The requirement to respect autonomy - The Royal New Zealand ...

VOLUME 2 • NUMBER 4 • DECEMBER 2010OF PRIMARY HEALTH CARE‘The requirementto respect autonomyends where harmto others begins’See Ethics, page 343Original Scientific PaperScreening for melanomaSee page 268Original Scientific PaperAssessing the Flinders Program TMof patient self-managementSee page 294Improving PerformancePractice nurses monitoringanticoagulation using astandardised protocolSee page 318Back to BackStatin use in the elderly whohave >15% CVD five-year riskSee page 330ViewpointFree health care for children undersix years of ageSee page 338EthicsShould the state fund bariatric surgeryfor the obese?See page 343

EDITORIALsfrom the editorPreparation for catastropheFelicity Goodyear-Smith MBChB, MGP,FRNZCGP, EditorCorrespondence to:Felicity Goodyear-SmithProfessor and GoodfellowPostgraduate Chair,Department of GeneralPractice and PrimaryHealth Care, TheUniversity of Auckland,PB 92019 Auckland,New Zealandf.goodyear-smith@auckland.ac.nzOur last issue, 1 September 2010, featureda seemingly prescient guest editorial ‘Arewe ready for the big one?’ 1 At 4:35 amon 4 September, Christchurch was struck by amagnitude 7.1 earthquake.The RNZCGP’s annual conference was halfwaythrough in Christchurch when the earthquake occurred.There were a plethora of GPs in town, myselfamong them. Dressing and evacuating frommy hotel by the light of my iPhone, I joined mycolleagues congregating in sub-zero temperatures.Googling ‘civil defence’ informed me that ‘Thereare no declared civil defence emergencies in NewZealand’. ‘Christchurch earthquake’ was morehelpful, stating that a 7.4 magnitude earthquakehad struck (later downgraded to 7.1) with few apparentcasualties. Fortunately there was little needfor the assembled doctors to offer our services atthe city hospital and emergency clinics.The earthquake caused significant damage inChristchurch city and the Canterbury region,although there was no loss of life and few injuries.This was in dramatic contrast to the January7.0 earthquake which devastated Port au Prince,Haiti, killing about 300 000 people, rending overa million homeless with after-effects including anoutbreak of cholera now sweeping the country. Itis a powerful reminder of the inequity existingbetween a poor and a developed country. TheNew Zealand (NZ) buildings largely withstoodthe earthquake, in stark contrast to Haiti’sshanties. Power was quickly restored, resourcesmobilised and essential services such as water andsewerage systems either repaired or alternativesprovided. There was a rapid, coordinated localand national government response, with adviceand aid soon available on many fronts.However the Christchurch quake and numerousaftershocks (2500 eight weeks post-quake) havetaken their toll on many, with sleep disturbanceand renewed anxiety as the jolts continue. Peopleexposed to the effects of earthquakes are susceptibleto post-traumatic stress disorder (PTSD) andtrauma-focussed cognitive behavioural therapy(CBT) is the most effective intervention. 1 PTSDonly can be diagnosed four weeks or more afterexposure to the traumatic experience. Parsonsonand Rawls have found that they can train professionalsin key CBT trauma intervention skills insix weeks, who then can intervene successfully inboth children and adults with rapid beneficial effectseven in cases of severe PTSD symptoms ‘sothat symptoms such as avoidance, re-experiencing,insomnia and panic attacks became manageable,allowing normal functioning to be achieved’. 1While our Christchurch primary care serviceshave coped admirably with the quake aftermath,the suggestion that NZ should have primary healthcare personnel trained to deliver CBT for trauma tobe prepared for the effects of any major catastropheseems sensible. This earthquake is likely to be moreof a wake-up call than the ‘big one’—our geographicallocation renders us potentially vulnerable tonatural disasters. Our capital city sits on the WellingtonFault, a collision zone between the Australianand Pacific Tectonic Plates. The Aucklandregion has 49 volcanoes and with the last eruptionabout 600 years ago, another eruption is inevitable,although not necessarily in our lifetimes.The Christchurch health sector certainly hasbeen getting experience in collaborative responsesto emergency. This issue includes a paper by Williamset al. describing the coordinated responseof Canterbury’s health services to the InfluenzaA H1N1 09 pandemic last year. 2This issue also includes several research papersaddressing the theme of chronic disease andpatient self-management. Cutler et al. reportthe evaluation of a primary care–based healthylifestyle programme for overweight women, 3 andLawrenson et al. explore the education patientswith newly diagnosed type 2 diabetes receive to266 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

EDITORIALsfrom the editorhelp them self-manage their condition. 4 Horsburghand colleagues report on the feasibilityof assessing the Flinders Program TM of ChronicCondition Self-Management 5 and surveyed NZpractice nurses trained in the Flinders model. 6Although 500 nurses have received training,use of Flinders tools and processes in practicesappears to be very limited. This has importantimplications regarding funding of training forcomplex interventions if the support and infrastructureare not available for the learning to beimplemented and sustained.A study by Rademaker and Oakley has found thatmelanomas detected by screening using wholebodyphotography and sequential digital dermoscopyimaging services are thinner than thosediagnosed by traditional diagnostic methods. 7It remains to be seen whether earlier detectionthrough screening translates into improved outcomes.Another study involving cancer screeningexplored experiences of women with high familialrisk of breast cancer gene mutations. 8 The researchersfound that contrary to expectations, genetictesting, screening and prophylaxis may reducerather than improve the women’s peace of mind.A couple of initiatives by NZ general practitioners(GPs) are reported. Use of a standardised protocolby practice nurses to request InternationalNormalised Ratio (INR) tests and adjust warfarindosage was found to be more efficient than theusual ad hoc GP method, without compromisingpatient care. 9 A Dunedin practice replicatedLawton et al.’s intervention for increasing opportunisticscreening for chlamydia. 10 Although theymanaged to increase their screening and detectionrates substantially, post-intervention auditrevealed that these had dropped back to baselinelevels. 11 This was similar to Lawton et al.’s findings,and barriers to sustaining opportunisticscreening are discussed. We invite other practicesto share their experiences on this issue.In a Viewpoint article about improving healthoutcomes for our children and achieving lowor no-cost funding for New Zealand under–six-year-olds, the authors encourage debate onwhether free child health care, including afterhourscare, can be realised. 12 Again Letters to theEditor are welcome.Other topics in this issue include a review ofrequirements by different countries for medicalregistration, recommending that increased flexibilitywould help address workforce shortages. 13Two doctors go Back to Back on whether patientsover 75 years with >15% five-year risk of a cardiovascularevent should receive statins. 14,15 TheEthics column explores whether public funding oftreatments such as bariatric surgery for obesity (acondition which the patient may be considered tohave ‘allowed to occur’ in some way) essentiallyharms others by unfairly laying claim to shared resources.16 Along with our other regular columns,there is plenty here for your summertime reading.References1. Parsonson B, Rawls J. Are we ready for the big one? Lessonsfrom a brief war that could apply to New Zealand primaryhealth care services following a major disaster. J Prim HealthCare. 2010;2(3):180–2.2. Williams D, Begg A, Burgess K, et al. Influenza H1N1 2009 inCanterbury: a case study in pandemic response co-ordination.J Prim Health Care. 2010;2(4):323–9.3. Cutler L, King B, McCarthy N, Hamilton C, Cook L. Appetitefor life: an evaluation of a primary care lifestyle programme. JPrim Health Care. 2010;2(4):281–7.4. Lawrenson R, Joshy G, Eerens Y, Johnstone W. How do newlydiagnosed patients with type 2 diabetes in the Waikato get theirdiabetes education? J Prim Health Care. 2010;2(4):303–10.5. Horsburgh M, Bycroft J, Mahony F, et al. The feasibility ofassessing the Flinders Program TM of patient self-managementin New Zealand primary care settings. J Prim Health Care.2010;2(4):294–302.6. Horsburgh M, Bycroft J, Goodyear-Smith F, et al. The FlindersProgram TM of chronic condition self-management in New Zealand:survey findings. J Prim Health Care. 2010;2(4):288–93.7. Rademaker M, Oakley A. Digital monitoring by whole bodyphotography and sequential digital dermoscopy detects thinnermelanomas. J Prim Health Care. 2010;2(4):268–72.8. Crump R, Fitzgerald R, Legge M. ‘Going-to-have-cancerness’:a study of living with increased risk of BRCA1 and BRCA2mutations for six South Island women. J Prim Health Care.2010;2(4):311–7.9. Wright K. An audit of two methods of anticoagulation monitoringin a general practice. J Prim Health Care. 2010;2(4):318–22.10. Lawton B, Rose S, Elley C, Bromhead C, McDonald J, Baker M. Increasingthe uptake of opportunistic chlamydia screening: a pilotstudy in general practice. J Prim Health Care. 2010;2(3):199–207.11. Lawless S. Letter to the Editor: Sustaining chlamydia screeningis difficult. J Prim Health Care. 2010;2(4):347.12. Fancourt N, Turner N, Asher I, Dowell T. Primary health carefunding for children under six years of age in New Zealand:why is this so hard? J Prim Health Care. 2010;2(4):338–42.13. Leitch S, Dovey S. Review of registration requirements for newpart-time doctors in New Zealand, Australia, the United Kingdom,Ireland and Canada. J Prim Health Care. 2010;2(4):273–80.14. Wells S. All people over 75 years with a five-year CVD risk of>15% should be treated with statins unless specifically contraindicated—the‘yes’ case. J Prim Health Care. 2010;2(4):330–2.15. Mangin D. All people over 75 years with a five-year CVD risk of>15% should be treated with statins unless specifically contraindicated—the‘no’ case. J Prim Health Care. 2010;2(4):333–5.16. Jonas M. Obesity, autonomy and the harm principle. J PrimHealth Care. 2010;2(4):343–6.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 267

ORIGINAL SCIENTIFIC PAPERSquantitative researchDigital monitoring by whole bodyphotography and sequential digitaldermoscopy detects thinner melanomasMarius Rademaker BM, FRCP(Edin), FRACP, DM; Amanda Oakley MBChB, FRACP, DipHealInfDermatology Department,Waikato Hospital, Hamilton,New ZealandABSTRACTIntroduction: Population screening for melanoma remains controversial. There are no studies demonstratingthat population screening increases survival. As prognosis of melanoma is directly related toBreslow thickness, a surrogate marker of survival is thickness of melanoma. The development of severalself-referred, whole-body photography and sequential digital dermoscopy imaging services reflects thepublic’s concern regarding melanoma.Aim: To assess the ability of one of these services to detect melanoma at an early, thin stage.Methods: Demographic and histological details from 100 melanomas diagnosed through self-referredwhole-body photography and sequential digital dermoscopy imaging service compared to those diagnosedthrough traditional methods from data held by the New Zealand Cancer Registry.Results: There were 52 invasive and 48 in-situ melanomas: 90% superficial spreading type, 6%lentigo-maligna type and 4% nodular on histology. Forty-eight were diagnosed on first visit; the remainderby serial digital dermoscopy. Thirty-five percent of patients reported having had previous primarymelanoma. In 60%, patients had been concerned by the lesion, the rest (40%) detected solely by screening.Patients diagnosed by whole-body photography and sequential digital dermoscopy screening hadthinner melanomas compared to the Registry data: 69%

ORIGINAL SCIENTIFIC PAPErSquantitative researchshould screening for melanoma ever be recommended,it will need to be performed in primarycare. Several self-referred whole-body photographyand sequential digital dermoscopy imagingservices have been developed and are being usedby the public, yet there is little published evidencethat they can effectively detect melanomaat an early stage in the primary care setting.This descriptive study looks at the thickness ofmelanomas diagnosed using a whole body photographyand sequential digital dermoscopy systemavailable in New Zealand (NZ) and compares themto those detected by traditional means, as reportedto the New Zealand Cancer Registry (NZCR). 8MethodsA number of proprietary whole-body photographyand sequential digital dermoscopy screening systemsfor melanoma have been developed, includingMoleMap NZ. The MoleMap database was queriedfor patients who had histologically confirmedmelanoma, or melanoma-in-situ, diagnosed followingwhole-body photography and sequential digitaldermoscopy. Demographic and histological detailswere obtained and compared to similar data ofmelanoma patients detected by standard methodsas reported to the NZCR during a 10-year period. 8Patients undergoing whole-body photographyand sequential digital dermoscopy are largelyself-referred, although an increasing number (approximatelya third) are being performed at therecommendation of a general practitioner and/or specialist (personal communication, Mr BlairStewart, MoleMap NZ). Each proprietary systemis different; for MoleMap, a standardised historyis obtained at each visit by a trained ‘melanographer’,usually an experienced nurse, and includesdemographic data and individual risk factors formelanoma.Panoramic views of the body are first taken tomap the location of the suspect skin cancer(s), followedby macroscopic views (30 mm field of view,‘macro’) and then dermoscopic views (15 mm fieldof view, ‘micro’) of the lesion(s) (Figure 1).WHAT GAP THIS FILLSWhat we already know: Thickness (Breslow) is the major determinant ofsurvival in malignant melanoma, even for thin melanomas (

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 1. Age distribution of patientsAge(years)Digital dermoscopic screeningn (%)NZCR registrationsn (%)>20 2 (2) 121 (0.8)20–29 5 (5) 700 (4.4)30–39 17 (17) 1555 (9.8)40–49 23 (23) 2615 (16.5)50–59 29 (29%) 3011 (19.0)60–69 18 (18%) 3049 (19.2)>70 6 (6%) 4788 (30.2)*Mean age 51 years 59 years* chi-square test, df 6, p

ORIGINAL SCIENTIFIC PAPERSquantitative researchACKNOWLEDGEMENTSWe are grateful for theassistance of Blair Stewartof MoleMap NZ, for accessto the MoleMap database.FUNDINGNo funding was receivedfor this study.COMPETING INTERESTSDr Rademaker and DrOakley have an establishedacademic interest indigital dermoscopyand teledermatology.Waikato Hospital hasrecently adopted wholebodyphotography anddigital dermoscopy asan alternative to faceto-facescreening formelanoma and nonmelanomaskin cancer.Both Drs Rademaker andOakley are contractedto read MoleMaps forMoleMap NZ; they arepaid an item of servicefee for reporting, buthave no financial or otherinterest in the company.These data werepresented on a posterat the annual meeting ofthe Australasian Collegeof Dermatologists atBroadbeach, Queensland,Australia in May 2009(Oakley A, RademakerM, Stewart B. Thinnermelanomas detectedby digital monitoring.Aust J Dermatol 2009;50 (Suppl 1): A34).there does not appear to have been a consequentdecrease in the number of thicker melanomasdetected. 6,8,19 Despite this in Australia, there hasbeen an encouraging decrease in mortality ratesin both men and women younger than 55 yearsof age, so perhaps it is just a matter of time beforeresearch shows that screening for melanomais of benefit. 19Clearly, the greatest opportunity for increasingsurvival in melanoma is in the earlier detectionof those melanomas that are most likely tometastasize. Our current understanding is thatthese are more often nodular melanomas, whichappear to have a different growth dynamic. 21-22Several studies now show that patients withthicker melanomas (>2 mm) are less likely tohave attended a physician in the previous threeyears. 23–24 There may therefore be an opportunityto ‘capture’ these more dangerous melanomasby offering digital screening in primary care,although the research has yet to be performedto demonstrate that earlier detection of these‘thicker, poorer prognosis’ melanomas results inimproved survival. Part of the problem is in notknowing at what depth (Breslow thickness) amelanoma metastasizes.This study demonstrates that self-referred,whole-body photography and sequential digitaldermoscopy performed in the community doesdetect early thin melanomas. As survival frommelanoma is strongly associated with depth ofinvasion, such programmes for at-risk individualsmay be advantageous. More research is needed toinvestigate how to encourage patients with possiblemelanomas to attend for screening earlier,especially older men.References1. Cancer Society of New Zealand Position Statement on SkinCancer and Early Detection 2006. http://www.cancernz.org.nz/reducing-your-cancer-risk/sunsmart/early-detectionof-skin-cancer/early-detection-for-health-professionals/(accessed December 3rd 2009).2. The Cancer Council Australia. National Cancer PreventionPolicy 2007–09. 2007. NSW, The Cancer Council Australia.3. US Preventive Services Task Force. Screening for skin cancer:recommendations and rationale. Am J Prev Med. 2001;20(3Suppl):44–6.4. Koh HK, Norton LA, Geller AC, et al. Evaluation of theAmerican Academy of Dermatology’s National Skin CancerEarly Detection and Screening Program. J Am Acad Dermatol.1996;34:971–8.5. Geller AC, Zhang Z, Sober AJ, et al. The first 15 years of theAmerican Academy of Dermatology skin cancer screeningprograms: 1985–1999. J Am Acad Dermatol. 2003;48:34–41.6. Clinical Practice Guidelines for the Management of Melanomain Australia and New Zealand. The Cancer Council Australiaand Australian Cancer Network, Sydney and New ZealandGuidelines Group, Wellington; 2008. http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineCatID=7&guidelineID=141 (accessed on 2/2/2010)7. Tan E, Yung A, Jameson M, Oakley A, Rademaker M. Successfultriage of patients referred to a skin lesion clinic usingteledermoscopy (IMAGE IT trial). Br J Dermatol. 2010 Mar 5.[Epub ahead of print]8. Richardson A, Fletcher L, Sneyd MJ, et al. The incidence andthickness of cutaneous malignant melanoma in New Zealand1994–2004. NZ Med J. 2008;121;18–26.9. Malvehy J, Puig S, Argenziano G, Marghoob AA, SoyerHP; International Dermoscopy Society Board members.Dermoscopy report: proposal for standardization. Results of aconsensus meeting of the International Dermoscopy Society. JAm Acad Dermatol. 2007;57:84–95.10. Youl PH, Janda M, Elwood M, et al. Who attends skin cancerclinics within a randomized melanoma screening program?Cancer Detect Prev. 2006;30:44–51.11. Janda M, Elwood M, Ring IT, et al. Prevalence of skin screeningby general practitioners in regional Queensland. Med JAust. 2004;180:10–5.12. Fritschi L, Dye SA, Katris P. Validity of melanoma diagnosisin a community-based screening program. Am J Epidemiol.2006;164:385–90.13. Aitken JF, Janda M, Elwood M, et al. Clinical outcomes fromskin screening clinics within a community-based melanomascreening program. J Am Acad Dermatol. 2006;54:105–14.14. Jonna BP, Delfino RJ, Newman WG, Tope WD. Positive predictivevalue for presumptive diagnoses of skin cancer and compliancewith follow-up among patients attending a communityscreening program. Prev Med. 1998;27(4):611–6.15. de Rooij MJ, Rampen FH, Schouten LJ, Neumann HA. Skincancer screening focusing on melanoma yields more selectiveattendance. Arch Dermatol. 1995;131:422–5.16. de Rooij MJ, Rampen FH, Schouten LJ, Neumann HA.Volunteer melanoma screenings. Follow-up, compliance, andoutcome. Dermatol Surg. 1997;23:197–201.17. Oakley A, Rademaker M, Stewart B. High risk patients selfselect for melanoma screening. Australas J Dermatol. 2009;50(Suppl 1), A34.18. McPherson M, Elwood M, English DR, et al. Presentation anddetection of invasive melanoma in a high-risk population. J AmAcad Dermatol. 2006;54:783–92.19. Warycha MA, Christos PJ, Mazumdar M, et al. Changes in thepresentation of nodular and superficial spreading melanomasover 35 years. Cancer. 2008;113:3341–8.20. Baade P, Coory M. Trends in melanoma mortality in Australia:1950–2002 and their implications for melanoma control. AustN Z J Public Health. 2005;29:383–6.21. Haass NK, Smalley KS. Melanoma biomarkers: current statusand utility in diagnosis, prognosis, and response to therapy.Mol Diagn Ther. 2009;13:283–96.22. Tejera-Vaquerizo A, Barrera-Vigo MV, López-Navarro N,Herrera-Ceballos E. Growth rate as a prognostic factor inlocalized invasive cutaneous melanoma. J Eur Acad DermatolVenereol. 2009 Jul 13.(epub)23. Swetter SM, Johnson TM, Miller DR, et al. Melanoma inmiddle-aged and older men: a multi-institutional surveystudy of factors related to tumor thickness. Arch Dermatol.2009;145:397–404.24. Geller AC, Elwood M, Swetter SM, et al. Factors related tothe presentation of thin and thick nodular melanoma from apopulation-based cancer registry in Queensland Australia.Cancer. 2009;115:1318–27.272 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchReview of registration requirements for newpart-time doctors in New Zealand, Australia,the United Kingdom, Ireland and CanadaSharon Leitch MBChB, MRNZCGP; 1 Susan M Dovey PhD 2Abstractintroduction: By the time medical students graduate many wish to work part-time while accommodatingother lifestyle interests.Aim: To review flexibility of medical registration requirements for provisional registrants in New Zealand,Australia, the United Kingdom, Ireland and Canada.1Amity Health Centre,Dunedin, New Zealand2Dunedin School ofMedicine, University ofOtago, DunedinMethods: Internet-based review of registration bodies of each country, and each state or province inAustralia and Canada, supplemented by emails and phone calls seeking clarification of missing or obscureinformation.Results: Data from 20 regions were examined. Many similarities were found between study countriesin their approaches to the registration of new doctors, although there are some regional differences. Mostregions (65%) have a provisional registration period of one year. Extending this period was possible in91% of regions. Part-time options were possible in 75% of regions. All regions required trainees to work inapproved practice settings.Discussion: Only the UK provided comprehensive documentation of their requirements in an accessibleformat and clearly explaining the options for part-time work. Australia appeared to be more flexiblethan other countries with respect to part- and full-time work requirements. All countries need to examinetheir registration requirements to introduce more flexibility wherever possible, as a strategy for addressingworkforce shortages.Keywords: Family practice; education, medical, graduate; government regulationIntroductionInternationally, changing medical workforcepatterns causes difficulties for health workforceplanners. While the demand for health careescalates due to ageing populations and otherprocesses, doctors are in scarce supply. This situationhas been attributed to feminisation of themedical workforce and cultural influences onwork practices.Women now make up at least 50% of medicalschool graduates in many countries, 1 includingNew Zealand (NZ), 2 Australia, 3 the UnitedKingdom (UK), 4 Ireland 5 and Canada. 6 Womendoctors have different work patterns from menin terms of activity rates while at work, hoursof work, lifetime work patterns and retirementrates. 7–9 Around 80% of women doctors aged over40 years have children and, like women traditionally,they bear the major burden of child-bearingand rearing and make the biggest career sacrificein terms of maternity leave and subsequent parttimework. 10,11Outdated hospital culture, debt from ‘user pays’culture, and generational cultural influencesall contribute to both male and female doctorsseeking flexibility in their training and employment.The influence of generation X (people bornbetween 1961 and 1981) and Y (the followinggeneration) doctors has also placed more emphasison balance of work, family and lifestyle, suchJ PRIM HEALTH CARE2010;2(4):273–280.Correspondence to:Susan DoveyAssociate Professor,Dunedin School ofMedicine, Universityof Otago, PO Box 913,Dunedin, New Zealandsusan.dovey@otago.ac.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 273

ORIGINAL SCIENTIFIC PAPERSquantitative researchthat flexible work hours and patterns are an attractiveoption for both males and females. 12,13These new generations of doctors are attemptingto fit into health care structures designed for theless self-empowered, less techno-competent usersof previous generations. 14Although a recent UK study shows that manyjunior doctors feel ill-prepared for the transitionfrom medical school into the medical workforce, 15we could find no published literature specificallyaddressing registration processes. Medicalregistration is required to work as a doctor inmost countries and internationally follows thesame basic pattern: mandatory registration beforecommencing employment as a doctor; provisionalregistration for an intensively supervisedperiod, followed by full registration with lesssupervision and increased flexibility. This studyfocuses on medical registration requirementsonly for same-country graduates as requirementsfor International Medical Graduates often differ.Governments invest a great deal in trainingdoctors, and hope to retain most of their ownmedical graduates, so if any flexibility is to befound for new medical graduates, it is likely tobe for same-country doctors. This study aimed tomake international comparisons of the flexibilityof registration requirements for medical graduateswishing to work part-time, particularly focussingon the first year following graduation (postgraduateyear one, PGY1, intern year, or core trainingperiod). Specifically, we aimed to find answers forthe questions: ‘what is required for provisionalmedical registration?’ and ‘is it possible for provisionalregistrants to work part-time?’The countries chosen for this study were NZ,Australia, the UK, the Republic of Ireland andCanada. These countries share key features:English is the dominant language, there is somereciprocity of recognition of degree qualifications,and there is similarity between the British-basededucational and medical philosophies.MethodMedical registrationMedical registration authorities take differentforms internationally. The New Zealand MedicalCouncil authorises the registration of practisingdoctors and monitors the training of medical studentsand new doctors. The professional Collegesare responsible for vocational training.The Australian Medical Council assesses and accreditsmedical courses and specialty training programmes,but independent Medical Boards of eachstate or territory are responsible for registration.Prevocational postgraduate medical training is theresponsibility of another independent body—thePostgraduate Medical Council or Institute ofMedical Education and Training. Vocational trainingis undertaken through the Colleges.In the UK, the General Medical Council is anindependent body responsible for keeping a registerof qualified doctors and promoting medicaleducation standards. Regional Foundation Schoolsprovide prevocational postgraduate education,offering new doctors a range of different settingsand clinical environments. Deaneries are responsiblefor postgraduate medical education andcontinuing professional development of all doctorsand dentists. Colleges provide vocational training.In the Republic of Ireland, the Medical Councilregisters Irish doctors and assures undergraduateand postgraduate medical education quality.Local medical school deans oversee prevocationalpostgraduate education. The Colleges providevocational training.The Medical Council of Canada provides thequalification Licentiate of the Medical Councilof Canada for entry into practice, which togetherwith an approved undergraduate medical degree,is required for medical registration. Registrationis the role of regional bodies, usually the Collegeof Physicians and Surgeons of (Region). MostCanadian new medical graduates are enrolledin university-based residency programmes andregistered for postgraduate education. Doctorsremain on the educational register untilthey complete residency, when they register forIndependent Practice. The national certifyingbodies (for family medicine the College of FamilyPhysicians of Canada and for other specialtiesthe Royal College of Physicians and Surgeons ofCanada) accredit the university-taught but hospital-basedresidency programmes. Many issues274 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchrelevant to the current research are determinedby universities rather than by the registeringbody. Canadian law regarding parental leave andassociated working conditions also applies tojunior doctors.Data collection methodsInternet searches during 2008 provided the maindata source. Further clarification was soughtby emailing and phoning the relevant bodies incharge of registration. A table of the web addressesby country can be found as Appendix 1in the online version of this paper.DataData were collected from each of 20 regionsshown in Table 1. Each state of Australia andCanada was analysed independently. Collectively,the countries and separate states are denoted‘regions’ in this report. Northwest Territories,Nunavut, Prince Edward Island and Yukon wereexcluded from Canadian data as they do not havean independent medical registration body. Non-English language information from Quebec wasalso excluded.Where answers to the study questions wereambiguous, such as ‘at board discretion’, morespecific information was requested by email.Phone calls were used as a final means of obtaininginformation.The investigation for each region commencedwith the relevant medical regulatory body website.This provided satisfactory information onlyfor NZ—the only study country where a singleMedical Council oversees every part of the registrationprocess. For Australia and the UK, thepostgraduate medical training body websites werethen examined. For Canada, university postgraduatemedical websites were examined and, if thiswas insufficient, the regional residents’ unioncollective agreement. This particularly appliedif the region had several different postgraduatemedical education providers. This informationwas used to construct tables to organise the dataand to facilitate comparison. Each section wasthen examined and qualitative comparisons madebetween regions.What gap this fillsWhat we already know: Doctors are in short supply internationally andthe junior doctor workforce tends to be internationally mobile. Their earlyvocational training period comes at a time in their lives when they are oftenseeking flexible work arrangements.What this study adds: This study offers new insights into the flexibilityof early vocational training in the countries most likely to be sharing their newmedical graduates. Australia may have the most flexible training requirements,the UK has the most accessible information, and Canada is substantiallydifferent from the other study countries.ResultsTable 1 (a, b, c) provides the study’s results forthe 20 regions.Time to complete provisional registrationIn all regions, time to complete provisional registrationwas either one or two years. Two-thirdsof regions had a provisional registration periodof one year (13: 65%), for six it was two years,and in one region this was not stated. In Canada,five (of nine) regions had an explicitly stated coretraining period of two years in a residency programme.Three others had a core training periodof one year or less, and in one region this wasnot stated. The core training period was usuallydetermined by the provider university.In the UK, junior doctors are enrolled in a twoyearfoundation programme, but provisionalregistration applies only for the first year. This isalso the case for at least four of the eight regionsin Australia.Extended provisional registrationProvisional registration, therefore, is mainly therealm of NZ, Australia, the UK and Ireland; atotal of 11 regions. Extending the provisionalregistration period was possible (for example, forreasons of maternity leave or working part-time)in 10 regions; one region did not state this information.Regions in Canada generally referred tolocal maternity leave legislation. This typicallyreferred to the length of leave allowed, ratherthan extending the training period. Canada wasVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 275

ORIGINAL SCIENTIFIC PAPERSquantitative researchthe only country stating that discretion wasavailable in terms of time required for satisfactorycompletion of the residency programme(stated for three of nine regions): this related tothe entire residency rather than specifically thecore training period.Excluding Canada, the time allowed for extendedprovisional registration period ranged from twoto four years. Some regions required the provisionalregistration period to be completed withintwo years (5: 45%). Two regions allowed thisperiod to be extended over three years. In SouthAustralia the provisional registration periodcould be extended over four years, but an emailstated that the internship must be completedwithin three years following registration. Threeregions did not state this information.Additional restrictions to registrationAdditional restrictions to registration were notedparticularly in reference to extending the provisionalregistration period, or working part-time.These additional restrictions had some commonthemes (Table 2).Part-time options in the provisional registrationperiod were available in 75% of the regions,not available in 10%, and possibly available inthe two regions whose registration bodies havedelegated this approval to another postgraduateTable 1. Pre-registration regulationsTable 1a. Pre-registration regulations for New Zealand, the UK, and the Republic of IrelandNew Zealand UK IrelandTime to completeprovisional registrationExtended provisionalregistration periodallowed (for maternityleave etc.)1 year 1 year 1 year2 years Yes; equivalent to full-time 1 year At discretion of dean of graduate’smedical schoolAdditional restrictionsto registrationNeed to complete four 10-weekrotations. Need to complete threeconsecutive 3/12 runs satisfactorilyprior to application for generalregistrationMust complete requirements forFoundation Year One Programme.Flexible trainees must work at leasthalf-timeUnder Statutory Instrument No. 285(2003) an internship should consist of12 consecutive months and must becompleted satisfactorily before theintern may be awarded a certificate ofexperiencePart-time/job shareoptionYes Yes No; at discretion of medical school deanRequired disciplinesduring registrationperiod1 category A medical run, 1category A surgical run, and 2 others(A or B)Medicine and surgeryMedicine and surgeryOptional disciplinesduring registrationperiodSee textVaries depending on post orprogrammeO&G, paeds, psych, emergency, GP,perioperative medicineApproved practicesettingYes Yes YesUniversity-basedpostgraduateprogrammeNoFoundation Programme (first2 years following graduation)overseen by a postgraduate dean,who heads each postgraduatedeanery. Undergraduate deanshead the medical schools. They arenot governed by, nor do they haveany formal relationship with, thepostgraduate deaneriesMedical school dean provides acertificate of experience276 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchTable 1b. Pre-registration regulations for Australian statesAustralianCapitalTerritoryNew SouthWalesNorthernTerritoryQueenslandSouthAustraliaTasmania Victoria WesternAustraliaTime tocompleteprovisionalregistration1 year 1 year 1 year 1 year 1 year 1 year 1 year 1 yearExtendedprovisionalregistrationperiodallowed (formaternityleave etc.)2 or more years 3 years 2 years 3 years Up to 4 years N/S If agreed byhospital andPostgraduateMedicalCouncil ofVictoria2 or moreyearsAdditionalrestrictions toregistrationPart-time/jobshare optionRequireddisciplinesduringregistrationperiodN/SNeed tocompletefive 10-weekrotationsNeed to haveone full-time10-week termcomponent(usuallycompleted atcommencementof internship)Need tocompletefour 10-weekrotationsNeed to haveone full-time10-week termcomponent(usuallycompleted atcommencementof internship)Each termmust beat least 10consecutiveweeks inlengthInternshipmust becompletedwithin 3years ofgraduationAvailabilityof parttimeworkdepends onhospital andPMITYes Yes Yes Yes Yes Possible Yes YesMedicine, surgery,emergency, plus 2other rotationsMedicine,surgery,emergencyMedicine,surgery,emergencyMedicine,surgery,emergencyMedicine,surgery,emergency,or generalpracticeMedicine,surgery,emergencyN/SMedicine,surgery,emergencyAvailabilityof parttimeworkdepends onhospitalMedicine andsurgeryOptionaldisciplinesduringregistrationperiodGeneral practiceGeneralpractice andrural runsEmergencydesirableApprovedpracticesettingsrequiredYes Yes Yes Yes Yes Yes Yes YesUniversitybasedpostgraduateprogrammeNoPlacementsallocatedby MedicalAppointmentsand Training Unitin ACT Dept ofHealth; ultimatelyoverseen by NSWIMETNoAllocationof internplacements,PG trainingand welfare ofprevocationaltraineesPGY1 and 2coordinatedby Instituteof MedicalEducation andTrainingNo2-yearPrevocationalClinicalEducationProgrammeoverseen byNorthernTerritoryPostgraduateMedical CouncilN/SPostgraduateMedicalCouncilaccreditsjunior doctortrainingprogrammes,mainly PGY1and PGY2NoTrainingoverseen byPostgraduateMedicalCouncilof SouthAustraliaNoPostgraduateMedicalInstitute ofTasmaniaresponsiblefor PGY1–3N/SPrevocationaltrainingoverseen byPostgraduateMedicalCouncilNoPrevocationaltrainingoverseen byPostgraduateMedicalCouncilN/S = not significantVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 277

