmenorrhoea and there does not seem to be one better than 

others. It was not possible to report a numbers needed to treat 

from the review, but in one of the typical papers it was about 

five. The review did not suggest when to start taking the 

medication, but some of the studies advised to start taking the 

medication at the onset of first cramps. 

NSAIDs for dysmenorrhoea 

NSAIDs for 

dysmenorrhoea 

Success Evidence Harms 

NNT of 

about 5 

Cochrane 

review 1 

Risk of renal injury and 

gastric bleeding 

NNT = numbers needed to treat for one person to get an improvement 

References 

1. Marjoribanks J, Proctor M, Farquhar C, Derks RS. Nonsteroidal anti-inflammatory 

drugs for dysmenorrhoea. Cochrane Database of Systematic Reviews 2010, 

Issue 1. Art. No: CD001751. DOI: 10.1002/14651858.CD001751.pub2. 

All people residing in New Zealand have access to the Cochrane Library 

via the Ministry website www.moh.govt.nz/cochranelibrary 



charms & harms 

Ginkgo 

Ginkgo biloba L., also known as fossil tree, 

kew tree, maidenhair tree, yin xing (whole plant), 

yin xing ye (leaves), bai guo (seeds) 

Preparations: The leaf is the part used medicinally; 

in Traditional Chinese Medicine and 

in Japan, the seed is also used, although it contains 

some toxic constituents. Extracts of ginkgo 

leaf are available in several dose forms, including 

capsules, tablets and tinctures. Chopped or 

powdered forms of the dried material are also 

available. Several products marketed as dietary 

supplements containing ginkgo are available on 

the New Zealand market. 

Active constituents: Ginkgo has been 

described as having polyvalent action; that is, the 

combined activities of several constituents are 

responsible for its effects. Important constituents 

of the leaves include the ginkgo flavonoid glycosides 

(e.g. glycosides of quercetin and kaempferol) 

and the terpene lactones (e.g. ginkgolides 

A, B and C). Modes of action demonstrated in 

preclinical studies include cardiovascular and 

haemorheological effects, antagonism of plateletactivating 

factor, antioxidant activity and effects 

on concentrations of certain neurotransmitters. 

Seeds contain ginkgotoxin (4-O-methylpyridoxine) 

and ginkgolic acids. 

Main uses: Ginkgo leaf and seed have a history 

of traditional use in China for asthma and the seed 

also as an antitussive and expectorant. Contemporary 

interest in ginkgo leaf is focussed on its use 

in cognitive deficiency and dementia, intermittent 

claudication (from peripheral arterial occlusive 

disease) and vertigo and tinnitus of vascular origin. 

It is also used and promoted for cognitive improvement 

in healthy individuals. 

Evidence for efficacy: Recent Cochrane 

systematic reviews are available of clinical trials 

that assessed the effects of standardised ginkgo 

leaf preparations in cognitive impairment and dementia, 

intermittent claudication, acute ischaemic 

stroke, tinnitus and age-related macular degeneration. 

These reviews conclude that there is no convincing 

evidence available to support the efficacy 

of the ginkgo preparations tested in cognitive impairment 

and dementia, intermittent claudication, 

recovery after ischaemic stroke and tinnitus; there 

was insufficient research to determine whether 

or not ginkgo is efficacious in age-related macular 

degeneration. Many trials, particularly older ones, 

have methodological limitations. 

A Cochrane systematic review of trials of ginkgo 

for cognitive improvement in healthy individuals 

is in preparation. 

Adverse effects: Typically, Cochrane systematic 

reviews of (usually small-scale) clinical trials 

have not shown any difference between ginkgo and 

placebo with respect to the frequency of adverse 

events, including bleeding episodes. However, spontaneous 

reports of adverse effects associated with 

the use of ginkgo preparations have raised concerns 

about the risk of haemorrhagic reactions, including 

intracranial and ocular bleeding. Many of these 

cases concern individuals who were also taking conventional 

antiplatelet and/or anticoagulant agents, 

although some concerned use of ginkgo only. 

A small number of drug interaction studies have 

indicated that ginkgo leaf extracts generally had no 

Joanne Barnes 

BPharm, PhD, MRPharmS, 

RegPharmNZ, FLS; 

Associate Professor 

in Herbal Medicines, 

School of Pharmacy, The 



Herbal medicines are a popular health care choice, but few have been tested to contemporary standards. 

CHARMS & HARMS summarises the evidence for the potential benefits and possible harms of wellknown 

herbal medicines. 



charms & harms 

Summary message 

Evidence for the efficacy of ginkgo extracts for cognitive impairment and 

dementia, intermittent claudication, acute ischaemic stroke, tinnitus and 

age-related macular degeneration is unconvincing. Ginkgo preparations 

have been associated with haemorrhagic reactions. Health professionals 

should be aware of the possibility of (undisclosed) use of ginkgo; use of 

ginkgo should be avoided, or at least used only with caution, in patients with 

bleeding disorders and those taking conventional anti-platelet or anticoagulant 

agents. If using ginkgo, these patients should be advised to be vigilant 

for signs of bleeding and to seek professional help. Suspected adverse drug 

reactions should be reported to CARM. As with all herbal medicines, different 

ginkgo products vary in their pharmaceutical quality, and the implications 

of this for efficacy and safety should be considered. 

statistically significant effects on antiplatelet effects 

and/or pharmacokinetics of clopidogrel or ticlopidine, 

or on the pharmacokinetics and pharmacodynamics 

(INR) of warfarin. However, these studies 

involved healthy volunteers and the relevance of 

these findings to the clinical setting is unclear. 

It is prudent to advise that use of ginkgo should be 

avoided in patients with bleeding disorders, since it 

is unlikely that the benefit–harm balance is favourable 

on the basis of current evidence. Likewise, 

ginkgo should only be used with caution in patients 

taking anticoagulant and/or antiplatelet agents. 

Some authors advise that the evidence is insufficient 

to advise patients taking such medicines to avoid 

using ginkgo. If ginkgo is used, patients should be 

advised to monitor for bruising and other signs of 

bleeding, and to seek professional help if this occurs. 

Contact with or ingestion of the fruit pulp can 

cause severe allergic reactions. 

Health professionals are reminded to report 

suspected adverse reactions associated with all 

medicines, including vaccines and complementary 

medicines, to the Centre for Adverse Reactions 

Monitoring (http://carm.otago.ac.nz). 

Drug interactions: See Adverse effects for 

information on interactions with antiplatelet/anticoagulant 

agents. 

Drug interaction studies involving healthy volunteers 

who received ginkgo leaf extracts have 

indicated that ginkgo induces the metabolism and 

lowers concentrations of omeprazole; it is unlikely 

that the benefit–harm balance for using ginkgo in 

patients being treated with omeprazole would be 

favourable on the basis of current evidence. Similar 

studies have shown that ginkgo leaf extracts did 

not appear to have clinically relevant pharmacokinetic 

interactions with alprazolam, caffeine, chlorzoxazone, 

dextromethorphan, diclofenac, digoxin, 

donepezil, fexofenadine, flurbiprofen, midazolam, 

propranolol, ritonavir, theophylline or tolbutamide. 

There is limited evidence from preclinical studies 

that the administration of ginkgo and amikacin 

may accelerate amikacin-induced ototoxicity, and 

that ginkgo may lead to raised concentrations of 

diltiazem and nifedipine and reduced concentrations 

of nicardipine. There is also some limited 

clinical evidence of an interaction with nifedipine. 

There is a small number of isolated case reports of 

breakthrough seizures in patients taking sodium 

valproate, with or without phenytoin, in patients 

who began taking ginkgo leaf extract or were 

taking several products containing ginkgo. Until 

further information is available, patients should be 

made aware of this possible interaction. 

Key references 

Barnes J, Anderson LA, Phillipson JD. Herbal medicines. 3rd edition. 

London: Pharmaceutical Press; 2007. 

Birks J, Grimley Evans J. Ginkgo biloba for cognitive impairment 

and dementia. Cochrane Database of Systematic Reviews 

2009, Issue 1. Art. No.: CD003120. DOI: 10.1002/14651858. 

CD003120.pub3. 

Nicolaï SPA, Kruidenier LM, Bendermacher BLW, Prins MH, Teijink 

JAW. Ginkgo biloba for intermittent claudication. Cochrane 

Database of Systematic Reviews 2009, Issue 2. Art. No.: 

CD006888. DOI: 10.1002/14651858.CD006888.pub2. 

Zeng X, Liu M, Yang Y, Li Y, Asplund K. Ginkgo biloba for acute 

ischaemic stroke. Cochrane Database of Systematic Reviews 

2005, Issue 4. Art. No.: CD003691. DOI: 10.1002/14651858. 

CD003691.pub2. 