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 1c. Pre-registration regulations for Canadian provincesTime tocompleteprovisionalregistration(equivalent)Extendedprovisionalregistrationperiodallowed (formaternityleave etc.)Additionalrestrictions toregistrationN/S = not significantAlbertaBritishColumbia2 years 2 years;core of44 weeksMaximumof 1 yearoff formaternityleaveWaiver oftrainingpossible inexceptionalcircumstancesMaximumof 1 yearoff formaternityleaveManitobaNewBrunswickNewfoundlandand LabradorNovaScotiaOntario Saskatchewan Quebec2 years 2 years 1 year 2 years 1 year 2 years N/SYes N/S YesMustcomplete anaccreditedpostgraduatetrainingprogramme.Part-timework must beequivalent tofull-time for2 yearsMustsatisfactorilycomplete anaccreditedpostgraduatetrainingprogrammeThecollege hasdiscretion tobe lenienton the totalamountcompletedMaximumof 1 yearoff formaternityleaveAll corerotations mustbe completedworking fulltime;part-timerotations must beat least 50% of afull-timeProgrammedirector’sdiscretion as towhen residencycompleteN/SMustsatisfactorilycomplete anaccreditedpostgraduatetrainingprogrammeMaximumof 1 yearoff formaternityleaveMustcomplete anaccreditedpostgraduatetrainingprogrammeand examinationsMaximumof 1 yearoff formaternityleavePart-timework generallyapproved if50–80% offull-timeN/S60%patientcontactFrenchagency (e.g. university). Table 3 shows the possibilityof part-time work, including the need forexplicit special approval.All regions required new doctors to work inpractice settings approved either by a postgraduatemedical body (Australia, Ireland, theUK), the Medical Council (NZ), or a university(Canada).Training during the first postgraduate year variedin delivery and was country-specific. Australia,NZ and the UK had intern education providedby the employing hospital, whereas Canadaand Ireland had a university-based postgraduateprogramme. All regions within Australia havetheir hospital-based training overseen by anindependent medical training institute. In NZthe hospital-based training is overseen by the NZMedical Council. In the UK, a postgraduate foundationprogramme is undertaken in the employinghospital, and is overseen by local independentmedical bodies known as postgraduate deaneries;these are unrelated to undergraduate (medicalschool) deans.DiscussionThis research project made an internationalreview of the flexibility of registration requirementsfor new medical graduates who wish toundertake paid employment and training on apart-time basis, as there is considerable internationalmovement in the junior doctor workforce.The research was limited to the provisionalregistration period, as this period may have theleast flexibility in working conditions but thegreatest consistency among the study countries,allowing comparisons to be made. The mainresult from this research was that there are manysimilarities between the study countries intheir approaches to junior doctors with regard toregistration requirements in the first postgraduateyear. We could find no previous research support-278 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchTable 2. Common themes for registration requirement restrictions in 20 regionsTheme No. of regions % of regionsMust complete postgraduate requirements 11 55%Full-time component to training required 5 25%Minimum part-time requirement stated 3 15%Rotation length specified 5 25%ing this result but it is important because of theincreasing globalisation of the medical workforce,particularly early in doctors’ careers.Flexibility of registration requirements wasindicated by the value accorded to allowing parttimework and by having limited prior approvalrules. We looked for guidelines that clearlystated how to meet registration requirements,including minimum requirements for part-timework, maximum time allowed for an extendedprovisional registration period, and whetherany full-time component is required. Additionalsigns of a flexible registration body may includeguidance for new medical graduates on work–lifebalance, how to job-share, and how to balanceservice with training requirements when workingpart-time.While registration requirements may be flexible,the ability to work part-time also dependson the flexibility of workplaces to accommodatepart-time doctors. In the traditional hospitalestablishment, shifting from the ‘house doctor’,available 24 hours a day, to ‘part-time’ doctormay be difficult. Well-linked teams and effectivejob-sharing may ease this transition and facilitatehealthier working hours. In many countries governmentregulations are already impacting hoursof work and forcing change. 16 Few regions hadthis type of information explicitly stated. Emailsfor further information were frequently misconstruedas from an international medical graduateseeking registration or employment advice, ratherthan from a researcher seeking information.Across all study regions there are similarities inmedical registration requirements, the primaryone being that doctors must be registered to practisemedicine. A provisional registration periodapplies to all study countries except Canada,where an educational registration is applicablefor doctors engaged in vocational training. Mostregions (65%) had a provisional registration periodof one year, even if they had foundation or coretraining periods of two years. Most regions allowedextensions of this provisional registrationperiod (73%), ranging from two to four years forcompletion. Restrictions to extension had severalcommon themes; the most common was thatdoctors must complete postgraduate requirementsduring the extended period. Part-time work waspossible in at least 75% of regions. Only tworegions stated part-time or job share options werenot possible. There was unanimous agreementthat basic training must occur within approvedpractice settings.There was a strong geographical distributionof results for some questions. Canada conductsmedical registration differently from the otherstudy countries, having neither a prevocationalpostgraduate period, nor a true equivalent for theprovisional registration period. Extensions of theprovisional training period were applicable onlyfor the other regions. Canadian literature referredTable 3. Potential to work part-time during provisional registration period in 20 regionsYes Possibly No Not stated TotalPart-time option possible 15 (75%) 2 (10%) 2 (10%) 1 (5%) 20 (100%)Special approval explicitly required 7 (35%) 2 (10%) 1 (5%) 10 (50%) 20 (100%)VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 279

ORIGINAL SCIENTIFIC PAPERSquantitative researchCompeting interestsDr Sharon Leitch declaresa potential competinginterest because shereceived funding fromthe RNZCGP under theResearch Fellowshipprogramme.to extending the training (residency) period onlythrough parental leaves of absence, and mademention of state parental leave policy.Delivery of postgraduate education varied bycountry, although most training worldwide tookplace within employing hospitals. Providers ofpostgraduate prevocational education in Australia,NZ and the UK were based in hospitals,while in Canada this education was provided bya university.Educational oversight and accreditation clearlyhad regional differences as well. In Australiathe regional Postgraduate Medical Councils orInstitute of Medical Education and Training bothaccredit junior doctor training programmes, andprovide oversight for the education provided. InIreland and Canada some educational oversightis provided by the Medical Council, and presumablyalso through the universities’ independentaccreditation processes. In NZ these roles are heldby the Medical Council. In the UK this role wasundertaken by local deaneries.Several regions stand out as being particularlyflexible. Australia, which may be more consistentacross the country than these results suggest,also appears quite flexible, particularly in the factthat the amount of full-time work required seemssmall but reasonable (one 10-week period) andrelatively manageable compared to NZ (requiringthree consecutive runs or nine months in arow full-time). The UK had all of the FoundationProgramme requirements fully stated in an easilyaccessible website. It was one of the very fewplaces to formally state the options for part-timework. The explicit statement of this informationindicated the matter had been given carefulconsideration, and that the special needs of achanging medical workforce have been taken seriously.While flexible registration requirements donot mean part-time work is readily available, theydo provide guidance for both employers and newdoctors seeking employment compatible with theconflicting needs of family and work.ConclusionThe medical workforce is changing, and medicalregistration is one prerequisite for employment asa doctor in most countries. This research providesa snapshot of 2008 practices of internationalmedical registering bodies for the provisionalregistration period. There are likely to be smallchanges since then as the processes evolve indifferent countries. The study gives new insightsinto the flexibility of the registering bodies’ability to accommodate new doctors who wish towork part-time. However, it was limited to onlysix countries and more research, involving morecountries, would give greater insight into thetraining and environments supporting junior doctors.All countries need to examine registrationrequirements and other components of medicaltraining and employment processes in light of thechanging medical workforce and the internationalhealth workforce crisis.References1. Potee R, Gerber A, Ickovics J. Medicine and motherhood:shifting trends among female physicians from 1922 to 1999.Acad Med. 1999; 74(8):911–19.2. The New Zealand Medical Workforce in 2006. Wellington:Medical Council of New Zealand; 2007.3. Brooks P, Lapsley H, Butt D. Medical workforce issues inAustralia: ‘tomorrow’s doctors—too few, too far’. Med J Aust.2003;179:206–8.4. McKinstry B. Are there too many female medical graduates?Yes. BMJ. 2008;336:748.5. Graham F, De La Harpe D. Implications of the increasing femaleparticipation in the general practice workforce in Ireland.Ir Med J. 2004;97:82–3.6. Burton K,Wong I. A force to contend with: the gender gapcloses in Canadian medical schools. Can Med Assoc J.2004;170:1385–6.7. Bloor K, Freemantle N, Maynard A. Gender and variationin activity rates of hospital consultants. J Roy Soc Med.2008;101:27–33.8. Quadrio C. Women and men and the medical workforce inAustralia. Med J Aust. 1997;166:7–8.9. Schofield D, Beard J. Baby boomer doctors and nurses: demographicchange and transitions to retirement. Med J Aust.2005;183:80–3.10. Sobecks N, Justice A, Hinze S, Chirayath H, et al. Whendoctors marry doctors: a survey exploring the professionaland family lives of young physicians. Ann Intern Med.1999;130(4):312–9.11. Woodward C. When a physician marries a physician. Can FamPhysician. 2005;51:850–1.12. Tolhurst H, Stewart S. Balancing work, family and otherlifestyle aspects: a qualitative study of Australian medicalstudents’ attitudes. Med J Aust. 2004;181:361–4.13. Vaughan C. Career choices for generation X. BMJ.1995;311:525–6.14. Kupperschmidt, BR. Understanding Generation X employees.J Nursing Admin. 1998;28(12):36–43.15. Chand M. Modernising medical careers and the British surgeonsof the future. BMJ. 2010;71(5):282.16. McIntyre HF, Winfield S, Sen T H, et al. Implementationof the European Working Time Directive in an NHS trust:impact on patient care and junior doctor welfare. Clin Med.2010;10(2):134–7.280 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchAppetite for life: an evaluation of a primary carelifestyle programmeLiz Cutler Dip HSc, Dip Teaching, Post Grad Dip Science (Community Nutrition); 1 Bronwen King BHSc, DipTeaching; 2 Nicky McCarthy BSc, PGDip Dietetics, PGCert Public Health; 1 Greg Hamilton PhD; 1 LynleyCook MBChB, MPH, FRNZCGP, FNZCPHM 2ABSTRACTIntroduction: Appetite for Life is a six-week primary care–based programme for women who areoverweight, and aims to achieve long-term health gain through establishing healthy eating and physicalactivity patterns and a healthier weight.1Canterbury District HealthBoard, Timaru, New Zealand2Partnership HealthCanterbury Te Kei o Te Waka,Christchurch, New ZealandAim: To evaluate the outcomes of Appetite for Life, a primary care–based healthy lifestyle programmefor women who are overweight.Methods: Two hundred and sixty-one women enrolled and consented to take part in the six-weekAppetite for Life programme via general practice and were followed for 12 months. Eating behavioursand physical activity levels were measured at baseline, six weeks, six months and 12 months. Anthropometricand biomedical data was collected at visits to the participants’ general practitioners at baselineand 12 months.Results: Positive lifestyle changes were reported that were sustained for the duration of the 12-monthfollow-up period. Participants reported an increase in intake of fruit and vegetables, dairy products,healthy fats and an increased level of physical activity. There was also an increase in reported enjoymentand participation in exercise. Mean weight was maintained over this time period. There was a reductionin mean LDL and total plasma cholesterol.Discussion: A healthy lifestyle programme offered through primary care that is based on a non-dietingapproach may help overweight women develop and sustain positive lifestyle changes.KEYWORDS: Health promotion; health status; obesity; weight loss, physical activityIntroductionRising rates of obesity, poor nutrition andinactivity contribute significantly to the burdenof disease in New Zealand and are a substantialcost to the health system. 1,2 A comprehensiveapproach is needed to address these problems; onethat includes both population strategies as wellas individual-level strategies that effect long-termlifestyle change. 3,4This paper reports the outcome evaluation of Appetitefor Life, an established primary care–basedhealthy lifestyle programme. This programmeaims to help women who are overweight to achievelong-term health gain through establishinghealthy eating and physical activity patterns andultimately a healthier weight. Lifestyle changes, inparticular increasing physical activity levels, canlead to improvement in health status in overweightadults, whether or not weight loss occurs. 5–7Appetite for Life was developed by public healthnutritionists at Community and Public Health(Canterbury District Health Board) followingrequests from general practice nurses for an effectivehealthy lifestyle programme that couldbe delivered in the primary care setting. Theprogramme was developed for women becauseof the key role women play in the planning andpreparation of food for their families.J PRIM HEALTH CARE2010;2(4):281–287.Correspondence to:Liz CutlerCommunity and PublicHealth, Canterbury DistrictHealth Board, P O Box 510,Timaru 7940, New Zealandliz.cutler@cdhb.govt.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 281

ORIGINAL SCIENTIFIC PAPERSquantitative researchThe Appetite for Life programme was modelledon a non-dieting approach. A non-dieting approachemphasises the importance of achievingsustainable, positive lifestyle changes rather thandietary restriction. 8,9 Although there are variations,the non-dieting approach includes professionaland social support as well as educational,behavioural and psychological strategies and areusually delivered in a group setting. 8,10–13 A dietingapproach (kilojoule restriction) was avoidedas, although it may be effective in the short-term,weight loss is infrequently maintained in thelong-term 4,14 and may have harmful effects suchas a weight-cycling, preoccupation with food andpoor self-esteem. 8,15The design of Appetite for Life is based on contemporarybehavioural research and theoreticalmodels of how adults learn and how learning in-The aim of this evaluation was to determine theoutcomes of the Appetite for Life programme in areal-world situation in primary care. 20MethodsAppetite for Life was delivered by trainedpractice nurse facilitators to groups of women(12–15) through six two-hour group sessions overa six-week period. This was delivered throughinformation provision and experiential learningdemonstration and food tastings in a groupsetting that allowed the development of socialsupport and self-efficacy.Participants were encouraged to follow the NewZealand Food and Nutrition Guideline Statementsfor Healthy Adults. 21 This included encouragementto eat a variety of nutritious foods fromA dieting approach (kilojoule restriction) was avoided as, althoughit may be effective in the short-term, weight loss is infrequentlymaintained in the long-term and may have harmful effects such asa weight-cycling, preoccupation with food and poor self-esteemfluences their health behaviour. Social CognitiveTheory, 16 the Health Belief Model 17 and CommunicationTheory 18 guided programme strategies toemphasise social support, reinforcement, attitudedevelopment and self-efficacy. Social CognitiveTheory suggests that environmental role modelsand societal expectations can significantly influencehealth behaviour. The programme used severaltechniques derived from this theory includingself-efficacy, role modelling, skills trainingand observational learning.The wide population coverage of primary healthcare (over 95% of people in the region are enrolled)provides an opportunity for widespreaddissemination of interventions. This programmeaimed to address barriers to diffusion of innovations19 by highlighting the programme’s simplicityand compatibility with existing practicesand resources.each of the four major food groups each day, to eatplenty of vegetables and fruits, to eat plenty ofbreads and cereals, preferably wholegrain, to includemilk and milk products in their diet (preferablyreduced or low-fat) and decrease or maintaina low intake of dietary fat. Participants were alsoencouraged to maintain or increase physical activitylevels by doing ‘as much as they can, as oftenas they can, going as hard as they can, for as longas they can.’ Participants were not given adviceabout kilojoule restriction and were discouragedfrom monitoring weight changes. Instead, theywere encouraged to develop new habits by workingthrough a series of behavioural goals.The Appetite for Life programme session included:• Session 1: Food, why do we need it;the importance of breakfast (food tasting)and why diets (per se) don’t work282 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative research• Session 2: Reducing fat; healthybreads and spreads (food tasting)and identifying what we eat• Session 3: Increasing fibre; healthy desserts(food tasting) and changing eating habits• Session 4: Becoming more physicallyactive; smarter snacking (foodtasting) and reading food labels• Session 5: Recipe modification; eatingmore legumes (food tasting) andwhat fat loss we can expect• Session 6: Nutrients women need; bodyimage; potluck dinner (food tasting) andongoing management and sustainability.Participants in the programme were supportedby the practice nurse facilitators to develop positivelifestyle changes at an individual and familylevel through problem solving, skill developmentand improved self-efficacy. Following the initialsix-week course, participants were supportedby their practice nurses and received quarterlynewsletters.The practice nurse facilitators participated inthe Appetite for Life course programme priorto receiving training from the Appetite for Lifetrainer (public health nutritionists and adulteducation experts) in adult learning and group facilitation.The trainer also supported the practicenurses in the delivery of their first course.Appetite for Life was offered in and publicisedthrough general practices, a newspaper advertisementand word of mouth, and was offered inSouth Canterbury, West Coast and Canterbury.The programme was promoted to women whowere overweight. There were no exclusion criteria.Those who participated between 2006 and 2007were invited to participate in the evaluation (279).The evaluation was commenced prior to theNational Ethics Advisory Committee’s guidelinedevelopment. Ethics approval was not formallysought for this evaluation as it was considered tobe an audit of existing practice. Informed writtenconsent was obtained from the participants.As the programme was primary care–based,participants’ National Health Index numberswere used as their unique identifiers to allowdata anonymity.WHAT GAP THIS FILLSWhat we already know: A non-dieting approach is an alternative to dietingand can lead to sustained positive lifestyles changes.What this study adds: A healthy lifestyle programme that takes a nondietingapproach may be effective in making sustained positive lifestyleschanges for participants outside the trial setting in primary care.The participants were followed up over a 12-monthperiod. The key outcomes were eating behaviours,physical activity levels, and weight. A questionnaireon eating behaviours and physical activitypatterns was conducted at baseline, completion ofthe programme, six months and 12 months.The questionnaire section on eating behaviourswas adapted from one used for similarprogrammes in Australia. The questionnairemeasured self-reported dietary intake of differentfood types, including breads and cereals, fruitand vegetables, dairy products (low and high fat)and dietary fat. The questionnaire also recordedattitudes towards eating and dieting, the impactof healthy eating on the participant’s family andenjoyment of, and ability to, exercise. Intake ofdifferent food groups was calculated as an indexscore based on responses from the questionnaire.This score represents healthier eating behavioursaligned with nutritional intake recommended bythe Ministry of Health. 22 The short version ofthe International Physical Activity Questionnairewas used to measure physical activity. 23,24Follow-up questionnaires were mailed to participantsand returned using a postage-paid envelope.At 12 months a reminder was sent to participantsto visit their primary health care practice forclinical measurements and a blood sample.Anthropometric and biomedical data wascollected at visits to the participants’ generalpractitioners at baseline and 12 months. The informationincluded demographic details, weight,height, waist circumference, total cholesterol,LDL cholesterol, HDL cholesterol, triglycerides,fasting blood glucose (for participants withoutknown diabetes) or glycated haemoglobin (forparticipants with known diabetes) and HbA1c.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 283

ORIGINAL SCIENTIFIC PAPERSquantitative researchParticipant addresses were geocoded to residentialaddress points using the Critchlow Ltd Geostangeocoding engine. Using ESRI ArcGIS Desktop9.3, addresses were assigned and aggregatedwithin 2006 census meshblocks. Each geocodedpoint was assigned the New Zealand DeprivationIndex 2006 (NZDep2006) decile of its correspondingmeshblock. 25Statistical analyses were conducted using SPSS(version 14.0). Biomedical and psychosocial datawere analysed using paired samples t-tests andchi-squared comparing baseline and 12-monthdata. To assess whether there was any differencein results between the three different regionswhere programmes were run one-way, ANOVAtests were performed using data relating tochanges in fruit and vegetable consumption.ResultsResponse ratesTable 1. Reported consumption of key food groupsFood group Time-point nIndexscore*Range ofscoresBreads and cereals Baseline 261 4.3 1–8p-valuePost-programme 206 5.2

ORIGINAL SCIENTIFIC PAPERSquantitative research57%. This could well lead to an over-emphasis ofthe positive outcomes, as those that completedfollow-up may be more likely to have had positiveoutcomes. Obtaining accurate self-reporting onfood and fluid on nutritional intake is notoriouslydifficult and therefore the results of the surveyinstrument may not be reliable. 36,37 This wasaccentuated by having no control group. Unfortunatelyretention rates in the six-week practicenurse–led programme were not recorded.The main implication of this evaluation is that ahealthy lifestyle programme can be successfullyimplemented in a New Zealand primary caresetting. In addition to the evaluation reportedhere, interviews with the participating practicenurse facilitators were conducted. They reportedhigh levels of satisfaction with the programmewhich has been accepted and adopted by primaryhealth care in the region. Other benefits that theAlthough the findings from this evaluation indicatepositive outcomes, they are insufficient toclaim outright that Appetite for Life is effective.Stronger research designs are required. Furtherresearch on the non-dieting approach shouldinclude the impact of this type of intervention onthe lifestyle of other family and household members.The change in lifestyle of the participantsis likely to influence other household membersthrough changes in purchasing and preparation offood for the family. This is particularly importantto explore because of its potential influence onchildhood obesity.A non-dieting healthy lifestyle programme inNew Zealand primary care settings appears promisingfor achieving sustainable lifestyle changesfor women who are overweight. These sustainedchanges are likely to lead to positive health benefitsregardless of whether weight loss occurs.Facilitators identified food tastings, the practicaladvice, effective group dynamics, locally-baseddelivery and support from nutritionists as factorskey to the programme’s successpractice nurse facilitators reported were increasednutrition knowledge, confidence in assistingoverweight clients and skills in motivatingclients for behavioural change. Facilitators identifiedfood tastings, the practical advice, effectivegroup dynamics, locally-based delivery andsupport from nutritionists as factors key to theprogramme’s success.The findings of this evaluation will help tofurther refine and develop Appetite for Life toimprove its success. Future developments willlook to strengthen elements that are known toincrease success in weight loss. As the non-dietingapproach has not developed a strong evidencebase to date, the success factors for a non-dietingapproach have not been reviewed. It is importantthat success factors from other similar types ofinterventions are incorporated into successiveprogramme development.References1. Ministry of Health. A portrait of health. Key results of the2006/07 New Zealand health survey. Wellington: Ministryof Health; 2008.2. Ministry of Health, The University of Auckland. Nutritionand the burden of disease: New Zealand 1997–2011. Wellington:Ministry of Health; 2003.3. Swinburn B, Egger G. Preventive strategies against weightgain and obesity. Obes Rev. 2002;3(4):289–301.4. Mulvihill C, Quigley R. The management of obesity andoverweight: an analysis of reviews of diet, physical activityand behavioural approaches: evidence briefing. 1st edition.NHS: Health Development Agency; 2003.5. Warburton DE, Nicol CW, Bredin SS. Health benefitsof physical activity: the evidence. Can Med Assoc J.2006;174(6):801–9.6. World Health Organization. Diet, nutrition and the preventionof chronic diseases. Geneva: WHO; 2003.7. Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise foroverweight or obesity. Cochrane Database Syst Rev.2006(4):CD003817.8. Foreyt J, Goodrick GK. Weight management without dieting.Nutrition Today. 1993;24(2):4–9.9. Polivy J, Herman C. Undieting: a program to help peoplestop dieting. Int J Eat Disord. 1992;11(3):261–268.10. National Health and Medical Research Council. Clinicalpractice guidelines for the management of overweight andobesity in adults. Canberra: National Health and MedicalResearch Council; 2003.11. Ikeda J, Amy NK, Ernsberger P, Gaesser GA, Berg FM, ClarkCA, et al. The National Weight Control Registry: a critique. JNutr Educ Behav. 2005;37(4):203–5.12. Provencher V, Begin C, Tremblay A, Mongeau L, Boivin S,Lemieux S. Short-term effects of a ‘health-at-every-size’approach on eating behaviors and appetite ratings. Obesity(Silver Spring) 2007;15(4):957–66.13. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptanceand intuitive eating improve health for obese, female chronicdieters. J Am Diet Assoc. 2005;105(6):929–36.286 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative research14. Anderson JW, Konz EC, Frederich RC, Wood CL. Long-termweight-loss maintenance: a meta-analysis of US studies. Am JClin Nutr. 2001;74(5):579–84.15. Polivy J. Psychological consequences of food restriction. J AmDiet Assoc. 1996;96(6):589–92; quiz 593–4.16. Bandura A. A social learning theory. Englewood Cliffs, NJ:Prentice Hall Inc.; 1977.17. Janz NK, Becker MH. The health belief model: a decade later.Health Educ Q. 1984;11(1):1–47.18. U.S. Department of Health and Human Services. MakingHealth Communications Work. Bethesda, Maryland: NationalInstitutes of Health; 1992.19. Rogers EM. Diffusion of innovations. New York: FreePress; 1995.20. Garfield SA, Malozowski S, Chin MH, Narayan KM, GlasgowRE, Green LW, et al. Considerations for diabetes translationalresearch in real-world settings. Diabetes Care.2003;26(9):2670–4.21. Ministry of Health. New Zealand Food and Nutrition guidelinestatements for healthy adults. 2007 August 5 [cited 10 July2010]. Available from: http://www.moh.govt.nz/moh.nsf/indexmh/nutrition-foodandnutritionguidelinestatements22. Ministry of Health. Food and nutrition guidelines forhealthy adults: a background paper. Wellington: Ministryof Health; 2003.23. Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML,Ainsworth BE, et al. International physical activity questionnaire:12-country reliability and validity. Med Sci Sports Exerc.2003;35(8):1381–95.24. Brown W, Bauman A, Chey T, Trost S, Mummery K. Comparisonof surveys used to measure physical activity usedin Australia and New Zealand. Aust N Z J Public Health.2004;28:128–34.25. White P, Gunston J, Salmond C, Atkinson J, Crampton P. Atlasof socioeconomic deprivation in New Zealand NZDep2006.Wellington: Public Health Intelligence, Ministry of Health;2008.26. Munsch S, Biedert E, Keller U. Evaluation of a lifestyle changeprogramme for the treatment of obesity in general practice.Swiss Med Wkly. 2003;133(9–10):148–54.27. Tanco S, Linden W, Earle T. Well-being and morbid obesityin women: a controlled therapy evaluation. Int J Eat Disord.1998;23(3):325–39.28. Carroll S, Borkoles E, Polman R. Short-term effects of a nondietinglifestyle intervention program on weight management,fitness, metabolic risk, and psychological well-being in obesepremenopausal females with the metabolic syndrome. ApplPhysiol Nutr Metab. 2007;32(1):125–42.29. Crerand CE, Wadden TA, Foster GD, Sarwer DB, PasterLM, Berkowitz RI. Changes in obesity-related attitudes inwomen seeking weight reduction. Obesity (Silver Spring).20 07;15(3):740 –7.30. Rapoport L, Clark M, Wardle J. Evaluation of a modifiedcognitive-behavioural programme for weight management. IntJ Obes Relat Metab Disord. 2000;24(12):1726–37.31. Bacon L, Keim NL, Van Loan MD, Derricote M, Gale B, KazaksA, et al. Evaluating a ‘non-diet’ wellness intervention for improvementof metabolic fitness, psychological well-being andeating and activity behaviors. Int J Obes Relat Metab Disord.2002;26(6):854–65.32. Hawley G, Horwath C, Gray A, Bradshaw A, Katzer L, Joyce J,et al. Sustainability of health and lifestyle improvements followinga non-dieting randomised trial in overweight women.Prev Med. 2008;47(6):593–9.33. Katzer L, Bradshaw AJ, Horwath CC, Gray AR, O’Brien S,Joyce J. Evaluation of a ‘nondieting’ stress reduction programfor overweight women: a randomized trial. Am J Health Promot.2008;22(4):264–74.34. Harvie MN, Bokhari S, Shenton A, Ashcroft L, Evans G, SwindellR, et al. Adult weight gain and central obesity in womenwith and without a family history of breast cancer: a casecontrol study. Fam Cancer. 2007;6(3):287–94.35. Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we seemore translation of health promotion research to practice? Rethinkingthe efficacy-to-effectiveness transition. Am J PublicHealth. 2003;93(8):1261–7.36. Vance VA, Woodruff SJ, McCargar LJ, Husted J, HanningRM. Self-reported dietary energy intake of normal weight,overweight and obese adolescents. Public Health Nutr.2009;12(2):222–7.37. Cook A, Pryer J, Shetty P. The problem of accuracy indietary surveys. Analysis of the over 65 UK National Dietand Nutrition Survey. J Epidemiol Community Health.2000;54(8):611–6.ACKNOWLEDGEMENTSKaaren Mathias(Community and PublicHealth, Canterbury DistrictHealth Board) assistedwith drafting the originalmanuscript. Kristi Calderassisted with the dataanalysis (Community andPublic Health, CanterburyDistrict Health Board).FUNDINGCommunity and PublicHealth, CanterburyDistrict Health Boardfunded the developmentof the Appetite for Lifeprogramme. CanterburyDistrict Health Boardfunded the evaluationof the programme.Partnership HealthCanterbury Te Kei oTe Waka funded themanuscript preparationand the ongoing deliveryof Appetite for Lifethrough several generalpractices in Canterbury.COMPETING INTERESTSNone declared.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 287

ORIGINAL SCIENTIFIC PAPERSquantitative researchThe Flinders Program TM of ChronicCondition Self-Management inNew Zealand: survey findingsMargaret P Horsburgh RN, EdD, MA (Hons), Dip Ed, FCNA(NZ); 1 Janine J Bycroft MBChB, Dip Obs, DipPaeds, MPH (Hons), FRNZGP; 2 Felicity A Goodyear-Smith MBChB, MGP, FRNZCGP; 2 Dianne E Roy RN,PhD, FCNA(NZ); 1 Faith M Mahony RN, MPH; 3 Erin C J Donnell; 4 Denise J Miller RN, P G Cert HSc (Adv Ng) 51School of Nursing, TheUniversity of Auckland,Auckland, New Zealand2Department of GeneralPractice and Primary HealthCare, School of PopulationHealth, The University ofAuckland3Research Fellow, Centre forHealth Services Researchand Policy, The University ofAuckland4Visible Learning Laboratory,The University of Auckland5Research Nurse, ClinicalTrials Research Unit, TheUniversity of AucklandABSTRACTIntroduction: The Flinders Program TM of Chronic Condition Self-Management in New Zealand (NZ)has been given focus as a useful and appropriate approach for self-management support and improvementof long-term condition management.AIM: To determine the use of the Flinders Program TM in NZ and identify barriers and enablers to its use.Method: A web-based survey was undertaken in June 2009 with 355 eligible participants of the 500who had completed ‘Flinders’ training in NZ since 2005.Results: 152 (43%) respondents completed the survey over a one-month time frame. Of those whoresponded, the majority were primary care nurses (80%; 118). Fifty-five percent (82) of survey respondentsreported using some or all of the Flinders tools. Of these, 11% (16) reported using all of the tools orprocesses with 77% (104) of respondents having completed six or fewer client assessments utilising theFlinders tools. This indicates that respondents were relatively inexperienced with use of the Flinders ProgramTM . Barriers to implementation were identified as the time needed for structured appointments (up toone hour), funding, resistance from colleagues, lack of space and insufficient ongoing support.Discussion: Despite the extent of training in the use of the Flinders Program TM , there is limited usein clinical practice of the tools and processes associated with the model. Without structured support forquality improvement initiatives and self-management programmes, the ability to implement learned skillsand complex interventions is limited.KEYWORDS: Self-management; long-term conditions; chronic conditions; chronic illness; primary care;nursesJ PRIM HEALTH CARE2010;2(4):288–293.Correspondence to:Margaret HorsburghAssociate Professor,School of Nursingc/o P O Box 25876,St Heliers, Auckland1071, New Zealandm.horsburgh@auckland.ac.nzIntroductionLong-term or chronic conditions account for approximately70% of all general practice encountersand 78% of all health care spending in NewZealand (NZ). 1 The 2006/7 NZ Health Survey 2found that two out of three New Zealandershave a long-term health condition. In Australia,general practice is estimated to engage with 87%of a population each year 3 and provide most ofthe long-term conditions care. The challengesfor primary care to respond to chronic illnessare considerable and increasing. The NZ reportMeeting the Needs of People with Chronic Conditions1 identifies client self-management as a keycomponent of long-term condition care and recommendsincorporating self-management supportinto chronic care frameworks in NZ.Self-management support is defined by Adamsand colleagues as ‘the systematic provision ofeducation and supportive interventions by healthcare staff to increase patients’ skills and confidencein managing health problems, includingregular assessment of progress and problems, goalsetting, and problem solving support’. 4288 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchA recent Cochrane review concluded a lack ofclarity around the active ingredient of successfulself-management, and that the evidence for theeffectiveness of self-management programmeson long-term health outcomes is inconclusive. 5Uptake of self-management programmes withinprimary care is also inconsistent. Organisationalbarriers to implementing self-management programmeshave been identified as limited teamwork in general practice, resistance to change andan approach where ‘doctors know best’. 6One study has identified the enablers for selfmanagementprogrammes in Australian generalpractice as including education of staff, skillstraining, inclusion of negotiated self-managementsupport in client care plans, assessment of clients’self-management capacity and developing the roleof practice nurses to provide self-managementsupport. 3 Increasingly the role of practice nursesin self-management programmes is recognised. 3A United Kingdom (UK) study suggests thatclients find nurses easier to approach for informationthan doctors. 7 The capacity of nurses, thelargest group of health professionals, to engagein this role however may require attention, withlittle being done to equip them with knowledgeand skills for self-management education. 8 Manypractice nurses lack the time and competencies toundertake self-management programmes. 3 A UKstudy of practice nurse involvement in self-managementprogrammes found that little attentionhad been given to the ways practice nurses workand support self-management for chronically illclients. 9 Nurses were more confident with clientsin the early stages of their illness. When clientsdid not make suggested lifestyle changes, nursesresorted to didactic information-giving. Thisstudy highlighted the complexities of deliveringself-management programmes where health professionalsmust create partnerships with clients.The Flinders Program TM of Chronic ConditionSelf-Management is a self-management programmedeveloped from the 1990 Australian CoordinatedCare Trials, 10 based on cognitive behaviour therapy,problem solving and motivational interviewingtechniques. This model utilises a set of tools (Partnersin Health Scale, Cue and Response Interview,Problems and Goals Assessment and a Client CarePlan) and processes. Clinicians work one-on-oneWHAT GAP THIS FILLSWhat we already know: The Flinders Program TM of self-managementhas been adopted in NZ as a useful and appropriate approach for improvinglong-term condition management. Over 500 health professionals have beentrained in the use of the programme. The evidence for the effectiveness ofself-management is, however, inconclusive, and support for the introductionof new and complex interventions in primary care inconsistent.What this study adds: This paper demonstrates that, despite the considerableresource being directed to training primary care nurses in particular inthe Flinders Program TM , there is limited use of the Flinders tools and processesin clinical practice. Training for new and complex interventions in primary caremay not be aligned with structured support and general practice priorities.with clients to assess collaboratively self-managementbehaviours, barriers, psychosocial issues andclient preferences, followed by client-identifiedproblems and goal setting, leading to individualisedcare plans. 11 A key point of difference from traditionalcare planning includes the shift in powertowards a client-centred partnership with clientsactively sharing decision-making on their physical,emotional and social well-being. The care plan isbased on shared, agreed issues, goals and interventionsthat align with the client’s values, prioritiesand beliefs. Approximately 45 to 60 minutes isrequired for a Flinders assessment once a clinicianhas become confident and reached competency.The Flinders Program TM has been given focusin NZ as a useful and appropriate approach forincreasing knowledge and understanding aroundself-management support and improving longtermcondition management. Since 2005 approximately500 NZ health professionals haveparticipated in Flinders training, attending atwo-day workshop. For health professionals touse the Flinders Program TM they first attend atraining workshop conducted by a trainer accreditedby the Flinders Human Behaviour andHealth Research Unit (FHBHRU). Followingthis, completion of three client assessments andcare plans to an acceptable standard, as assessedby the accredited trainer, enables the health professionalto receive a Certificate of Competencein Chronic Condition Self-Management fromFlinders University. Flinders University charge alicence fee for each workshop attendee. This feeentitles the workshop participant to access ongoingprogramme updates. The Partners in HealthVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 289