Hilton MP, Stuart EL. Ginkgo biloba for tinnitus. Cochrane Database 

of Systematic Reviews 2004, Issue 2. Art. No.: CD003852. DOI: 

10.1002/14651858.CD003852.pub2. 

Evans JR. Ginkgo biloba extract for age-related macular degeneration. 

Cochrane Database of Systematic Reviews 1999, Issue 3. 

Art. No.: CD001775. DOI: 10.1002/14651858.CD001775. 

Lee H, Birks J. Ginkgo biloba for cognitive improvement in 

healthy individuals (Protocol). Cochrane Database of Systematic 

Reviews 2004, Issue 1. Art. No.: CD004671. DOI: 

10.1002/14651858.CD004671. 

Bent S et al. Spontaneous bleeding associated with ginkgo biloba. A 

case report and systematic review of the literature. J Gen Intern 

Med. 2005;20:657–661. 

Williamson EM, Driver S, Baxter K. Stockley’s herbal medicines 

interactions. London: Pharmaceutical Press; 2009. 



pounamu 

A whanau ora approach to 

health care for Maori 

Jacquie Kidd PhD, RN; 1 Veronique Gibbons MSc, BSc(Hons), RN; 2 Ross Lawrenson MD, FRCGP, FFPH, 

FAFPHM; 2 Wayne Johnstone MA (Hons), BA 3 

A 

whanau ora approach to health care is 

becoming well-established within the 

primary health care sector, which means 

that we now see many providers, particularly 

Maori providers, employing whanau ora workers 

who work not just directly with individuals 

but with families to help to support individuals 

often with chronic disease or mental health 

problems. At the same time a number of important 

initiatives have emerged including marae 

and community-based clinics which emphasise 

a positive approach to Maori health, philosophy 

and models. However, it is evident that there are 

subtle variations in how people and organisations 

perceive a whanau ora approach; indeed it is an 

approach that is used not only in health but in 

education and the social welfare sector. It should 

also be acknowledged that there may be local 

and iwi-based differences in understanding what 

whanau ora is. 

The term whanau ora was promoted by Mason 

Durie 1 as the component of good health that 

relates to the support from and connection to 

the family. Since then the term has been more 

widely used to affirm the importance of whanau 

planning and management of their own health 

including wairua (spirituality), te ao Maori (the 

Maori way of living in the world), tikanga (Maori 

customs and protocols), self-determination, and 

economic and social factors. This broadened view 

of health is part of the government’s Maori policy 

document He Korowai Oranga and is defined 

as ‘Maori families supported to achieve their 

maximum health and wellbeing.’ 2 Ora relates to 

well-being or health. When paired with whanau, 

the meaning is expanded to suggest the health 

and well-being of the family within the environment 

in which they interact. A more modern 

translation of whanau represents not only blood 

relations but also the relationship through a common 

goal or similar interests. 3 

Throughout the various District Health Boards, 

Maori providers and other health service providers, 

whanau ora has been used as a guiding 

principle and value, a goal, and in some instances 

it has been used to describe a type of health 

service being delivered to local Maori communities. 

While each has varying definitions on what 

whanau ora is to their particular region and/ 

or service, it is clear that the overall goal is to 

achieve maximum wellness for the whanau. 

When structuring a kaupapa Maori research 

project that explores the whanau ora experiences 

of Maori men who have chronic disease or cancer, 

our team of Maori and non-Maori clinicians, 

academics and health care service managers 

concluded that the development of a local understanding 

of whanau ora was required. Bishop, 4 

in discussing kaupapa Maori as a preferred 

1 

The University of Auckland, 


2 

Waikato Clinical School, 

The University of Auckland 

3 

Te Puna Oranga (Maori 

Health Service), Waikato 

District Health Board 


Jacquie Kidd, 

Peter Rothwell Academic 

Centre, Waikato Clinical 

School, Waikato District 

Health Board, PB 3200, 

Hamilton, New Zealand 

j.kidd@auckland.ac.nz 

Pounamu 

Maori primary health care treasures 

Pounamu (greenstone) is the most precious of stone to Maori. 

‘Ahakoa he iti, he pounamu’ 

(Although it is small, it is valuable) 



POUNAMU 

methodology, includes the principles of 

whakapapa (genealogy), whanau, te reo 

(language), tikanga, rangatiratanga (selfdetermination), 

and aroha ki te tangata 

(respect, accountability and valuing all 

those involved with and affected by 

the research). In addition to providing 

a sound cultural and ethical basis for 

the proposed research, 5 these principles 

are congruent with the generic research 

aims and form a basis to what Cram 6 

describes as talk as data. 

To this end, the Oranga Tane project 

team sought guidance from Waikato 

Kaumatua to determine what a local 

definition of whanau ora might look 

like. This was done through a series of 

hui (meetings) held with local Kaumatua 

in each of the Tainui iwi areas: Waikato, 

Maniapoto, Raukawa and Pare Hauraki. 

Hui are an oral and aural medium for 

discussing, debating and coming to a 

shared understanding about issues, and 

have a defined process to follow; this 

was undertaken by the Kaumatua for the 

research team, Kingi Turner. Kaumatua, 

defined as men and women elders who 

are guardians of genealogy, spirituality 

and Maori knowledge, were invited 

through their particular marae-based 

organisations to attend the hui and respond 

to the researchers’ request to ‘tell 

us what you understand by the term 

whanau ora.’ The ensuing discussion was 

captured on a whiteboard by a member 

of the research team who is fluent in te 

reo Maori. This ensured that the content 

of the discussion was accurately recorded 

and provided the participants with the 

opportunity to correct any misunderstandings 

or missed points as an integral 

part of the hui process. 

Although the overall aim of the study 

is focussed on Maori men, the guidance 

that came from Kaumatua encompassed 

the whanau as a whole. The well-being of 

mokopuna (grandchildren) was a focus, 

with many discussions about the importance 

for all the whanau to stay healthy 

so the children’s well-being could be 

assured. Other areas of interest included 

the importance of whanau-based 

health education and the importance of 

wairuatanga (spiritual connection) to 

health, although the hui also acknowledged 

a general reluctance to attend 

health screening and early treatment, the 

perceived unfriendliness of Westernbased 

health services, and the difficulties 

for some whanau who need to travel to a 

main centre to access health services. 

The issue of who speaks or acts on 

behalf of the whanau was also explored, 

with some of the Kaumatua arguing for 

a departure from the traditional gender 

separation of women’s and men’s health 

information. It was proposed that the 

whanau as a whole should be aware of 

the health needs of their members, and 

be prepared to advocate and encourage 

self-care for the well-being of the wider 

whanau. These concerns are common to 

international indigenous populations. 7 

In addition, wide-ranging discussions 

took place about how to connect te ao 

Maori, whanau, and health care services 

so that whanau ora is achieved. The need 

for health services to be integrated into 

social and economic services was clearly 

articulated, and is consistent with national 

policy directions. 8 

What became clear throughout the hui 

is that whanau ora is complex, with 

many interconnecting facets. Our findings 

indicate that difficulties accessing 

primary health care remains an issue for 

Maori, despite an apparent awareness of 

the need for health screening and early 

treatment. It appears that there is a still 

unmet need for culturally-appropriate 

health care to improve acceptability of 

health care provision. The Kaumatua 

were emphatic about the need for their 

whanau to be engaged with health care 

education, which they viewed as being 

important for the future health of their 

mokopuna. The value of the whanau 

ora approach is that the connections 

between health care providers, the world 

of Maori and the people of the whanau 

are made explicit and measurable. Maori 

community health workers provide 

general practitioners and others with 

the opportunity for such connections to 

be made and for improved health care 

outcomes for Maori. 9 

Overall we have presented in this paper 

the beginnings of a local whanau ora 

definition which is consistent with the 

understanding shown in a number of 

studies to have improved access and 

health outcomes. We would encourage 

primary health care workers to work 

with Maori providers and others who 

are involved in whanau ora provision 

to avail themselves of this expertise 

in order to improve outcomes for their 

Maori patients. 

References 

1. Durie MH. Whaiora: Maori health development. 

Auckland: Oxford University Press; 1994. 

2. Ministry of Health. He Korowai Oranga: Maori 

Health strategy. Wellington, New Zealand: Ministry 

of Health; 2002. 

3. Smith GH. Whakaoho whanau: new formations 

of whanau as an innovative intervention into 

Maori cultural and educational crises. He Pukenga 

Korero. 1995;1(1):18–36. 

4. Bishop R. Freeing ourselves from neocolonial domination 

in research: a Kaupapa Maori approach 

to creating knowledge. In: The sage handbook 

of qualitative research. Denzin NK and Lincoln Y, 

editors. Thousand Oaks: Sage; 2005. p 109–138. 