ORIGINAL SCIENTIFIC PAPERSquantitative research(PIH) tool is available for general use, but theother Flinders tools are available only to peoplewho have completed a Flinders ‘workshop’.The requirements for the Certificate of Competenceare also embedded in a NZ postgraduateprimary care nurse course offered since 2007 bythree university academic nursing departments.The intent of this has been to enable nursesenrolled in a ‘long-term conditions’ postgraduatecourse to also achieve the Flinders UniversityCertificate of Competence, increasingly valued byemployers. Principles of client self-managementand other models of self-management are includedin the academic course.Anecdotal evidence suggests that in NZ, as inAustralia, 12,13 there has been limited uptake ofself-management programmes and it is not clearwhether findings from international studies ofself-management programmes translate into NZprimary care settings.In 2008/9 a pilot study to assess the feasibility ofundertaking a substantive long-term trial to gaugethe effectiveness of the Flinders Program TM whenused by practice nurses in NZ was undertaken.The report of this study is published separately.This paper reports the findings from a survey ofNZ primary health care professionals who hadcompleted training in the Flinders Program TM ofChronic Condition Self-Management. The surveywas undertaken in conjunction with the feasibilitystudy. The purpose of the survey was todetermine use of the Flinders Program TM and toidentify barriers and enablers to its use.MethodA web-based survey was undertaken in June2009 using the LimeSurvey tool (open sourcesoftware http://www.limesurvey.org/) with participantswho had completed Flinders training inNZ since 2005.The survey contained multiple choice and freetext responses to ascertain patterns of use, barriersand enablers, preferences and experiences.The tool was piloted to reduce question ambiguityprior to wider distribution.The FHBHRU hold a database of people whohave attended training in the Flinders Program TM .While the database does not hold completerecords, of the New Zealanders in this database,400 had given permission at the time of trainingto be contacted at future dates. There were 45out-of-date or duplicate addresses giving a potentialof 355 participants.The survey was sent from The University ofAuckland. Respondents had one month to respondwith a reminder at two weeks.Ethical approval was granted by the NZ NorthernY Regional Ethics Committee as an extensionto the feasibility study.ResultsOne hundred and fifty-two (43%) surveyresponses were received, with 148 responses includedin the analysis. Four respondents had notcompleted Flinders training and their responseswere excluded.RespondentsThe majority of respondents were primary care orpractice nurses (118 or 80%). Of these, 73 (49%)stated that they were practice nurses. ‘Other’ primarycare nurses included chronic care, diabetic orrespiratory nurses. Other health workers includedgeneral practitioners, dietitians, psychologists,social worker and community health workers.One hundred and twenty-three (83%) respondentswere aged over 40 years. Females numbered 140(95%), the majority being NZ European (107;72%). Four Maori health professionals participatedtogether with six Pacific and six who recordedtheir ethnicity as Asian. Respondents were froma wide geographic area, with the majority (112;76%) in the central and upper North Island,reflecting NZ’s population spread.Use of Flinders Program TM in clinical practiceWithin the survey, 81 (55%) respondents werecurrently using some or all of the Flinders tools,with 16 (11%) using all of the tools and processes(Table 1).290 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchRespondents were asked how many assessmentsthey had completed, how long an assessment takesand to rate their confidence in the use of the Flinderstools using a 5-point Likert scale (1=Not at all confident,to 5=Totally confident). Responses to thisinclude those from respondents who may be usingonly the assessment component of the Flinders ProgramTM . Results are shown in Table 2. The majority(114; 77%) had completed six or fewer assessments,including the three assessments required to achievethe Certificate of Competence, and took one hour orless to complete an assessment, all with reasonablyhigh self-reported confidence with use of the tools.Participants who indicated that they used all orsome of the Flinders tools in their practice wereasked which they were using. The 82 respondentswho replied to this section used SMART goalsetting most frequently (Table 3). Multiple optionswere possible.Of the 16 respondents using all the Flinderstools, one respondent indicated that she wouldcomplete one Flinders assessment each week;three respondents once a fortnight and eightwould use the tools once a month on average.TrainingThe majority of respondents had completed theFlinders training since 2007 (133; 90%), with 21(14%) completing in 2009. Only seven people hadcompleted training in either 2005 or 2006. Of thosewho had completed training, 100 (68%) had completedthe three assessments and care plans requiredto receive the Flinders Certificate of Competence.BarriersLack of time was considered the major barrier tousing the Flinders Program TM . This related to thelength of time needed for a structured appointmentto complete an initial assessment within abusy working environment. A significant numberof respondents (126; 85%) stated that they hadexperienced barriers. Multiple options wereselected. (Table 4).Free text comments endorsed the identified barriers,but also indicated that time as a barrier maybe reduced as experience was gained:Table 1. Use of Flinders model/programmeUse of Model Number PercentageCurrently use model 16 11Use some of the Flinders tools 65 44Used to use 23 16Not at all 44 29Total 148 100Table 2. Number of Flinders assessments completedAssessmentscompletedNumberPercentageNone 9 6Mean ConfidenceScore (1–5)1–3 36 24 3.24–6 69 47 3.77–10 22 15 3.711–25 8 5 4.1More than 25 4 3 4.0Total 148 100Table 3. Flinders tools used in practiceFlinders tool Number using PercentageSMART goal setting 67 82Self-management care plans 53 65PIH 48 59Cue and Response 39 48At the moment time is the main barrier but as I getmore experienced in assessing I anticipate that thisbarrier will lessen.EnablersThe 82 respondents who indicated that they usedsome of the tools, also listed enablers to the useof the Flinders Program TM . Multiple options wereselected with 55 indicating that there were nospecific enablers (Table 5).When asked what might be useful to assist withimplementation, respondents indicated that a specialinterest group (40), an Internet support group(34) and ongoing contact with the course trainer(29) would be useful.DiscussionFlinders training is relatively new in NZ, withthe majority of training completed by nursesVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 291

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 4. Barrierssince 2007. Many of these nurses will not yethave reached a confident level of practice, with298 nurses undertaking their training in conjunctionwith a postgraduate academic programmebetween 2007 and 2009. An advantage of anapproach which embeds training in an academicprogramme is achieving a high completion ratefor the Certificate of Competence and thereforecompletion of three client assessments and careplans. Becoming confident, efficient and gainingcompetence in the use of the Flinders toolsrequires, however, experience beyond the threeclient assessments and care plans needed to fulfilthe requirements for the Certificate. Anecdotallya minimum of six client assessments maybe required before a health professional is fullyconfident in the use of the tools.While there were limitations in the survey reported(43% response rate), with only 100 respondentsachieving a Certificate of Competence, togetherBarrier Number PercentageTime 126 85Lack of funding 39 26No electronic version 37 25Resistance from clients to pay 36 24Client reluctance for long visit 31 21No space or spare room 25 17Resistance from GPs 21 14Resistance from nurses 18 12Resistance from management 18 12Lack of mentoring 12 8Language—not a Maori framework; clientsdo not have English as first languageTable 5. Enablers5 3Repeats questions; not user-friendly 3 2Lack of confidence 2 1Other 8 5Enabler Number PercentageStrong leadership in practice 29 35Ongoing contact with trainer 27 33Funding for programme 20 24Support from nurses 18 22Support from GPs 17 21Newsletters/conferences 3 4with the short time frame since the Flinders ProgramTM has been implemented in NZ, the findingsare of interest. Although 82 (55%) of the healthprofessionals surveyed were using some or all ofthe Flinders tools and processes, the low surveyresponse rate may indicate that a greater numberof health professionals who have trained in theFlinders Program TM are not using the Flinderstools and therefore may have ignored the survey.The majority of respondents in the survey were alsostill relatively inexperienced (77% had completedsix or fewer assessments) suggesting there may be alarge gap between training and implementation inclinical client care. The resources required to trainnurses are considerable and ongoing educationand support for the nurses completing self-managementtraining is essential if they are to developconfidence and maintain their competence. 14Comments from the nurses who responded to thesurvey indicate value gained in learning to developa collaborative approach to client care planningwith active participation of clients. The FlindersProgram TM specifically ensures that a collaborativeapproach to decision-making occurs betweenthe client and health professional. While thetool most frequently used is that related to goalsetting, there is the possibility that goals may notbe client-centred or client-determined withoutuse of the Flinders problem identification process.Identifying which clients will benefit most fromself-management support 15 may enable prioritisingand tailoring of support to client needs. 16The evidence for the effectiveness of variousmodels of self-management on long-term healthoutcomes is variable. 17–19 Nevertheless, there islikely to be an ongoing and increasing focus onself-management programmes in NZ primarycare, particularly with a nurse role. The FlindersProgram TM is one approach to structured longtermcondition management that has been availablein NZ since 2005. The survey findings suggestthat while training has been predominatelywith primary care nurses, the uptake and implementationof the full Flinders Program TM is limited.Barriers to implementation are reported asincluding time for one-hour structured appointments,resistance from colleagues, lack of spaceand insufficient ongoing support. Consideration292 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchshould be given to implementation of complexinterventions before extensive training resourcesare committed. Without structured support forquality improvement initiatives and long-termcondition programmes such as the Flinders ProgramTM , the ability to implement learned skills isdifficult. The identification of ongoing supportfrom the trainer cannot be considered a sustainableoption other than in the short term. Furtherresearch is needed to both provide evidencefor the value of the Flinders Program TM in NZprimary care and also to determine how complexinterventions and new models of care can best beintroduced into primary care.NZ general practice has access to fundingstreams such as Care Plus which can provide forlong-term condition management programmes.There is however great variability in how PrimaryHealth Organisations (PHOs) and generalpractices utilise funding streams, highlightinga need for support for overall change in generalpractice. Some PHOs have utilised the FlindersProgram TM as a structured assessment for CarePlus enrolment. 20 If self-management support isto work, there is a need to better understand theinfrastructure, systems and training needed forclients, health professionals, policy makers andhealth care organisations. 19 Several authors 21,22consider that new models of practice are needed,with policy makers appreciating that supportis needed not only at a client level, but also apractice level. Harris et al. 3 argue that while implementingself-management support in generalpractice is challenging, there are difficulties notonly in the context of work pressures, but alsoin the traditional, more directive, approach ofgeneral practice.Practices most successful with long-term conditionprogrammes in general are recognised aspractices that have systematically assessed theirchronic care systems and apply client-centredgoal setting and action planning, have establishedlong-term condition clinics and provide dedicatednursing time. 6,23 Without addressing barrierssuch as infrastructure, adherence to fundingstreams, delivery systems and resistance frommanagers and some health professionals, the introductionof new and complex patient interventionsin primary care remains difficult.References1. National Health Committee. Meeting the needs of peoplewith chronic conditions. Wellington: National Health Committee;2007.2. Ministry of Health. The 2006/2007 New Zealand HealthSurvey. Wellington: Ministry of Health; 2008.3. Harris MF, Williams AM, Dennis SM, Zwar NA, Davies GP.Chronic disease self-management: implementation with andwithin Australian general practice. MJA. 2008;189(10):17–20.4. Adams K, Griener A, Corrigan J. The 1st annual crossing thequality chasm summit—a focus on communities. WashingtonDC: National Academic Press; 2004.5. Coster S, Norman I. Cochrane reviews of educational and selfmanagementinterventions to guide nursing practice: a review.Int J Nurs Stud. 2009;46:508–528.6. Bycroft J, Tracey J. Self-management support: a win-win solutionfor the 21 st century. N Z Fam Physician. 2006;33(4):243–248.7. Collins S. Explanations in consultations: the combined effectivenessof doctors’ and nurses’ communication with patients.Med Educ. 2005;39:785–796.8. Astin F, Closs JS. Guest editorial: chronic disease managementand self-care support for people with long-termconditions: is the nursing workforce prepared. J Clin Nurs.2007;16(7b):105–106.9. Macdonald W, Rogers A, Blakeman T, Bower P. Practicenurses and the facilitation of self-management in primary care.J Adv Nurs. 2008;62(2):191–199.10. Battersby M. Health reform through coordinated care: SAHealth Plus. BMJ. 2005;330:662–665.11. FHBHRU 2009 [cited The ‘Flinders Model’ of Chronic ConditionSelf-Management. Available from: http://som.flinders.edu.au/FUSCA/CCTU/self_management.htm12. Hordacre A, Howard S, Moretti C, Kalucy E. Report of the2005–2006 Annual Survey of Divisions of General Practice.Adelaide: Primary Health Care Research and InformationService, Department of General Practice, Flinders Universityand Australian Government, Department of Health and Ageing;2007.13. Shortus T, McKenzie S, Kemp L, Proudfoot J, Harris MF. Multidisciplinarycare plans for diabetes—how are they used? MJA.2007;187(2):78–81.14. Jordan JE, Osborne RH. Chronic disease self-management educationprograms: Challenges ahead. MJA. 2007;186(2):84–87.15. Newman SP, Steed L, Mulligan K. Self-management interventionsfor chronic illness. Lancet. 2004;364:1523–1537.16. Osborne R. Optimising care for people with chronic disease.MJA. 2008;189(10):5.17. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patientself-management of chronic disease in primary care. JAMA.2002;288(19):2469–75.18. Glasgow NJ, Jeon Y-H, Kraus SG, Pearce-Brown CL. Chronicdisease self-management support: the way forward for Australia.MJA. 2008;189(10):s14–s16.19. Jordan JE, Briggs AM, Brand CA, Osborne RH. Enhancing patientengagement in chronic disease self-management supportinitiatives in Australia: the need for an intergrated approach.MJA. 2008;189(10):9–13.20. Hill J. Care Plus enrolment Manaia PHO. Personal communication.Nov 2008.21. Newman SP. Chronic disease self-management approacheswithin the complex organisational structure of a health caresystem. MJA. 2008;189(10):7–8.22. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart E,Stange KC. Initial lessons from the first national demonstrationproject on practice transformation to a patient-centred medicalhome. Ann Fam Med. 2009;7(3):254–260.23. Zwar N, Harris M, Griffiths R, Roland M, Dennis S, PowellDavies G, et al. A systematic review of chronic disease management:Australian Primary Health Care Research Institute;September 2006.ACKNOWLEDGMENTSProfessor MalcolmBattersby and Dr SharonLawn provided advicefor the project and thesurvey participantsare acknowledged fortheir contribution.FUNDINGThe project receivedfunding from the STARResearch fund.COMPETING INTERESTSDr Janine Bycroft is aFlinders accredited trainer.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 293

ORIGINAL SCIENTIFIC PAPERSquantitative researchThe feasibility of assessing the FlindersProgram TM of patient self-management inNew Zealand primary care settingsMargaret P Horsburgh RN, EdD, MA (Hons), Dip Ed, FCNA(NZ); 1 Janine J Bycroft MBChB, Dip Obs, DipPaeds, MPH (Hons), FRNZGP; 2 Faith M Mahony RN, MPH; 3 Dianne E Roy RN, PhD, FCNA(NZ); 1 Denise JMiller RN, P G Cert HSc (Adv Ng); 4 Felicity A Goodyear-Smith MBChB, MGP, FRNZCGP; 2 Erin C J Donnell 51School of Nursing, TheUniversity of Auckland,Auckland, New Zealand2Department of GeneralPractice & Primary HealthCare, School of PopulationHealth, The University ofAuckland3Centre for Health ServicesResearch and Policy, Schoolof Population Health, TheUniversity of Auckland4Clinical Trials Research Unit,The University of Auckland5Visible Learning Laboratory,The University of AucklandABSTRACTIntroduction: The Flinders Program TM has been adopted in New Zealand as a useful and appropriateapproach for self-management with primary care clients who have chronic conditions. The FlindersProgram TM has not been evaluated in New Zealand settings.AIM: To assess the feasibility of undertaking a substantive long-term trial to gauge the effectiveness of primarycare nurses using the Flinders Program TM to improve health outcomes for New Zealand populations.Methods: A pilot study was undertaken considering four components of feasibility of conducting along-term trial: practice recruitment, participant recruitment, delivery of the intervention and outcomemeasures. This included comparing 27 intervention and 30 control patients with long-term health conditionswith respect to change in self-management capacity—Partners in Health (PIH) scale—qualityof care using the Patient Assessment of Chronic Illness Care (PACIC) scale and self-efficacy across sixmonths. Intervention participants received care planning with practice nurses using the Flinders ProgramTM in general practices, while control participants received usual care in comparable practices.Results: General practice and participant recruitment was challenging, together with a lack of organisationalcapacity and resources in general practice for the Flinders Program TM . The measures of selfmanagementcapacity (PIH), quality of care (PACIC) and self-efficacy were useful and valuable primaryoutcome measures.Discussion: The overall findings do not support a substantive trial of the Flinders Program TM in primarycare. Difficulties associated with participant recruitment and ability of practice nurses to undertakethe Flinders Program TM within general practice need to be resolved.KEYWORDS: Self-management; long-term conditions; chronic conditions; chronic illness; primary care;nursesJ PRIM HEALTH CARE2010;2(4):294–302.Correspondence to:Margaret HorsburghAssociate Professor,PO Box 25876,St Heliers, Auckland1740, New Zealandm.horsburgh@auckland.ac.nzIntroductionIncreasingly, self-management programmeswithin primary care are being considered a keystrategy for improving chronic care in a numberof countries throughout the world. 1 In NewZealand (NZ), long-term or chronic conditionsare responsible for approximately 70% of allgeneral practice encounters and 78% of all healthcare spending. 2 The 2006/7 NZ Health Survey 3found that two out of three New Zealanders havea long-term health condition, with Maori andPacific tending to experience more severe chronicdisease than non-Maori, non-Pacific. 4The Flinders Program TM of Chronic ConditionSelf-Management, developed by the FlindersHuman Behaviour and Health Research Unit (FH-BHRU), Australia, is an evidence-based self-managementprogramme developed from the learningsof the Coordinated Care Trials in Australia. 5294 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchThe programme is based on cognitive behaviourtherapy, problem solving and motivational interviewingtechniques to support positive behaviourchange. This model utilises a number of tools andprocesses that enable clinicians and clients to collaborativelyassess self-management behaviours,barriers, psychosocial issues and client preferencesfollowed by client-identified problems and goalsetting leading to individualised client care plans. 6The Flinders Program TM has been adopted in NZas a useful and appropriate approach for selfmanagementwith primary care clients who havechronic conditions. Since 2005 approximately500 NZ health professionals have participated in‘Flinders’ training. The largest group of healthprofessionals participating in training have beenprimary care nurses with 298 nurses completingthe training in 2007–9 within a postgraduatecertificate course which focuses on long-termconditions. The Flinders Program TM has not beenevaluated in NZ settings.While the evidence for self-management supportis considerable, 7 several authors 8,9 consider theevidence base for self-management to be underdevelopedand to have not provided convincingevidence. Australian studies of the FlindersProgram TM have not focussed on practice nursesin primary care settings. Other authors 9 considerthat men and ethnic groups are under-representedin studies.The aim of the 2008/2009 study was to assess thefeasibility of undertaking a substantive long-termtrial, including the usefulness of primary outcomemeasures, in order to assess the effectiveness ofprimary care nurses using the Flinders Program TMto improve health outcomes for ‘high needs’ NZpopulations (particularly Maori and Pacific).The overall challenges of undertaking researchwhich attempts to assess the evidence base for acomplex intervention in NZ primary care settingsare reported separately. 10MethodsWHAT GAP THIS FILLSWhat we already know: The Flinders Program TM of self-managementhas been adopted in NZ as a useful and appropriate approach for improvinglong-term condition management. Over 500 health professionals have beentrained in the use of the programme. The evidence for the effectiveness ofself-management is, however, inconclusive, and support for the introductionof new and complex interventions in primary care inconsistent.What this study adds: This paper shows that, despite considerableresources being directed to training primary care nurses in particular in theFlinders Program TM , undertaking a substantive trial to evaluate the effectivenessof the Program TM is not feasible. Difficulties with introducing a new andcomplex intervention in primary care with structured support need to beresolved before a trial is undertaken.There were four components that required assessmentin terms of the feasibility of a substantivetrial: practice recruitment, participant recruitment,delivery of the intervention, and outcomemeasures. A pilot study was conducted to enableassessment.Recruitment of general practicesFor the pilot study, 100 patients were recruitedfrom 20 general practices with the intentionthat 50 patients would receive assessment andcare planning from nurses using the FlindersProgram TM (intervention group) in 10 generalpractices compared with a group of 50 patientswho received ‘usual care’ (control group) in 10comparable general practices. The interventionpractices employed nurses trained in the FlindersProgram TM whereas the control practices did nothave nurses similarly trained. The practices wereselected to allow for geographic spread and distributionacross socioeconomic areas.Recruitment of participantsEligible participants were enrolled generalpractice patients, aged over 18 years, with oneor more long-term conditions such as, but notlimited to, asthma, arthritis, gout, diabetes, heartdisease, metabolic syndrome, COPD, depression,as well as those with high CVD risk with modifiablerisk factors (15% or greater). Participantswere required to give informed consent, havesufficient English, Maori, Samoan or Tongan languageskills to complete written questionnairesand to be agreeable to follow-up over at least sixmonths. Questionnaires were not translated forVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 295

ORIGINAL SCIENTIFIC PAPERSquantitative researchnon-English speakers; however, Maori, Samoanand Tongan interpreters were utilised. Exclusioncriteria included enrolment in Counties ManukauDHB’s Chronic Care Management Programmeand having recently moved from a practice wherethey may have worked with a nurse utilising theFlinders Program TM . Previous/concurrent participationin a self-management programme such asthe Arthritis NZ ‘Living a Healthy Life’ programmewas not stated as an exclusion criterion.Usual care included enrolment in Care Plus.Lists of eligible patients were compiled using thepatient database for each practice and electronicsearching through practice management systemsfor each disease category. Lists were combinedand sorted by surname and ethnicity. In orderto achieve the aim of enrolling 10 patients ineach practice, a list of 50 potential patients wasdetermined to be necessary. In order to overselectfor Maori and Pacific, 20 patients shouldidentify as Maori and 20 as Pacific. Gender mixwas not included in the sampling process. Whenpatient lists were combined and duplicate surnamesremoved, each patient was given a randomnumber and the patient list sorted by randomisednumber. A list of the first 50 patients from therandomised list was then discussed with thepractice and any patient considered inappropriate(e.g. receiving palliative care or having significantcognitive impairment) removed. A letter of invitationto participate in the study was sent fromthe practice to the first 13–15 patients (of whomfive identified as Maori and five Pacific) on the approvedlist. Patients were invited to opt out of thestudy by contacting the practice. For those whodid not opt out, a research assistant telephonedto confirm their willingness to participate andarrange a time to visit, discuss the study further,complete the consent process and undertake abaseline assessment. Participants had the opportunityto complete this assessment in their ownhome or to come to the practice. Where the initialletter of invitation did not allow for a sampleof 10 clients from a practice, further letters weresent to the next patients on the randomised list.Delivery of interventionFor patients in the intervention practices thenurses contacted the patient following the baselineassessment and scheduled an appointmentat the practice for a Flinders assessment and developmentof their client care plan. The FlindersProgram TM involves the patient first completingthe Partners in Health (PIH) questionnaire.The PIH scale utilises 13 questions to assess anindividual’s self-management skill and capacityon an eight-point scale (very good through tovery poor). It is based on the understanding thatself-management of chronic conditions requiresconsideration of the individual, their family,carers and health professionals; requires anholistic approach that acknowledges medical andpsychosocial issues and is aimed at empoweringthe individual through proactive strategies. 11The tool assesses self-reported knowledge ofthe individual’s condition and treatment, abilityto share in decision-making with their healthprofessional, engage in activities that promotehealth, monitor signs and symptoms and managethe impact of their condition on physicalfunctioning, emotions and interpersonalrelationships.The second stage, the Cue and Response questionnaire,involved the health professional goingthrough the same questions and comparing theirassessment where the patient is asked what theirmain life problem is. This problem may not be a‘health’ problem. A goal is identified around theproblem and transferred to a care plan, whichwill also include issues identified from the Cueand Response questionnaire as well as other keymedical, psychosocial or carer issues.Follow-up of the intervention patients was asappropriate, for example to discuss progress withspecific goals or review medication, but alsoat three and six months to assess progress andrecord problem and goal scores in accordance withthe Flinders Program TM .Outcome measuresOutcome measures were assessed at baseline andat six months (26 weeks) for all participants (controland intervention) by a research assistant whowas blinded as to whether the participant was inthe intervention or control group.The primary outcome measures were:296 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative research• Self-management capacity—Partnersin Health (PIH) scale. The selfadministeredrating of a patient’s selfmanagementskill and capacity.• Patient assessment of quality of care—Patient Assessment of Chronic Illness Care(PACIC). The PACIC is a validated patientself-report instrument which assesses theextent to which a patient’s care aligns withthe principles of chronic care management, i.e.one that is patient-centred, proactive, plannedand includes collaborative goal setting,problem solving and follow-up support. 12,13• Self-Efficacy for Managing ChronicDisease 6-Item Scale. This scale containsitems from self-efficacy scales and isvalidated by the Stanford Patient EducationResearch Centre for their ChronicDisease Self-Management studies. 14Secondary outcome measures were collected aspart of evaluating the feasibility and usefulnessof a broad range of outcome measures. Theseincluded the European Quality of Life Scale(EuroQoL), a health-related quality of life outcomemeasure which assesses outcome in six broadareas (mobility, self-care, activities, pain, psychologicalfunctioning, and self-reported overallhealth-related quality of life); 15 the SF-12 HealthStatus Questionnaire, a 12-item, self-administeredquestionnaire that assesses symptoms, functioningand quality of life; 16 and the PHQ 9,17 a nine-itemdepression scale used for diagnosing depression.Clinical outcome measures were not collected, asthere was a relatively short follow-up period andchanges would not be expected.Demographic data, current medication, selfreportedinformation on smoking, medicationadherence and physical activity levels, togetherwith patient knowledge of their recorded diagnosis,were collected.including paired and independent samples t-testswere performed to assess differences at baselineand six months within the groups.EthicsEthical approval for this study was granted bythe NZ Northern Y Regional Ethics Committee.ResultsPractice recruitmentA total of 35 general practices in the wider Aucklandarea were approached to achieve an initial sampleof 20 practices which were randomised into 10intervention practices with a practice nurse trainedin the Flinders Program TM and 10 control practiceswhere no nurses had completed Flinders training.Participant recruitmentIn order to achieve an initial sample of 100 participants,331 letters of invitation to participatein the study were sent. Forty-three of the 100participants did not complete the study (Table 1).Of the 22 control group participants who did notcomplete, 16 were not followed when it becameapparent that the intervention sample would notreach target. Withdrawals from the interventiongroup included one death, two participants withdeteriorating health withdrawn by the practicenurse and 18 who declined to complete the study.Reasons for declining included moving out of thearea, deteriorating health and, for one participant,objection to the questioning approach.A wide spread of patients across disease categorieswas achieved. The average age of patients was 55years for the intervention group and 61 years forthe control group. No statistically significant differencein the age range between the two groupswas demonstrated (Table 2).AnalysisData were loaded into the Statistical Packagefor the Social Sciences (SPSS), version 15.0.1 forWindows, for data analysis. An alpha level ofp

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 2. Participant demographicsIntervention (n=27) Control (n=30)Age range 25–90 yrs 25–90 yrsAverage age 61 yrs 55 yrsMedian age 62 yrs 55 yrsGenderMale 16 14Female 11 16EthnicityNZ/Euro 11 17Maori 8 6Pacific 8 6Indian 0 1DiseaseCVD/stroke/PVD/HT 13 15Asthma/COPD 10 16Diabetes 16 10Arthritis/gout 14 15Other 16 16With comorbidities 22 23Outcome measuresThe sample size was smaller than planned andit was evident from the pilot findings that thestudy was not powered sufficiently to detectchanges in secondary outcome measures and selfreportedinformation on smoking, medication adherenceand physical activity levels from baselineto six months. These measures are therefore notreported. Primary outcome measures are reportedas part of assessing the feasibility of utilisingthese measures in a substantive trial.Partners in Health (PIH)In Australian studies 18 where sample size hasbeen small (n=31), PIH scores have been amalgamatedto allow reporting in six domains: knowledgeof condition; treatment adherence; sharingcare; measuring symptom progress; impact of illnessand progress with adopting healthy lifestylehabits. Utilising this approach a paired samplest-test demonstrated no statistically significantdifference between baseline and 26 weeks in theintervention group (Table 3). With this scale alower score at 26 weeks indicates improvement.Table 3. Paired sample t-test for Partners in Health amalgamated scoresInterventionNBaselineMean (SD)26 weeksMean (SD)P-valueKnowledge 24 3.33 (3.06) 2.79 (3.23) 0.345Sharing 24 0.75 (1.22) 0.38 (0.82) 0.214Measure symptom 24 6 (4.53) 6.26 (4.26) 0.743Treatment 22 2.5 (3.98) 1.73 (3.60) 0.392Impact 24 3.92 (3.79) 3.71 (4.16) 0.805Lifestyle 23 1.35 (1.74) 1.17 (1.96) 0.701PIH total score 21 19.76 (13.50) 16.1 (12.84) 0.126ControlKnowledge 30 3 (3.21) 3.03 (3.05) 0.951Sharing 30 0.96 (1.71) 0.7 (1.8) 0.485Measure symptom 30 5.93 (4.07) 5.56 (3.09) 0.645*Treatment 26 3.34 (4.48) 2.19 (4.08) 0.044*Impact 30 4.26 (4.40) 2.7 (3.29) 0.034Lifestyle 30 1.6 (2.14) 1.26 (2.09) 0.482*PIH total score 26 18.23 (10.88) 14.88 (9.99) 0.048Paired sample t-test where * denotes significant difference between baseline and six months at p

ORIGINAL SCIENTIFIC PAPErSThe Partners in Health (PIH) self-ratings byboth groups showed positive ratings of self-managementskill and capacity on all domains (withone exception, measuring symptom progress).Questions are raised about the care taken by participantsin noticing that the PIH scale operatesin the opposite direction from other scales usedin this study, i.e. from positive responses (a lot,always or very well) scoring low scores to negaquantitativeresearchPatient Assessment of ChronicIllness Care (PACIC)The PACIC scale includes 20 items and assesseson a five-point scale (1=none of the time, 2=alittle of the time, 3=some of the time, 4=most ofthe time, 5=all of the time) the extent to whichpatients report receiving care that accords with achronic care model of care, including care that ispatient-centred, proactive, planned and includescollaborative goal setting, problem solving andfollow-up support. 2 A higher score at follow-upindicates perceived improvement. The 20 itemscombine to five sub-scales which relate to differentaspects of providing care congruent withchronic care management: patient activation oractions that solicit patient input and involvementin decision-making; delivery system design oractions that organise care and provide informationto patients to enhance their understandingof care; goal setting or the patient acquiringinformation for and setting of specific collaborativegoals; and follow-up or coordination of carewhere clinic treatment is extended and reinforcedand proactive contact with patients to assessprogress and coordinate care. 12 There was a statisticallysignificant improvement (paired samplest-test) at six months from baseline in goal setting(p=0.000), problem solving (p=0.009) and followup(p=0.001) for the intervention group (Table 4).Self- efficacyThe self-efficacy scale enables individuals to ratetheir confidence on a 10-point scale (not at allconfident through to totally confident) on keepingtheir physical discomfort or pain, symptomsand emotional distress from interfering withthings they want to do; different tasks and activitiesmanaged in order to reduce the need to seea doctor; and confidence in doing things otherthan just taking medication to reduce the effectof illness on their everyday life. A higher score atfollow-up indicates improved confidence. For theintervention group there was deterioration in thelevel of self-reported confidence on all scales, althoughthese scores were not significant (Table 5).For the control group there was improvement onseveral of the scales from baseline to six months,with improved confidence with managing emotionaldiscomfort and other symptoms statisticallysignificant (p=0.01 and p=0.042) (Table 5).DiscussionPrimary outcome measuresThis study was designed to test the feasibility ofundertaking a substantive trial and to determineuseful outcome measures for such a trial.Despite the small sample size, some findings areof interest and value in determining directionfor future studies.Figure 1. PACIC sub-scales 12 —goal setting; problem solving; follow-upThe goal setting sub-scale includes the items:‘Over the past six months when I received care for my chronic condition I was:• Asked to talk about my goals in caring for my condition• Helped to set specific goals to improve my eating and exercise• Given a copy of my treatment plan• Encouraged to go to a specific group or class to help me cope with my chronic illness• Asked questions either directly or on a survey about my health habits.’The problem solving sub-scale includes the items :‘Over the past six months when I received care for my chronic condition I was:• Sure that the doctor or nurse thought about my values, beliefsand traditions when they recommended treatments to me• Helped to make a treatment plan that I could carry out in my daily life• Helped to plan ahead so I could take care of my illness even in hard times• Asked how my chronic illness affects my life.’The follow-up sub-scale includes the items :‘Over the past six months when I received care for my chronic condition I was:• Contacted after a visit to see how things were going• Encouraged to attend programmes in the community that could help me• Referred to a dietitian, health educator or counsellor• Told how my visits with other types of doctors like an eye doctor or surgeonhelped my treatment• Asked how my visits with other types of doctors were going.’VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 299

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 4. Paired sample t-test—Patient Assessment of Chronic Illness Care (PACIC) at baseline and six monthsNBaselineMean (SD)26 weeksMean (SD)P-valueInterventionPatient activation 23 2.04 (1.54) 2.63 (1.46) 0.085*Delivery system 23 2.34 (0.91) 2.92 (1.02) 0.012*Goal setting 22 1.30 (1.34) 2.40 (1.27)

ORIGINAL SCIENTIFIC PAPErSquantitative researchtive (very little, never, not very well) scoring atthe high end. While there was no evidence thatconfusion occurred in this study, discussion withparticipants suggests that individuals prefer ratingfrom negative (low) to positive (high scores).The PACIC scale is useful in assessing theperceived quality of care provided. PACIC hasbeen developed from ACIC (Assessment ofChronic Illness Care), an instrument used toenable clinicians and health care teams to assessthe extent to which the care they provide alignswith ‘best practice’ chronic care management. 12By using similar domains, the PACIC enables anassessment of the quality of care being deliveredfrom the patient’s perspective. This study diddemonstrate that the Flinders Program TM showeda perceived improvement in the overall quality ofcare and, in particular, evidence-based elementsof chronic care management (CCM) such as goalsetting, problem solving and follow-up.The self-efficacy scale provided a useful measureof self-reported confidence in managing chronicdisease. The small sample size can account for thefinding that the intervention group showed deteriorationon their overall self-reported confidence(self-efficacy). A further explanation may be thatwith the improved opportunity to understandtheir condition and treatment through participationin the Flinders Program TM there is a diminishedconfidence seen at six months. Improvingpatient confidence requires ongoing support overa time frame longer than six months and a longerstudy would be needed to determine this.A failure to demonstrate difference within andbetween the ‘control’ and ‘intervention’ groupscan partially be attributed to the extensive baselineand follow-up data collection process whichin itself proved to be an intervention. Completionof the data collection form required approximatelyone hour and, for both groups of patients, thisprovided an opportunity to reflect on their illnessand the effect this may have on their lives.Secondary outcome measuresThe secondary outcome measures collected, butnot reported in this paper, meant that data collectionwas onerous for patients. These measuresadded no value. Clinical outcome measures wouldonly be of value in a study of adequate length.General practice recruitmentThe short time frame for completion and thecomplexity of the general practice environmenthighlights the difficulties with undertakingstudies in primary care with patients who havelong-term conditions. Difficulties with practiceworkloads, staff changes and competing nursedemands resulted in only seven interventionpractices completing study requirements withinthe nine-month time frame of the study. Controlpractices were also difficult to recruit, as manypractices were reluctant to participate in a studywhere the perceived patient care of the chroni-Completion of the data collection formrequired approximately one hour and, forboth groups of patients, this provided anopportunity to reflect on their illness andthe effect this may have on their livescally ill may be shown to be of ‘lesser’ qualitythan in the intervention practices. This resultedin the control general practices who ‘volunteered’to participate in the study being those practiceswhere chronic care programmes were established.Patients in the control practices, while notcompleting a Flinders assessment, may have beenlinked into goal setting and care planning as supportfor management of their condition.Patient recruitmentHigh-needs patients with long-term conditionsare frequently a mobile population, and inaccurateaddresses and phone numbers combinedwith difficulties with the accuracy of diseasecoding in practice management systems resultedin over 300 patients being contacted to recruit asample of 100. Likewise, follow-up at six monthswas challenging with many unknown addresses.Data completion required participants to completeVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 301

ORIGINAL SCIENTIFIC PAPERSquantitative researchACKNOWLEDGEMENTSProfessor MalcolmBattersby is acknowledgedfor advice onresearch design.FUNDINGThe study receivedfunding support from theSTAR Research Fund.COMPETING INTERESTSDr Janine Bycroft is aFlinders accredited trainer.self-reported outcome measures. This resultedin missing values where participants failed toanswer some questions.InterventionWhile the nurses in the intervention practiceshad completed training in the Flinders Program TM ,none were using the approach in their usual workor were able to use the tools initially with confidence.Additionally, the nurses were not accustomedto the length of structured appointmenttime required for a patient consultation (up to onehour) using the Flinders Program TM , and practiceworkloads made this difficult. The nurses didnot routinely have booked patient case loads andwere working to maximal capacity. The need fornurses to be confident and competent with theintervention prior to study commencement is animportant part of future studies.In order to reduce complexity, a narrower diseaserange may also have facilitated study processes. AUnited Kingdom study 19 found that nurses weremore confident in working with patients in theearlier, less complex, stages of their illness. Theseissues, alongside a lack of practice organisationalcapacity and resources for the introduction of theintervention, all contribute to the difficulties ofundertaking a substantive trial.ConclusionSelf-management programmes in primary carewill continue to have focus and increasingly thiswill be a nurse role. However, the overall findingsfrom this study do not support a substantiveresearch trial of the Flinders Program TM in primarycare at this stage. Further work is first neededto determine how ‘new’ complex interventionscan best be introduced into primary care. Thisincludes considering the report of Finlayson etal. 20 on primary care nursing which identifiesbarriers to nurses expanding their practice. Theseinclude heavy nurse workloads, lack of physicalresources, lack of support and motivation fromgeneral practitioners (GPs), GP attitudes, lack ofleadership and poor nurse remuneration. Somenurses in the Finlayson study also reported a lackof self-confidence and a lack of a willingness toembrace change.References1. Bycroft J, Tracey J. Self-management support: A win-win solutionfor the 21 st century. NZ Fam Phys. 2006;33(4):243–248.2. National Health Committee. Meeting the needs of peoplewith chronic conditions. Wellington: National Health Committee;2007.3. Ministry of Health. The 2006/2007 New Zealand HealthSurvey. Wellington: Ministry of Health; 2008.4. Ajwani S, Blakely T, Robson B, Tobias M, Bonne M. Decadesof disparity: ethnic mortality trends in New Zealand1980–1999. Wellington: Ministry of Health and University ofOtago; 2003.5. Battersby M. Health reform through coordinated care: SAHealth Plus. BMJ. 2005;330:662–665.6. FHBHRU 2009 [cited The ‘Flinders Model’ of chronic conditionself-management. Available from: http://som.flinders.edu.au/FUSCA/CCTU/self_management.htm7. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patientself-management of chronic disease in primary care. JAMA.2002;288(19):2469–75.8. Glasgow NJ, Jeon Y-H, Kraus SG, Pearce-Brown CL. Chronicdisease self-management support: the way forward for Australia.MJA. 2008;189(10):s14–s16.9. Jordan JE, Briggs AM, Brand CA, Osborne RH. Enhancing patientengagement in chronic disease self-management supportinitiatives in Australia: the need for an intergrated approach.Med J Aust. 2008;189(10):9–13.10. Horsburgh M, Goodyear-Smith F, Bycroft J, Mahony F, RoyD, Miller D, et al. Lessons learned from attempting to assessthe evidence base for a complex intervention introduced intoNew Zealand general practice. Qual Saf Health Care. 2010;published online April 8, 2010; qshc.bmj.com doi: 10.1136/qshc.2009.03443911. Battersby M, Ask A, Reece M, Markwick M, Collins J. ThePartners in Health scale: the development and pyschometricproperties of a generic assessment scale for chronic conditionself-management. Aust J Prim Care. 2003;9(2&3):41–52.12. Glasgow R, Wagner EH, Schaefer J, Mahoney L, ReidR, Greene S. Development and validation of the PatientAssessment of Chronic Illness Care (PACIC). Med Care.2005;43(5):436–444.13. Glasgow NJ, Whitesides H, Nelson C, King D. Use of the PatientAssessment of Chronic Illness Care (PACIC) with diabeticpatients: relationship to patient charactersitics, receipt of careand self-management. Diabetes Care. 2005;28(11):2655–61.14. Lorig K, Sobel D, Ritter P, Layrent D, Hobbs M. Effect of a selfmanagementprogram for patients with chronic disease. EffClin Pract. 2001;4:256–262.15. The EQOL Group. EuroQol: a new facility for the measurementof health related quality of life. Health Policy. 1990;16:199–208.16. Stewart A, Hays R, Ware J. The MOS short-form generalhealth survey: reliability and validity in a patient population.Med Care. 2005;1988(26):724–735.17. Kroenke K, Spitzer R, Williams J. The PHQ-9: Validityof a brief depression severity measure. J Gen Int Med.2001;16(9):606–13.18. Lawn S. PIH Comparisons on Noarlunga Mental Health Project.In. Personal communication ed. Adelaide; 12 Nov 2009.19. Macdonald W, Rogers A, Blakeman T, Bower P. Practicenurses and the facilitation of self-management in primary care.J Adv Nurs. 2008;62(2):191–199.20. Finlayson M, Sheridan N, Cumming J. Nursing developmentsin primary care 2001–2007. Wellington: Victoria University ofWellington; 2009.302 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchHow do newly diagnosed patients withtype 2 diabetes in the Waikato get theirdiabetes education?Ross Lawrenson MD, FRCGP, FAFPHM, FFPH; 1 Grace Joshy MSC; 1 Yoska Eerens; 2 Wayne Johnstone MA 3ABSTRACTINTRODUCTION: Education is accepted as the mainstay of management for people with diabetes.However, there are few population-based studies describing what education has been delivered from thepatient’s perspective.Aim: To ascertain the sources of education for patients with newly diagnosed type 2 diabetes; whateducation was received and what were the patients’ views of group education. Delivery of education toMaori was compared with non-Maori.1Waikato Clinical School,The University of Auckland,Hamilton, New Zealand2University of Otago,Dunedin, New Zealand3Te Puna Oranga, WaikatoDistrict Health Board,Hamilton, New ZealandMethods: A cross-sectional survey of patients identified from the Waikato Regional Diabetes Servicedatabase. Patients identified in one calendar year, having a diagnosis of type 2 diabetes and being agedbetween 20 and 89 years were included in the survey. Patients were sent a four-page questionnaire. Nonresponderswere followed up by telephone.Results: 333/667 patients (50%) responded. The principal source of education for Waikato patientswas general practice, from the general practitioner and/or the practice nurse. Ninety-three percent ofpatients reported that they had received some education about diabetes at the time of diagnosis. Therewas no difference between Maori and non-Maori in the reported levels of diabetes education received,but the patient perceived knowledge score was significantly lower for Maori in all aspects studied.DISCUSSION: The overall impression was that patients were receiving appropriate information aboutdiabetes, but there does appear to be room for improvement in some areas, particularly the importanceof blood pressure and lipid control. We believe that further research on the educational needs of Maoriand ethnic minorities is needed.Keywords: Diabetes; family practice; education; New ZealandIntroductionType 2 diabetes is a lifelong condition that isassociated with increased risk of cardiovasculardisease, 1 renal disease, 2 peripheral vascular diseaseand blindness. 3 It is a disease that requires selfmanagementby the patient and so it is understoodthat when they are diagnosed they need access torelevant information about their disease. Some diabeteseducation programmes have been shown toimprove self-care, 4 glycaemic control 5,6 and generalhealth status and well-being in patients. 7,8,9 Educationprogrammes have also been used to targetthe reduction of risk factors such as weight, bloodpressure and serum lipids, 10 but with less success.Patients who are from a lower socioeconomicbackground may be less receptive to educationand less likely to implement behavioural changes11 yet often these groups are also most at risk ofdeveloping complications of diabetes. 12 Reachingdisadvantaged groups such as Maori and ethnicminorities needs to be an important considerationin all education programmes to allow the educationto be delivered as effectively as possible. 13The Waikato District Health Board serves a populationof 360 000 people, of whom 21% identifyas being Maori. It has a well developed regionaldiabetes service which provides advice for patientsJ PRIM HEALTH CARE2010;2(4):303–310.Correspondence to:Ross LawrensonProfessor, WaikatoClinical SchoolWaikato Hospital, PB 3200Hamilton, New Zealandross.lawrenson@waiktodhb.health.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 303

ORIGINAL SCIENTIFIC PAPERSquantitative researchwith diabetes—particularly those with type 1 diabetesor those with complications of their diabetessuch as renal disease or established cardiovasculardisease. The service also offers a retinal screeningservice and so almost all newly diagnosedpatients with type 2 diabetes within the Waikatoare known to the service. 14 The Waikato RegionalDiabetes Service mentors and supports generalpractices in the management of diabetes throughthe provision of a practice nurse education programme,regular updates for general practitionersand the provision of 17 diabetes nurse specialistsof whom 10 are based in the community. Thereare also community health services provided bythe District Health Board (DHB), including sevencommunity dieticians who provide a comprehensiverange of dietetic services. Some of thesedieticians are available to see patients with type 2diabetes in the community if required.Initial management of newly diagnosed patientswith type 2 diabetes, including their education, isexpected to be managed in primary care. Withinthe Waikato DHB, primary care is provided bya number of different agencies—there are fourPrimary Health Organisations (PHOs), two maingeneral practice management groups and 11Maori providers.The Waikato Local Diabetes Team (a multidisciplinarygroup set up by the DHB to advise ondiabetes services) were concerned that patientsmay not be receiving sufficient diabetes educationTable 1. Demographic characteristics of respondents,N=333EthnicityMaori 57 (17%)Non-Maori 276 (83%)NZ European 251 (75%)Pacific 10 (3%)Indian 8 (2.4%)Asian 4 (1.2%)Other 3 (0.9%)GenderFemale 153 (45%)Male 180 (54%)after diagnosis. They had received a proposal topurchase a community-based diabetes educationprogramme, based on group education sessions,that would be available to all newly diagnosedpatients. Before any decision on purchasing sucha programme was reached, it was proposed thata survey should be carried out to ascertain howpatients were currently receiving their education,what education they were receiving and whattheir views were of group education. We alsowanted to compare the experiences and views ofMaori with non-Maori to ensure any changes tothe delivery of diabetes education would reflectthe needs of Maori patients.MethodsThe study was a cross-sectional survey carriedout in December 2008, of patients categorisedas having type 2 diabetes and diagnosed in a12-month period. Patients were identified fromthe Waikato Regional Diabetes Service register.The register is held on a Microsoft Office Accessdatabase and holds information on patients’ age,gender, ethnicity, type of diabetes and year ofdiagnosis. We selected patients with a year ofdiagnosis of 2007, aged between 20 and 89 yearsof age and categorised as having type 2 diabetes.A questionnaire was developed asking a seriesof questions including basic demographic data,a series of questions regarding the educationreceived, who provided it and self-perceivedknowledge. Demographic data was collected tohelp validate the data from the Waikato RegionalDiabetes Service register. Input into the design ofthe questionnaire was obtained from a specialistdiabetes nurse, a dietician, a Maori researcher, ageneral practitioner and consumer representatives.The questionnaire was then piloted by a diabetesnurse educator on a small sample of diabetespatients who would not be involved in the mainstudy. This led to some minor modifications. Thefinal questionnaire focussed on important aspectsof diabetes care such as diet, blood glucose, bloodpressure, cholesterol, foot care, eye care, exerciseand smoking. The patients who responded tothe survey were assigned to a group known as‘respondents’. Patients who had not respondedafter a period of six weeks were followed up bytelephone and were assigned to a group known as304 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative research‘late-responders’. Maori patients were followed upby two Maori researchers.Ethnicity was categorised into New Zealand European,Maori, Pacific (i.e. having an ethnic originfrom the Pacific Islands—principally the CookIslands, Samoa, Tonga etc.), Asian (meaning fromSouth East Asia, i.e. China, Japan, Korea etc.) orIndian (i.e. from India, Sri Lanka or Pakistan) orother. For the purpose of analysis we comparedMaori with non-Maori. Ethical approval wasgranted by the Ministry of Health’s Northern YEthics Committee (Reference NTY/08/84/EXP).AnalysisAll data were entered into a Microsoft Office Excelspreadsheet. Analysis was undertaken usingSPSS statistical package. Kruskal–Wallis test wasused to test the difference in knowledge scoresbetween Maori and non-Maori. Chi-square testwas used to test the differences between Maoriand non-Maori in method of diabetes diagnosis,diabetes education and support.ResultsWe identified 675 patients aged between 20 and89 years, diagnosed in 2007 and categorised ashaving type 2 diabetes. Two hundred and sixtythreepatients responded to the initial mail-out,eight of whom were excluded (six were deceased).We attempted to contact all the remaining patientsby telephone. This resulted in a further 78‘late responders’ who completed questionnairesafter this follow-up. The remainder declined toparticipate or were not contactable by phone. Wetherefore estimated a 333/667 (50%) response rate.The mean age of respondents was 63 years comparedwith 59 for non-respondents. New ZealandEuropeans were most likely to respond (58%)whilst there was a lower response rate for Maori(39%) and Asian/Indian (36%).In those that responded there was a 91% agreementbetween the self-identified ethnicityreported on the questionnaire compared withthe ethnicity recorded on the Waikato RegionalDiabetes Service register and there was a 95%agreement with the year of diagnosis ±1 year.Fifteen percent of patients said they were currentWHAT GAP THIS FILLSWhat we already know: There is evidence from many studies that educationis effective for patients with type 2 diabetes. Waikato has the largestnumber of diabetes specialist nurses per population, but general practice isexpected to be the principal source of education for newly diagnosed type 2patients.What this study adds: This study shows that a range of sources are used.We found most patients access education through primary care. There wasno difference in the amount of diabetes education received when comparingMaori and non-Maori, but perceived levels of knowledge about diabeteswere lower for Maori. The study highlights that different ways of providingeducation may be needed for Maori and Asian patients.smokers, 12% of non-Maori and 27% of Maori.The responses to the questions were analysedcomparing Maori and non-Maori (Table 2)A small number of patients reported that theyhad not received any education about diabetes atthe time of diagnosis. Information on other keytopics was also reported as having not been providedby a minority of patients (Table 2). Therewas no significant difference between Maoriand non-Maori in the reported levels of diabeteseducation, with the exception of education onsmoking cessation (which is not surprising giventhat Maori smoking rates are higher). However,the patient perceived knowledge score was significantlylower for Maori in all aspects studied.With regards to exercise, 37% of patients saidthey were doing more exercise than when theywere diagnosed, 9% were doing less and 54% hadnot changed the amount of exercise they did.Several people noted that one of the reasons theywere now doing less exercise was due to decreasedmobility associated with old age, or due to comorbidities.Some people also noted that they havealways been very active and therefore the amountof exercise they do has remained the same.We can see from Figure 1 that the principalsource of education for Waikato patients diagnosedwith type 2 diabetes is their general practice.Some topics are more likely to be coveredby the practice nurse (general education, diet,blood glucose monitoring) whilst other topics theVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 305

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 2. Diabetes diagnosis, diabetes education, support and self-perceived knowledgeAll patients Maori Non-MaoriBy whom were you diagnosed?By your general practitioner 300 (90%) 51 (89%) 249 (90%)By your local hospital 20 (6%) 4 (7%) 16 (6%)By someone else 13 (4%) 2 (4%) 11 (4%)Method of diagnosis*Have symptoms and go to your doctor expecting you might have diabetes? 42 (13%) 13 (23%) 29 (11%)Go to your doctor/hospital with an illness but not think of diabetes as a diagnosis? 69 (21%) 17 (30%) 52 (19%)Have a routine blood test which showed diabetes? 207 (63%) 24 (43%) 183 (67%)Some other route to diagnosis 12 (4%) 2 (4%) 10 (4%)Support groupBelong to Diabetes NZ (7 people belonged to other organisation as well) 49 (15%) 9 (15%) 40 (15%)Belonged to another group, but not DNZ 6 (2%) 3 (5%) 3 (1%)None 268 (83%)Knowledge score out of 10 (mean ± SD)Knowledge of diabetes in general* (n=312) 6.9 ± 2.1 6.3 ± 2.5 7.1 ± 1.9Knowledge of diet and diabetes* (n=318) 7.0 ± 2.1 6.4 ± 2.5 7.2 ± 2.0Knowledge of blood pressure* (n=321) 6.4 ± 2.5 5.6 ± 2.7 6.5 ± 2.5Knowledge of cholesterol* (n=320) 6.4 ± 2.6 5.7 ± 2.8 6.6 ± 2.6Knowledge of foot care* (n=321) 6.6 ± 2.8 5.6 ± 3.0 6.8 ± 2.8Knowledge of eye checks* (n=316) 6.8 ± 2.5 5.9 ± 2.7 7.0 ± 2.8No information received about:Diabetes management at the time of diagnosis 24 (7%) 3 (5%) 21 (8%)Diet/healthy eating 16 (5%) 4 (7%) 12 (4%)Exercise 48 (15%) 11 (20%) 37 (14%)Monitoring blood glucose 49 (15%) 8 (14%) 41 (15%)Importance of blood pressure check 88 (27%) 10 (18%) 78 (29%)Reducing blood cholesterol 63 (19%) 11 (19%) 52 (19%)Importance of foot check (comment—asked as a knowledge question) 21 (7%) 7 (15%) 14 (5%)Importance of regular eye check 34 (10%) 9 (16%) 25 (9%)Smoking cessation* 48 (15%) 11 (20%) 37 (14%)*Significant difference between Maori and non-Maori, p

ORIGINAL SCIENTIFIC PAPErSquantitative researchOnly eight people said they got most of theirinformation about diabetes from the Internet.Figure 1. Three most common sources of diabetes educationDiscussionWe identified 675 new cases of type 2 diabetesin the Waikato district in 2007. This is likelyto be an underestimate of the incidence as weknow from other studies in our region thatsome 10–15% of patients are not referred to theRegional Diabetes Service and are therefore noton the register. 14 We have shown that diabetesis most commonly diagnosed in asymptomaticpatients who attend their general practitioner.This is especially true for non-Maori where 67%appear to have been identified through routinescreening. On the other hand, only a minority ofMaori (43%) surveyed, reported being identifiedthrough screening. Peel et al. have shown thatthose diagnosed through screening are likely tohave a more emotional response to their diagnosis15 which may influence the patient’s ability toabsorb information at the time of diagnosis.As expected, diabetes education was mainlydelivered in primary care by general practitioners,practice nurses and allied health professionals.Only a few patients said they had receiveddiabetes education from diabetes nurse specialistsor hospital consultants. Whilst 93% of patientsreported receiving education at the time of diagnosis,it is a concern that 7% say they were notgiven information. As well as assessing whetherpatients had received education on key topics, we(GP—general practitioner; PN—practice nurse; DN—diabetes nurse)also tried to estimate the effectiveness of patienteducation. Whilst acknowledging that patientperceptions are subjective, we believed it wasuseful to get some feedback about their level ofknowledge. This exercise showed that, generally,Maori considered their knowledge at a lowerlevel than non-Maori. More objective measuresof patient knowledge could have been used. Thiswas considered but would have made the questionnaireextremely long and may have worsenedTable 3. Sources of diabetes education, n (%)GP PN DN DT PH PO Eye Other HDGeneral diabetes education at diagnosis 179 (54%) 199 (60%) 51 (15%) 7 (2%) – – – – 11 (3%)Blood glucose monitoring 117 (46%) 130 (51%) 37 (15%) 8 (3%) 9 (4%) – – 22 (9%) –Importance of blood pressure check 146 (69%) 79 (37%) 17 (8%) 4 (2%) 3 (1%) – – 11 (5%) –Reducing blood cholesterol 178 (75%) 61 (26%) 17 (7%) 13 (5%) 1 (0.4%) – – 17 (7%) –Importance of foot check* 101 (41%) 117 (48%) 32 (13%) 3 (1%) – 23 (9%) 1 (.4%) 29 (12%) –Importance of regular eye check 115 (43%) 95 (36%) 25 (9%) – – – 69 (26%) 23 (9%) –Diet/healthy eating 111 (33%) 198 (59%) – 93 (28%) – – – – –Exercise education 183 (55%) 150 (45%) – – – – – – –GP—general practitioner; PN—practice nurse; DN—diabetes nurse; DT—dietician; PH—pharmacist; PO—podiatrist; Eye—eye clinic/ophthalmology services;HD—hospital doctor* comment—asked as a knowledge questionVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 307

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 4. Diabetes education practice and preferences, N (%)All patients Maori (n=57) Non-Maori (276)Access to informationHaving Internet access 203 (61%) 28 (49%) 175 (63%)…at home 172 (52%) 22 (39%) 150 (54%)…elsewhere 31 (9%) 6 (11%) 25 (9%)Have used Internet to look for diabetes information 94 (28%) 9 (15%) 85 (31%)Diabetes education—practice and preferencesHave a family member included in diabetes education 112 (34%) 25 (43.9%) 87 (31.5%)Would like to have family included in diabetes education 60 (31%) 14 (41%) 46 (29%)Have attended group education session 22 (7%) 7 (12%) 15 (5%)Would not want a group session 145 (57%) 18 (44%) 127 (59%)Would prefer group sessions 36 (14%) 10 (24%) 26 (12%)the response rate. An alternative would be tolink patient responses to measures such as bloodpressure, HbA1c or cholesterol levels. Reportedunderstanding about blood pressure and lipidswas poorer than knowledge in other areas. It maybe that some patients did not receive informationabout blood pressure or lipids because they didnot have evidence of hypertension or hypercholesterolaemia.However, management of bloodpressure 16 and lipids 17 has been shown to be ofmajor importance in reducing cardiovascular riskin patients with type 2 diabetes and increased emphasison these topics by primary care staff maybe needed. Fifteen percent of patients said theyhad not been advised about exercise and only athird of patients had increased their exercise sincediagnosis. Regular exercise has many benefits forpeople with diabetes and increased emphasis onthis by educators would seem to be somethingelse to be targeted. It does seem that there is roomto improve patients’ knowledge of diabetes andits complications. In particular, although Maorireport receiving education at similar rates to non-Maori, their self-reported measure of efficacy islower, suggesting that the problem is not access toeducation but its effectiveness.This study shows that the Internet is widelyavailable to patients, but only 28% of patients(and 15% of Maori) have used the Internet to findinformation about diabetes. This suggests thatmany patients prefer to get their informationfrom other sources. Some researchers have suggestedolder and less-educated diabetes patientsare less likely to use the Internet. 18 Anotherstudy found more than 50 Internet sites providingpatient-centred information for people withdiabetes. 19 Whilst it is an easily available portalto information, perhaps we should considergiving patients advice about how to judge therelevance and reliability of information on theInternet. One excellent source of information isDiabetes New Zealand and it is disappointingthat only 15% belong to this organisation anddirectly receive the educational material that isavailable to members. We are aware that DiabetesNew Zealand pamphlets are often providedthrough general practice surgeries and so itsinfluence is likely to be greater than has been describedby patients in this survey. Another sourceof information we had not considered prior tothis research was the role of companies such asRoche. They were identified by several peopleas a source of information regarding control ofblood sugar levels and their involvement may bean option that could be explored further.There were a number of people who made commentssuch as ‘I don’t want my type 2 to turninto type 1’ and ‘how do I get rid of my diabetes’.These misconceptions indicate that, despitegenerally a comprehensive uptake of education,patients’ understanding of diabetes and how thedisease progresses is not always accurate. Part ofthe patient information provided should includean understanding of insulin, when insulin is rec-308 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchommended for people for type 2 diabetes and therole it plays in management of blood glucose.Qualitative responses from patients on the questionnairesuggested more information was wantedabout food and diet. One way of providing thiseducation would be to offer group educationsessions particularly as we have shown only aminority of patients access a dietician. Groupeducation has been shown to be effective inreducing HbA1c, weight and blood pressure andincreasing exercise rates. 20,21,22 In our survey therewas a small group of 36 people who indicatedthat they would prefer group sessions, with anadditional 58 people saying they would be happyto attend. However, the majority of respondents(57%) said they would not want to attend groupsessions. Perhaps by offering group sessions as anoption to newly diagnosed patients we can reachsome of the people who are currently missingWe believe this is important in that it may notonly help the person with diabetes obtain bettercontrol, but also influence other family membersto make some lifestyle changes and reduce theirown risk of developing diabetes.Strengths of this study were that it recordedpatients’ experiences of the health care systemand information was collected from a populationbasedsample of patients who were diagnosedwithin the same year. A weakness is that therewas only a 50% response rate and for ethnicminority groups this was even lower. We tried toensure a more representative sample of Maori byusing the services of the Maori Health Unit totelephone Maori non-responders and, to a certainextent, this strategy was successful, althoughwe only achieved a 39% response rate. The lowresponse rate may be because Maori can be moremobile and so addresses and telephone numbersPerhaps by offering group sessions as an option to newly diagnosedpatients we can reach some of the people who are currently missingout; however group sessions would need to be implemented withseveral factors in mind, such as location, cost and timingout; however group sessions would need to beimplemented with several factors in mind, suchas location, cost and timing. Many of the peoplesurveyed still work and may be unable to attendday sessions. Some people also mentioned cost asa factor, saying they would only attend if it wasfree, with others saying they would be happy topay a small fee. Almost everyone who expressedinterest in group sessions said location was themost important factor, with people not willingto travel long distances. Anyone considering theintroduction of group education sessions shouldtake into account patient preferences.Including spouse/family/whanau was consideredvery important by some people, and even thosewho said they did not want their family includedoften said that they had shared their information.Giving people the option of bringing theirspouse/family/whanau with them to medicalappointments can help educate the entire family.are less reliable when trying to contact patients.The initial response rate from the Asian, Indianand Pacific populations was also disappointing.When following up on the non-responders bytelephone, one of the major obstacles encounteredwas the language barrier. This was mainly anissue with the patients who were Asian, althoughit was also encountered with some of the Indianand Pacific patients. Several of the Asian patientscontacted spoke very little or no English anddid not understand the purpose of the call. Ofthe people who did understand, all but one werereluctant to return the survey. Two of the peoplewho declined cited language barriers as thereason for not wanting to return the survey. Thislanguage barrier could also result in a decreasedunderstanding of the education provided aboutdiabetes and could in turn lead to decreasedcontrol of their diabetes. A study of Asian/Indian health in New Zealand found that theyhave a higher prevalence of diabetes and are lessVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 309

ORIGINAL SCIENTIFIC PAPERSquantitative researchAcknowledgementsWe thank the WaikatoLocal Diabetes Team,especially Dr DaveMaplesden and Mrs PatBent for their advice onthe questionnaire. MrsChristine Bierre, diabetesspecialist nurse fortrialling the questionnaireand her comments onthe final draft, Dr PeterDunn for access to theWaikato Regional DiabetesService database andMr Rawiri Blundell forhis help in interviewingMaori participants.FundingThis study was fundedthrough a grant from theWaikato District HealthBoard’s summer studentscholarship programme.Competing interestsNone declared.likely to access health services. The study suggeststhat developing educational materials thatare available in languages other than English maybe required if this growing population of Asian/Indian patients with diabetes are to receive appropriateaccess to information about their diabetes. 23SummaryIn summary, whilst overall there seemed tobe wide availability and coverage of diabeteseducation for newly diagnosed patients, a smallnumber of patients are missing out. The informationfrom this study has been reported to thegeneral practice management group and to theWaikato Regional Diabetes Service. Suggestionsinclude a routine question at the annual diabetesreview to reveal those patients who had additionalneeds, and more emphasis on educationabout monitoring of blood pressure and lipids.There also seems to be a demand from patientsfor additional information about diet, exerciseand lifestyle advice—this demand could be metby assessing the current information available atgeneral practice surgeries in the form of booklets/pamphlets, identifying any gaps and ensuringadditional materials are available. Encouragingpeople who have access to the Internet to accessthe Diabetes New Zealand website as a source ofinformation might also be an option. Finally webelieve that the disparities in perceived knowledgeby Maori patients and the poor uptake ofthis survey by Asian and Indian patients wouldsuggest that further research on the educationalneeds of Maori and ethnic minorities is needed.References1. Mulnier HE, Seaman HE, Raleigh VS, Soedamah-Muthu SS,Colhoun HM, Lawrenson RA, de Vries CS. Risk of myocardialinfarction in men and women with type 2 diabetes in the UK:a cohort study using the General Practice Research Database.Diabetologia. 2008;51(9):1639–45.2. Joshy G, Dunn P, Fisher M, Lawrenson R. Ethnic differencesin the natural progression of nephropathy among diabetespatients in New Zealand: hospital admission rate for renalcomplications, and incidence of end-stage renal disease andrenal death. Diabetologia. 2009;52(8):1474–8.3. Joshy G, Simmons D. Epidemiology of diabetes in NewZealand: revisit to a changing landscape. N Z Med J.2006;119(1235):U1999.4. Trento M, Passera P, Borgo E, Tomalino M, Bajardi M, CavalloF, Porta M. A five-year randomized controlled study of learning,problem solving ability, and quality of life modifications inpeople with type 2 diabetes managed by group care. DiabetesCare. 2004;27(3):670–5.5. Tilly KF, Belton AB, McLachlan JF. Continuous monitoring ofhealth status outcomes: experience with a diabetes educationprogram. Diabetes Educ. 1995;21(5):413–9.6. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Selfmanagementeducation for adults with type 2 diabetes: ameta-analysis of the effect on glycemic control. DiabetesCare. 2002;25(7):1159–71.7. Kinmonth AL, Woodcock A, Griffin S, Spiegal N, CampbellMJ. Randomised controlled trial of patient centred care ofdiabetes in general practice: impact on current wellbeing andfuture disease risk. BMJ. 1998;317(7167):1202–8.8. Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME,Cradock S et al. Effectiveness of the diabetes education andself management for ongoing and newly diagnosed (DES-MOND) programme for people with newly diagnosed type2 diabetes: cluster randomised controlled trial. BMJ. 2008;336(7642):491–5.9. Blonde L. Current challenges in diabetes management. ClinCornerstone. 2005; 7 Suppl 3: S6–17.10. Tankova T, Dakovska G, et al. Education of diabetic patients—aone year experience. Patient Educ Couns. 2001;43(2):139–45.11. Albano MG, Crozet C, d’Ivernois JF. Analysis of the 2004–2007 literature on therapeutic patient education in diabetes:results and trends. Acta Diabetologica. 2008;45(4):211–9.12. Metcalf PA, Scragg RR, Schaaf D, Dyall L, Black PN, JacksonRT. Comparison of different markers of socioeconomicstatus with cardiovascular disease and diabetes risk factorsin the Diabetes, Heart and Health Survey. N Z Med J.2008;121(1269):45–56.13. Ross Barnett J, Pearce J, Howes P. ’Help, educate, encourage?’:Geographical variations in the provision and utilisationof diabetes education in New Zealand. Soc Sci Med.2006;63(5):1328–43.14. Lawrenson R, Gibbons V, Joshy G, Choi P. Are there disparitiesin care in people with diabetes? A review of care provided ingeneral practice. J Prim Health Care. 2009; 1(3):177–183.15. Peel E, Parry O, Douglas M, Lawton J. Diagnosis of type 2diabetes: a qualitative analysis of patient’s emotional reactionsand views about information provision. Patient Educ Couns.2004;53:269–275.16. UK Prospective Diabetes Study Group. Tight blood pressurecontrol and risk of macrovascular and microvascularcomplications in type 2 diabetes: UKPDS 38. BMJ. 1998 Sep12;317(7160):703–13.17. Costa J, Borges M, David C, Carneiro AV. Efficacy of lipidlowering drug treatment for diabetic and non-diabetic patients:meta-analysis of randomised controlled trials. BMJ.2006;332:1115–8.18. Grant RW. Cagliero E. Chueh HC. Meigs JB. Internet useamong primary care patients with type 2 diabetes: the generationand education gap. J Gen Intern Med. 2005;20(5):470–3.19. Thakurdesai PA, Kole PL, Pareek RP. Evaluation of the qualityand contents of diabetes mellitus patient education on Internet.Patient Educ Couns. 2004;53(3):309–13.20. Sarkadi A, Rosenqvist U. Experience-based group educationin type 2 diabetes: a randomised controlled trial. Patient EducCouns. 2004;53(3):291–8.21. Deakin T, McShane CE, Cade JE, Williams RD. Group basedtraining for self-management strategies in people with type 2diabetes mellitus. Cochrane Database Syst Rev. 2005 Apr18;(2): CD003417.22. Rickheim PL, Weaver TW, Flader JL, Kendall DM. Assessmentof group versus individual diabetes education: a randomizedstudy. Diabetes Care. 2002;25(2):269–74.23. Scragg R, Maitra A. Asian health in Aotearoa: an analysis ofthe 2002/03 New Zealand Health Survey. The Asian NetworkInc.; 2005.310 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquaLitative research‘Going-to-have-cancerness’: a study ofliving with increased risk of BRCA1 and BRCA2mutations for six South Island womenRaewyn J Crump MHealSci (Otago), PGDipHealSci, BHealSci; Ruth P Fitzgerald PhD (Otago), FRAI, PGCertTT,PGD, BA, AssDipAppSci; Michael Legge PhD (Essex), FIBMS, FNZIMLS, MIBIOL, BScABSTRACTintroduction: Mutations in the BRCA (breast cancer) 1 and 2 genes are thought to lead to 5–10% ofbreast cancers.Department of Anthropology,Gender and Sociology,University of Otago,Dunedin, New ZealandAim: A qualitative study to explore six New Zealand women’s experiences of living with increased riskfor a genetic susceptibility to breast cancer.Methods: Six women were interviewed using semi-structured interviews, to explore their experiencesof living at high risk for developing breast cancer due to familial and/or individual genetic susceptibilities.Results were analysed using thematic coding. After a three-year interval, interviewees were contactedagain to discuss their experiences (although two were lost to follow-up).FINDINGS: The women held fatalistic views on developing cancer and drew on family experience asmuch as biomedical research to assess their situation. They became increasingly immersed in biomedicalscreening and prophylaxis without accompanying improvement to their peace of mind and withunrealistic ideas of it ‘preventing’ cancer. The biomedical management options and advice they reportedreceiving was factually inconsistent and a discrepancy emerged between women’s expectations of breastcancer health services (including genetic testing) and the delivered support and services.Conclusion: This small sample group cannot be used to draw implications on the views of the widergroup of higher risk patients, but for these six women, genetic testing, screening and prophylaxis have notprovided peace of mind; rather the reverse has occurred. The findings are provocative as they challengethe biomedical idea of patients’ experience of managing their genetic risk information as routinely positive.KEYWORDS: Qualitative research; genes BRCA1; genes BRCA2; breast neoplasm; riskIntroductionThis paper explores six patients’ experiences ofliving with a familial and/or individual geneticsusceptibility for breast cancer which is the mostcommon cancer diagnosed in females in NewZealand. 1 Only 5–10% of these breast cancers arethought to develop from a genetic susceptibilitythrough mutations in the BRCA (breast cancer)1 and 2 genes. 2,3 The genetic mutation can beinherited either paternally, maternally or arise denovo 4 and demonstrates variable penetrance. Asgenetic testing cannot determine who of thosewith BRCA mutations will develop breast cancer,the age of onset or the severity of the malignancy(if diagnosed), the clinical usefulness of BRCAtest results is somewhat difficult to assess. 4–8Furthermore, while previously a confirmed geneticsusceptibility was thought to place the lifetimecumulative risk for developing breast cancer at87% by the age of 70, 6,9 there is now disagreementabout the magnitude of the risk associated withBRCA1 or BRCA2 mutations 10 and recent metaanalysesof BRCA penetrance provide differingestimates depending upon the sub-populationsanalysed. Some estimates suggest a 48% cancerrisk by age 75 years for BRCA1 and 32% up to75 years for BRCA2. 11,12 The cumulative risks ofJ PRIM HEALTH CARE2010;2(4):311–317.Correspondence to:Ruth FitzgeraldSocial Anthropology,Division of Humanities,University of Otago,PO Box 56 Dunedin,9054, New Zealandruth.fitzgerald@stonebow.otago.ac.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 311