5. Smith LT. On tricky ground: researching the native 

in the age of uncertainty. In: The sage handbook 

of qualitative research. Denzin NK and Lincoln Y, 

editors. Thousand Oaks: Sage; 2005. p 85–108. 

6. Cram F, et al. Kaupapa Maori research and Pakeha 

social science: epistemological tensions in a study 

of Maori health. Hulili. 2006;3(1):41–68. 

7. Mowbray M and the WHO commission on social 

determinants of health. Social determinants and 

Indigenous health: the international experience 

and its policy implications. In: International symposium 

on the social determinants of indigenous 

health. Geneva, Adelaide: World Health Organization; 

2007. 

8. Public Health Advisory Committee. The health of 

people and communities. A way forward: public 

policy and the economic determinants of health. 

Wellington, New Zealand: National Health Committee; 

2004. 

9. Boulton AF, HH Gifford, Potaka-Osborne M. 

Realising Whanau Ora through community action: 

the role of Maori community health workers. 

Education for Health. 2009:22(2). 


ethics 

Too much information? 

Grant Gillett MBChB, D.Phil (Oxon), FRS NZ, FRACS; Donald Saville-Cook BSc, PGDip.HealSci (Otago), D.E.T.C.C. 

A 

number of recent cases have 

raised the issue of the risks that 

are posed both by everyday 

medicines and by alternatives to standard 

medical interventions, an aspect of 

practice that has been made especially 

significant by the recent NZ Medical 

Council advice about fringe medicine 1 

and from the tendencies in contemporary 

medical literature and social policy 

to favour what can be referred to as 

‘marketing-based medicine’ masquerading 

as evidence-based medicine. 2 

The partial and selective information 

provided by the medical establishment 

raises questions about how many risks we 

should unwittingly run or be allowed to 

run by our medical advisors. The answer 

to this question must, however, be balanced 

against two other considerations in 

the area of information and disclosure. 

i. An ordinary consulting doctor, 

within the constraints of a clinical 

practice, cannot be expected to run 

through all the potentially relevant 

information relating to a condition 

and its management as part of a 

normal consultation with a patient, 

although there must be some required 

level of diligence. 

ii. Although the doctor has a legally well- 

established duty to answer a patient’s 

questions truthfully and to the best 

of their ability, the patient should not 

have to play a macabre game of 20 

questions to find out about aspects of 

their condition and its treatment that 

they might regard as significant. 

The problem of information and what is 

required to satisfy rights 5 and 6 of the 

New Zealand Code of Health and Disability 

Services Consumers’ Rights 3 is 

made pressing by two possibilities. The 

first is the existence of potentially very 

serious but systematically downplayed 

or concealed side effects from heavily 

marketed and promoted medications 

(such as statins) and the second is the existence 

of unorthodox or fringe regimens 

for diseases with a standard therapeutic 

profile (such as psychiatric syndromes or 

cardiovascular disease). 

A case study 

Statin therapy has been associated with 

some serious and poorly documented side 

effects in that there is a link between not 

only myalgia but also rhabdomyolysis 

and statins. 4,5 Various reports in sources 

ranging from The American Journal of 

Medicine to The New York Times have 

listed multiple neuromuscular conditions 

associated with statins, although this evidence, 

by its very nature, may be underreported 

because of its varying severity. 

A number of patients may well not be 

told of this association and its potentially 

life-affecting consequences, despite the 

fact that it is alluded to in the drug 

information, in part, because of the lack 

of emphasis on this aspect of the drugs in 

the literature and the widely publicised 

prophylactic benefits of statins. The 

importance of prevention of heart attacks 

and strokes (and the attendant mortality 

and morbidity) makes us very ready to 

swallow the industry message (not to say 

the pills). Therefore, even if patients have 

a right to know about such problems, 

it is not clear to what extent a doctor 

should foreground them (despite the clear 

warnings on the Medsafe website) nor to 

what extent s/he could be the subject of 

complaints that potentially debilitating 

side effects were not mentioned. Given 

that patients often take their cue from the 

doctor about what is relevant to discuss in 

a clinic appointment, the omission could 

be serious in certain cases. 

The second problem is posed by the 

recent NZ Medical Council advice in its 


Grant Gillett 

Professor of Medical Ethics, 

Otago Bioethics Centre, 

University of Otago Medical 

School, PO Box 913, 

Dunedin, New Zealand 

grant.gillett@otago.ac.nz 

The ethics column explores issues around practising ethically in primary health care 

and aims to encourage thoughtfulness about ethical dilemmas that we may face. 

THIS ISSUE: Grant Gillett, Professor of Medical Ethics from Otago, and his colleague, 

Donald Saville-Cook, address the issue of how much information needs to be given 

to patients, firstly about serious and potentially life-threatening adverse effects of 

commonly-prescribed medications (such as statins) and, secondly, our duty to raise the 

options of radical or fringe treatments, and then explain why risk might outweigh benefit. 


ethics 

Ethics 101 column. 6 The tone of the piece 

is to equate all non-orthodox practices 

with quackery or fraud and to dismiss 

them out of hand. But the idea that our 

biomedical theories are fully adequate to 

the intractable bestiary of ‘medicine in 

the (urban) jungle’ is a gross simplification. 

In reality, a complex nexus of socioeconomic 

variables, genetic dispositions, 

patterns of referral and categorisation, 

market-based selection of disseminated 

medical information, and so on, 2 and the 

rise of the psycho-neuro-humero-immunological 

concepts of human health and 

disease muddy the waters. 7 What, given 

this mish-mash and the lack of undistorted 

and scientific evidence relating to 

wide swathes of medical practice such 

as primary care, community psychiatry, 

and everyday unwellness, ought one to 

say and do? 

mentioned to patients with OCD or 

depression? We seem to be on notice by 

the Medical Council of NZ that if that 

were done they would not regard the 

practice as ethical, but the HDC code 

Right 6(a) demands of providers ‘an 

explanation of the options available’ 3 (of 

which more anon). Suppose the patient 

found prescribed alternatives distressing 

or to have unwanted side effects (like 

weight gain)? The well-intentioned and 

patient-centred doctor is likely to be in 

a quandary in such a case, particularly 

if the patient is one in whom untoward 

events might be predicted. One might 

want to mention the possibility of 

something a bit ‘fringe’ but what is the 

ethical stance to doing so? It seems that 

the patient is entitled to a fair representation 

of current medical opinion and 

answer problematic. There obviously 

needs to be some kind of weighting 

of advice about risks, but how should 

that be done. The language of material 

risk—the kind of risk a reasonable person 

would take into account in making 

a decision—that is often used does not 

tell us how well established those risks 

should be. A risk of rhabdomyolysis or 

polyneuropathy is likely to be material 

to anyone even though it is rare, 

and common problems like myalgia 

are plausibly material in that the kind 

of group who take statins might find 

their physical activity significantly 

compromised by such a side effect. But 

these may not be foregrounded in the 

information available to the average 

practitioner, so that the question arises 

as to what constitutes due diligence in 

The problem is intensified when we 

consider cases such as the following: an 

18-year-old male underwent cognitive 

behavioural therapy for severe obsessive 

compulsive disorder (OCD) and depression 

which had the effect of mitigating 

it from severe to moderate. He then 

underwent an ‘ABAB, (n of 1)’ trial of 

a nutritional formula during which ‘his 

mood stabilised, his anxiety reduced, 

and his obsessions were in remission’. 8 

A return to normal diet provoked a relapse 

in his symptoms. This single case 

study may never be supported by any 

‘robust clinical evidence’ considering 

patterns of research funding, publication 

and promulgation in contemporary 

medicine, 9 quite apart from the reality 

of the situation. Nevertheless it is the 

kind of case behind the major damages 

awarded to Truehope as a result of a 

class 1 withdrawal of drugs required by 

Health Canada. 10 

This is a classical example of fringe 

medicine (contra the Medical Council 

document, 3 rationally and scientifically 

reported and assessed) but should 

the option it reports be offered or even 

Perhaps all that one can say is that the doctor should be a 

trustworthy guide and partner in the information sharing 

required for effective treatment, a role that is hard to 

specify but that is a key element of good clinical practice 

one should probably position the advice 

being given against that framework in 

any consultation. 11 

A number of further questions arise 

from these problems about the ethics 

of medical information and the responsibilities 

of doctors in their advice to 

patients. 

To what extent are patients 

entitled to information about 

risks of their treatment? 

A number of blanket statements state 

that a patient is entitled to know of any 

significant risks associated with a proposed 

course of treatment (as in Right 

6.1(b) of the code) but the existence of 

contested or unusual risks makes that 

accessing the relevant information, a 

problem compounded by the abundance 

of medical information of varying quality 

on the Internet. 

How should doctors deal with risks 

that a patient has found about 

from the Internet and other sites? 

Here one faces the nightmare scenario 

of the patient who ‘cannot see the 

wood for the trees’. There are in every 

practice patients who will make a major 

issue out of a possibility that most 

people would not be overly concerned 

about to the point where they might 

make bad decisions from a faulty appraisal 

of the evidence available. The 

idea of truly patient-centred medicine 

takes us a certain way in that the doc- 


ethics 

tor should assess the patient and the 

ways in which the patient is likely to 

distort or misinterpret evidence in the 

light of idiosyncratic personality factors 

so as to form a harmful or prejudicial 

opinion about their illness and its management. 

But one can imagine pitfalls 

aplenty in certain cases. Perhaps all that 

one can say is that the doctor should 

be a trustworthy guide and partner in 

the information sharing required for 

effective treatment, a role that is hard 

to specify but that is a key element of 

good clinical practice. 

What options should a doctor or 

health care professional provide 

the patient with information about? 

This question raises the issue of what 

is ‘reasonable medical care’ or ‘a reasonable 

body of medical opinion’ (both 

terms are often used in disciplinary 

hearings). The concept becomes difficult 

to interpret when there are options 

available that may or may not be 

regarded as standard treatment in the 

context of the doctor’s practice. That 

problem became pressing in a NZ surgical 

case where a patient found out, via 

the Internet, about a radical approach 

to the treatment of brain tumours 

and took that option. Subsequently a 

complaint was made that he had not 

been told of the possibility as part of 

his clinical management. The Health 

and Disability Commissioner’s opinion 

was that the advice given to the patient 

should have indicated the controversial 

possibility of more radical treatment 

than that which was offered. 

It was held that the neurosurgeon should 

have taken the time to discuss the option 

of further surgery. Although it would 

not be reasonable to expect him to offer 

to perform a procedure that he did not 

believe was a viable option, he needed 

to raise the option of further surgery 

(which was available elsewhere in New 

Zealand and in Australia) and explain 

why he thought the risks outweighed any 

potential benefit. The surgeon was found 

in breach of Right 6(1)(b). 

The more radical surgical option was 

commented on by other neurosurgeons 

who wrote to the Commissioner in 

the following terms: ‘whether or not a 

doubtful procedure should be advised 

to an anxious patient who will clutch 

at any straw is indeed arguable’; ‘Dr [X] 

gave advice to the patient and his family 

in keeping with standard… opinion’; ‘it 

is difficult to see why a surgeon should 

apologise for a management plan that 

was correct.’ These remarks express what 

many feel is sound and sensible when 

doctors are giving recommendations to 

patients about treatments. Nevertheless, 

the finding is in keeping with the 

Medical Council recommendation that 

a patient is entitled to know how the 

advice s/he has received compares with 

a range of clinical opinion in the area 

concerned. This is probably sound advice 

also in the light of the controversies 

surrounding complementary and alternative 

medicines (CAM) and ‘fringe’ or 

‘natural’ therapies. 

Should patients be encouraged 

to do their own homework? 

The ethical response to this question 

follows from the arguments above. In 

general, a patient should be encouraged 

to be an active participant in the 

problem-solving partnership that is a 

clinical relationship. In that context, a 

negotiated mix of spontaneous disclosure 

(conveying a more or less standard 

medical opinion about the patient’s 

problem) and a responsive disclosure 

(about matters raised by the patient) 

is likely to be the best that a wellintentioned 

doctor can do. The scope of 

information that gets into that conversation 

is potentially broad but should 

have the effect of helping the patient 

find his/her way around in the strange 

land that is Clinicum 11 with its often 

poorly understood hazards and variably 

well-understood therapeutic responses 

to those hazards and where a great deal 

of the guidance that one gets in the 

normal course of practice is both interested 

and promotional. 

References 

1. Medical Council of New Zealand. Statement on 

complementary and alternative medicine. Wellington; 

March 2005. 

2. Spielmans G, Parry P. From evidence-based medicine 

to marketing-based medicine: evidence from 

internal industry based documents. J Bioethic Inq. 

2010;7(1). In press. 

3. NZ Health and Disability Commissioner website. 

02 HDC 18414. Accessed 27 Jan 2010. 

4. Canadian Adverse Drug Center. Newsletter. 

Statins: rhabdomyolysis and myopathy. Canadian 

Adverse Drug Reaction Newsletter. Toronto; January 

2002;12(1). 

5. Statins. http://www.medsafe.govt.nz/profs/puarticles/statinmyop.htm. 

Accessed 1 Feb 2010. 

6. Medical Council of New Zealand. Ethics 101. 

Medical Council News. Wellington; Dec 2009; 48. 

p 10–11. 

7. Ader R, Cohen N, Felten D. Psychoneuroimmunology: 

interactions between the nervous system and 

the immune system. Lancet. 1995;345:99–103. 

8. Rucklidge J. Successful treatment of OCD with a 

micronutrient formula following partial response 

to cognitive behavioural therapy. J Anxiety Disorders. 

2009;23(6):836–840. 

9. Elliot C. The drug pushers. Atlantic Monthly. 

2006;212:2–13. 

10. Woodruff C. Health Canada attacks successful 

nutritional approach to treating bipolar disorder. 

J Clin Psychiatry. 2003;64(3):1. 

11. Gillett G. Bioethics in the Clinic Baltimore: Johns 

Hopkins University Press; 2009; esp Ch 4. 


LETTERS TO THE EDITOR 

PSA screening reply 

In his Back to Back argument in favour of PSA screening, 

Robin Smart claims that PSA screening performs 

well compared to other screening programmes. 1 He gives a 

number needed to screen to save one life of 80, and number 

needed to treat to save one life of two to five. The source 

for these figures is not given, but they are very different 

from the preliminary estimates from the ERSPC study 

(which he quotes elsewhere) which found the number 

needed to screen over nine years to prevent one death was 

1410 and that the number needed to treat to prevent one 

death was 48. 2 

If men are to make an informed decision about whether 

to have a PSA test, then it is important that they are 

provided with the best estimates of the potential benefits 

and harms of the test. Smart’s figures give a misleadingly 

optimistic impression. 

Dr Ben Hudson 

References 

1. Smart R. New Zealand should introduce population screening for prostate 

cancer using PSA testing: Yes. J Primary Health Care. 2009;1(4):319–20. 

2. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer 

mortality in a randomized European study. N Engl J Med. 2009 March 18, 

2009:NEJMoa0810084. 

Cardiovascular disease risk profile tools and New 

Zealand—absolutely the best way forward 

I 

n December 2009, the Journal of Primary Health Care published 

a non–peer reviewed essay about the use of cardiovascular 

disease (CVD) risk profile tools in New Zealand. 1 The 

authors of this essay, Boland and Moriarty, used a crosssection 

analysis undertaken by our research group (Bannink 

et al. 2006) 2 and an outdated systematic review (Brindle et al. 

2006) 3 to argue against the use of CVD risk profile tools. As 

co-authors of the Bannink et al. paper we would appreciate the 

right of response. 

Boland and Moriarty are correct that our paper described 

the CVD risk factor status of the first 18 000 patients profiled 

in routine general practice in New Zealand using the PRE- 

DICT-CVD tool. They also correctly stated that the PREDICT 

decision support system is based entirely on evidence-based 

guidelines—the updated PREDICT CVD-Diabetes containing 

recommendations from the New Zealand Guidelines for CVD 

Risk Assessment and Management and the Management of 

Type 2 Diabetes. 

However, the authors of the essay inappropriately criticise 

this paper as not being able to show evidence of effectiveness 

of CVD risk profile tools. The Bannink paper was simply a 

cross-sectional analysis of risk factor profiles generated opportunistically 

in general practice. The purpose of this first paper 

by the PREDICT investigators was to describe the baseline 

characteristics of a cohort to be used to generate new risk prediction 

tools and to demonstrate how a cohort study could be 

undertaken in routine primary care practice using a web-based 

clinical decision support system (CDSS). This paper never was 

nor ever could be a study of effectiveness of decision support 

tools, nor would ever be included in a systematic review of 

the impact of CVD risk profile tools. It represented the first 

stage of a large New Zealand cohort study, the most appropriate 

study design for generating risk prediction equations. 

The Framingham equation used in New Zealand CVD 

risk assessment and management guidelines 4 has long been 

acknowledged as having deficiencies leading to over-prediction 

of risk in low risk populations and under-prediction of risk 

in high risk populations. 3 In the six years since the publication 

of Bannink et al., New Zealand GPs and practice nurses 

have produced a cohort of over 120 000 participants using the 

PREDICT decision support system. By linking the risk profiles 

in this cohort to hospitalisations and deaths, it will be possible 

to develop up-to-date risk prediction equations relevant 

for all New Zealanders and for specific high risk population 

subgroups such as those of Maori, Pacific and South Asian 

ethnicities. Boland and Moriarty raise concerns about possible 

missing ethnicity data. As ethnicity is an integral variable in 

New Zealand risk prediction algorithms, it is not possible to 

get a risk prediction score using PREDICT without having 

complete data entry. Indeed, there is no missing risk assessment 

data on anyone in the PREDICT cohort. 

Letters may respond to published papers, briefly report original research or case reports, or raise matters of interest relevant to 

primary health care. The best letters are succinct and stimulating. Letters of no more than 400 words may be emailed to: 

editor@rnzcgp.org.nz. All letters are subject to editing and may be shortened. 


LETTERS TO THE EDITOR 

The authors develop a debate against the effectiveness of 

CVD risk profile tools citing the systematic review by Brindle 

et al. published in 2006. They state that ‘…this review found 

no conclusive evidence that the use of CVD risk profile tools 

significantly improves patient care.’ 

The review, now out-dated, found that ‘four randomised 

controlled trials confined to people with hypertension or 

diabetes found no strong evidence that a cardiovascular risk assessment 

performed by a clinician improves health outcomes.’ 

The four randomised controlled trials investigated the impact 

of giving patients a CVD risk score. CVD risk assessment 

and management requires a long-term committment to our 

patients. It is well-known that one-off advice rarely leads to 

persisting changes in patient behaviour. So it is not surprising 

that providing a CVD risk assessment at one point in time did 

not change patient health outcomes. Furthermore, two of the 

trials had a CDSS, the others did not. In the two trials using a 

CDSS there was very poor uptake of the systems by practitioners, 

and one was not integrated with the patient’s electronic 

medical record—one of the most important factors shown to 

support uptake and use of CDSSs. 5 PREDICT is integrated 

into practitioners’ patient management systems, provides decision 

support at the time and location of decision-making and 

generates a comprehensive, personalised set of evidence-based 

management recommendations, not just a risk score. The latter 

functionalities have also been shown to be critical independent 

predictors of improved clinical practice. 5 

Furthermore, Boland and Moriarty did not base their argument 

on up-to-date evidence of the effectiveness of CDSS for 

CVD. A more relevant systematic review was conducted in 

2008. 6 This review identified 42 randomised controlled trials 

of computerised systems for assessment and management of 

CVD risk or risk factors in primary care. All of the older trials 

including non–user friendly, non-integrated systems were 

included. The evidence for the impact of CDSS in general has 

been moderately favourable in terms of improving desired 

practice. Of the randomised trials of CDSS for assessing or 

managing CVD risk, about two-thirds reported improvements 

in provider processes (such as improved documentation, increase 

in recommended examinations, investigations, providing 

advice or management plans) and two-fifths reported some 

improvements in intermediate patient outcomes (reduction 

in CVD risk, BP or cholesterol levels). Most importantly, no 

harms were reported. 

We believe that CVD risk profile tools incorporated within 

general practice management systems have significant potential 

to improve the quality of patient care in New Zealand. The 

unique advantage offered by the PREDICT system is its ability 

to also provide real-time aggregated reports to individual 

practices on their patient care and to generate a cohort study 

for developing new risk prediction tools that are based on New 

Zealand populations. Moreover we have now integrated into 

PREDICT the ‘Your Heart Forecast’ (www.yourheartforecast. 

co.nz) tool that we developed in collaboration with the National 

Heart Foundation to support and improve risk communication. 

This has been well-received by clinical users. Evaluation 

to determine whether Your Heart Forecast faciltates patient 

understanding of a CVD risk score and supports behaviour 

change is underway. 

We challenge Boland and Moriarty to find both more 

appropriate and more up-to-date evidence to support their 

arguments. 

Sue Wells, Tania Riddell and Rod Jackson 

References 

1. Boland P, Moriarty H. Cardiovascular disease risk profile tools and New 

Zealand—the best way forward? J Primary Health Care. 2009;1(4):328–31. 

2. Bannink L, Wells S, Broad J, Riddell T, Jackson R. Web-based assessment of 

cardiovascular disease risk in routine primary care practice in New Zealand: the 

first 18,000 patients (PREDICT CVD-1). N Z Med J. 2006;119(1245):U2313. 

3. Brindle P, Beswick A, Fahey T, Ebrahim S. Accuracy and impact of risk assessment 

in the primary prevention of cardiovascular disease: a systematic review. 

Heart. 2006 Dec;92(12):1752–9. 

4. New Zealand Guideline Group. The assessment and management of cardiovascular 

risk. Wellington: New Zealand; 2003. 

5. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice 

using clinical decision support systems: a systematic review of trials to identify 

features critical to success. BMJ. 2005;330:765–72. 

6. Wells S. Getting evidence to and from general practice consultations for cardiovascular 

risk management using computerised decision support. PhD thesis. 

Auckland: University of Auckland; 2008. 


PREDICT was developed by a collaboration of clinical epidemiologists 

at the University of Auckland, IT specialists at Enigma Publishing 

Ltd (a private provider of online health knowledge systems), primary 

health care providers, secondary care specialist opinion leaders, 

primary health care organisations, non-governmental organisations 

(New Zealand Guidelines Group, National Heart Foundation, 

Diabetes New Zealand, Diabetes Auckland), several district health 

boards and the Ministry of Health. PREDICT software platform 

is owned by Enigma Publishing Ltd (PREDICT is a trademark of 

Enigma Publishing Ltd). The PREDICT research project has support 

by HRC grants 03/183 and 08/121 from the Health Research 

Council. TR and SW are co-principal investigators (Maori–non 

Maori partnership) and RJ is the supervisory investigator. SW, 

TR and RJ have no commercial involvement in PREDICT. 


BOOK REVIEW 

Interpreting in New Zealand, the pathway 

forward 

by Diana Clark and Caroline McGrath 

Reviewed by Ben Gray, GP Newtown Union Health Service. 

General practitioners (GPs) face many risks in 

the course of an average day. These cluster 

alarmingly when a doctor manages a patient 

who speaks little or no English. As well as risks 

to diagnosis, discussion and treatment, impaired 

communication means there are shadows over informed 

consent, disclosure of previous history, and 

how to agree and implement a management plan. 

The RNZCGP’s practice accreditation document 

Aiming For Excellence is almost silent on how to 

deal with this problem. Few of us have thought 

about professional and ethical issues as they 

might apply to interpreters. They are probably 

the only mainstream health professional without 

an agreed training programme, agreed professional 

ethics or requirement for registration and 

monitoring of quality. 

The Office of Ethnic Affairs has produced a book 

as a way of informing and encouraging debate on 

how New Zealand (NZ) addresses these important 

issues and goes forward as a multilingual country. 

This book sets out in more than 20 contributions 

from NZ and overseas, expertise, insights and 

experience in interpreting and related fields. The 

submissions range from the anecdotal (should an 

interpreter tell a nurse the patient is a former doctor 

from Russia who feels her ear is not being syringed 

in the right way?) to ethics, both here and overseas, 

to a useful chart setting out the difference between 

the activities undertaken by the interpreter and the 

translator. There are contributions from educators, 

interpreting practitioners and from those with long 

experience in the deaf community. 

The book is not an academic text. It is more of a 

manual enabling someone who wanted to know 

about working with an interpreter to do so and to 

be aware of some of the fish hooks. 

Today NZ demographics almost guarantee GPs 

will have patients with limited English. Almost a 

quarter of residents were not born here. Though 

many speak English, others don’t. All are entitled 

to have access to the services offered by GPs and 

management of health issues will be a very important 

part of effective settlement for them all. 

In the past, children routinely have been used 

as bilingual helpers with no way of establishing 

the quality of their language knowledge nor the 

consistency or accuracy of their interpretations. 

Grim stories of serious consequences and misunderstandings 

abound, but it seemed there was no 

alternative. 

If you have felt bewildered, irritated or alarmed 

at the challenges and risks inherent in diagnosing 

and providing health care to someone who 

doesn’t speak English, then this book is for you. 

There is a way forward if we can have accurate, 

confidential and cost-effective interpreting 

because this change will affect all of us as our 

practices become more multilingual. 

Language Line, the telephone service and the 

source of this book, is available to all NZ doctors 

and medical practices through their membership 

of PHOs or similar organisations. It offers 40 

languages—see www.languageline.govt.nz for 

more information and to access the book. 

Publisher: Steele Roberts, Wellington 

Date of Publication: 2009 

Number of pages: 207 


POLICY STATEMENT FOR AUTHORS 

Conflict of interest in peer-reviewed medical 

journals: The World Association of Medical Editors 

(WAME) position on a challenging problem 

Lorraine E Ferris 1 and Robert H Fletcher 2 

Conflict of interest in medical publishing 

exists when a participant’s private 

interests compete with his or her responsibilities 

to the scientific community, readers, and 

society. While conflict of interest is common, 

it reaches the level of concern when ‘a reasonable 

observer might wonder if the individual’s 

behavior or judgment was motivated by his or her 

competing interests’. 1 Having a competing interest 

does not, in itself, imply wrongdoing. But it 

can undermine the credibility of research results 

and damage public trust in medical journals. 

In recent years, the extent of conflict of interest 

in medical journal articles has been increasingly 

recognised. Medical journals and the popular 

media have published numerous examples of 

competing interests that seemed to have biased 

published reports. 2,3,4 Organisations have 

expressed concern for the effects of conflicts of 

interest on research, 5 publication, 1,6,7 teaching 8 

and continuing medical and nursing education. 9 

The World Association of Medical Editors 

(WAME) is one of the institutions engaged 

in this discussion. WAME was established in 

1995 10,11 to facilitate worldwide cooperation and 

communication among editors of peer-reviewed 

journals, improve editorial standards, and 

promote professionalism in medical editing. 12 

Membership in WAME is open to all editors of 

peer-reviewed biomedical journals worldwide; 

small journals in resource-poor countries are wellrepresented. 

As of December 2009, WAME had 

1595 individual members representing 965 journals 

in 92 countries. WAME has broad participation 

as there are no dues and WAME activities are 

largely carried out through the member list serve 

and the member password-protected website. 

In March 2009, WAME released an updated policy 

statement, Conflict of interest in peer-reviewed medical 

journals. 1 It details the issues WAME believes 

journals should address when establishing their 

own policies for conflict of interest. The editors 

of this journal thought that the issues were important 

enough to share with its readers. A summary 

of the statement is presented in Table 1 and the 

full statement 1 can be found on WAME’s website. 12 

How does this statement differ from 

earlier conflict-of-interest statements? 

First, WAME expands the scope of competing 

interests. Other statements have been concerned 

almost exclusively with conflicts of interest related 

to financial ties to industry—companies that 

sell health care products. The assumption is that 

financial incentives are especially powerful and 

are not readily recognised without special efforts 

to make them apparent. WAME has extended the 

concept of financial conflict of interest to include 

the effects of clinical income. For example, 

physicians who earn their livelihood by reading 

mammograms or performing colonoscopies may 

be biased in favour of these technologies. WAME 

has also included non-financial conflicts of interest 

(or the appearance of one) related to scholarly 

commitment: ‘intellectual passion’, (the tendency 

to favour positions that one has already espoused 

or perhaps even established); personal relationships 

(the tendency to judge the works of friends/ 

colleagues or competitors/foes differently because 

of the relationship); political or religious beliefs 

(the tendency to favour or reject positions because 

it affirms or challenges one’s political or religious 

beliefs); and institutional affiliations (the 

tendency to favour or reject results of research 

because of one’s institutional affiliations). 

1 

Chair, WAME Ethics 

Committee, Clinical 

Epidemiology Unit, 

Sunnybrook Health Sciences 

Centre, Toronto, Ontario, 

Canada 

2 

Chair, WAME Policy 

Committee, Harvard Medical 

School, Boston MA, USA 



Second, WAME did not prescribe a universal 

standard for when meaningful conflict of interest 

exists. Rather, it defined and recommended elements 

of conflict of interest policies and encouraged 

journals to establish their own standards. 

WAME left operational definitions and standards 

on the basic issues to member journals, recognising 

that journals exist in very different contexts 

across the globe, standards for conflict of interest 

are evolving, and some journals already have 

well-established policies and standards. WAME 

does not presume to judge which conflicts require 

action and what the appropriate action may be, 

although its policy does offer factors to consider. 

1 Obviously, excessive concern for these and 

more comprehensive lists of possible competing 

interests could paralyse the peer review and 

publication process and is not feasible. Editors 

must make judgments as to the strength of the 

conflict, but to do so must have uncensored 

information. Similarly, readers need transparency 

about conflicts, and therefore editors should 

publish with every article all relevant author 

disclosures. 1 

Third, WAME confirms the seriousness of 

failure to disclose conflict of interest by indicating 

that editors have a responsibility for investigating 

and, if relevant, acting, if competing 

interests surface after a manuscript is submitted 

Table 1. Summary of key elements for peer reviewed medical journal’s conflict of interest policies 

Element Key aspects Comments 

1. Definition and 

scope 

2. Types of 

competing interests 

3. Declaring conflicts 

of interest 

4. Managing conflicts 

of interest 

A clear definition the journal uses as to what 

is conflict of interest and who is captured in 

the definition. 

A clear statement of examples of the types 

of competing interests (and their definitions) 

the journal says must be declared. Should 

include the following as examples, but there 

could be others: 

(a) Financial ties 

(b) Academic commitments 

(c) Personal relationships 

(d) Political or religious beliefs 

(e) Institutional affiliations 

Clear statements on: 

(a) what is to be declared, when and to 

whom; 

(b) format for declaration; 

(c) a journal’s role in asking additional 

questions or seeking clarification about 

disclosures; and 

(d) consequences for failing to disclose 

before or after publication. 

A clear statement on how conflict of interest 

will be managed by the journal, including the 

position that all relevant conflict of interest 

disclosures (or the declaration of no conflict 

of interest) will be published with the article 

and clarity about what conflict of interest 

situations will result in a manuscript not 

being considered. 

Sample definition: Conflict of interest 

exists when a participant in the publication 

process (author, peer reviewer or editor) 

has a competing interest that could unduly 

influence (or be reasonably seen to do so) 

his or her responsibilities in the publication 

process (submission of manuscripts, 

peer review, editorial decisions, and 

communication between authors, reviewers 

and editors). 

There is a need to consider a wide range 

of competing interests (and a recognition 

that they can coexist) which the individual 

assesses as to whether they unduly influence 

(or be reasonably seen to do so) his or her 

responsibilities in the publication process. 

Examples and definitions of what competing 

interests should be declared need to be 

articulated with journals moving beyond just 

financial conflict of interest. 

Journals rely on disclosure about the facts 

because routine monitoring or investigation 

is not possible. This creates a particular 

onus on the declarer to report carefully and 

comprehensively. It also means that journals 

should ask about conflict of interest in such 

a way that there will be a high likelihood of 

reporting relevant conflict of interest. 

Journals use various rules about how they 

will deal with conflict of interest and conflict 

of interest disclosures and these need to 

be made known to all those involved in the 

publication process. 



or published. The intent is that allegations of failure 

to declare conflicts of interest must be taken 

seriously by journals. 

Finally, WAME has addressed in a single statement 

the conflicts of interest threatening all 

participants in the research and publication continuum, 

including authors, peer reviewers, and 

editors. Conflicts between editors and journal 

owners, which might affect both the accuracy of 

articles and the credibility of journals, have been 

addressed in another WAME policy statement. 13 

What can be done about conflicts 

of interest in medical journals? 

Conflicts of interest cannot be eliminated altogether, 

but it can be managed so that it has the 

smallest possible effects on journal content and 

credibility. The backbone of managing conflicts 

of interest is full written disclosure; without it, 

nothing else is possible. Currently, authors may 

not reveal all of their competing interests and, 

even if they do, journals too often do not publish 

them, 14 so there is plenty of room for improvement. 

Even so, disclosure alone is an imperfect 

remedy; editors still must determine whether a 

conflict has sufficient potential to impair an individual’s 

objectivity such that the article should 

not be published. Even more work may be needed 

on reviewers’ and editors competing interests, 

given their critical role as gatekeepers for the 

medical literature. 

No statement will solve the conflict of interest 

problem, nor will it ever be solved altogether. As 

understanding of the problem and its management 

evolves, journals should be given latitude 

to establish their own standards, matching their 

policies to the best standards of their discipline 

and culture. WAME believes journals should 

make these policies readily accessible to everyone. 

All of us—editors, authors, reviewers, and 

readers—should be paying more attention to 

conflicts of interest than we have been. We hope 

this statement serves that purpose. 

This editorial may appear in other medical and 

biomedical journals whose editors are members of 

the World Association of Medical Editors (WAME). 

References 

1 WAME statement on conflict of interest in peer-reviewed 

medical journals. http://www.wame.org/conflict-of-interestin-peer-reviewed-medical-journals 

2 Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts 

of interest in biomedical research: a systematic review. 

JAMA. 2003;289(4);454–65. 

3 Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical 

industry sponsorship and research outcome and quality: 

systematic review. BMJ. 2003;326(7400);1167–1170. 

4 Altman LK. For science’s gatekeepers, a credibility gap. 

The New York Times. 2 May 2006. http://www.nytimes. 

com/2006/05/02/health/02docs.html?scp=58&sq=conflict+ 

of+interest+%26+medicine&st=nyt 

5 Institute of Medicine. Conflict of interest in medical research, 

education, and practice. Washington, DC: National Academies 

Press. 2009 (April). http://www.iom.edu/Reports/2009/ 

Conflict-of-Interest-in-Medical-Research-Education-and- 

Practice.aspx 

6 International Committee of Medical Journal Editors (ICMJE) 

Uniform requirements for manuscripts submitted to biomedical 

journals; ethical considerations in the conduct and reporting 

of research: conflicts of interest. http://www.icmje.org/ 

ethical-4conflicts.html 

7 International Committee of Medical Journal Editors (ICMJE) 

Uniform format for disclosure of competing interests in ICMJE 

journals. October 2009. http://www.icmje.org/format.pdf 

8 American Association of Medical Colleges. Industry funding 

of medical education: report of an AAMC task force. 

June 2008. 

9 Hager M, Russell S, Fletcher, SW (editors). Continuing education 

in the health professions: improving healthcare through 

lifelong learning. Josiah Macy J Foundation. November 2007. 

http://www.josiahmacyfoundation.org/documents/pub_ 

ContEd_inHealthProf.pdf 

10 Squires BP, Fletcher SW. The World Association of Medical 

Editors (WAME): thriving in its first decade. Science Editor. 

2005;28(1):13–16. 

11 Launching the World Association of Medical Editors: report 

of the conference to promote international cooperation 

among medical journal editors. 1995. http://www.wame/org/ 

Bellagio.htm 

12 WAME website. http://www.wame.org 

13 WAME policy on the relationship between journal editorsin-chief 

and owners (formerly titled Editorial Independence). 

http://www.wame/org/resources/policies#independence 

14 Bhargava N, Qureshi J, Vakil N. Funding source and conflict 

of interest disclosures by authors and editors in gastroenterology 

specialty journals. American J of Gastroenterology. 

2007;102(6);1146–1150. 

ACKNOWLEDGMENTs 

The authors wish to thank 

the World Association of 

Medical Editors (WAME) 

Officers warmly for their 

helpful comments on 

an earlier version of this 

editorial. Many thanks to 

President Margaret Winker 

(USA); Past President 

Michael Callaham (USA); 

Vice-President John 

Overbeke (Netherlands); 

Treasurer Tom Lang (USA); 

and Secretary Farrokh 

Habibzadeh (Iran). 

The WAME Statement 

on Conflict of Interest in 

Peer-Reviewed Medical 

Journals was approved by 

the WAME Board in March 

2009. Many thanks to the 

members of the WAME 

Ethics Committee and 

to the WAME Editorial 

Policy Committee for their 

insightful and helpful 

comments on an earlier 

version of the statement. 

Warm thanks to the 

WAME Board for their 

input and comments: 

Margaret Winker; Michael 

Callaham; John Overbeke; 

Tom Lang; Farrokh 

Habibzadeh; Adamson 

Muula (Malawi) and Rob 

Siebers (New Zealand). 


As a WAME Director, 

Lorraine Ferris did not 

participate in the WAME 

Board vote to approve the 

statement or the vote to 

endorse the editorial. 

The authors have no 

conflicts of interest 

to declare. 


RESEARCH GEMS 

Gems of New Zealand 

Primary Health Care Research 

Increase in use of cardiovascular 

preventive medication 

This study measured trends in cardiovascular 

preventive medication prescribing 

in New Zealand primary care from 2000 

to 2003 using data from the Dunedin 

RNZCGP Research Unit database of 

men aged over 44 and women aged over 

54 years who consulted a doctor in 

2000–2003 in practices supplying electronic 

clinical notes. Cardiovascular risk 

as calculated by the Framingham-based 

risk equation could only be estimated 

for one-third of the study population 

due to missing risk factor information. 

The treatment of all patient groups with 

a five-year cardiovascular risk of >10% 

increased by about 4% per year, and by 

3% per year in the five to 10% cardiovascular 

risk bracket. 

Selak V, Rafter N, Parag V, Tomlin A, Vander 

Hoorn S, Dove, S, Rodgers A. Cardiovascular 

treatment gaps: closing, but slowly. N Z Med 

Journal. 2009;122(1293). Corresponding 

author: V. Selak. Email: vanessa.selak@ 

waitematadhb.govt.nz 

Pharmacists’ perceptions of 

roles and accreditation 

The Ten Year Vision for Pharmacists 

outlines the roles pharmacists are expected 

to provide now and in the future. 

The aim of this study was to determine 

pharmacists’ views on these roles and 

the need for accreditation. Findings from 

a national postal survey suggest the majority 

of pharmacists believe they should 

continue to undertake traditional clinical 

and technical roles. Less than one-third 

suggested accreditation for these roles. 

There was a positive but more tempered 

view regarding the uptake of enhanced 

or collaborative roles. There was recognition 

of a need for accreditation suggesting 

a cautious optimism about adopting 

new services. 

Scahill S, Harrison J, Sheridan J. Pharmacy 

under the spotlight: New Zealand 

pharmacists’ perceptions of current and 

future roles and the need for accreditation Int 

J Pharm Pract. 2010:18;59–62. DOI 10.1211/ 

ijpp/18.01.0010. Corresponding author: 

S. Scahill. Email: s.scahill@auckland.ac.nz 

Describing the organisational 

culture of a selection of 

community pharmacies 

This paper outlines the use of a predominantly 

interpretative mixed methods 

technique known as concept mapping 

to develop a map which pictorially 

represents dimensions of organisational 

culture. Concept mapping involves the 

integration of brainstorming techniques 

to develop culture statements, along 

with robust statistical processes. Eight 

cultural dimensions were identified: 

leadership and staff management; valuing 

each other and the team; free thinking, 

fun and open to challenge; trusted 

behaviour; customer relations; focus on 

external integration; providing systematic 

advice and embracing innovation. 

These dimensions assist in understanding 

factors that influence effectiveness 

within community pharmacy. 

Scahill S, Harrison J, Carswell P. Describing 

the organizational culture of a selection of 

community pharmacies using a tool borrowed 

from social science. Pharm World Sci. 

2010:32;73–80. DOI 10.1007/s11096-009- 

9345-5. Corresponding author: S. Scahill. 

Email: s.scahill@auckland.ac.nz 

How useful are clinical priority 

assessment tools? 

The original aim of this research was to 

study the use of clinical priority assessment 

criteria (CPAC) tools. However, in 

a sample of 47 videotaped consultations 

with 15 different surgeons, CPAC tools 

were never explicitly used. The research 

therefore shifted to an investigation of 

interactional factors that might preclude 

the use of such tools. Our analysis 

suggested that decision-making about 

operative thresholds is an interactionally 

complex matter that does not lend itself 

to the rigid following of a protocol. It 

should be acknowledged that diagnosis 

and planning of care constitute different 

interactional activities to prioritisation 

on a waiting list. 

Dew K, StubbeM, Macdonald L, Dowell A, 

Plumridge E. The (non) use of prioritisation 

protocols by surgeons. Sociology of Health 

GEMS are short précis of original papers published by NZ researchers. For a copy of a full paper please 

email the corresponding author. Researchers, to have your work included please send a 100 

word summary of your paper and the full reference details to: editor@rnzcgp.org.nz 


RESEARCH GEMS 

& Illness. 2010;32(4):1–18. DOI 10.1111/ 

j.1467-9566.2009.01229. Corresponding 

author: M. Stubbe. Email: maria.stubbe@ 

otago.ac.nz 

Pharmacists not ready for 

increased clinical roles 

This paper reports on a 2002 survey of 

general practitioners and community 

pharmacists, exploring the perceptions 

of the role of the community pharmacist. 

There were significant differences 

in the perceptions of the role of 

community pharmacists, with general 

acceptance of technical roles (dispensing, 

checking accuracy, counselling on ADRs 

and monitoring for compliance) but 

less acceptance of more clinical patient 

care roles. The barriers to increased 

clinical roles for community pharmacists 

included a perceived lack of mandate, 

legitimacy, adequacy and effectiveness 

of the roles. There also appeared to be a 

lack of readiness to change for community 

pharmacists. 

Bryant L, Coster G, Gamble G, McCormick 

R. General practitioners’ and pharmacists’ 

perceptions of the role of community 

pharmacists in delivering clinical services. 

Res Soc Admin Pharmacy. 2009;5:299–301. 

Corresponding author: L. Bryant. 

Email: l.bryant@auckland.ac.nz 

Investigating prescription 

interventions conducted 

by pharmacists 

This study investigated the time spent 

and the types of interventions pharmacists 

in Dunedin perform when 

dispensing prescription medications. 