ORIGINAL SCIENTIFIC PAPERSquaLitative researchdeveloping breast cancer at 70 years of age havebeen estimated to be 55% for BRCA1 and 47% forBRCA2. 12 However, the actual risk level is oftenunknown for breast (and other cancers) 6 relativeto the specific mutation present in the family. 3,8Studies of primary health care provision to theaffected patients suggest wide cultural variationsin practice. 13 Anglo-Saxon countries view thevalue of genetic testing as a means of preventingcancer in which patients carry high responsibilitiesfor making appropriate lifestyle changes. Frenchguidelines, on the other hand, favour the preservationof fertility and bodily integrity. Variationsin referral for genetic testing exist within Anglo-Saxon countries as well 14 with suggestions from theUSA for more uniform approaches to both communicatingand assessing risk. A recent USA surveydemonstrated a trend for family physicians to referinappropriate (i.e. low risk) patients for genetictesting when the patients themselves request theservice. 15 Internationally there have been severalstudies noting the need for better understanding ofthe principles of genetic risk assessment by primaryand tertiary health care providers; 16,17,18 the value ofproviding education programmes; 19–22 and the needto focus on education in how to approach the topicof risk in concrete terms within clinical practicerather than in abstracted terms of bioethics or biologicalscience. 23,24 A United Kingdom (UK) studyfrom 2002 exploring patients’ understandings ofGP consultations over presumed high familial riskof breast cancer indicated that GPs had a major taskof reassurance. Failure to reassure in these circumstancesresulted from the GPs lacking awarenessthat patients frequently held very differentunderstandings of the mechanisms of disease andheredity in relation to their specific medical risk. 24This paper explores how six New Zealand womenlived with the knowledge of the increased familialand/or personal risks of cancers associatedwith BRCA1 and 2 mutations against the broaderbackdrop of these studies. This project was conductedas research for a Masters Thesis in HealthSciences (Bioethics).MethodsA semi-structured interview on the general topicof living with a high familial and/or individualrisk of breast cancer, lasting one to two hours,was undertaken with six women who had consideredgenetic counselling for their perceived highrisk for a BRCA mutation. The participants representedfive distinct families with increased familialrisk for the mutations in the South Island.The first round of interviews was conducted during2003/2004, the second interviews in 2007,although two participants were lost to follow-up(via illness and relocation). The second interviewscaptured data regarding the continued experienceof living with the knowledge of increased risk.Table 1 contains a summary of the demographiccharacteristics of the participants. All six identifiedwith New Zealand European ethnicity andfour out of six participants had been tested priorto the first round of interviews. Since the firstinterviews, two of the participants each have hada sister diagnosed with breast cancer.The initial interviews covered the topics ofparticipants’ experiences of a family history ofbreast cancer, their understanding of the riskof a predisposition to inherited breast cancer,issues around screening recommendations andprophylactic interventions, influences on decidingwhether to undergo genetic counselling and/or testing, the use of genetic testing, impacts onrelationships once genetic test results are known,disclosure of any genetic information gained, andmethods used to adjust to the information. Thesecond interviews reviewed participants’ originalcomments to evaluate the relevance of the initialfindings to their current views.Data collection and analysis was qualitative,based on audiotaped interviews, transcribedverbatim and returned to each participant forchecking. Selected interview passages were thematicallycoded 25 and then collated into commonthemes of interest by the first author and checkedby the second author.These results cannot be used to predict widertrends in this subpopulation of high risk womenbecause of the small number of participants;however they do reflect the views of members offive different families within the South Island.Morse suggests that six participants are adequatefor distilling the ‘essence of experience’ and312 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquaLItative researchStake also supports the intensive study of purposivelysampled individuals for such a purpose. 28,29Ethical approval was obtained from the Otago,Southland and Canterbury (02/12/197) ethicscommittees. The low number of participantsresulted from initial ethical approval beingcontingent upon recruitment via a third party(the Genetics Service) with its attendant poorresponse rate and lengthy time delay. Subsequentapproval removed this criterion. Ethicsapproval required that family members were notmade aware of other family members’ participation,thus prohibiting the use of a ‘snowballing’recruitment strategy.FindingsThe eight themes identified (see Table 2) werecommon to all six interviewees at first interview.At second interview, themes 1, 5, 6, and 8emerged as increasingly dominant for the remainingfour women in the study.DiscussionWHAT GAP THIS FILLSWhat we already know: The responsibilities of primary care providersto explain and refer individuals and families for genetic testing is interpreteddifferently in different cultural settings. Furthermore, patients may not sharethe same understanding of genetics and heredity as providers, with resultingdifficulties in establishing a common base of knowledge.What this study adds: This small South Island study explores six patients’perspectives of the experiences of living longer-term with personal and familialrisk for BRCA1 and 2 mutations. It demonstrates the difference in theirunderstandings of their risk to that of conventional biomedical and primarycare accounts of such risk, and the implications of this difference.At first interview, all the informants spoke to alleight themes with equal emphasis (Table 2) indicatingthat the narrative of living with BRCA1and 2 mutation risk was organised around thesesocial experiences. Over the three-year interval,however, these women’s lived experiences ofmanaging high familial and/or personal risks ofcancer caused them to shift anxiously towardsdeeper medicalisation (theme 6) of lives that (forfive out of six of them) were seemingly healthy.The women spoke of living with an increasedcancer risk as a state of ‘hypochondria’, ‘paranoia’,‘stress’, ‘anxiety’ and having it always ‘atthe back of your mind’. Another less obviouseffect was the implication from their GPs thatTable 1. Demographics and family historyParticipants 1 2 3* 4 5* 6Recruitment method GS GS GS Advert Medical Specialist AdvertAge at first interview 52 45 47 28 52 38Age at testing 50 43 45 Ineligible 50 UntestedEducational attainment 3 years high school School cert. Degree Masters degree Polytech cert. Trade cert.Participant cancer diagnosis No No No No Yes NoMutation confirmed Yes Yes Yes Not tested No useful result Not testedNo. of relatives tested—mutation confirmedNo. of relatives tested—no mutation detectedNo. of relatives diagnosedwith breast cancer(at 1 st interview)No. of relatives diagnosedwith other cancers(at 1 st interview)GS: Genetic Service*Lost to follow-up (i.e. moved, presumed deceased) at time of 2nd interview5/5 5/5 3/6 – – –– – 3/6 – – –3 3 5 6 7 3– – 3 4 4 2VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 313

ORIGINAL SCIENTIFIC PAPERSquaLitative researchTable 2. Interview themes with illustrative quotesThemeInterview themes with illustrative quotes1 † Explaining risk via family histories not biomedicine‘I’m heading up to 40 and I’m in the trouble area where Mum was when shewas my age’‘It’s not too big a concern for me [ovarian cancer] at the moment because asfar as I know there’s been no-one in our family that’s had ovarian cancer, soit does seem to be that breast cancer is the stronger one…’2 Self-image and prophylactic surgical options‘It doesn’t worry me if I’ve got something out, it doesn’t worry me that I‘vegot something missing’‘Yes, you can have [breast] reconstructive surgery but it’s not the same, it’sa part of your body that you are killing’3 Genetic fatalism‘You can’t rail against genetics’‘Intellectually I can say “oh well, I am not as high a risk as I thought”, butemotionally I still expect to die in 20 years time’4 Information gathering as risk management‘…I went on the Internet and I looked up all sorts of things and read up abouthow it was quite possible that our high dairy intake could have some effecton breast cancer… so I started on all sorts of dietary changes…’‘…so I was quite keen to catch up with [the doctor] after that [conference]and just find out what he had found out—cos I just thought there mighthave been a wee light at the end’5 † Lay (mis)understandings of screening and prophylactic interventions‘There is self examination, there’s the mammography and there’s theultrasound. If you do each of them in isolation you’ve got one third chance,but if you do all three of them… you should be OK’‘One of the important things that’s happened to me is that since I’ve knownI’ve decided to get [my] ovaries out and that rules out ovarian cancer... that’sone less thing we’ve got to worry about... maybe happening to us’6 † The effects of genetic knowledge on health behaviour‘They’ll probably find everything is associated with cancer…’‘The major things I keep up with… I don’t have red meat… I stay away frompassive smoking…I try to be quite careful…’7 Caring for other family members’ genetic knowledge‘I feel a slight obligation that we should do something, because we haveinformation that they don’t’‘…I have an address for this aunt now [and] I would post her the relevantinformation to pass on to family members… after testing the reaction to theletter’8 † Expectations about medicine’s responsibility‘…how do I know anymore what is the truth?… even the GP… sometimeseven they are not sure’‘You know, you go onto the [breast screening] register when you turn 50,you can get yourself put on it then it’s two yearly. I believe that for peoplewho have got the gene at the highest level, because they are in the highestrisk group the screening has to be automatic from the moment they’re told,right through’† Significant themes from 2nd interviews. (Further quotes can be found in Appendix 1 of Crump. 38 )once their status was known, the women wouldautomatically make changes to their lives toavoid cancer, ranging from increased surveillanceto dietary changes. To ‘do nothing’ wasnot viewed as a viable course of action. Managingthis pressure then became another burdenleading to a sense of futility or, by failing toadhere to behavioural changes, the experienceof guilt. For the four remaining participants,these issues had only intensified (themes 1, 5,6, 8) by the time of their second interviews. Forthese reasons we suggest the ‘benefits’ of testing,screening and prophylaxis appear to have causedsome iatrogenic harm. Such negative experienceshave been found for other national groups inrelation to women’s personal estimations of deathfrom breast cancer from genetic, environmentaland social causes. 26In summary, the overall effect of living withtheir proven or suspected high risk of cancer forthese women was a substantial medicalisationof mostly healthy lives. This is demonstratedin the dominance of themes 1, 5, 6, and 8 overtime as women combined various screeningmodalities in a cumulative manner, attemptedbehaviour changes, looked to already-diagnosedwomen in the family for their own futures andincreasingly sought medical intervention andguidance for their situation. Further to that, suchmedicalisation rests on an unproven basis, withrecent literature 4,7,8 suggesting great complexityand variation in assessment of lifetime risksof developing cancers and a downward trend intheir estimation for the many forms of BRCA1and 2 mutations. Such medicalisation mightbe acceptable if the result were to be a reductionin anxiety and fatalism; however for thesestudy participants, their experience of life wasbetter defined in their own words as a far moregenetically determined destiny of ‘going–to-havecancerness’.Their self-described lives of anxiety,stress and watchfulness made their commonlabel of the ‘at-risk-well’ quite inappropriatelypositive for the effect of the information ontheir lives. The self-reported advice provided byGPs to these women that genetic testing wouldprovide peace of mind has proved to be incorrectregardless of whether each participant’s exposureto increased genetic risk was confirmed, merelyfamilial or unproven.314 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquaLItative researchPart of this negative experience was expressedin the women’s dismay at the lack of a BRCAregister for high-risk women, as they consideredthemselves ‘abandoned’ by the medicalprofessionals. During the time in which theyhad become alerted to their high risk status, asnoted, the lifetime risk of developing cancer fromBRCA1 and 2 mutations had been recalculateddownwards; however the women were unawareof this trend, despite their information-seekingbehaviours (theme 4). Women also expressedtheir awareness of an underlying imperative fromtheir primary health care providers that, whenmaking the decision about testing, the ‘right’decision was to be tested. This belied women’ssubsequent experiences of resulting difficulties‘add together’ screening procedures for ‘increasedprotection’ (theme 5) indicating that participantswere confused in their understandings of theadvice offered about screening’s value. It couldalso indicate that they were offered inappropriateadvice—an aspect of primary health care that hasbeen criticised both nationally and internationally.27,39 All reported negatively the conflictingnature of the information that they received fromthis variety of sources and distrust and disillusionmentemerged over the level of knowledgeexpressed by their local GPs. For example, mostwomen reported being told that male familymembers could not transmit BRCA1 and 2mutations to offspring and men were generallynot invited for testing in high risk families. OneWomen also expressed their awareness of an underlyingimperative from their primary health care providers that, whenmaking the decision about testing, the ‘right’ decision was to betested. This belied women’s subsequent experiences of resultingdifficulties in living…and the impossibility of unlearning theknowledge gained from genetic testingin living—such as insurance problems, difficultywith accessing information, conflicting information,little or no support being provided by themedical establishment, continued uncertainty,feeling responsible for testing and screening, noabsolutely preventive options being available, andthe impossibility of unlearning the knowledgegained from genetic testing.The accepted risk management of high-riskwomen is through the use of screening andprophylactic measures (e.g. bilateral mastectomy,oophorectomy, and chemoprevention) recommendedon the basis of ‘presumed efficacy’ 30 and‘expert opinion’ rather than empirical evidence. 8,10In line with this, all of the women reported beingencouraged to take up long-term screening bytheir local physicians. However, over time theyspoke of the screening as coming to represent atalisman for cancer-free existence. They tended todeeply angry woman had been told the familialrisk was on her ‘father’s side of the family’ andthus would not apply to her, and then developedbreast cancer. The constant information searching(theme 4) was used to double-check the informationfrom their local doctors. The implications aretroubling for patient care. For instance, inappropriateuse of screening could hold costing implicationsif these women’s experiences are shown ina wider study to reflect a common response.While appropriate management of at-risk individualscan also involve the consideration of surgicalprophylaxis, 4,8,31 in this study most participantstended to initially avoid breast surgery, opting insteadfor oophorectomy, while continuing a breastsurveillance regime. 10,37. However, breast surgeryappeared to be more readily considered as timepassed and concerns over personal risk continued.Chemoprevention (e.g. Tamoxifen) is anotherVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 315

ORIGINAL SCIENTIFIC PAPERSquaLitative researchroute to prophylaxis, although the optimal doseand treatment duration is unknown, there areside effects, 35,36 and concerns efficacy may becompromised by the tumour’s hormonal status. 9However, chemoprevention was not reported bythe women to have been considered. The NewZealand Guidelines Group recommends all suchoptions be discussed with very high risk womeni.e. BRCA1 and 2 mutation carriers. 8Even so, how adequately these prophylactic optionsmight be conveyed to patients is a mootpoint given the incorrect understandings thesewomen already exhibited regarding the purposeof screening. Similar problems of interpretationarose over the significance of test results andgenetic counselling. Women with a confirmedmutation, for instance, indicated that it wasdifficult to comprehend the possibility of a genemutation being present yet not expressed. Becauseprophylaxis only reduces risks for the individual,some women in this study were considering thepossibility of either forgoing childbearing or usingegg donors to remove the risk of the mutationbeing passed on to their children. These intentionshighlight the concerns raised in themes 3,6 and 7. Increasingly, in vitro fertilisation clinicsoffer preimplantation embryo testing for BRCAmutations and are discarding carrier embryos becauseof their associated predisposition for diseaserisk. 34 Such contemporary clinical practices (in thecontext of the declining BRCA1 and 2 risk estimates)convey the same thread of genetic fatalism(theme 3) that the women reported of themselves.Uncoupling risk from personal destiny and a mutationfrom its full expression would appear thento be a conceptual task required on both sides ofthe consultation desk.In conclusion, these results, while not representativeof the whole population, are still interestingas they provide an alternative to the predominantmedical view of the usefulness of geneticknowledge to individual patients. The fatalisticemotional and intuitive experience of genetic riskwhich these women described as ‘going-to-havecancerness’coupled with the sense of failure ofexpected support from the health care systemcreated a negative experience of anxiety, futilityand guilt. In light of the downward numericalmovement of risk calculations, this createsa moral imperative for health care providersto provide frank discussions of this currentlyconfusing state of risk assessment and also todiscover a means of keeping in touch with clientsto update them of changes in their risk status.Careful enquiry into how people make sense oftheir risk status as time progresses is also needed.While a role exists for GPs in ongoing educationand support of these women, as previously noted,this support needs to be factually correct, toavoid genetic fatalism, and (given these women’sexperiences) to be critically informed as to thebenefits of not testing. Finally, the study suggeststhe value of a wider and systematic enquiryinto the experiences of living with high personalor familial risk of BRCA1 and 2 mutations. Insuch a study, the views of medical practitionerson the management of such cases (e.g. referralsbetween primary, secondary and tertiary serviceproviders) would also give a more completeunderstanding of the situation surroundingthe long-term management of living with thisgenetic knowledge.References1. Ministry of Health, New Zealand. Cancer in New Zealand:trends and projections 2000–2004 update. Pub Health IntelligenceOccasional Bulletin. 2004:49.2. Parmet S, Lyn C, Glass RD. Genetics and breast cancer. JAMA.2004;292:522.3. Evans DGR, Lalloo F. Risk assessment and management of highrisk familial breast cancer. J Med Genet. 2002;39:865–871.4. Narod SA, Foulkes WD. BRCA1 and BRCA2: 1994 and beyond.Nature Reviews: Cancer. 2004;4:665–676.5. Anglian Breast Cancer Study Group. Prevalence andpenetrance of BRCA1 and BRCA2 mutations in a populationbased series of breast cancer cases. Brit J Cancer.2000;83:1301–1308.6. Blackwood MA, Weber BL. BRCA1 and BRCA2: from moleculargenetics to clinical medicine. J Clin Oncol. 1998;16:1967–1977.7. Thompson A, Brennan K, Cox A, et al. Evaluation of currentknowledge limitations on breast cancer research: a gap analysis.Breast Cancer Res. 2008; 10: R26 (doi10.11.1186/bcr1983)8. New Zealand Guidelines Group Management of Early BreastCancer. Wellington: New Zealand Guidelines Group; 2009.9. Morrow M, Gradishar W. Breast cancer. BMJ.2002;324:410–414.10. Press N, Reynolds S, Pinsky L, et al. ‘That’s like chopping off afinger because you’re afraid it might get broken’: disease andillness in women’s views of prophylactic mastectomy. Soc SciMed. 2005;61:1106–1117.11. Pharoh PDP, Day NE, Duffy S, et al. Family history and the riskof breast cancer: a systematic review and meta-analysis. Int JCancer. 1997;71:800–809.12. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2penetrance. J Clin Oncol. 2007;25:1329–1333.13. Bouchard L, Blancquaert I, Eisinger F, et al. Prevention and genetictesting for breast cancer: variations in medical decisions.Soc Sci Med. 2004;58:1085–96.316 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquaLItative research14. Wideroff L, Freedman A, Olson L, et al. Physician use ofgenetic testing for cancer susceptibility: results of a nationalsurvey. Cancer Epidemiol Biomarkers Prev. 2003;12:295–303.15. Pinkowish MD. Family physicians and referrals of low-riskwomen for BRCA1/2 genetic services. CA Cancer J Clin.2009;59:70–72.16. McCann S, Macauley D, Barnett Y. Genetic consultations inprimary care: GPs’ responses to three scenarios. Scand J PrimHealth Care. 2005;23:109–114.17. Aalfs CM, Smets E, de Haes H, Leschot N. Referral forgenetic counselling during pregnancy: limited alertness andawareness about genetic risk factors among GPs. Fam Pract.2003;20(2):135–141.18. Tyler C, Snyder C. Cancer risk assessment: examiningthe family physician’s role. J Am Board Fam Med.2006;19(5):468–544.19. Calefato J, Nippert I, Harris J, et al. Assessing educationalpriorities in genetics for general practitioners and specialistsin five countries: factor structure of the genetic educationalpriorities (Gen-EP) scale. Genet Med. 2008;10(2):99–106.20. Gorin S, Ashford A, Lantigua R, et al. Effectiveness of academicdetailing on breast cancer screening among primarycare physicians in an underserved community. J Am BoardFam Med. 2006;19(2):110–121.21. Watson E, Clements A, Yudkin P, Rose P, Bukack C, Mackay J,Lucassen A, Austoker J. Evaluation of the impact of two educationalinterventions on GP management of familial breast/ovarian cancer cases: a cluster randomised controlled trial. Br Jof Gen Pract. 2001;51(471):817–21.22. Julian-Reynier C, Nippert I, Calefato J, et al. Genetics inclinical practice: general practitioners’ eduational priorities inEuropean countries. Genet Med. 2008;10(2):107–113.23. Barlow-Stewart K, Gaff C. Working in partnership withsupport services in the era of the ‘new genetics’. Med J Aust.2003;178(10):515–519.24. Grande G, Hyland F, Walter F, Kinmonth A. Women’s viewsof consultations about familial risk of breast cancer in primarycare. Patient Educ Couns. 2002;48(3):275–282.25. Tolich M, Davidson C. Starting fieldwork: an introductionto qualitative research in New Zealand. Auckland: OxfordUniversity Press; 2001.26. Pinsky L, Culver J, Hull J, et al. Why should primary care physiciansknow about breast cancer genetics? West J Med. 2001Sep;175(3):168–173.27. Baars M, Henneman L, Ten K, Deficiency of knowledge ofgenetics and genetic tests among general practitioners, gynaecologistsand paediatricians a global problem. Genet Med.2005;7(9):605–10.28. Morse J. The significance of saturation. Qual Health Res.1995;5:147–149.29. Stake RE. Case studies. In: NK Denzin and YS Lincoln, editors.The SAGE handbook of qualitative research. Thousand Oaks:Sage; 2000.30. American Society for Clinical Oncology. Genetic testing forcancer susceptibility. J Clin Oncol. 2003;21:2397–2406.31. Haynes DF. Follow-up of patients with early breast cancer. NEngl J Med. 2007;356:2505–2513.32. Chlebowski RT, Kuller LH, Prentice RL, et al. Breast cancer afteruse of estrogen plus progestin in postmenopausal women.N Engl J Med. 2009;360:573–587.33. Punglia MJ, Morrow M, Winer EP, Harris JR.Local therapy andsurvival in breast cancer. N Engl J Med. 2007;356:2399–2405.34. Jasper MJ, Liebelt J, Hussey ND. Preimplantation genetic diagnosisfor BRAC1 exon 13 duplication mutation using linkedpolymorphic markers resulting in a live birth. Prenat Diagn.2008 Apr;28(4):292–298.35. Shapiro CL, Recht A. Side effects of adjuvant treatment ofbreast cancer. N Engl J Med. 2001 Jun;344(26):1997–2008.36. Smith IE, Dowsett M. Aromatase inhibitors in breast cancer. NEngl J Med. 2003;348:2431–2442.37. Ziegler LD Kroll SS. Primary breast cancer after prophylacticmastectomy. Am J Clin Oncol. 1991 Oct;14(5):451–454.38. Crump RJ. ‘Going-to-have-cancerness’ experiences of breastcancer genetic susceptibility. Unpublished Master of HealthScience (Bioethics) thesis, University of Otago; 2005.39. White S, McLeod D. Genetic testing: a survey of New Zealandgeneral practitioners’ knowledge and current practice.Prepared for the National Health Committee, General PracticeDepartment, Wellington School of Medicine and Health Sciences,University of Otago, New Zealand; 2003.40. Lerman C, Croyle RT, Tercyak KP, Harman H. Genetic testing:psychological aspects and implications. J Consult Clin Psychol.2002 Jun;70(3):784–797.ACKNOWLEDGEMENTSThanks to the participantsand the supervisorsof the earlier MastersThesis, Ruth Fitzgeraldand Lynley Anderson.COMPETING INTERESTSNone declared.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 317

improving performanceAn audit of two methods of anticoagulationmonitoring in a general practiceKerr R Wright MBChB, DRCOG, MRCGP, FRNZCGPABSTRACTBackground and context: Patients with atrial fibrillation (AF) and a five-year stroke risk >15%should be on long-term oral anticoagulant therapy with adjusted dose warfarin unless there is a clearcontraindication.Assessment of problem: Ad hoc adjustments of warfarin dose and anticoagulation monitoring bya general practitioner is less efficient than a standardised protocol administered by the practice nurses.This study was a retrospective audit of patient anticoagulation control before and after a change inmethod of warfarin adjustment. Measures were frequency of testing, time spent in the therapeutic rangeand mean International Normalised Ratio.Results: Thirty-two patients were studied over a 12-month period. The method change resulted inimportant improvements in practice efficiency while maintaining the standard of anticoagulation controlwith no significant increase in frequency of venesection.Strategies for improvement: General practices still using ad hoc adjustments of warfarin therapycan adopt a standardised nurse-managed protocol to achieve greater efficiency without adverselyaffecting patient care.Lessons: A move from the heavily doctor-intensive ad hoc system to the entirely nurse-led systemimproved practice efficiency. The doctor was liberated from the process. The nurse no longer had to actas liaison with the doctor. The receptionist did not have to ask patients to ring back once the doctor hadseen the results. Patients received their instructions more quickly and their care was not compromised.KEYWORDS: Anticoagulation monitoring; warfarin; family practice.CORRESPONDENCE TO:Kerr R WrightGeneral practitioner,44 Sedgwick Road,Opotiki, Eastern Bay ofPlenty, New Zealanddoctor@heritagehealth.co.nzBackgroundPatients with atrial fibrillation (AF) and a fiveyearstroke risk of over 15% should be on longtermoral anticoagulant therapy with adjusteddose warfarin unless there is a clear contraindicationto doing so. 1 The target InternationalNormalised Ratio (INR) is 2.5, range 2.0–3.0. 2The monitoring of anticoagulation representsa significant workload to general practices. ANew Zealand (NZ) study from 2005 suggeststhat less than half of eligible patients in NZreceive anticoagulation. 3 If these figures are tobe improved, then the workload associated withanticoagulation monitoring in general practice isset to increase. Efficient ways of managing thisworkload are required.Outline of local contextThis study took place in a rural Eastern Bay ofPlenty general practice. At the time of the audit,there was one full-time GP and two practicenurses working 1.2 full-time equivalents. The enrolledpopulation was 2430. Thirty-four percentof the practice was aged under 19 years and 20%aged 60 years or over. Forty-two percent of thepatients identified themselves as Maori.Assessment of problemsApproach takenThe traditional method of monitoring anticoagulationin our practice was similar to that used in318 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performancemany general practices—a system often describedin the literature as ‘ad hoc adjustments’. Resultsfrom the venesection were faxed from the lab tothe practice. The doctor decided if a dose adjustmentwas required and when the next test shouldbe. The practice nurse would then contact thepatient with the new instructions.As the doctor involved in the dose adjustments, Itook into considerations several factors other thanthe patient’s past INR results. These included myimpression of the patient’s ‘reliability in followinginstructions’, transport and mobility issues.In order to improve efficiency, we decided todevolve the clinical decision-making process tothe practice nurses by adopting a standardisedmethod for INR adjustment. Following an inhouseclinical education meeting, we decided toimplement the guideline produced by the BritishColumbia Health Service as this appeared wellvalidated and easily understood. 4 For the firstmonth of the new regime, all INR adjustmentsmade by the nurse following the anticoagulationguidelines were checked by the doctor and noerrors were found.The change from a method that was ‘tailor-made’by the doctor for each patient to a ‘one size fitsall’ nurse-led method had resulted in importantimprovements in efficiency. Gains in practice efficiencyare sometimes achieved at the expense ofpatient care. Our aim was to discover if any alterationhad occurred in the standard of anticoagulationcontrol or frequency of patient venesection.Measurement of problemUsing patients as their own controls, a retrospectiveaudit was performed for a period of sixmonths before (ad hoc arm) and six months afterthe change in practice (standardised arm). Patientswho commenced or discontinued warfarin duringthe study period were excluded. Only thosepatients whose target INR was 2.0–3.0 wereincluded. Only a small number of patients inthe practice had a target range higher than this.They were patients with mechanical heart valvesand, while they were managed using the sameguidelines, their numbers were too small to allowany meaningful analysis.WHAT GAP THIS FILLSWhat we already know: Most monitoring of anticoagulation occurswithin the primary care setting. Some practices use ad hoc methods ofwarfarin dose adjustment which can be time-consuming and of untestedeffectiveness.What this study adds: Switching from ad hoc adjustments to a standardisedprotocol improved our efficiency and maintained effectiveness.The dates of testing and the INR results for the12-month period were extracted from the practicemanagement software and analysed in order toanswer the following three questions:1. Has there been any change in the frequencyof testing of INRs? To establish this, thelength of time between tests was measuredfor each patient for both study periods. Amean was calculated with a standard deviationto establish whether a significant change inthe frequency of testing had occurred foreach individual and for the group as a whole.Ninety-five percent confidence intervals wereused in establishing significance.2. Has there been any change in the amountof time spent by the patients in thetarget range over the two study periods?Establishing length of time within thetherapeutic range is a complex issue. It canonly be known for sure whether someone iswithin or outside the range on a particularday when an INR test has been performed. Iftwo consecutive results are within the targetrange then an assumption is made that thepatient has been in range for the entire intervalbetween the tests. If consecutive results showone result in target and one out of target thena linear estimate is made of when the patiententered or exited the therapeutic range. Usingthese assumptions, the percentage of timewithin the therapeutic range was calculatedfor each patient for both study periods using95% confidence intervals in establishingsignificance. A mean and standard deviationwas calculated for the test group for bothstudy periods to establish whether or not asignificant change had taken place.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 319

improving performance3. Has there been a change in patient’s meanINR? In other words, did the change in systemresult in patients sitting in a different partof the therapeutic range? Ninety-five percentconfidence intervals were used in establishingsignificance.Approval from an ethics committee was notsought because this was an audit conducted bya health provider for the purpose of qualityimprovement.Results of assessmentThirty-two patients formed the study group. Ofthose, 30 patients had AF and were on warfarinto reduce stroke risk and two were on warfarin toprevent recurrent deep vein thromboses. A summaryof the data is presented in Table 1.Frequency of testingIn the ‘ad hoc’ arm the most frequently testedpatient had an INR performed on average everyfour days and the least frequently tested patientaveraged 46 days between tests. The frequency oftesting ranged between seven and 45 days in the‘standardised’ arm. Across the entire study periodthree patients showed a statistically significant decreasein the frequency of testing after changing tothe ‘standardised’ model, and one patient showeda statistically significant increase in frequency.The remaining 28 patients showed no statisticallysignificant change in frequency of testing.The mean number of days between tests for the‘ad hoc’ arm as a whole was 18 days and for the‘standardised’ arm 17 days. This increased frequencyof testing in the ‘standardised’ arm wasnot statistically significant.Time in the therapeutic rangeIn the ‘ad hoc’ arm the patient with the poorestcontrol spent only 32.1% of the time within thetherapeutic range (of 2.0–3.0) while the best controlledpatient was in this range for 93.9% of thetime. Comparable figures for the ‘standardised’arm were 32.2% and 100%.The mean percentage time spent in the therapeuticrange for the ‘ad hoc’ arm was 65.3(SD 15.7%) and for the ‘standardised’ arm 69.3(SD 17.6%). This difference is not statisticallysignificant.Mean INRIndividual patients had their mean INR comparedover the two study periods. Two patientshad significantly different mean INRs under thedifferent systems; one higher and one lower. Theother 30 patients showed no statistically significantchange in mean INR.Strategies for quality improvementFrequency of testingIt is important to measure frequency of testingwhen examining different methods of anticoagulationmonitoring to ensure that one methoddoes not demonstrate superior results simplyby virtue of more or less regular testing. Theresults show no significant change in frequencyof testing between the two methods of INRmonitoring allowing an equitable comparison.Frequency of testing is also an important measureof patient care. Many patients find venesectionuncomfortable and inconvenient. For this reason,and to minimise cost, we would not wish to testfor good anticoagulation control more frequentlythan is necessary.Time in the therapeutic rangeThe individual variation between patients, withthe best controlled patients spending three timesas long in the therapeutic range as the poorestcontrolled, is a stark reminder of the importanceof individual patient factors (be they biological,social or behavioural) in the control of anticoagulation.Those individuals who showed poorcontrol in the first arm of the study were thesame individuals showing poor control in thesecond arm of the study. Patient to patient variabilitywas noticeably greater than any variabilitydemonstrated between the two methods ofanticoagulation monitoring.320 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performanceTable 1. Summary of resultsAd hoc armStandardised armPatientNumber% time intherapeutic bandINR(95% CI)Days between tests(95% CI)% time intherapeutic bandINR(95% CI)Days between tests(95% CI)1 75.2 2.2 ± 0.1 13 ± 3 88 2.6 ± 0.1 14 ± 22 93.9 2.2 ± 0.3 11 ± 6 93.3 2.3 ± 0.1 18 ± 43 92.5 2.5 ± 0.4 20 ± 6 86.3 2.5 ± 0.2 29 ± 124 93.1 2.4 ± 0.4 19 ± 14 100 2.4 ± 0.2 45 ± 195 53.6 2.7 ± 0.1 15 ± 8 72.5 2.9 ± 0.3 15 ± 36 84.4 2.3 ± 0.1 16 ± 3 76.3 2.3 ± 0.2 20 ± 47 49.7 2.6 ± 0.3 27 ± 7 74 2.5 ± 0.2 16 ± 48 50.3 2.5 ± 0.2 17 ± 2 76.3 2.4 ± 0.2 12 ± 29 60.7 2.9 ± 0.2 11 ± 2 75.6 2.6 ± 0.2 13 ± 210 61.1 2.8 ± 0.1 12 ± 8 39.7 2.5 ± 0.2 7 ± 211 86.2 2.4 ± 0.2 13 ± 3 78.4 2.3 ± 0.2 13 ± 212 62.9 2.9 ± 0.1 18 ± 2 89 2.6 ± 0.2 16 ± 413 55.1 2.5 ± 0.2 24 ± 4 63.6 2.4 ± 0.2 18 ± 814 79.6 2.5 ± 0.2 17 ± 2 85.6 2.2 ± 0.2 18 ± 515 51.3 3 ± 0.3 19 ± 8 69.8 2.7 ± 0.2 12 ± 216 71.5 2.7 ± 0.2 16 ± 2 75.7 2.3 ± 0.2 14 ± 217 70.2 2.4 ± 0.2 23 ± 8 50.3 2.7 ± 0.3 9 ± 318 72.3 2.6 ± 0.3 17 ± 6 71.3 2.4 ± 0.2 13 ± 219 67.1 2.6 ± 0.2 28 ± 12 50 2.2 ± 0.3 16 ± 420 68.3 2.3 ± 0.2 26 ± 4 72.8 2.3 ± 0.3 29 ± 1521 53.6 2.7 ± 0.2 19 ± 7 51.2 2.6 ± 0.2 9 ± 122 56.6 2.5 ± 0.2 41 ± 17 38.3 3 ± 0.3 25 ± 1423 44.4 2.9 ± 0.2 18 ± 5 68 2.6 ± 0.3 11 ± 224 65 2.7 ± 0.6 20 ± 3 84.2 2.4 ± 0.2 27 ± 525 72.3 2.5 ± 0.2 12 ± 6 54 2.7 ± 0.2 7 ± 126 32.1 2.8 ± 0.5 6 ± 3 62.5 2.3 ± 0.2 10 ± 127 64.7 2.5 ± 0.2 46 ± 14 32.2 1.9 ± 0.3 41 ± 2228 59.1 2.3 ± 0.2 17 ± 5 80.4 2.6 ± 0.3 20 ± 529 58.5 2.3 ± 0.4 11 ± 12 38.3 2.5 ± 0.3 9 ± 230 66.1 1.9 ± 0.4 8 ± 4 85.8 2.4 ± 0.2 18 ± 531 34.8 2.9 ± 0.8 4 ± 2 53.7 2.4 ± 0.2 7 ± 132 82.1 2.6 ± 0.3 14 ± 4 79.9 2.4 ± 0.3 11 ± 3Mean = 65.3% Mean = 18 Mean = 69.3% Mean = 17VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 321

improving performanceFigure 1. An example of an INR recordfrom practice management software. A MicrosoftOffice Excel spreadsheet could be produced easilywhich would allow the exercise to be reduced to asimple matter of data entry.AcknowledgmentsI would like toacknowledge the work ofmy son Kyle Wright whoperformed the statisticalanalysis for this study whilehe was an undergraduatestudent in mathematics.FundingNo funding was receivedfor this study.Conflict of interestNone declaredIndividual mean INRWith one patient showing a rise in mean INRand another a fall and the majority showingno change, it can be concluded that the changein method did not have a significant impact onmean INR.Lessons and messagesMachin suggests that a reasonable standard forgood control of warfarin therapy is an INRwithin the therapeutic range 60% of the time. 5The British guidelines for anticoagulation controlquote 50%. 6 It would appear that this standardcan be achieved in my practice either by using myad hoc approach (65.3%) or by my nurses usingthe ‘British Columbia Health Service’ standardisedprotocol (69.3%).This is a study with a small number of patientsin a single practice. Factors such as ethnic mix,educational status and socioeconomic status maylimit the ability for these results to be generalisedto other general practices in NZ.While it is likely that most doctors would followthe same general principles, the effectiveness ofan individual doctor’s ad hoc approach will beunknown unless the practice data is audited. Theraw data for a practice audit is easily obtainedThe switch in my practice away from the heavilydoctor-intensive ad hoc system to the entirelynurse-led system was motivated by a desire to improvepractice efficiency and free up doctor time.Our experience was that this was achieved. Thedoctor was liberated from any part in the process.The nurse’s time was used more efficiently by nolonger having to act as a liaison with the doctor.Patients were able to get their instructions morequickly and were able to discuss the adjustmentwith the nurse making the clinical decision.Nobody was more pleased by the change than ourreceptionist who no longer had to inform patients‘the doctor hasn’t had time to look at your resultsyet, can you phone back later?’. This improvedefficiency is likely to be even greater in a grouppractice where several doctors may be involved inthe warfarin adjustment process.Changing from one system to the other can bedone quickly and with a minimum of planning.While new anticoagulant drugs not requiringsuch rigorous monitoring are under trial elsewherein the world, it is likely that we in NZ arestill several years away from having a safe andeffective alternative to using warfarin.References1. Lafuente-Lafuente C, Mahe I, Extramiana F. Management ofatrial fibrillation. BMJ. 2010;340:40–45.2. New Zealand Guidelines Group. The management of peoplewith atrial fibrillation and flutter. 2005.3. Nair A, Hazell W, Sutton T, Pillai S. Antithrombotic therapy inatrial fibrillation: an assessment of compliance with guidelines.N Z Med J. 28 Jan 2005; 118(1208).4. Guidelines and Protocol Advisory Committee. Initiation andmonitoring of warfarin therapy. British Columbia Medical Association.2004;1–8.5. Machin SJ. Medico legal problems associated with oral anticoagulantservices. In: Fitzmaurice DA and Murray ET, editors.Oral anticoagulation management and stroke prevention:the primary care perspective. Newmarket: Hayward MedicalCommunications. 2002;50–57.6. Baglin T et al. Guidelines on oral anticoagulation. Br J Haematol.1998;101:374–387.322 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performanceInfluenza H1N1 2009 in Canterbury: a casestudy in pandemic response co-ordinationDaniel Williams BA, MBChB, Dip Obs, MPH, FNZCPHM; 1 Annabel Begg BMedSci, MBChB, MPH,FNZCPHM; 1 Kim Burgess MBChB, DPH; 2 Michele Hider BA, Cert Journalism APR; 1 Lance Jennings PhD,FRCPath; 1 Mary Martin-Smith BScN, MSc; 1 Paul McCormack MBChB, FRNZCGP; 3 Jon Mitchell BA, PGDip(Geography and Planning), Grad Dip (Emergency Management); 4 Alan Pithie; 1 Phil Schroeder MBChB, DipObs, FRNZCGP; 5 Anja Werno MD FRCPA 1AbstractBackground and context: Reviews of overseas pandemic responses have suggested thatstronger links between primary care and other parts of the health sector are required. The influenza A(H1N1) 2009 (‘H1N1 09’) pandemic was the first real test of New Zealand’s pandemic preparedness.Assessment of problem: In the six months from May to October 2009, there were 595 confirmedcases of H1N1 09 in Canterbury, with 187 hospitalisations and three deaths. This paper describes the waya range of Canterbury agencies worked together in a co-ordinated health-led response aimed at minimisingthe impact of H1N1 09 in the community and maintaining effective health care services for bothinfluenza and non-influenza patients.Strategies for improvement: Key strategies included sector-wide response co-ordination, intelligenceand communications, a combined public health/primary care response during the ‘containment’phase, and universal red/green streaming supported by dedicated ’flu centres and an 0800 call centreduring the ‘manage it’ phase.1Canterbury District HealthBoard, Christchurch,New Zealand2New Brighton Village HealthCare, Christchurch3Independent HealthConsultant, Christchurch4Canterbury Civil Defenceand Emergency ManagementGroup, Christchurch5Rolleston Medical Centre,ChristchurchLessons: Despite the considerable impact of the H1N1 09 virus in Canterbury, health care serviceswere not overwhelmed. The key lesson learned from the Canterbury H1N1 09 response has been theimportance of preparing and working together across the sector.Keywords: Influenza, human; pandemic; primary health care; public health; mass media; civil defenceBackgroundThere are important overlaps between the essentialfunctions of primary care and public health. 1Prior to 2009, Canadian and Australian reviewssuggested that stronger links between primarycare and other parts of the health sector, particularlypublic health, were required. 2,3Canterbury is New Zealand’s second largestgeographic region, with the second biggestpopulation (522 000 at the 2006 census).Canterbury agencies had a history of workingtogether on pandemic preparedness prior to2009, including responding to SARS (2003),avian influenza (2004), and two major nationalpandemic exercises in 2006 and 2007. An intersectoralpandemic planning group includingkey sector leaders continued to meet monthlyfollowing the 2007 exercise. All agencies werefamiliar with the National Pandemic ActionPlan 4 (see Text Box 1) and the Co-ordinatedIncident Management System (CIMS) 5 andhad their own response plans in place (seeText Box 2).Assessment of problemCanterbury’s H1N1 09 response was initiatedon 25 April. The ‘keep it out’ and ‘stamp it out’phases of the response lasted until 19 June, whenCorrespondence to:Daniel WilliamsClinical Director,Community and PublicHealth DivisionCanterbury District HealthBoard, P O Box 1475Christchurch 8140,New Zealanddaniel.williams@cdhb.govt.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 323

improving performanceFigure 1. Canterbury Pandemic CIMS structureREGIONAL CDEMCDHB INCIDENTCONTROLLERADVISORY GROUPCOMMUNICATIONSPLANNING /INTELLIGENCE(CPH)OPERATIONSLOGISTICSMANAGERWORKFORCECOMMUNITY &PUBLIC HEALTHSECONDARYPRIMARY1. Minimise transmission—‘flatten the curve’Text Box 1. Stages of the New Zealand influenza pandemicaction plan 20062. Minimise infection rate in primary health care workers3. Maintain safe, quality care within general practice and the rest of the health systemfor non-’flu patients1. Plan for it2. Keep it out (border management)3. Stamp it out (cluster control)4. Manage it5. Recover from itText Box 2. Aims of the Canterbury response4. Provide safe and accessible care for patients with ’fluit was clear that H1N1 09 was spreading extensivelyin Canterbury and a shift to ‘manage it’was announced, coinciding with the opening ofthe central city ’Flu Centre. 6From May to October 2009 there were 595 confirmedcases of pandemic influenza A (H1N1 09)in Canterbury, with 187 hospitalisations andthree deaths. Confirmed cases were only asmall minority of community cases. A randomtelephone survey of 600 households in Augustestimated that 25% of Canterbury residentshad developed an influenza-like illness in thepreceding 10 weeks, a finding consistent with asubsequent national serosurvey. 7The aim of this paper is to describe the strategiesdeveloped by range of Canterbury agenciesto work together in a co-ordinated health-ledresponse with the goal of minimising the impactof H1N1 09 in the community and maintainingeffective health care services for both influenzaand non-influenza patients.StrategiesResponse co-ordinationFrom 25 April, Canterbury District HealthBoard’s (CDHB’s) Chief Medical Officer assumedoverall leadership of the response andestablished a CIMS structure that included allmajor operations groups (see Figure 1). The responsegroup met daily throughout the response.Significant CDHB funding (up to $2.8 million)was approved to support proactive managementby the sector.324 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performanceThe Primary Care Coordination Room (PCCR),led by general practitioners and based at PegasusHealth—Christchurch’s largest IndependentPractitioner Organisation (IPA)—co-ordinatedpandemic activity for primary care throughoutCanterbury.Sector intelligenceThroughout the response CDHB’s public healthdivision, Community and Public Health (CPH),provided a regular web-based intelligence reportto the DHB responses in Canterbury, South Canterburyand the West Coast. The report includedinput from all local response agencies, as well asnational and international information. Accesswas available to all involved in the response, includinglinks from general practitioner intranets.CommunicationsConsistent community messages about infectioncontrol, isolation, and when and where to seekmedical advice were critical to managing patientnumbers. Canterbury’s pandemic communicationswere co-ordinated by the CDHB Communicationsteam. Key spokespeople included the ChiefMedical Officer, Medical Officers of Health andPrimary Care leaders. Prior involvement of localmedia in pandemic planning meant that most hada good understanding of the rationale for Canterbury’sH1N1 09 response, and media coveragewas largely supportive.CDHB’s influenza website www.fluinfo.org.nz wasupgraded, and between 28 April and 31 Augustthere were 21 185 site visits and 87 074 page views.Email updates, media releases and other backgroundinformation were disseminated to a widerange of community organisations. A public awarenesscampaign promoted a series of simple, brightlyillustrated messages (see Text Box 3) via a variety ofmedia, including bus shelter advertising, posters,newspaper advertising, and other print media.From 19 June to 21 August Canterbury peoplewere advised not to go to their general practitionerif they had ’flu-like symptoms but to call an0800 line which offered recorded information andthe option to speak to an operator for advice or a’Flu Centre appointment. Over two months theWhat gap this fillsWhat we already know: Influenza pandemics occur on average threetimes each century and cause significant morbidity and mortality. Reviews ofoverseas pandemic response structures have suggested that stronger linksbetween primary care and other parts of the health sector are required. Theinitial wave of the H1N1 09 pandemic was the first real test of New Zealand’spandemic preparedness.What this study adds: Canterbury’s H1N1 09 response showed thatsignificant reconfiguration of health care services, including universal red/green streaming, can be achieved if there is effective sector-wide planningand co-ordination.Text Box 3. Community messages• Stop the ’flu (accompanied all other messages)• Sick? Stay home• Cover coughs and sneezes• Wash hands• If you are worried about your ’flu symptoms call 0800 37 30 37• For more information visit www.fluinfo.org.nzFigure 2. Calls to 0800 lineline received 33 080 calls, with a daily maximumof 2183 calls and a daily late-morning peak (seeFigure 2). The call centre was managed by CDHBand staffed by a mix of contracted call centrestaff, CDHB staff, and primary care nurses.Logistics supportOnce the response was under way sector-wideprocurement became a logical extension of theVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 325

improving performanceFigure 3. ‘Flu Centre attendanceCDHB logistics role. CDHB also co-ordinatedsome sector-wide workforce requirements, includingprovision of clinical staff for the 0800 line.Border and cluster controlDuring the containment phase, CDHB’s CPH undertookborder and cluster control. Public healthnurses met all international flights arriving inChristchurch from 28 April to 3 July. While fewpassengers presented at the airport, subsequentpresentation of recent travellers to general practicewas more common, and a combined public health /primary care screening clinic was established toassess patients who met the suspect case definitioneither at the border or in the community.During this phase, public health staff also arrangedisolation of patients meeting the casedefinition. This included an arrangement witha Christchurch hotel to accommodate travellersnot able to be quarantined at home. Once acase was confirmed, their in-flight and domesticcontacts were traced, asked to remain in homequarantine, and provided with prophylacticOseltamivir (Tamiflu ® ). By 19 June, Oseltamivirhad been provided to over 780 cases and contactsin Canterbury.Aranui ClinicThe initial large cluster of cases in Christchurch’sSamoan community stretched resources. Inresponse to this, Christchurch’s first ’Flu Centrewas set up in Aranui, at the heart of the affectedcommunity. The centre saw 141 patients overthree days, and was primary care–led with strongsupport from CPH and local Samoan communityleaders. The clinic bridged the ‘stamp it out’ and‘manage it’ phases, and for the first time in theresponse, patient and contact management wasbased largely on clinical diagnosis, rather thanrelying on laboratory confirmation.Central city ’Flu CentreThe formal move to ‘manage it’ on 19 June wasmarked by the initiation of the 0800 line andthe opening of the central city ’Flu Centre. Asthe pandemic progressed, the severity of illnessin patients seen at the ’Flu Centre also increased,requiring additional staff resources and equipment.Staffing was initially a mix of primary andsecondary care doctors, nurses and administrationstaff, but clinical staffing drew more heavily fromprimary care as the pandemic progressed. Thededicated information system was populated withdemographic data from the primary care database.Patient volume and patient characteristics at the’Flu Centre were reported daily in the CDHB intelligencereport, and were an important indicatorof the progression of the pandemic and of overalldemand for services. The centre worked closelywith the Emergency Department, 24 Hour Surgeryand other after-hours clinics and saw 5092individual patients with a total of 6227 visitsbetween 19 June and 18 August (see Figure 3).Rural ’flu centresEight other ’flu centres were opened in ruralareas as demand required. These generally weresmall community cooperative ventures with localauthority support operating in close associationwith the local general practices. Between22 June and 11 August they saw 706 patients.Logistic support, communications, and sometimesappointment bookings for these rural centres occurredthrough the PCCR and 0800 line.Institutionalised and high risk patientsImmobile institutionalised patients and patientswith risk factors qualifying them for Osel-326 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performancetamivir but not sufficiently ill to visit the ’FluCentre were recognised as special groups. Systemswere set up so the patient’s usual GP couldeither visit using appropriate personal protectiveequipment, or use a comprehensive telephoneassessment and then arrange an Oseltamivirprescription.CDHB secondary carePandemic plans had anticipated an overloadingof hospital services. Red and green streams wereestablished for admission through the EmergencyDepartment and dedicated ’flu wards wereestablished. A staff ’flu clinic was established andprovided advice, post-exposure prophylaxis andprompt treatment of unwell staff. High risk patientsattending hospital outpatient departmentswere identified and offered prophylaxis.for secondary care patients, with a correspondingrestriction in use of testing in the community.Civil Defence EmergencyManagement / WelfareRegional communication and coordination oflocal authority Civil Defence and EmergencyManagement (CDEM) functions were providedby the Regional Emergency Management Office(EMO), consistent with the National PandemicAction Plan 4 and MCDEM Pandemic PlanningGuide. 8 A website was established for registrationof volunteers and arrangements were madefor volunteer efforts to be co-ordinated by localauthorities with primary care input.The Regional EMO’s Emergency ManagementSurvey provided information on the community’sDespite the considerable impact of the H1N1 09 virus inCanterbury, health care services were not overwhelmed. TheCanterbury H1N1 09 response was based on extensive planningand strong relationships formed well before the pandemicThese measures, the relatively mild nature ofmost cases of H1N1 09 and the diversion ofpatients with influenza-like illness (ILI) to the’Flu Centre meant that most hospital services, includingthe Emergency Department, continued tooperate relatively normally. The notable exceptionwas the Intensive Care Unit, which operated overcapacity for a significant period.LaboratoriesLaboratory services guided clinical and publichealth management of cases and contacts andinformed surveillance. CDHB’s CanterburyHealth Laboratories provided both a local and aregional service. Laboratory staff were closelyinvolved in the development and ongoing reviewof clinical testing guidelines, which were a keytool in management of demand for laboratoryservices. During the ‘manage it’ phase there wasan increasing focus on use of laboratory servicesexperience of both influenza-like illness andinterruption of access to resources. A second surveywas conducted by CPH, and rolling surveyswould have continued if required.Lessons and messagesDespite the considerable impact of the H1N1 09virus in Canterbury, health care services were notoverwhelmed. The Canterbury H1N1 09 responsewas based on extensive planning and strongrelationships formed well before the pandemic. Inparticular, monthly intersectoral pandemic planningmeetings had maintained engagement acrossthe sector, which in turn laid the foundations forrapid response activation and adaptation of existingplans in response to the particular characteristicsof the H1N1 09 pandemic.The CIMS was adopted by both the CDHBco-ordination team and a number of participat-VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 327

improving performanceing organisations, and was adapted to suit eachorganisation’s needs. It provided an effectiveframework for leadership, decision-making, communicationand allocation of workforce and otherresources, and a clear sense for all involved thatthis response was not ‘business as usual’.In contrast to some other jurisdictions, wherenational or state response structures had difficultyadapting to challenges such as rapidspread of infection or the generally less severethan expected nature of H1N1 illness, 2,3,9–11the Canterbury response was actively managedat a regional level, and the daily meetings ofall response leaders allowed timely review andconsultation, including involvement of front-linegeneral practitioners.The prompt establishment of the Aranui Clinic(within 48 hours of inception) and rapid con-Pandemic planning in primary care is both a riskmanagement and a pubic health matter whichrequires partnership between general practiceand public health. 12 The ‘keep it out’ and ‘stampit out’ responses, which lasted over six weeks,provided valuable time to prepare other componentsof the response, with early cases effectivelyisolated and contacts treated and quarantined.Laboratory identification of cases and timely provisionof results were vital, with negative resultsas important as positive results for the publichealth response. Existing arrangements withborder agencies and the hotel industry allowedsystems to be established with minimal delay.By the time a cluster of cases was identified inthe Christchurch Samoan community, centredon a recent traveller who had not sought medicalattention for ILI, containment was no longer possible.The Aranui Clinic was a prompt responseto the needs of this community as the overallThe prompt establishment of the Aranui Clinic (within 48 hours ofinception) and rapid conversion of an empty inner-city warehouseinto Christchurch’s first ’Flu Centre were striking examples of whatcould be achieved when agencies worked effectively togetherversion of an empty inner-city warehouse intoChristchurch’s first ’Flu Centre were strikingexamples of what could be achieved when agenciesworked effectively together.The attitudes of lead general practitioners have animportant effect on pandemic responses effectiveness.3 Canterbury had robust existing primarycare organisations and leadership, and the PrimaryCare Co-ordination Room was a centralcomponent of the response. It was supported byCDHB, but led by general practitioners. Sited atthe IPA, based on peer leadership and buildingon existing relationships, it was able to mobiliseand reconfigure primary care in an unprecedentedway, including persuading general practitioners ofthe value of reorganising practice routines so theycould contribute to the staffing of the red streamfunction at the ’Flu Centre.system transitioned to ‘manage it’, and again wasmade possible by existing relationships—in thiscase between local Samoan community leadersand primary care organisations.Reconfiguration of health care services would nothave been effective without significant changesin the way patients approached the system. Effectiveco-ordination of community communicationswas essential for public understanding of howto manage mild illness without medical attention,and how to access services by telephone ifrequired. While this occurred at national level inother countries, 13 Canterbury’s regional responsestructure allowed communications to be matchedto the situation as it evolved locally, with reviewof all communications by CDHB, CPH andprimary care. Overall low rates of workplaceabsenteeism and of primary care consultations328 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performancefor other illnesses during the pandemic suggestthat community infection control messagescontributed to reduced rates of not just influenza,but also other winter illnesses, and the CDEMsurvey demonstrated a high level of awarenessamong Canterbury people of what to do if theyor someone in their family developed ILI.A well co-ordinated response also requires wellinformedstaff. The web-based format of theCDHB intelligence report provided ready accessto key information about the pandemic andthe national and local response for all involvedand was the starting point for most planningmeetings and for regular fax and email updatesto primary and secondary care. It was complementedby the primary care pandemic website,providing detailed local advice to all primarycare providers.7. Institute of Environmental Science and Research Limited.Seroprevalence of the 2009 influenza A (H1N1) pandemic inNew Zealand: Wellington; 2010.8. Ministry of Civil Defence and Emergency Management. NZLocal Authority and CDEM Group Pandemic Planning Guide.Information for the CDEM Sector. Wellington; 2006.9. Grayson M, Johnson P. Australia’s influenza containmentplan and the swine flu epidemic in Victoria. Med J Aust.2009;191:150.10. Irving L, Hampson A. Influenza A (H1N1 09): Public healthlessons and questions. Aust Fam Physician. 2009;38:567.11. Eizenberg P. The general practice experience of the swine fluepidemic in Victoria—lessons from the front line. Med J Aust.2009;191:151–153.12. Nori A and Williams M. Pandemic preparedness: risk managementand infection control for all respiratory infectionoutbreaks. Aust Fam Physician. 2009;38:891–895.13. Hine D. The 2009 Influenza Pandemic: An IndependentReview of the UK Response to the 2009 Influenza Pandemic:London; 2010; Cabinet Office. http://www.cabinetoffice.gov.uk/media/416533/the2009influenzapandemic-review.pdf p1 of 19Although there was little demand for co-ordinatedwelfare services during this pandemic wave,a more severe event would require much greaterinvolvement of the welfare sector, including localauthorities, and while current plans do includewelfare, considerably more planning and resourcingcould be required.The most important message from the CanterburyH1N1 09 response has been the importanceof preparing and working together across thesector. The response has further strengthenedexisting relationships, and has enhanced Canterbury’scapacity to provide a co-ordinated responsenot only to future pandemics, but also to otherhealth system challenges.References1. Rowan MS, Hogg W and Huston P. Integrating public healthand primary care. Healthc Policy. 2007;3(1):1–22.2. National Advisory Committee on SARS and Public Health.Learning from SARS: Renewal of Public Health in Canada:Ottawa; 2003; Health Canada. http://www.phac-aspc.gc.ca/publicat/sars-sras/naylor/3. Sweet M. Pandemic lessons from Australia. Br Med J.2009;339:3317.4. Ministry of Health. New Zealand Influenza Pandemic ActionPlan 2006. Wellington; 2006.5. New Zealand Fire Service Commission. The New ZealandCoordinated Incident Management System (CIMS): teamworkin emergency management. Wellington; 1998.6. Jennings LC. Influenza A(H1N1)09: New Zealand’s response tothe pandemic threat. NZ Med J. 2009;122:1298; http://www.nzma.org.nz/journal/122-1298/3700/AcknowledgementsWe thank Peter Mitchelland Chris Ambrose, whoprovided data on serviceutilisation, Nigel Millar,who led the Canterburypandemic response, andthe many dedicated staffwho contributed to theresponse throughoutCanterbury.FundingNo specific funding wasreceived for this paper.Competing interestsNone declared.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 329

BACK TO BACKAll people over 75 years with a five-yearCVD risk of >15% should be treated withstatins unless specifically contraindicatedSue Wells MBChB,MPH(Hons), PhDSection of Epidemiologyand Biostatistics, Schoolof Population Health, TheUniversity of Auckland,Auckland, New ZealandYES‘I don’t think about my age. It’s only a number.’—James Biggs (104-year-old resident in a Dallasretirement community)This commentary addresses three questionsrelated to the health of older people:• What do we want to achieve?• How applicable are CVD risk prediction tools?• What is the evidence for statin benefitand harm?Wells S. All people over 75years with a five-year CVDrisk of >15% should be treatedwith statins unless specificallycontraindicated—the ‘yes’case. J Prim Health Care.2010;2(4):330–332.Short answerOlder men and women—the grandparents ofour society, are treasures. As a group, they are atthe highest risk of CVD and, if they survive anevent, it may have considerable impact on theirquality of life and independence. Observationalstudies show that older people with favourableCVD risk factor levels are more likely to have ahealthier end of life as well as less life spent livingwith disability. Systematic reviews of primaryprevention trials demonstrate that statins willreduce CVD event rates by about 20% within fiveyears in people over 65 years, with little risk ofserious side effects. There is no good evidencethat this will simply change their mode of death(i.e. to cancer). Therefore, if elderly patients arethought to have a healthy life expectancy of fiveyears or more, those meeting guideline criteriafor statins should be offered them.What do we want to achieve?Ideally we want to delay the onset of illness anddisability, reduce the impact of morbidity andsupport our older patients to retain independenceand quality of life (QoL) as long as possible. Theprobability of death is 100%; the manner of livingprior to our dying is more negotiable.Cardiovascular disease (CVD) is a leading causeof death and healthy life years lost in NewZealand. 1 While having a heart attack and dyingin your sleep may seem to be a good way to go,many people will not die in this manner. Theprevalence of having had (and survived) a CVDevent rises exponentially after retirement age inNew Zealand; 35% of 75-year-old women (45% ofmen) and 45% (50% of men) by the age of 80 yearswill have suffered an event. 2 The QoL for thosefollowing a myocardial infarction or stroke isBACK TO BACK this issue:Sue WellsDerelie ManginWhile 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 withhis or her own set of conditions, capabilities, beliefs, expectations and socialcircumstances. There are areas of uncertainty, ethics and aspects of care for whichthere is no one right answer. General practice is an art as well as a science. Qualityof care also lies with the nature of the clinical relationship, with communication andwith truly informed decision-making. The Back to Back section stimulatesdebate, with two professionals presenting their opposing views regarding a clinical,ethical or political issue.330 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BACK TO BACKvariable, with some left with profound disability.A significant proportion of people with coronaryheart disease progress to congestive heart failurewhere QoL, as measured by symptom burden,depression, and spiritual well-being, is akin tothat of people with advanced cancers. 3‘And in the end it’s not the years in your life thatcount. It’s the life in your years.’—Abraham LincolnProspective cohorts about late-life function andsurvival to 90 or 100 years, 4,5 show that CVDrisk factors mirror longevity. Furthermore, thosewith healthy behaviours and lower CVD riskfactors at age 70 years are likely to have betterlate-life physical function, mental well-being andlower incidence of chronic diseases. If they dodevelop a chronic disease, the onset is typicallythree to five years later. 5How applicable are CVDrisk prediction tools?CVD risk is typically presented as the predictedprobability of having a symptomatic CVD eventduring a subsequent time period and is derivedfrom cohort studies that estimate the combinedeffect of multiple risk factors on event rates. Ofall the risk factors, age is not surprisingly themost powerful predictor of a future CVD event,because age is a proxy for the amount of exposureto the combined known and unknown risk factors.CVD risk prediction tools used in New Zealandare based on the Framingham Heart Study whichonly investigated people between 30 and 74years of age. A recent study has questioned thevalidity of the Framingham equation for thoseover 85 years, but the cohort was very small (250participants) and the authors conclude that theirfindings require validation in a separate cohort. 6As the accuracy of CVD risk prediction over 75years is not well studied, New Zealand guidelinesrecommend risk assessing a person over 75years as if they were 75 years. This will delivera conservative estimate of their five-year CVDprognosis, so if older patients are estimated tohave a CVD risk over 15% in five years they willalmost certainly have been correctly classified asbeing at high absolute risk.Erratum—Clarification about citation of Back to Back debates.It has been brought to my attention that both authors may be includedin a joint citation, for example ‘Marks R, Potter JD. New Zealand shouldhave mandatory fortification of bread with folic acid. J Prim Health Care.2010;2:74–8.’ This is confusing because it appears as though the authorarguing against a moot actually supports it. All Back to Back articles shouldtherefore be cited separately, as in:Marks R. New Zealand should have mandatory fortification of bread withfolic acid—the ‘yes’ case. J Prim Health Care. 2010;2:74–5.Potter JD. New Zealand should have mandatory fortification of bread withfolic acid—the ‘no’ case. J Prim Health Care. 2010;2:76–8.—The EditorThe greater the short-term absolute CVD risk,the greater the short-term benefit of interventionsthat lower risk factors. Hence most CVDguidelines recommend management to be basedon short-term absolute risk. While lifestyleadvice on a healthy heart diet, smoking cessationand physical activity are key recommendations forall, our current guidelines recommend commencingstatin therapy for those estimated to be >15%five-year CVD risk.What is the evidence forstatin benefit vs harm?The Cholesterol Treatment Trialists’ Collaborationwas an enormous meta-analysis of 90 056individuals who participated in randomised trialsof statin treatment. 7 They demonstrated a 12%proportional reduction in all-cause mortality permmol/L reduction in LDL cholesterol. Benefitsfrom treatment were significant within the firstyear of treatment and increased in subsequentyears. After five years of follow-up, they demonstrateda 21% decrease in any major vascularevent (including 23% reduced risk of heartattacks and 17% reduced risk of stroke). Thismeta-analysis included five trials that includedparticipants over 75 years. They found that therewas nothing magic about age that makes drugswork differently—the proportional reductionswere about the same.In terms of major harms, rhabdomyolysis wasexceedingly rare 9/39 884 patients (0.023%) onVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 331