Interventions related to generic substitution 

and legal errors and omissions were 

responsible for 50% of their time spent. 

This could be reduced significantly by 

prescribing generically. The remaining 

50% of time spent was on clinical 

interventions, however these occurred 

at a much lower rate. The time spent on 

bureaucratic issues may be seen as a significant 

barrier for pharmacists providing 

clinical services to patients. 

Braund R, Furlan HM, George K, Havell 

MMA, Murphy JL, West MK. Interventions 

performed by New Zealand community 

pharmacists while dispensing prescription 

medications. Pharm World Sci. 2010;32:22– 

25. Corresponding author: R. Braund. 

Email: Rhiannon.braund@otago.ac.nz 

Women may be missing out 

on preventive drugs 

Among 1089 women (40–79 years) 

recruited through 17 general practices 

to a lifestyle study in the Wellington 

region in 2005–2007, 109 (10%) had 

a five-year cardiovascular (CVD) risk 

>15%. Of these women, only 36% were 

taking aspirin, 55% were on blood 

pressure–lowering medication, 45% 

were taking lipid-lowering medication 

and only 17% were taking all three 

CVD guidelines–recommended medications. 

Our coverage of CVD preventive 

medications for high-risk women may 

be lower than ideal. 

Bupha-Intr O, Rose S, Lawton B, Elley 

C, Moyes S, Dowell A. Are at-risk New 

Zealand women receiving recommended 

cardiovascular preventive therapy? N Z 

Med J. 2010;123:26–36. Corresponding 

Author: B. Lawton. Email: bev.lawton@ 

otago.ac.nz 

Including type 2 diabetes in 

cardiovascular risk equations 

A new cardiovascular risk equation was 

derived from routinely-collected data 

on 36 127 patients with type 2 diabetes 

assessed through the primary care Get 

Checked programme between 2000 and 

2006 in New Zealand. New cardiovascular 

events or deaths were recorded 

2000–2008. Testing the new equation 

on 12 626 patients from a geographically-different 

area over the same time 

showed that the new equation was more 

accurate than the currently used equation 

for people with diabetes, especially 

for Maori, Pacific and Indian populations 

and those with poorly controlled diabetes 

or renal impairment. The currently 

used equation often underestimates 

risk for these groups. The new equation 

could be incorporated into existing risk 

assessment tools. 

Elley C, Robinson E, Kenealy T, Bramley 

D, Drury L. Derivation and Validation of a 

New Cardiovascular Risk Score for People 

with Type 2 Diabetes, Diabetes Care; 

33 (6) Mar 18. [Epub ahead of print]. 

Corresponding author: R. Elley. 

Email: c.elley@auckland.ac.nz 

Asking about help is helpful 

The CHAT (Case-finding and Help Assessment 

Tool) is a short validated and 

self-administered questionnaire which 

detects lifestyle (inactivity, tobacco use, 

alcohol and other drug misuse, problem 

gambling, abuse, and anger problems) 

and mental health issues (depression and 

anxiety) in adult primary health care 

patients. The question asking whether 

patients want help (either during this 

consultation or later) for each item increases 

specificity without compromising 

sensitivity and reduces false positives, 

allows patients with comorbidities to 

prioritise issues they wish to address, indicate 

their readiness to change, promote 

self-determination, and gives the GP an 

indication of which topics to pursue. 

Goodyear-Smith F, Arroll B, Coupe N. 

Asking for help is helpful: validation of a 

brief lifestyle and mood assessment tool 

in primary health care. Annals of Family 

Medicine. 2009;7:239–244. doi: 10.1370/ 

afm.962i2009. Corresponding author: 

F. Goodyear-Smith. Email: f.goodyear-smith@ 



about the journal of primary health care 

The Journal of Primary Health Care 

(JPHC) is a peer-reviewed journal 

which has replaced the New Zealand 

Family Physician. It is a interdisciplinary 

publication aimed at moving research into 

primary health care practice and practice into 

research. This includes the fields of family 

practice, primary health care nursing and 

community pharmacy as well as areas such 

as health care delivery, health promotion, 

epidemiology, public health and medical 

sociology of interest to a primary health care 

provider audience. 

The journal publishes peer-reviewed quantitative 

and qualitative original research, 

systematic reviews, papers on improving performance 

and short reports that are relevant 

to its primary health care practitioners. For 

the aim, scope, instructions to authors and 

templates for publications see www.rnzcgp. 

org.nz/journal-of-primary-health-care/. 

JPHC acts as a knowledge refinery to provide 

busy practitioners with up-to-date knowledge 

about the latest evidence and best practice. 

Continuing professional development 

includes pithy summaries of the latest evidence 

such as Cochrane Corner, a String of 

PEARLS (Practical Evidence About Real Life 

Situations) and Charms & Harms (evidence of 

effectiveness and safety of complementary 

and alternative medicines). JPHC includes 

Poumanu (treasures of Maori wisdom) and 

Gems of NZ Primary Health Care Research 

published at home and internationally. 

Evidence can help inform best practice. However 

sometimes there is no evidence available 

or applicable for a specific patient with his 

or her own set of conditions, capabilities, 

beliefs, expectations and social circumstances. 

Evidence needs to be placed in context. 

General practice is an art as well as a science. 

Quality of care lies also with the nature of the 

clinical relationship, with communication and 

with truly informed decision-making. JPHC 

publishes viewpoints, commentaries and reflections 

that explore areas of uncertainty on 

aspects of care for which there is no one right 

answer. Debate is stimulated by the Back to 

Back section where two professionals present 

their opposing views on a topic. There is a 

regular Ethics column. Letters to the Editor 

are welcomed. 

While published in New Zealand by the Royal 

New Zealand College of General Practitioners, 

much of this research has generic 

implications. Our Editorial Board comprises 

renowned and active primary care clinicians, 

clinical and scientific academics and health 

policy experts with both New Zealand and 

international representation. 

Editor 

Dr Felicity Goodyear-Smith: Professor and 

Goodfellow Postgraduate Chair, Department 

of General Practice and Primary Health 

Care, University of Auckland, Auckland, New 

Zealand; editor@rnzcgp.org.nz 

Deputy Editors 

Dr Derelie Mangin: Associate Professor, 

Department of Public Health and General 

Practice, University of Otago, Christchurch, NZ 

Dr Tony Dowell: Professor and Head of the 

Department of Primary Health Care and General 

Practice, Wellington School of Medicine, 

University of Otago, NZ 

Editorial Board 

Dr Bruce Arroll: Professor and Head of the 

Department of General Practice & Primary 

Health Care, University of Auckland, NZ 

Dr Jo Barnes: Associate Professor of 

Pharmacy, School of Pharmacy, University of 

Auckland, NZ 

Dr Jenny Carryer: Professor of Nursing, 

School of Health and Social Services, Massey 

University, Palmerston North, NZ 

Dr Peter Crampton: Dean and Head of 

Campus, Wellington School of Medicine and 

Health Sciences, University of Otago, NZ 

Ms Eileen McKinlay: Senior Lecturer in 

Primary Health Care, Department of Primary 

Health Care and General Practice, University 

of Otago Wellington, NZ 

Dr Barry Parsonson: Psychologist for NZ Ministry 

of Education and International Consultant, 

UNICEF (Georgia) Training Project for Institutional 

Staff working with disabled children 

Dr Shane Reti: Assistant Professor, International 

Program Director Clinical Informatics 

and CEO of Clinical Informatics Industrial 

Research, Harvard Medical School, USA 

Dr Kurt Stange: Professor of Family 

Medicine, Case Western Reserve University, 

Cleveland, OH, USA and Editor, Annals of 

Family Medicine 

Dr Colin Tukuitonga: Associate Professor 

and CEO of the Ministry of Pacific Island Affairs, 

Wellington, NZ 

Submissions 

Please send all submissions to: 

The Editor: editor@rnzcgp.org.nz, or to: 

The Editorial Assistant—Cherylyn Borlase: editorialassistant@rnzcgp.org.nz 

accompanied by a covering letter as outlined at: 

http://www.rnzcgp.org.nz/journal-of-primary-health-care/#cover 

Subscription and advertising queries 

Cherylyn Borlase, Publications Coordinator 

RNZCGP, PO Box 10440, Wellington 6143, New Zealand; jphcnz@rnzcgp.org.nz 

JPHC is printed on uncoated, acid-free paper which meets the archival requirements of ANSI/ 

NISO Z39.48-1992 (Permanence of Paper) and is Forest Stewardship Council (FSC)–certified 

which meets the highest environmentally responsible standards. 

The Journal of Primary Health Care is the official journal of the RNZCGP. However, views expressed are not necessarily those of the College, 

the Editor, or the Editorial Board. ©The Royal New Zealand College of General Practitioners 2010. All Rights Reserved.

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