BACK TO BACKstatins and 6/39 817 control patients (0.015%). 7Combining multiple trials found no consistentevidence that statins increased overall cancerrisk, or at any particular site, for any particularage group or by duration of treatment. 7 All-causemortality was reduced 7 allaying fears suggestedby a single trial re-analysis. 8Given that so many older patients alreadyhave CVD, it is also important to examinethe effect of statins in secondary prevention.A meta-analysis of nine secondary preventiontrials with almost 20 000 patients aged 65–82years reported a 22% reduction in all causemortality within five years of starting statins.Just under 30 patients required treatment toprevent one death. 9risk assessed in routine general practice. Justover one-third of these elderly have had a CVDevent, just under one-third are at high estimatedrisk (>15% five-year CVD risk) and theremaining third are at moderate or low estimatedrisk for whom lifestyle advice, not drugs,is recommended.In conclusion, people over 75 years with a fiveyearCVD risk of >15% and a healthy life expectancyof five years can substantially reduce theirrisk of CVD and all cause mortality by takingstatins and should all be offered this opportunityunless specifically contraindicated.‘The idea is to die young, as late as possible.’—Ashley MontaguA significant proportion of people with coronaryheart disease progress to congestive heart failurewhere QoL, as measured by symptom burden,depression, and spiritual well-being, is akin tothat of people with advanced cancersSome practical considerationsThere will always be a need to balance quality oflife and comorbidities (e.g. dementia, disability ormajor physical illnesses such as cancer, renal failureand COPD) along with exploring preventivecare possibilities. Adding a statin will contributeto polypharmacy. Therefore this needs to be partof the discussion. Life expectancy is also pertinent.If a man has survived to 75, 80 or 85 years,Statistics New Zealand estimate they will onaverage have a further 11, eight and six years—long enough to reap the full benefits of five yearsof statin treatment. Women fare slightly better(add a couple of extra years).Contrary to many beliefs, prescribing statinsto those over 15% CVD risk, will not resultin prescribing for all the over 75s. The NewZealand PREDICT cohort currently has about10 000 people over 75 years who have beenReferences1. World Health Organization. Global burden of disease. Deathand DALY estimates for 2004 by cause for WHO memberstates. Geneva: World Health Organization; 2009.2. Chan WC, Wright C, Riddell T, Wells S, Kerr AJ, Gala G,et al. Ethnic and socioeconomic disparities in the prevalenceof cardiovascular disease in New Zealand. N Z Med J.2008;121(1285):11–20.3. Bekelman DB, Rumsfeld JS, Havranek EP, Yamashita TE, HuttE, Gottlieb SH, et al. Symptom burden, depression, and spiritualwell-being: a comparison of heart failure and advancedcancer patients. J Gen Int Med. 2009;24(5):592–8.4. Terry DF, Sebastiani P, Andersen SL, Perls TT. Disentanglingthe roles of disability and morbidity in survival to exceptionalold age. Arch Int Med. 2008;168(3):277–83.5. Yates LB, Djousse L, Kurth T, Buring JE, Gaziano JM.Exceptional longevity in men: modifiable factors associatedwith survival and function to age 90 years. Arch Int Med.2008;168(3):284–90.6. de Ruijter W, Westendorp RGJ, Assendelft WJJ, den ElzenWPJ, de Craen AJM, le Cessie S, et al. Use of Framingham riskscore and new biomarkers to predict cardiovascular mortalityin older people: population based observational cohort study.BMJ. 2009;338:a3083.7. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G,Pollicino C, et al. Efficacy and safety of cholesterol-loweringtreatment: prospective meta-analysis of data from 90,056participants in 14 randomised trials of statins. Lancet.2005;366(9493):1267–78.8. Packard CJ, Ford I, Robertson M, Shepherd J, Blauw GJ,Murphy MB, et al. Plasma lipoproteins and apolipoproteinsas predictors of cardiovascular risk and treatment benefit inthe PROspective Study of Pravastatin in the Elderly at Risk(PROSPER). Circulation. 2005;112(20):3058–65.9. Afilalo J, Duque G, Steele R, Jukema JW, de Craen AJM, EisenbergMJ. Statins for secondary prevention in elderly patients:a hierarchical bayesian meta-analysis. J Am Coll Cardiol.2008;51(1):37–45.332 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BACK TO BACKAll people over 75 years with a five-yearCVD risk of >15% should be treated withstatins unless specifically contraindicatedNOKey points• Cardiovascular risk estimates for youngerpeople do not work to predict outcomesin the same way for those over 75.• Statins do not work for primary prevention inpeople in this age bracket. Including secondaryprevention data indicates that they may simplyshift the cause of death and morbidity ratherthan improving the length of life or morbidity.• There is significant potential harmin indiscriminate prescribing.Suggesting all over–75-year-olds should be treatedwith statins is surely a John McEnroe ‘You cannotbe serious’ statement. There are a number of reasonswhy this idea is nonsense: In this age group,the absolute risk approach doesn’t work, the drugsdon’t work and there is potential for adding to theburden of morbidity rather than relieving it.Risk in older populationsIt is dangerous to infer benefit based on researchin younger populations. Risk tables cannot beapplied in the same way to older populations andthere is good evidence that cardiovascular riskoperates differently in older individuals. A studyusing the Framingham model has demonstratedthat in people over 85 years who had not developedcardiovascular disease, the classic risk factorsincluded in a Framingham risk score did not predictthose at high risk of cardiovascular mortalityin the way it does in younger populations. 1Estimates of absolute risk enable assessment ofpotential benefits of particular treatments inyounger populations. However, this approach isnot a good model in older age when the likelihoodof morbidity due to multiple and compoundingdiseases is increased. The absolute riskof dying of any one or more of these diseasesor in fact something completely different isincreased simply because the time of death isproportionately closer. This magnifies the apparenteffect of a single intervention for a specificcondition, despite overall survival being onlyminimally affected.This notwithstanding, preventive treatmentmight still be justified in terms of postponementof morbidity, even when there is nochange in mortality. The use of statins forprevention of cardiovascular disease in the elderlyprovides a case study for examining theseissues further.Evidence for lipid-loweringagents in older ageSo how effective are these drugs in the elderly?There is no evidence that giving statins to all patients>15% risk of CVD improves either quantityor quality of life in this age group—i.e. mortalityand morbidity are unaffected.There is only one large randomised controlledtrial, carried out in over 5000 70–82-year-olds,that highlights the effect of statins in primaryprevention in this age group.The data in this study revealed no demonstrablebenefit for pravastatin in primary prevention inthis group (Figure 1). A number of studies andanalyses have been produced (often sponsored bypharmaceutical companies), obscuring this lackof benefit over 75 by including those 65–75 yearsin the group of ‘older’ patients. Further obfusca-Derelie Mangin MBChBDPH, Department ofPublic Health andGeneral Practice,Christchurch Schoolof Medicine, Universityof Otago, Christchurch,New ZealandMangin D. All people over 75years with a five-year CVDrisk of >15% should be treatedwith statins unless specificallycontraindicated—the ‘no’case. J Prim Health Care.2010;2(4):333–335.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 333

BACK TO BACKFigure 1. Effect of statin treatment: primary prevention 2Figure 2. Primary and secondary outcomes in the PROSPER trial. 2Figure 3. Overall outcomes in the PROSPER trial. 3benefit using the primary composite endpoint ofcoronary heart disease death or non-fatal myocardialinfarction (absolute risk reduction 2.1%,numbers needed to treat 48). This is shown inFigure 2. 2This looks more promising in terms of effectiveness.However, it is helpful to consider these datain the context of the patients we see in generalpractice—overall mortality and morbidity. Despitea change in these cardiovascular compositeoutcomes, there is no change in all-cause mortality:hazard ratio (HR) 0.97 (95% CI 0.83–1.14).In contrast, rates of cancer diagnosis and deathwere increased in the treatment group comparedwith placebo. 2 The HR for cancer death was 1.28(0.97–1.68) and the HR for cancer diagnosis 1.25(1.04–1.51), with an absolute risk increase of 1.7%and numbers needed to harm of 59 (Figure 3). Sooverall there was no change in time to point ofdeath or in morbidity. If the data from morbidityand mortality were combined in the same way asfor the CVD outcomes it is likely that this effectwould be more marked.The increase in new cancer diagnoses countersany arguments of compression of morbidity. Preventingone cause of death and morbidity simplyreveals another.The clinical contextIf a patient asks a medical practitioner for helpwith symptoms or disease from which they aresuffering, the doctor does the best they can and arenot responsible for defects in medical knowledge.There are extra ethical responsibilities around bothscreening for disease and subsequently giving preventivetreatments—whether it is colorectal canceror measuring cholesterol or blood pressure. If thepractitioner initiates procedures and treatments fora disease from which a patient is not suffering theyare in a very different situation and a much greaterlevel of certainty is required.tion occurs by conflating primary and secondaryprevention by including patients with establishedcardiovascular disease.This paper then combined data for primary andsecondary prevention, which showed a modestThe evidence for statins in this age group doesnot support this level of certainty. Enthusiasticextrapolation is not enough. The half-life of scientific‘truth’ is often short in medicine. The latterpoint is reinforced by the recent evidence onaspirin for primary prevention—it now appears334 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BACK TO BACKthere is no net benefit for aspirin use in primaryprevention of cardiovascular disease. The overenthusiasmfor the efficacy of statins in primaryprevention has become even clearer (in all agegroups) following a very recent meta-analysis ofstatins for primary prevention in patients at anyage at high risk of cardiovascular disease whichshows no effect on all-cause mortality. 4HarmsThere are potential harms in indiscriminate prescribing.There are the obvious direct harms ofthe drug, and reports of musculoskeletal, cognitiveand affective side effects have clear implicationsfor quality of life in an older person—useof statins increases the odds of musculoskeletalcomplaints 1.5-fold in primary care patients. 5The second problem is the potential for polypharmacyand drug interactions that this indiscriminateapproach to medicine use carries. Polypharmacyis as much if not more of a threat to healthin older age as chronic disease. 6,7References1. de Ruijter W, Westendorp RGJ, Assendelft WJJ, et al. Useof Framingham risk score and new biomarkers to predictcardiovascular mortality in older people: populationbased observational cohort study. BMJ. 2009 January 13,2009;338(jan08_2):a3083–.2. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderlyindividuals at risk of vascular disease (PROSPER): a randomisedcontrolled trial. The Lancet. 2002;360(9346):1623–30.3. Mangin D, Sweeney K, Heath I. Preventive health care inelderly people needs rethinking. BMJ. 2007 August 11,20 07;335(7614):285–7.4. Ray KK, Seshasai SRK, Erqou S, et al. Statins and all-causemortality in high-risk primary prevention: a meta-analysis of11 randomized controlled trials involving 65 229 participants.Arch Intern Med. 2010 June 28;170(12):1024–31.5. Mosshammer D, Lorenz G, Meznaric S, Schwarz J, Muche R,Morike K. Statin use and its association with musculoskeletalsymptoms—a cross-sectional study in primary care settings.Fam Pract. 2009 April 1, 2009;26(2):88–95.6. Frazier S. Health outcomes and polypharmacy in elderly individuals:an integrated literature review. J Gerontol Nurs. 2005Sep;31(9):4–11.7. Trygstad TK, Christensen D, Garmise J, Sullivan R, WegnerS. Pharmacist response to alerts generated from medicaidpharmacy claims in a long-term care setting: results from theNorth Carolina Polypharmacy Initiative. J Manag Care Pharm.2005 Sep;11(7):575–83.Assessing the value of medicines for preventionin old age should consider duration of life extension,length of treatment, and take into accountmortality and morbidity due to all causes as wellas the harms attributable to treatment. Using thismodel, some preventive interventions will provideoverall benefits in older populations. Others,statins included, will not.This shows the clear danger in taking fragmentsof information—looking at partial, statisticallives of populations and applying them to thecomplex life of an individual. An older patientwho has elected to ‘reduce the risk of heart attack’may make a different decision when told‘you will not extend the duration of your life andyou will increase your risk of being diagnosedwith, and dying of, cancer’ The balance of riskshas a much broader scope than the adverse effectsof single drugs.The key contraindication to the use of statinsover 75 is the lack of evidence that life will beeither better or longer. Individuals over age 75who are still only ‘at risk’ have probably won thecholesterol race.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 335

continuing professional developmentpearlscochrane cornerString of PEARLSPractical Evidence About Real Life Situationsabout eczema and asthmaPEARLS are succinct summaries of Cochrane Systematic Reviewsfor primary care practitioners—developed by Prof. Brian McAvoyfor the Cochrane Primary Care Field (www.cochraneprimarycare.org), New Zealand Branch of the Australasian Cochrane Centre at theDepartment of General Practice and Primary Health Care, Universityof Auckland (www.auckland.ac.nz/uoa), funded by the New ZealandGuidelines Group (www.nzgg.org.nz) and published in NZ Doctor(www.nzdoctor.co.nz.).Topical pimecrolimus is less effective for treatingeczema than moderate and potent corticosteroidsand tacrolimusThere is no clear evidence of benefit for antimicrobialinterventions in atopic eczemaProbiotics are not effective for eczemaRegular inhaled corticosteroids reduces exerciseinducedasthmaHouse dust mite control measures do not reduceasthma symptomsHomemade spacers are effective in deliveringbronchodilator therapy to children with asthmaCulture-specific programmes for minority groups withasthma improve some outcomesDisclaimer: PEARLS are for educational use only and are not meantto guide clinical activity, nor are they a clinical guideline.Spironolactone (when allelse fails) in hypertensionBruce Arroll MBChB, PhD, FRNZCGP; Professor of General Practiceand Primary Health Care, The University of Auckland, PB 92019,Auckland, New Zealand; Email: b.arroll@auckland.ac.nzThe problem: Your patient is on four antihypertensives andtheir blood pressure is still 180/120.Clinical bottom line: Spironolactone has a place in hypertension,but as a last option before referral to secondary care(assuming underlying causes have been ruled out). I personallyhave found it much better than doxasosin in lowering bloodpressure in those who are really difficult to manage. It is not adrug that patients like and is associated with gastrointestinalsymptoms (sometimes serious), 1 gynecomastia in men and hyperkalemiaand death. 2 The Cochrane review found in a meta-analysisof five crossover studies a reduction in SBP of 20.09 mmHg(95%CI:16.58–23.06, p

continuing professional developmentcharms & harmsFeverfewBachelor’s buttons, Featherfew (Tanacetum parthenium L. akaChrysanthemum parthenium L. aka Pyrethrum parthenium L.)Felicity Goodyear-Smith MBChB, MGP, FRNZCGP; Professor, Department of General Practice and PrimaryHealth Care, School of Population Health, The University of Auckland, Auckland, New ZealandPreparations: Feverfew is native to southeasternEurope. It is a short perennial with small,daisy-like yellow flowers which give off a strong,bitter odour. The dried leaves and sometimesflowers and stems are used to make supplements,including capsules, tablets, and liquid extracts.Active constituents: Parthenolide andtanetin are the suspected active ingredients.Preparations may be standardised to contain0.2–0.4% parthenolides. Laboratory evidenceindicates that feverfew causes vasodilation andreduces inflammation. Feverfew’s constituentsinhibit phagocytosis, platelet aggregation, andsecretion of inflammatory mediators (arachidonicacid and serotonin).Main uses: The main contemporary uses forfeverfew are for migraine headaches and rheumatoidarthritis. It has been used as a herbal remedyfor centuries for fevers, headaches, stomachaches, toothaches, insect bites, infertility, andproblems with menstruation and with labourduring childbirth.Evidence for efficacy: There is insufficientevidence from five randomised, double-blindtrials to suggest an effect of feverfew over andabove placebo for preventing migraine. There isno evidence from one randomised, double-blindtrial to suggest an effect of feverfew over andabove placebo for treating rheumatoid arthritis.Adverse effects: 5–15% of users developaphthous ulcers and/or gastrointestinal tractSummary MessageThere is insufficient evidence to support the use of feverfew for preventionof migraine headaches or for treatment of rheumatoid arthritis. Feverfew cancause mouth ulcers and gastrointestinal upsets and occasional allergic reactions.Health professionals should be aware of the possibility of (undisclosed)use of feverfew in patients on aspirin or warfarin. As with all herbal medicines,different feverfew products vary in their pharmaceutical quality, andthe implications of this for efficacy and safety should be considered.irritation. It also may increase the tendency tobleed. Allergic reactions to feverfew can occur.People who are allergic to other members of thedaisy family (including ragweed and chrysanthemums)are more likely to be allergic to feverfew.People taking regular feverfew may experience awithdrawal syndrome characterised by reboundheadache, anxiety, fatigue, muscle stiffness, andjoint pain and are advised to stop the preparationslowly. Historically feverfew has been used to inducemenstrual bleeding and it should be avoidedin pregnancy.Drug interactions: Possible interactionswith warfarin and aspirin.Key referencesPittler MH, Ernst E. Feverfew for preventing migraine. CochraneDatabase of Systematic Reviews. 1, 2009.Pattrick M, Heptinstall S, Doherty M. Feverfew in rheumatoidarthritis: a double blind, placebo controlled study. Ann RheumDis. 1989 Jul;48(7):547–9.Little CV, Parsons T. Herbal therapy for treating rheumatoid arthritis.Cochrane Database of Systematic Reviews. 1, 2009.Hobbs C. Feverfew: a review. HerbalGram. 1989;20:2636.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 wellknownherbal medicines.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 337

viewpointPrimary health care funding for childrenunder six years of age in New Zealand:why is this so hard?Nicholas Fancourt BMedSc(Hons), MBChB, MBHL; 1 Nikki Turner MBChB, FRNZCGP, MPH; 2 M Innes AsherBSc, MBChB, FRACP; 3 Tony Dowell MBChB, FRNZCGP 41Counties Manukau DistrictHealth Board, Auckland,New Zealand2Department of GeneralPractice and Primary Care,Faculty of Medical and HealthSciences, The University ofAuckland, Auckland,New Zealand3Department of Paediatrics:Child and Youth Health,Faculty of Medical and HealthSciences, The University ofAuckland4Department of PrimaryHealth Care and GeneralPractice, University of Otago,Wellington, New ZealandABSTRACTThe intention of this viewpoint article is to prompt discussion and debate about primary health care fundingfor children under the age of six. While New Zealand offers a superb natural environment for childhood,our child health outcomes continue to be poor, ranking lowest amongst 29 countries in a recent reportby the Organisation for Economic Co-operation and Development. Since 1996, various funding arrangementshave been introduced with the goal of achieving free primary health care for children under six yearsof age and nearly 80% of practices now offer care to this group without charge. Universal no cost or verylow cost access for young children, however, remains elusive, particularly for after-hours care, and this isimportant given that at least one in five children lives in poverty.We are under no illusions about the complexity of primary care funding mechanisms and the challengesof supporting financially-sustainable systems of after-hours care. Good health care early in life, however,is a significant factor in producing a healthier and more productive adult population and improving accessto primary care lessens the impact of childhood illness.We suggest that reducing cost barriers to primary care access for young children should remain animportant target, and recent examples show that further reductions in cost for primary care visits foryoung children, including after-hours, is possible. Further funding is needed to make this widespread,in conjunction with innovative arrangements between funding authorities, primary care providers, andemergency departments. We encourage further debate on this topic with a view to resolving the questionof whether the goal of free child health care for young children in New Zealand can be realised.Correspondence to:Nikki TurnerP O Box 17360Greenlane, Auckland1061, New Zealandn.turner@auckland.ac.nzIntroductionDespite a superb natural environment for childhood,New Zealand has a disappointing record inchild health compared to many other developedcountries. In a recent report of 29 member countriesof the Organisation for Economic Co-operationand Development (OECD), New Zealandranked lowest for health and safety indicatorsof child well-being, and was noted to spend lessthan half as much on children under six as for12–17-year-olds. 1Access to care is recognised as an important elementin promoting child health and reducing disparitiesin health. 2,3 In New Zealand, two foundationdocuments on primary care 4,5 highlight theimportance of access, and the potential for costto be a barrier to access. Since the introduction ofthe ‘Free Child Health Care Scheme’ (FCHCS) in1996, significant success has been achieved in reducingcost barriers to primary care for childrenunder six years of age. Despite excellent use ofthis and subsequent funding packages, the goalof universal free care remains unmet, particularlyfor after-hours care, and may be contributing topoor child health statistics in New Zealand.This article aims to review attempts at, and challengesto, removing financial barriers to primarycare for children under the age of six. We wishto open and progress debate amongst practitioners338 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

viewpointabout why achieving low or no cost funding forchildren under six years of age in New Zealandshould be so hard.BackgroundThe FCHCS is popularly assumed by the communityto be a policy that ensures all childrenunder the age of six receive free health care. 6 Yetit was never designed to guarantee free access toprimary care: at its initiation, the scheme offeredan increased subsidy of $32.50 per consultationfor children under six, but successive governmentshave not wished to remove professionalrights to charge co-payment.Although the FCHCS provided a significantinvestment in children’s health care, it offeredno commitment to ongoing funding for increasedoperational costs or inflation, and contained twopieces of incomplete policy detail. The first areaof uncertainty was the level of co-payment thatpractices might be expected to add, both at thetime and into the future. The second relativepolicy vacuum concerned the funding of afterhourscare. Today the FCHCS remains part ofa complex system of primary care funding andpatient co-payments.Further initiatives have been made to maintainlow or zero fees for the under-sixes. The ‘VeryLow Cost Access Scheme’ was introduced in2006 to support, encourage and reward PrimaryHealth Organisations (PHOs) to deliver low costprimary care. To be eligible for this scheme,practices had to commit (amongst other measures)to free consultations for the under-sixes.In 2007 the Government announced the ‘ZeroFees For Under Sixes’ package, which providedadditional funding totalling $8.25m for practicesthat ‘commit to providing free care to the undersixes’. 6 Alongside annual adjustment of capitationby the Government, this brought total fundingto $45.70 per notional visit.Despite these initiatives, the goal of establishinguniversal free care for children under the age ofsix has not been achieved. In 2007, 61% of practiceshad no charge for children under six duringwork hours, with a national average of $5 copaymentper consultation. 6 By 2010, 78% of practiceswere providing free care to the under-sixes(personal communication, Ministry of Health).A Ministry of Health report on after-hours feespresented to Cabinet in October 2007 stated that‘the problem of after hours fees is more widespreadthan previously thought’ and identified119 locations where after-hours consultations forchildren under the age of six cost $16 or more (20of which charged over $41). 7The importance of primarycare for childrenEarly childhood is a crucial period for developmentand well-being. A healthy start to life cannot only reduce later morbidity, but also produceindividuals who are more able to participatein society. 8,9 Primary care directly influenceschildren’s health from provisions of services suchThe goal of universal free care remainsunmet, particularly for after-hours care, andmay be contributing to poor child healthstatistics in New Zealandas the immunisation schedule and Well Childchecks, through to assessment and managementof acute and chronic illness. Primary care also hasan acknowledged role in reducing differences inchild health outcomes between different groupsin the population. 10Current figures indicate that the health status ofNew Zealand’s children is poor by internationalstandards, 1,11 the disparities between ethnicgroups and by socioeconomic status are large, 12and some preventable diseases have increased inprevalence since the early 1990s, correlated with amarked rise in child poverty. 13 For example, ratesof rheumatic fever have failed to decrease sincethe 1980s; they remain some of the highest reportedin a developed country and have increasedamong Maori and Pacific children over the last 10years, 14 while hospital admissions for serious skininfections doubled between 1990 and 2006. 12VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 339

viewpointThe impact of many childhood illnesses isreduced with early intervention, using bothprevention and treatment that is available at theprimary care level, with access to primary carebeing pivotal to improving health outcomes. 15,16,17An all-ages analysis of New Zealand hospitaldischarge data from 1989 to 1998 suggested thatone in three hospital admissions was potentiallyavoidable, 18 and a 2010 report from the PublicHealth Advisory Committee recommended implementingfree primary health care at all hoursfor children under six years. 19Despite the overall international evidence supportingthe role of primary care in improvinghealth outcomes 20 there has been little study ofthe effectiveness of current primary care arrangementson child health outcomes in New Zealandapart from the example of immunisation. 21Some information is available from the initialevaluation of the FCHCS conducted for the thenHealth Funding Authority in 1997, one year afterthe scheme’s introduction. 22 Despite the shorttime frame of the study, Sue Dovey and colleagues23 concluded that, after the introductionof the FCHCS, free care was widely available,especially in working hours, and more childrenconsulted with a general practitioner. There waslittle information about which families benefitedmost or any health benefits gained, although theauthors highlighted a reduction in hospital admissionsfor respiratory illnesses. Qualitative analysisof comments made by general practitioners suggesteddoctors were generally supportive, noting‘better follow-up, less pressure to prescribe andthe ability to deal with problems earlier’.Cost as a barrier to care for childrenThere is significant evidence that lower socioeconomicstatus poorly affects health outcomes,including children. 8,24,25 Where cost is a barrier, afamily may delay seeking appropriate and timelycare, thereby potentially letting the child’s illnessworsen. For people with financial difficulties, adelay in seeking care is common. 26 The Ministryof Health identified ‘high fees’ as $15 or more forchildren aged 0–5 years. 7 But even $15 is likelyto represent a barrier for those on the lowestincomes where earnings are insufficient to coverall essentials, and choices must be made betweenpaying for food, clothing, housing, educationalcosts, transport, and so on.According to the Ministry of Social Development,child poverty rates are generally worst foryounger children and remain higher than in the1980s, 27 with 19% of New Zealand children livingin serious hardship in 2008. 28 Previous harsheconomic times have led to increases in povertyand socioeconomic differentials in health. 29 Therecent recessionary environment is likely to be nodifferent. 30,31 Those children living in significantpoverty are three times more likely to be sickthan those from higher income families. 24After-hours—the forgotten careWhile significant attempts have been made bycentral government to reduce fees for primarycare for children during work hours, no suchprogrammes have been funded for after-hourscare. Funding arrangements for after-hours aredelegated to individual District Health Boards(DHBs) who have taken a varying degree of responsibilityfor these. Some initiatives have beenundertaken by individual PHOs.The roughly 75% of each week that is outside thestandard working hours of 8am to 5pm can be animportant time for access to care for children fortwo reasons. Firstly, many childhood illnessestypically deteriorate during the course of anevening. Respiratory diseases such as asthma andcroup, for example, have a natural pattern of deterioratingnocturnal symptoms. Many other illnessesare unpredictable and may not necessarilycause concern only during working hours, or mayarise at the weekend. Secondly, after-hours canrepresent a sole time for access to care for families,especially those living in poverty. Limitedaccess to transport or parental work constraintscan mean that families are not able to seek medicalcare for their children until after-hours.Why is this so hard? The beginningof a debate to find solutionsThe funding of general practice and primary carein New Zealand is complex and opinions are diverseand firmly held as to the merits of different340 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

viewpointfunding options. However, significant progresshas been made; the various funding packages supportmany thousands of New Zealand families,and practitioners and practices involved seemsatisfied with the arrangements.Some, though limited, progress has been madewith after-hours care. For example, an AucklandPHO in 2004 created free access at all hours forchildren under six. 32 A Whangarei PHO droppedafter-hours fees to $5 in 2009. 33 These examplesdemonstrate that further change is possible andwe suggest that universal zero fees for undersixes24 hours a day seven days a week is an idealthat should be debated. However, it is importantthat this discussion is not confused with the meritsor otherwise of the general debate regardingco-payment as a means of maintaining previousand current agreements between the governmentand professions over primary care funding. Wesuggest that the needs of children under six, asa vulnerable group with no active voice of theirown, are best served by a system that effectivelyremoves financial barriers to access.How might a zero/very low cost–feesystem work?Firstly, funding solutions need to be universallyapplicable so that potential tensions do not arise betweendifferent practices and between regular daywork and after-hours. Previously suggested solutionshave foundered because they do not take intoaccount the economic reality of practice funding.Given the uptake of the various under-sixesfunding arrangements, it is clear that practicesin high income areas and in comparable parts ofthe same city are able to participate in the schemewithout apparent financial penalty. It is importantthat both those who are participating andthose who are not debate the rationale for theirdecision and include both financial and ethicaldimensions to their views.Finding a solution is particularly important withafter-hours funding. Some after-hours servicesare running with minimal, if any, financialviability while others may be able to make asignificant income. Experiences such as thoseat the Whangarei and Auckland PHOs showthat solutions are possible, and it is importantthat these experiences are shared and developed.Additional funding will be necessary to securefree out-of-hours services and DHBs and PHOsshould all work to identify the sums of moneyrequired. The costs may not be as significant asfeared: for example, an estimate from a mediumsized North Island DHB indicates nearly$100,000 would be required per annum to secureGP-led after-hours provision for a population ofaround 13 000 children (personal communication).However, in other areas, particularly thosewith low throughput, the financial viability ofGP-based after-hours, especially overnight, islikely to be unrealistic. These areas may requiredifferent creative solutions, such as working moreclosely with emergency departments or transportoptions to bigger hubs.Contracting arrangements will need to be trustworthyand realistic, which has not always beenthe case in primary care funding. In this area theequivalent of a higher salaries commission mightdevelop an agreed formula for after-hours funding.It is also important that appropriate local arrangementsare developed with emergency departments.Despite indications of pressure on thesedepartments, there is a dearth of informationabout the proportion of current presentations thatmight appropriately be managed in primary careinstead. There is also a need for constructive jointprogrammes to both educate the public and agreeon referral patterns between emergency departmentsand after-hours providers. We suggestfurther modelling of different funding and workloadpatterns at different geographically-basedsites to explore this.ConclusionsNew Zealand has a long-established movementtowards providing free health care to the undersixes.Yet complete implementation of this goalremains elusive. Further information must besought alongside any changes in access arrangements.Continuing evaluation of the aim of fundingarrangements should be incorporated in theconsensus about the role of general practice andprimary care in child health. It is important thatrealistic expectations are debated around healthVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 341

viewpointoutcomes such as recurrent illness, immunisationrates and hospital admissions. Further research tounravel the interactions between cost, socioeconomicdeprivation, and access to primary care inthis age group is needed, but developing a morecomprehensive approach to primary care fundingshould not wait.Appropriate access to primary care is pivotalto the health and well-being of New Zealand’schildren, and to their future. There are manypossible solutions to enhancing access, and theyall involve agreement and constructive debate betweenexisting primary care providers, emergencydepartments, after-hours providers, and fundingauthorities. Several funding models from healthauthorities might be possible, varying for eachcommunity, but imminent action is needed toestablish programmes that enable increased andconsistent access for children at all hours.We ask that this viewpoint article provide a focusfor debate of an issue that, while complex andchallenging, is not impossible to resolve; NewZealand children are waiting for our answer.References1. OECD. Doing better for children. Paris: OECD; 2009.2. Forrest CB, Simpson L, Clancy C. Child health services research:challenges and opportunities. JAMA. 1997;277:1787–1793.3. Andrulis DP. Access to care is the centerpiece in the eliminationof socioeconomic disparities in health. Ann Intern Med.1998;129:412–416.4. Ministry of Health. The primary health care strategy. Wellington:Ministry of Health; 2001.5. After Hours Primary Health Care Working Party. Towardsaccessible, effective and resilient after hours primary healthcare services: report of the After Hours Primary Health CareWorking Party. Wellington: Ministry of Health; 2005.6. Hodgson P. More support for free doc visits for under-6s. [Internet]Wellington: Beehive 2007 Aug 27 [cited 26 May 2010]Available from: http://www.beehive.govt.nz/node/304317. Ministry of Health. After hours service coverage and highfees: report to the Minister of Health. 18 October 2007.8. Marmot M. Fair society healthy lives: strategic review ofhealth inequalities in England post-2010. London: The MarmotReview; 2010.9. Hertzman C, Siddiqi A, Hertzman A, et al. Tackling inequality:get them while they’re young. BMJ. 2010;340:346–348.10. National Health Committee. Improving health for NewZealanders by investing in primary health care. Wellington:National Health Committee; 2000.11. UNICEF. Child poverty in perspective: an overview of childwell-being in rich countries (Innocenti Report Card 7). Florence:UNICEF Innocenti Research Centre; 2007.12. Craig E, Jackson C, Han DY, NZCYES Steering Committee.Monitoring the health of New Zealand children and youngpeople: indicator handbook. Auckland: Paediatric Society ofNew Zealand, New Zealand Child and Youth EpidemiologyService; 2007.13. Turner N, Asher I. Health perspectives on child poverty. In: StJohn S, Wynd D, editors. Left behind: how social and incomeinequalities damage New Zealand children. Auckland: ChildPoverty Action Group; 2007:73–90.14. Jaine R, Baker M, Venugopal K. Epidemiology of acuterheumatic fever in New Zealand 1996–2005. J Paediatr ChildHealth. 2008;44:564–71.15. Casanova C, Starfield B. Hospitalizations of children and accessto primary care: a cross-national comparison. Int J HealthServ. 1995;25(2):283–94.16. Veugelers P, Yip A. Socioeconomic disparities in health careuse: Does universal coverage reduce inequalities in health? JEpidemiol Community Health. 2003;57(6):424–28.17. Parker JD, Schoendorf KC. Variation in hospital discharges forambulatory care-sensitive conditions among children. Pediatrics.2000;106(4):942–48.18. Jackson G, Tobias M. Potentially avoidable hospitalisationsin New Zealand 1989–98. Aust NZ J Public Health.2001;25(3):212–21.19. Public Health Advisory Committee. The best start in life:achieving effective child health and wellbeing. Wellington:Ministry of Health; 2010.20. Starfield B, Shi L, Macinko J. Contribution of primary care tohealth systems and health. Milbank Q. 2005;83(3):457–502.21. Grant C, Turner N, York D, Goodyear-Smith F, Petousis-HarrisH. Factors associated with immunisation coverage and timelinessin New Zealand. Br J Gen Pract. 2010;60:180–86.22. Dovey S, Tilyard M. Evaluation of the free child health carescheme: a report to the Health Funding Authority. Dunedin:University of Otago; 1998.23. Dovey S, Morton L, Tilyard M. What is happening to primaryhealth care access for young children: Evaluation of the freechild health care scheme. Childrenz Issues. 1999;3(2):18–22.24. Case A, Fertig A, Paxson C. The lasting impact of childhoodhealth and circumstance. J Health Econ. 2005;25(2):365–89.25. Easton B, Ballantyne S. The economic and health status ofhouseholds. Wellington School of Medicine; 2002.26. Barnett JR. Coping with the costs of primary care?: Householdand locational variations in the survival strategies of the urbanpoor. Health and Place. 2001;7:141–57.27. Perry B. Household incomes in New Zealand: trends in indicatorsof inequality and hardship 1982 to 2008. Wellington:Ministry of Social Development; 2009.28. Perry B. Non-income measures of material wellbeing and hardship:first results from the 2008 New Zealand Living StandardsSurvey, with international comparisons. Wellington: Ministryof Social Development; 2009.29. Barnett R, Barnett P. Primary health care in New Zealand:problems and policy approaches. Soc Policy J NZ.2004;21:49–66.30. Blakely T, McLeod M. Will the financial crisis get under ourskin and affect our health? Learning from the past to predictthe future. NZ Med J. 2009;122:1307.31. Johnson A. A road to recovery: a state of the nation reportfrom the Salvation Army. Manukau City: Salvation Army; 2010.32. King A. Launch new Tamaki Healthcare PHO–White Crossafter hours service. [Internet] Wellington: Beehive 2004 Dec2 [cited 26 May 2010] Available from: http://www.beehive.govt.nz/speech/launch+new+tamaki+healthcare+phowhite+cross+after+hours+service33. Manaia PHO. Whitecross—Whangarei will only charge $5to children under 6yrs after hours and weekends. [Internet]Whangarei: Manaia PHO 2009 Sept 8 [cited 26 May 2010]Available from: http://www.manaiapho.co.nz/node/236342 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ETHICSObesity, autonomy and the harm principleMonique Jonas PhDAutonomy and its limitsThe value of patient autonomy and the respectdue to it is by now well recognised in health care.This recognition is visible in requirements toobtain valid consent for treatment and to acceptand respect the health-regarding decisions thatpatients reach. It is visible in efforts to enablepatients to manage their own health and to makeinformation about health and disease readilyavailable. Of course, we all know that autonomywith respect to health status or outcomes ispatchy: there are many factors that affect healthwhich are, in practical terms, beyond the controlof either patients or their physicians. Perhaps thatmakes the sphere of control that does exist all themore important. Where health-affecting decisionscan be made, for the most part, (competent)patients ought to be the ones to make them.Autonomy is limited practically and it is alsolimited in a moral sense. The requirement torespect autonomy ends where harm to othersbegins: we are not obliged to enable some toact in ways which compromise the interests ofothers. This idea is encapsulated in John StuartMill’s harm principle and has gained widespreadendorsement. 1 In a standard case, the applicationof the principle is clear: I am not obligedto stand by and watch one man attack another.In such a case, intervention is justified, perhapseven obligatory, even if the attack has all thehallmarks of autonomous action. I do not wrongthe violent man by interrupting his attack, ashis rights to act autonomously do not extend toharmful activity.Applying the harm principle is not always sucha walk in the park, however. In some cases itmight not be clear whether harm has in factoccurred: it can be difficult to judge whetheran action makes someone worse off than theyotherwise would have been. Decisions aboutchild rearing can have this quality: it may beunclear whether, for instance, a custody decisionhas harmed a child, because the outcomes associatedwith alternatives are uncertain. Part of thedifficulty here is establishing what the relevantbaseline is for identifying harm. 2In other cases, an action may have harmful consequenceswithout it being clear whether these consequenceswarrant intervention, or what kind ofintervention might be appropriate. Mill specifiedthat actions that merely cause offence to others donot warrant intervention, but others may disagree,or consider that some types of offence shouldbe prevented, but not others. In some situationsquestions may arise about the severity, rather thanthe type, of harm. An appropriate response to verymild harms might be to point them out to the ‘perpetrator’,rather than to intervene to prevent them.In other cases, it might not be clear who therelevant ‘perpetrator’ actually is. In situations involvingnumerous people, all of whom contributein some way to the outcome, establishing whosecontributions are harmful is no easy feat.The ethics column explores issues around practising ethically in primary health care and aims toencourage thoughtfulness about ethical dilemmas that we may face.THIS ISSUE: Monique Jonas, ethicist with the School of Population Health at The University ofAuckland, explores ethical considerations around the debate over whether public funding of treatmentssuch as bariatric surgery for obesity essentially harms others by unfairly laying claim to shared resources.Correspondence to:Monique JonasLecturer in Ethics, HealthSystems, School ofPopulation Health, TheUniversity of Auckland,Auckland, New Zealandm.jonas@auckland.ac.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 343

ethicsEthical principles that everyone agrees apply, butdisagrees about how, are worrying things indeed.They can generate serious ethical disputes. Itseems to me that the harm principle falls intothis category. It appears to support a number ofconflicting claims about specific issues, dependingupon the way in which it is unpacked and applied.One debate that suffers in this way is that overthe funding of treatment for health conditionsthat are in some way attributable to the choicesthat patients make. A good example of this, andone that has attracted quite a lot of attentionrecently, relates to the funding of treatmentssuch as bariatric surgery for obesity. Some peopleobject violently to the public funding of suchprocedures, suggesting that recipients are es-Opposing claims often appear to proceed onthe basis of importantly different assumptionsabout how to identify and measure harm; howto respond to different kinds of harm, andwhere to locate responsibility for harmsentially doing harm to other citizens, by unfairlylaying claim to shared resources. 3 Others focus onthe ways in which many obese people appear tobe harmed by policies and facts about our societythat increase the risk of developing obesity. 4Strong claims are lodged about the legitimacy ofclaims upon the public purse and all sorts of proclamationsof wrong doing and moral responsibilityare hurled about. Opposing claims often appearto proceed on the basis of importantly differentassumptions about how to identify and measureharm; how to respond to different kinds of harm,and where to locate responsibility for harm.The dispute is likely to rumble along unproductivelyuntil key claims supporting opposingpositions are presented and exposed to carefulconsideration. To that end, it is worth trying toidentify and analyse the moral claims that supportthe many positions relating to publicly-fundedobesity-related treatment. This involves somedegree of inference and speculation, as people arenot always very clear about the moral foundationsof their position, and consistency and loyalty tounderlying claims are sometimes absent in publicdebate. But as a tentative first step I’ll outlinewhat I take to be a plausible account of the claimsthat people draw upon in opposition to publiclyfundedtreatment of obesity, and offer a fewcomments about them.An argument against publicfunding of treatment for obesityClaim 1: Competent adults have a responsibility tominimise their claims to limited public resources,such as those available for health care.In a publicly-funded system in which scarcity exists,the claims that one person makes can impactupon what is available for others. Given this,it might be thought that we have an obligationto use only what we ‘need’ and to ensure thatwe do not act in ways that are likely to increasethe amount of health resources that we need (orat least, that we do not act in these ways whenwe are able to avoid action without incurringsignificant costs). To fail to do this would be towrong and to harm fellow citizens, by taking foroneself what one had no right to, to the potentialdetriment of others.Claim 2: Obesity is a recognised and predictablesource of elevated claims upon public resources,because it increases the risk of developingserious health conditions such as diabetes.Claim 3: Claim 2 is widely recognised.Claim 4: Obesity can be avoided throughregulation of energy intake and output.Claim 5: Claim 4 is widely recognised.Claim 6: People should regulate theirenergy intake in this way, not only as amatter of expedience, but also as a matterof moral obligation, related to Claim 1.Conclusion: Given claims 1–6, treatment forobesity should not be publicly funded.344 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ethicsCritiqueIf this account of the argument against publicfunding of treatments for obesity such as bariatricsurgery is accurate, it exposes a number ofpoints that warrant further investigation.Claim 1 makes a substantive normative claimabout the general duties of citizens. It is rathera plausible claim to make, tapping into easilyaccepted ideas about fair shares, and the moralimportance of being attentive to the effect ofone’s actions upon others. The idea is that claimsto common resources that arise from genuineand unavoidable need are legitimate, and do notwrong or harm others, whilst claims that are notso based are illegitimate, and harm others byreducing available public funds without legitimatecause.One aspect of this claim that requires clarificationrelates to baselines for harm. In what senseare those in need of health care harmed by theclaims of others? The intuitive response would beto say that the claims of one, P, reduce the fundsavailable to satisfy the claims of another, Q. Ifthat means that a lower standard of care is availableto Q, perhaps Q is harmed by P.But we wouldn’t normally think that patientsharm each other by drawing on public resources.The resources are there for all who need them,and it is in the nature of communal resources thatcompromises in individual claims are sometimesrequired. The entitlement of Q is not reducedby P, since P was never entitled to more than areasonable share, given competing demands.But this does not fully diffuse Claim 1. Thepoint it advances is that there is a differencebetween legitimate claims (those which could notreasonably be minimised) and illegitimate claims(those which the patient has in some way allowedto arise). Legitimate claims do not harm others,because they do not reduce entitlements, butillegitimate claims do: they wrongfully lay claimto resources that could otherwise have been usedto satisfy truly unavoidable health needs.The idea that we ought to minimise our claimson public resources has intuitive appeal. Butif we consider the vast range of activities thatwe consider permissible, and even valuable insociety, the idea that there is an absolute dutyto minimise claims to public resources loses itslustre. Surely we are not required to refrain fromabsolutely every activity that might elevate claimsto public resources, since many of the activitiesthat we value—having children, playing contactsports, entering certain professions (the fire service;the military; and perhaps medicine)—harbourpalpable health-related risks.To rescue Claim 1 from the perils of implausibility,it is necessary to find some way to distinguishbetween worthwhile activity of the kind that isto be fostered by society and activity that doesnot justify the associated risks. Perhaps it shouldbe rephrased as follows:‘Claim 1: Competent adults have a responsibilityto minimise their claims to limited publicresources whilst pursuing worthwhile life goals.’This rephrasing exposes its inevitably judgementalnature. To argue against funding treatment forobesity on the basis of Claim 1, one has to showthat the actions and choices that lead to obesityare not compatible with the pursuit of worthwhilelife goals. That may not be as easy as itseems. The reasons that people become obese maybe much more value-laden than one might gatherfrom some commentators. Eating is a source ofenormous personal, social and cultural importand can solidify and confirm a sense of personaland group identity. 5–9 In some cases, particularrituals and routines around food may be risky.One can object to the risk, and call for it to bereduced, without claiming that becoming obeseis in contravention of a responsibility of the sortexpressed in Claim 1.Claims 2–5 take an empirical form and thus standor fall according to the evidence. But even if itcould be demonstrated that the vast majority ofadults do recognise the health risks attached toobesity, these claims might remain problematic.Obesity often has its roots in childhood and,once obesity is established, it is very difficult tobanish through conventional means like dietingand increased physical activity. 10–12 Althoughadults may well be expected to know that obesityVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 345

ethicsentails health risks, children will not necessarilyknow this, and messages of this kind may be confusingor difficult to interpret for children whosedomestic and social experiences deliver conflictingfood-related messages. Should adults be heldresponsible for failures to rid themselves offood-related attitudes and behaviours entrenchedin childhood?Claim 6 ties up the preceding claims with a normativebow, telling us that not only is successfulregulation of weight possible, it is also morallyrequired. In ethics, it is very often claimed that‘ought implies can’; that is, that one can onlybe obliged to do what it is possible to do. Theargument as cast above asserts that it is possiblefor individuals to avoid obesity through attentiveregulation of energy intake and output. Clearly,at one level, this is true, but this account glazesover many of the forces that act upon individualsin ways which load the bases in favour of, oragainst, successful regulation of energy consumptionand expenditure.There is by now a great deal of evidence to suggestthat obesity is not just a problem that societyfaces, but also a problem that society causes. 4The availability, pricing, and marketing of food,along with a slew of other factors (obeso-genicenvironments, changes in the nature of activitiesundertaken for work and recreation, geneticand familial predisposers; transport trends andimportant socioeconomic factors) combine forcesin a way that encourages, or even produces, obesity.13,14 Some people are more exposed to thesefactors than others, or are less able to avoid theirobesity-inducing effects. This means that obesityand the health problems associated with it occurunevenly across the population, in many casesconsolidating and extending pre-existing healthand other social inequalities.Whilst it may be possible for most people toavoid obesity, some face many more obstaclesto achieving this than others, many of whichare not the result of personal choices. If weas a society accept certain social arrangementsthat increase the difficulty of avoiding obesity,it would seem unfair to then deny accessto treatment for obesity on the basis that theobese have been morally irresponsible. In fact, itmay be that the obese have a harm-based claimagainst society, or some parts of it, for the harmto which obeso-genic policies and arrangementshave exposed them.These comments reveal the difficulty, in the contextof obesity at least, in establishing with certaintyprecisely what harms have occurred, whois responsible for them and what the appropriateresponse to them might be. If responsibility forharm is potentially disparate, it would be undulyharsh to distribute the full force of responsibilityto identifiable individuals.That is essentially what would happen if obeseindividuals were denied access to publicly-fundedtreatments like bariatric surgery on the groundsthat to provide access would be to facilitate harmto others. The harms involved in obesity and theobligations that they produce are too debatable,and responsibility for the production of harm istoo diffuse, to warrant refusal of public funding,at least on the grounds set out here.References1. Mill JS. On liberty. London: Penguin; 1974.2. Garrard E, Wilkinson S. Selecting disability and the welfare ofthe child. The Monist. 2006;89(4):482–504.3. Coddington D. Funding stapling is a kick in the guts for taxpayers.New Zealand Herald On Sunday. 2010 Feb 14.4. Swinburn BA. Obesity prevention: The role of policies, lawsand regulations. Aust New Zealand Health Policy. 2008;5(12).5. Christakis NA, Fowler JH. The spread of obesity in a large socialnetwork over 32 years. N Engl J Med. 2007;357:370–379.6. Mulvaney-Day N, Womack CA. Obesity, identity and community:leveraging social networks for behavior change in publichealth. Public Health Ethics. 2009;2(3):250–260.7. Epiphaniou E, Ogden J. Successful weight loss maintenanceand a shift in identity. J Health Psychol. 2010:10.8. Moore S, Daniel M, Pacquet C, Dube L, Gauvin L. Associationof individual network social capital with individual adiposity,overweight and obesity. J Public Health 2009;31(1):175–183.9. Mokhtar N, Elati J, Chabir R, et al. Diet culture and obesity inNorthern Africa. J Nutr. 2001;131(Supplement):887s–892s.10. Ebbeling CB, Pawlak D, Ludwig DS. Childhood obesity: publichealth crisis, common sense cure. Lancet. 2002;302:473–482.11. Kaufman L, Karpati A. Understanding the sociocultural rootsof childhood obesity: food practices among Latino families ofBushwick, Brooklyn. Soc Sci Med. 2007;64:2177–2188.12. Gibson LY, Byrne SM, Davis EA, Blair E, Jacoby P, Zubrick SR.The role of family and maternal factors in childhood obesity.Med J Aust. 2007;186(591–595):591.13. Butland B, Jebb S, Kopelman P, et al. Foresight. Tackling obesities:future choices—project report. 2nd ed. London (UK):Government Office for Science; 2007.14. Sobal J, Stunkard AJ. Socioeconomic status and obesity: areview of the literature. Psychol Bull. 1989;105(2):260–275.346 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

LETTERS TO THE EDITORSustaining chlamydia screening is difficultread with interest the article on increasing opportunisticI chlamydia screening in general practice. 1 Having heard theauthors present this same research at the New Zealand SexualHealth conference in Dunedin in 2009, we undertook toreplicate their intervention in our practice in 2009–10. Weaudited six months of screening for chlamydia in 15–25-yearoldpatients and then introduced a number of measures toattempt to increase screening rates. These included a discussionof the Wellington research, a staff update session on chlamydia,an alert on all files of 15–25-year-old patients , ordering alarge supply of patient information leaflets on chlamydia, andstocking each consulting room with chlamydia packs (maleand female swabs, urine containers and patient informationleaflets). The free sexual health consultation for under 25 yearswas available to be used to fund visits if patients had chlamydiatesting or treatment.We ran the intervention for three months, and thought wewould be able to outperform the original study by increasingand sustaining higher rates of chlamydia screening—but wewere wrong! Although our incentives for chlamydia screeningwere smaller than in the Wellington study (we awarded achocolate fish each month to the clinician who performed themost tests) we were able to substantially increase our screeningrates for the period of the intervention, particularly for males(see table). We also had a marked increase in chlamydia detection,finding eight times as many cases per month during theintervention. However a repeat audit post-intervention showedour rates had dropped back to that of the baseline period, asthey did in the Wellington study.It is interesting to reflect on the barriers to achieving highchlamydia screening rates in general practice. We have awell-informed and highly motivated team who demonstrateda useful clinical outcome (increased detection) by increasingour screening rates. In spite of this we have been unable tomaintain vigilance. Why is this?Table: Percentage of consultations with 15–25-year-old patients wherechlamydia test doneFemaleMaleInitial audit period 8.3% 2.9%During intervention 18.8% 18.9%Post-intervention 9.7% 1.3%Part of the effect may be due to the fact that we achievedquite high coverage rates during the intervention, so therewere fewer patients attending who had not been offered testing.Making time for screening is also important—introducinga whole new topic into an unrelated consultation is oftenavoided when we are busy. Probably the most significantbarrier, however, is the difficulty of introducing a sensitivesubject (sex), when the patient has come about another problemaltogether. This is particularly difficult in the context of afamily general practice, where many of our adolescent patientshave been known to us since birth, and are usually accompaniedby their parents.We would be interested to hear from practices who havefound ways of overcoming these barriers and are maintaininggood opportunistic screening rates.Dr Susie LawlessAmity Health Centre, DunedinReferences1. Lawton B, Rose S, Elley C, Bromhead C, McDonald J, Baker M. Increasing theuptake of opportunistic chlamydia screening: a pilot study in general practice. JPrim Health Care. 2010;2(3):199–207.Letters may respond to published papers, briefly report original research or case reports, or raise matters of interest relevant toprimary 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.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 347

BOOK REVIEWSIntroduction to Obstetrics and Gynaecology—3rd editionCynthia Farquhar and Helen RobertsReviewed by Jon Wilcox, general practitioner, Glenfield, AucklandThis updated third edition is a 200-page handbook designed largelyas an undergraduate manual formedical and midwifery students and alsofor medical graduates doing their diplomasin obstetrics and medical gynaecology.The second edition came out some13 years ago and clearly medical sciencein O&G does change rapidly enough todemand the occasional update.Important current topics which havebeen highlighted in this edition includeprenatal screening, advances in preimplantationgenetic diagnosis, contraception,cervical screening technology,sexual health and newer surgicaltechniques.It is an introductory textbook and, assuch, would probably not have enoughdetail to be a big seller for general practitionersunless considering pursuing adiploma course. As might be expected,there is not much reference data andnone of the synoptic text is specificallyreferenced.There are good, albeit brief, updated sectionson foetal, pregnancy and synergisticendocrinology, a good update on earlypregnancy loss and the important reclassificationinto non-viable and viable loss, agood selection of schematically value-addedultrasound images, a comprehensivesection on the utilisation of ultrasound(earmarked to be the next exciting primarycare technology), prenatal screeningto include the application of NT and maternalserum screening protocols, severalchapters on normal pregnancy, labourand the puerperium, neonatal care, theabnormal pregnancy (preterm labour andmedical disorders of pregnancy), antepartumand postpartum bleeding, multiplepregnancy, obstetric interventions andan up-to-date section on infertility.The gynaecology section includes chapterson contraception, therapeutic abortion(medical and surgical), menstrualdisorders, modern cervical screening andgynaecological neoplasia management,painful gynaecological disorders, gynaecologicalinfections and STIs. There is ahelpful small section on sexual difficultiesand also prolapse and incontinencesurgery and a short four-page chapter onthe menopause.While this handbook should not replacea good and perhaps appropriately morecomprehensive text on obstetrics, gynaecologyand women’s health, at wellunder $100 I feel it should be a veryuseful addition to the general practice library,albeit mainly perhaps for nursingstaff, medical students and maybe forthe expected influx of new GP registrarsover the next few years.Publisher: The University of AucklandDate of publication: 2010No. of pages: 236Health Care and the LawEditor: Rebecca KeenanReviewed by John Kennelly, Senior Lecturer, Department of General Practice and Primary Health Care, The University of Auckland, AucklandHealth Care and the Law is writtenfor health practitioners, riskmanagers, lawyers, educators andstudents. As a reference text, and withselective reading of this text, a healthpractitioner will gain insight into NewZealand health law. The book aims togive an overview of a wide range ofmedicolegal topics. It is inevitable thatthe book is compared to Medical Law inNew Zealand (Brookers; 2006), a similarbook but with a greater academic focusand a narrower range of legal topics.Health care law (synonymous with medicallaw) as a field of law has been variouslydescribed as a ‘…an established andthriving academic discipline’ and ‘a disjointedset of statutes and doctrines, designedmainly with nonmedical cases inmind’, so the book is a welcome additionto an expanding repertoire for a field oflaw seeking coherence. Health Care andthe Law has a wide mix of legal topicsincluding the legal system, regulation,rights, consent, information, medicines,contracts and employment, workers compensationand injury, coronial inquiries,public health and ethics. The book couldnot be said to suffer from the weaknessof a 1958 health law text, described as an‘ungainly mixture of law and morals’. Itis, however, an analysis of the mixture348 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BOOK REVIEWSof law and morals that is likely to appealto medical practitioners.The book’s breadth is its strength. Itcomplements the book Medical Law inNew Zealand with its more detailedacademic discussion of traditional healthcare law topics.Giving breadth to a specialist text riskssacrificing meaning for simplicity. Forexample, it is a Herculean challenge toexplain legal philosophical topics such asHohfeldian rights in a page-long sectioncalled ‘what is a right’. Hohfeld wasnever clear on the meaning of a right andhe never intended to describe ‘four distinctkinds of rights’ when he presentedhis ‘fundamental legal conceptions’.Hohfeld’s contribution to legal discoursewas significant, but for most readers adiscussion about the meaning of a healthcare or human right, while challenging,is of greater interest to a health carepractitioner than is Hohfeld’s analysis.International law is dealt with briefly.The author of that chapter states thatan international human rights treatyis not ‘enforceable’. International legalinstruments are difficult to enforce butmost would accept that there is a processwhereby international legal rules becomeintegrated into enforceable domestic law,and therefore become enforceable.The book could be criticised on the basisthat the editors do not ‘offer any generalizations,any theory or philosophy of[their] own in regard to the total subject.There is not a single page of synthesis inthe book’. This criticism was levelled atthe 1958 text mentioned above.The book is worthy of purchase for themanager and the postgraduate studentstudying for professional exams with theadvice that the topics presented in thisbook are a starting point for further study.References to quotations are with thereviewer.Publisher: Brookers, WellingtonDate of publication: 2010No. of pages: 569A Bitter Pill: How the Medical System is Failing the Elderlyby John SloanReviewed by Bruce Arroll, Professor, Department of General Practice and Primary Health Care, The University of Auckland, AucklandIcame across this book as a resultof listening to a podcast from theTherapeutics Education Collaborationin Canada (http://therapeuticseducation.org/). Dr John Sloan was interviewed byJames McCormack (a clinical pharmacist)and Mike Allen (an academic familyphysician from Alberta) on the fragileelderly. It was a fascinating series ofprogrammes. The podcasts are usuallyevidence-based but it was clear from DrSloan that the fragile elderly are never includedin randomised trials so it is an evidence-freezone. In the place of evidence,Dr Sloan provided large amounts of adviceand experience which made sense. Heapproaches every patient as a new entityand is always doing informal ‘singlepatient trials’. You can never predict theresponse of a fragile elderly patient to anytreatment. In the book he highlights thefact that we often feel better about startingmedication than stopping it, which isin some ways irrational. Most people don’tbenefit from most medication (numbersneeded to treat are usually greater thantwo and frequently greater than 30 meaning29 people don’t benefit) while all canget harmed by medication.The book and the podcast gave me acompletely new view on prescribing. I cansee that in future the skill of prescribingwill be working out what to stop and howand when in patients as they get increasinglyfragile. Dr Sloan is very frank abouthis successes and his failures and that isvery refreshing. We all learn from thesuccesses and failures of our colleagues. Itis a ‘dangerous’ occupation that we are inand, although we spend most of our timetrying to avoid harm, it inevitably occurs.There are some wonderful tips in thebook, such as the focus for the fragileelderly is comfort and function and thatwe should forget prevention of most diseasesas that is not the priority. Another isthat keeping someone at home when theyare sick is not abandonment (even if theymay die). Sending a fragile elderly personto an acute hospital can be abandonmentand we need to have informed discussionwith family members. My own experienceof sending such people to hospitalis that they end up in an acute ward, bedbound,and rapidly become less able to goback home and then end up in a rest home.They also acquire hospital infectionswhich complicates their care. Dr Sloandescribes acute hospitals as the ‘antithesisof dying’ which is often what is happeningto the fragile elderly. Knowing whoto talk with in the family is a key skillin dealing with this group of patients.Overall, this is a must read for all GPs.It is easy to read and provides a greatdeal of wisdom.Publisher: Greystone Books, D&MPublishers Vancouver/Toronto/BerkeleyDate of publication: 2009No. of pages: 256VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 349

RESEARCH GEMSGems of New ZealandPrimary Health Care ResearchAll you need to know aboutcongestive heart failureThis paper provides an overview of thediagnosis and management of congestiveheart failure (CHF) in primary care.It highlights the distinction betweensystolic (low ejection fraction CHF) anddiastolic (preserved ejection fractionCHF) and valvular causes which requiresan echocardiogram. This is essential asthe management is quite clear for systolicdysfunction requiring maximal ACEinhibitors (e.g. cilazapril 5 mg daily)and maximal beta blockers (metoprolol190 mg daily or carvedilol 25 mg twicedaily). If that does not work then spironolactone25 mg per day and/or digoxin arepossibilities. There is little evidence forthe management of diastolic dysfunction.Arroll B, Doughty R, Andersen V.Investigation and management of congestiveheart failure. BMJ. 2010;341:c3657Corresponding author: Bruce ArrollEmail: b.arroll@auckland.ac.nzTargeting CVD modifiable riskfactors in Pacific people mayredress health inequalitiesPREDICT is a web-based clinical decisionsupport programme for assessingand managing cardiovascular disease(CVD) risk in primary care. Over70 000 risk assessments were undertakenbetween 2002 and 2009. Pacificpatients tended to be risk-assessed fouryears younger than Europeans. Amongthose who were assessed, Pacific menwere 1.5 times as likely to smoke asEuropeans. Pacific patients were alsothree times as likely to have diabetes andhad significantly higher diastolic bloodpressures and higher CVD risk thanEuropeans. Targeting these modifiablerisk factors may help redress some ofthe health disparities between Pacificpeoples and Europeans.Grey C, Wells S, Riddell T, Kerr A, GentlesD, Pylypchuk R, Marshall R, Ameratunga S,Drury P, Elley CR, Kyle C, Exeter D, Jackson R.A comparative analysis of the cardiovasculardisease risk factor profiles of Pacific peoplesand Europeans living in New Zealandassessed in routine primary care: PREDICTCVD-11”. N Z Med J. 2010;123: 62–75.Corresponding author: Corina GreyEmail: c.grey@auckland.ac.nzLearning to fit in on the surgical wardThis is an observational study of 4thyear medical students in their first yearof clinical training who were observeddoing their surgical attachment. Communitiesof clinical practice are groupsof health professionals who cometogether with the specific and commonpurpose of patient care and the studentsjoin these transient communities as participantswho are both peripheral and legitimate.In these groups students learnand internalise the normative professionalvalues and behaviours they witnessand experience within the disciplinaryblock of the medical school and teachinghospital and through their participationlearn how to ‘be one of us’.Jaye C, Egan T, Smith-Han K. Communities ofclinical practice and normalising technologiesof self: learning to fit in on the surgical ward.Anthropology & Medicine. 2010;17(1):59–73.Corresponding author: Chrystal JayeEmail: chrystal.jaye@otago.ac.nzThe impact of point of carelaboratory testingThis study looked at the impact ofintroducing point of care (POC) laboratorytesting into a small rural hospitalin the Far North ( Rawene Hospital).This enabled clinicians to perform asmall range of on-site laboratory tests foracutely unwell patients. Previous turnaroundtime for laboratory results was24–72 hours. Data collected includedtest indication, differential diagnosisand planned patient disposition pre- andpost-POC tests. POC testing significantlyimproved diagnostic certainty,reduced overall hospital admissions by18% and inter-hospital transfers by 62%,resulting in substantial overall savingsto the health service.Blattner K, Nixon G, Dovey S, Jaye C,Wigglesworth J. Changes in clinical practiceand patient disposition following theintroduction of point-of-care testing in arural hospital. Health Policy. 2010;96:7–12.doi;10.1016/j.healthpol.2009.12.002Corresponding author: Katharina BlattnerEmail: katiblattner@hokiangahealth.org.nzGEMS are short précis of original papers published by NZ researchers. For a copy of a full paper pleaseemail the corresponding author. Researchers, to have your work included please send a 100word summary of your paper and the full reference details to: editor@rnzcgp.org.nz350 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

RESEARCH GEMSCommunication skills acquired bymedical students during GP runsUsing both quantitative and qualitativemethods, this study explored what medicalstudents at the University of Otagofelt they were learning about the doctor–patient relationship, compared to whatfaculty and clinicians felt they wereteaching. Teaching of relationship skillson hospital wards was highly variable,rarely explicit, and seemed to be primarilydependent on role-modelling. Thetension between service commitmentsand student teaching in hospital-basedattachments seemed to contribute to aninsufficient focus on students learningabout communication and relationshipskills. In contrast, general practice runsincluded explicit teaching with feedbackthat reinforced skills taught in the preclinicalcurriculum.Egnew T, Wilson H. Faculty and medicalstudents’ perceptions of teaching and learningabout the doctor–patient relationship. PatientEduc Couns. 2010;79(2):199–206.Corresponding author: Tom EgnewEmail: tom.egnew@multicare.orgWorkers with occupational overusesyndrome engage in battleThis paper explores the dominantmetaphor, ‘battling’, in the narratives ofNZ workers with occupational overusesyndrome. Battles were fought overdiagnoses, over occupational health andsafety in the workplace, and over entitlementsto therapy and income compensation.However, participants were alsobattling to maintain their identities ashard workers, while resisting and challengingnormalising technologies of selfand morally charged negative identitiesoffered them by employers, state fundedaccident and injury insurance agencies,and the medical profession. Inherent intheir narratives is a critique of the neoliberalcapitalist political economy thatallows workers’ bodies to be exploited(and sacrificed) for employers’ profits.Jaye C, Fitzgerald R. The lived politicaleconomy of occupational overuse syndromeamong New Zealand workers. Sociol HealthIllness 2010; 32 (7);1–16 doi: 10.1111/j.1467-9566.2010.01259.Corresponding author: Crystal JayeEmail: chrystal.jaye@otago.ac.nzHealth policy and communitypharmacy: implications forthe primary care sectorHealth care reform is ongoing and thispaper exposes the challenges that reformis exerting on community pharmacy.Ramifications for key stakeholderswithin the wider primary care sector arealso argued. To successfully implementpolicy, community pharmacists mustchange the way they think and act andmust engage vigorously with the sector.There are expected benefits for the wholeprimary care sector and there is a need forDistrict Health Boards (DHBs), PrimaryHealth Organisations (PHOs), PHAR-MAC, general practitioners and primarycare nurses to be aware of the challengescommunity pharmacy faces in order toachieve population health outcomes.Scahill S, Harrison J, Carswell P, Shaw J.Health care policy and community pharmacy:implications for the New Zealand primary caresector. N Z Med J. 2010;123(1317): 41–51.Corresponding author: Shane ScahillEmail: s.scahill@auckland.ac.nzMeasuring cannabis useCannabis use and misuse are serious publichealth concerns worldwide. Decreasingcannabis initiation age (

about the journal of primary health careThe Journal of Primary Health Care(JPHC) is a peer-reviewed journalwhich has replaced the New ZealandFamily Physician. It is a interdisciplinarypublication aimed at moving research intoprimary health care practice and practice intoresearch. This includes the fields of familypractice, primary health care nursing andcommunity pharmacy as well as areas such ashealth care delivery, health promotion, epidemiology,public health and medical sociologyof interest to a primary health care provideraudience. The journal is MEDLINE-listed.The journal publishes peer-reviewed quantitativeand qualitative original research,systematic reviews, papers on improving performanceand short reports that are relevantto its primary health care practitioners. Forthe aim, scope, instructions to authors andtemplates for publications see www.rnzcgp.org.nz/journal-of-primary-health-care/.JPHC acts as a knowledge refinery to providebusy practitioners with up-to-date knowledgeabout the latest evidence and best practice.Continuing professional developmentincludes pithy summaries of the latest evidencesuch as Cochrane Corner, a String ofPEARLS (Practical Evidence About Real LifeSituations) and Charms & Harms (evidence ofeffectiveness and safety of complementaryand alternative medicines). JPHC includesPoumanu (treasures of Maori wisdom) andGems of NZ Primary Health Care Researchpublished at home and internationally.Evidence can help inform best practice. Howeversometimes there is no evidence availableor applicable for a specific patient with hisor 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 theclinical relationship, with communication andwith truly informed decision-making. JPHCpublishes viewpoints, commentaries and reflectionsthat explore areas of uncertainty onaspects of care for which there is no one rightanswer. Debate is stimulated by the Back toBack section where two professionals presenttheir opposing views on a topic. There is aregular Ethics column. Letters to the Editorare welcomed.While published in New Zealand by the RoyalNew Zealand College of General Practitioners,much of this research has genericimplications. Our Editorial Board comprisesrenowned and active primary care clinicians,clinical and scientific academics and healthpolicy experts with both New Zealand andinternational representation.EditorDr Felicity Goodyear-Smith: Professor andGoodfellow Postgraduate Chair, Departmentof General Practice and Primary HealthCare, University of Auckland, Auckland, NewZealand; editor@rnzcgp.org.nzDeputy EditorsDr Derelie Mangin: Associate Professor,Department of Public Health and GeneralPractice, University of Otago, Christchurch, NZDr Tony Dowell: Professor and Head of theDepartment of Primary Health Care and GeneralPractice, Wellington School of Medicine,University of Otago, NZSubmissionsFull instructions for authors can be found at:http://www.rnzcgp.org.nz/information-for-authorsPlease send all submissions to the Editor:editor@rnzcgp.org.nzEditorial BoardDr Bruce Arroll: Professor and Head of theDepartment of General Practice & PrimaryHealth Care, University of Auckland, NZDr Jo Barnes: Associate Professor ofPharmacy, School of Pharmacy, University ofAuckland, NZDr Jenny Carryer: Professor of Nursing,School of Health and Social Services, MasseyUniversity, Palmerston North, NZDr Peter Crampton: Dean and Head ofCampus, Wellington School of Medicine andHealth Sciences, University of Otago, NZMs Eileen McKinlay: Senior Lecturer inPrimary Health Care, Department of PrimaryHealth Care and General Practice, Universityof Otago Wellington, NZDr Barry Parsonson: Psychologist for NZ Ministryof Education and International Consultant,UNICEF (Georgia) Training Project for InstitutionalStaff working with disabled childrenDr Shane Reti: Assistant Professor, InternationalProgram Director Clinical Informaticsand CEO of Clinical Informatics IndustrialResearch, Harvard Medical School, USADr Kurt Stange: Professor of FamilyMedicine, Case Western Reserve University,Cleveland, OH, USA and Editor, Annals ofFamily MedicineDr Colin Tukuitonga: Associate Professorand CEO of the Ministry of Pacific Island Affairs,Wellington, NZSubscription and advertising queriesCherylyn Borlase, Publications CoordinatorRNZCGP, PO Box 10440, Wellington 6143, New Zealand; jphcnz@rnzcgp.org.nzJPHC 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)–certifiedwhich 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.352 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE