Programmatic evaluation of interprofessional education: a quality improvement tool.

Robust demonstration of high-quality, fit-for-purpose interprofessional education (IPE) is essential for today's health professional students, staff, curricula, and regulatory bodies. As IPE moves from discrete "events" to fully embedded spirals of learning across degree programme curricula, effective mechanisms for monitoring continuous quality improvement are paramount. An accreditation tool was therefore developed for all learning activities contributing to the IPE curriculum of a university in Aotearoa New Zealand. We worked over 15 months, introducing a user-friendly tool to collect data, managing accreditation processes, and integrating with wider systems. We identified key levers to monitor, adjust, and continuously improve quality in IPE teaching and learning at individual-activity and programmatic levels.

Improving management of sexually transmitted infections in primary care: feasibility and acceptability of a new patient management tool for clinicians.

INTRODUCTION Routinely following an evidence-based clinical pathway of care for bacterial sexually transmitted infections (STIs) such as chlamydia or gonorrhoea is important to help reduce the spread of infections, prevent reinfections and avoid associated health complications. AIM To develop an easy-to-use tool for routine use by primary care clinicians to ensure best practice management of patients tested for and diagnosed with chlamydia or gonorrhoea. METHODS The tool (a MedTech Advanced Form) was developed in consultation with seven primary care clinicians and included different tabs for use during the STI care pathway (testing, treatment, advice, partner notification and follow up) with clickable links to relevant online resources. The tool was trialled over 3 months by 19 clinicians in three Wellington primary care clinics - two youth health and a student health service. Outcome measures were frequency of use, completeness of fields related to best practice care and clinician acceptance of the tool (from focus group feedback). RESULTS The tool was used for approximately one in four patients who were tested during the trial period, with 'forgetting' reported as the most common reason for non-use. Clinician views about the tool were favourable, with most indicating they would like to continue use and would recommend it to colleagues. Documentation of best practice care was excellent; fields to record reasons for testing, discussion of sexual history, provision of treatment and advice given were used for most patients for whom the form was completed. CONCLUSIONS Inclusion of this STI management tool in the electronic patient records system appeared to improve primary care clinicians' delivery and documentation of best practice sexual health care at a practice level. Wider use of a modified version of this tool could facilitate more comprehensive best practice management of bacterial STIs.

'Should I vaccinate my child?' comparing the displayed stances of vaccine information retrieved from Google, Facebook and YouTube.

Whether to vaccinate or not is currently a hot topic in social discourse. Despite the majority view that childhood vaccination is safe and effective, websites and social media content opposing such vaccination are common. In this study, we searched the internet platforms Google, Facebook and YouTube for childhood vaccine information. We made every attempt to minimise selection bias generated by internet algorithms. We compared the displayed stances of vaccine information retrieved. Most of the information had a clearly stated stance on vaccines or made some sort of recommendation on whether or not to vaccinate. Despite our careful attempt to search comprehensively and systematically for vaccine information with as little bias as possible, this search yielded a sizeable minority of vaccine negative information. This research shows that negative vaccine information persists and is readily accessible online despite algorithm and policy changes in recent years, even when searching in the least biased way possible. It is important that vaccine-promoting entities and agencies continue to make every effort to maximize their presence online so that parents searching the internet to answer the question 'should I vaccinate my child?' continue to receive vaccine positive information.

Chlamydia trachomatis and Neisseria gonorrhoeae Retesting and Reinfection Rates in New Zealand Health Care Settings: Implications for Sexually Transmitted Infection Control.

BACKGROUND: Reinfection with chlamydia or gonorrhea is common and can lead to significant reproductive health complications so testing for reinfection after treatment is recommended. This study described retesting and reinfection rates in regions of New Zealand with higher-than-average population rates of chlamydia. METHODS: This retrospective cohort study analyzed chlamydia and gonorrhea testing data from 2 laboratories providing community testing services for 4 higher-rate regions in the North Island of New Zealand. Three years of data were obtained (2015-2017) to include a minimum of 6-month follow-up for all individuals. Retesting and reinfection rates between 6 weeks and 6 months of a positive result were calculated, and time to retesting was plotted using Kaplan-Meier curves. Logistic regression modeling was used to determine the odds of retesting (outcome 1) and reinfection (outcome 2) between 6 weeks and 6 months of follow-up. RESULTS: Overall, 34% (3151/9241) of the cohort was retested within the recommended period, of whom 21% retested positive. Significant differences were observed in the odds of retesting by sex, age band, ethnic group, clinic type, and region (P < 0.01). The odds of a subsequent positive on retesting within 6 months differed significantly by sex, age band, and ethnic group (P < 0.01). CONCLUSIONS: These findings reflect substantial gaps in the delivery of best-practice sexually transmitted infection management in New Zealand. There is a clear need to prioritize the implementation of clinic-level processes to support clinicians in the routine delivery of best-practice sexual health care. These should include routine provision of patient advice about retesting and strategies to promote timely and equitable access to retesting.

Clinician education, advice and SMS/text reminders improve test of reinfection rates following diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae: before and after study in primary care.

BACKGROUND: Evidence-based guidelines for the management of Chlamydia trachomatis and Neisseria gonorrhoeae recommend testing for reinfection 3-6 months following treatment, but retesting rates are typically low. METHODS: Participants included six primary care clinics taking part in a pilot study of strategies designed to improve partner notification, follow-up and testing for reinfection. Rates of retesting between 6 weeks and 6 months of a positive chlamydia or gonorrhoea diagnosis were compared across two time periods: (1) a historical control period (no systematic approach to retesting) and (2) during an intervention period involving clinician education, patient advice about reinfection risk reduction and retesting, and short messaging service/text reminders sent 2-3 months post-treatment inviting return for retesting. Retesting was calculated for demographic subgroups (reported with 95% CI). RESULTS: Overall 25.4% (61 of 240, 95% CI 20.0 to 31.4) were retested during the control period and 47.9% (116 of 242, 95% CI 43.2 to 55.1) during the intervention period. Retesting rates increased across most demographic groups, with at least twofold increases observed for men, those aged 20-29 years old, and Maori and Pasifika ethnic groups. No significant difference was observed in repeat positivity rates for the two time periods, 18% (11 of 61) retested positive during the control and 16.4% (19 of 116) during the intervention period (p>0.05). CONCLUSIONS: Clinician and patient information about retesting and a more systematic approach to follow-up resulted in significant increases in proportions tested for reinfection within 6 months. These simple strategies could readily be implemented into primary healthcare settings to address low rates of retesting for bacterial sexually transmitted infections. TRIAL REGISTRATION NUMBER: ACTRN12616000837426.

Addressing Gaps in the Management of Chlamydia trachomatis and Neisseria gonorrhoeae in Primary Care: Lessons Learned in a Pilot Intervention Study.

BACKGROUND: We aimed to test the acceptability and utility of strategies designed to facilitate the delivery of clinical best practice for patients diagnosed with chlamydia or gonorrhea in primary care. METHODS: A nonrandomized pilot intervention study with a historic control period was run over 9 months in six primary health care clinics (2 youth services, 3 low-fee clinics, and 1 student health service) in Wellington, New Zealand. "Study nurses" in participating clinics oversaw the implementation of strategies designed to facilitate partner notification and follow-up for patients diagnosed with chlamydia or gonorrhea. Clinics chose which of 2 approaches they wished to trial-either managing all study processes themselves or drawing on the assistance of an external specialist sexual health advisor. Outcome measures included acceptability and utility of study processes ascertained via structured interviews with study nurses and collection of clinical data. RESULTS: Outcomes for 287 patients seen during the intervention were compared with 240 historic controls. Participant views on study processes were positive overall, and all clinics intended to continue all or most of the study processes implemented. During the intervention, substantial improvements were observed in documented patient management (sexual history, partner notification, and outcomes, P < 0.05). Increases were observed in percentages of patients reached for follow-up (74% vs. 26% at baseline, P < 0.05) and partners reported to have been notified (79% vs. 23%, P < 0.05). CONCLUSIONS: Nurse-led strategies implemented were deemed acceptable and appeared to facilitate delivery of best practice care for patients diagnosed with bacterial sexually transmitted infections in participating primary care practices.

Partner notification and retesting for Chlamydia trachomatis and Neisseria gonorrhoeae: a case-note review in New Zealand primary care.

INTRODUCTION Bacterial sexually transmitted infections (STIs) contribute to a significant burden of ill-health despite being easy to diagnose and treat. STI management guidelines provide clinicians with evidence-based guidance on best-practice case management. AIM To determine the extent of adherence to STI management guidelines for partner notification, follow up and testing for reinfection following diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae. METHODS Retrospective review of electronic patient records for individuals diagnosed with chlamydia or gonorrhoea in eight primary care clinics in Wellington, New Zealand. At each clinic, 40 clinical records were reviewed (320 in total). Outcome measures were: overall numbers (%) of cases with documented evidence of reason for testing, sexual history, treatment, advice, partner notification and follow up. Partner notification outcomes were: n (%) with evidence of partner notification discussion and n (%) with partners advised, tested and treated. Proportions retested between 6 weeks and 6 months and n (%) positive on retesting were also determined. RESULTS Presenting features and treatment were generally well documented. Recent sexual history including number of partners was documented for half of cases reviewed (159/320). Partner notification discussion was documented for 74% (237/320) of cases, but only 24.4% (78/320) had documentation on numbers of partners notified and 17% (54/320) on numbers of partners treated. Testing for reinfection between 6 weeks and 6 months occurred for 24.7% (79/320), of whom 19% (15/79) re-tested positive. CONCLUSIONS This research suggests there are gaps in important aspects of patient care following bacterial STI diagnosis - a factor that may be perpetuating our high rates of infection. A more systematic approach will be needed to ensure people diagnosed with an STI receive the full cycle of care in line with best practice guidelines.

Exploring interprofessional, interagency multimorbidity care: case study based observational research.

BACKGROUND: The increase in multimorbidity or co-occurring chronic illnesses is a leading healthcare concern. Patients with multimorbidity require ongoing care from many different professionals and agencies, and often report a lack of integrated care. OBJECTIVE: To explore the daily help-seeking behaviours of patients with multimorbidity, including which health professionals they seek help from, how professionals work together, and perceptions and characteristics of effective interprofessional, interagency multimorbidity care. DESIGN: Using a case study observational research design, multiple data sources were assembled for four patients with multimorbidity, identified by two general practitioners in New Zealand. In this paper, two case studies are presented, including the recorded instances of contact and communication between patients and professionals, and between professionals. Professional interactions were categorized as consultation, coordination, or collaboration. RESULTS: The two case studies illustrated two female patients with likely similar educational levels, but with different profiles of multimorbidity, social circumstances, and personal capabilities, involving various professionals and agencies. Engagement between professionals showed varying levels of interaction and a lack of clarity about leadership or care coordination. The majority of interactions were one-to-one consultations and rarely involved coordination and collaboration. Patients were rarely included in communications between professionals. CONCLUSION: Cases constructed from multiple data sources illustrate the complexity of day-to-day, interprofessional, interagency multimorbidity care. While consultation is the most frequent mode of professional interaction, targeted coordinated and collaborative interactions (including the patient) are highly effective activities. Greater attention should be given to developing and facilitating these interactions and determining who should lead them.

Chlamydia testing and diagnosis following initiation of long-acting reversible contraception: A retrospective cohort study.

BACKGROUND: Long-acting reversible contraception (LARC) effectively protects against pregnancy but provides no protection against sexually transmitted infections (STIs). AIM: To compare rates of chlamydia testing and diagnosis for women initiating long-acting versus oral contraception. MATERIALS AND METHODS: Retrospective cohort study involving data collection for 6160 women initiating post-abortion contraception at a large New Zealand regional public hospital abortion clinic (2009-2012), with chlamydia testing data obtained from the local laboratory during two-year follow up. Negative binomial regression modelling examined the effect of contraceptive method on two outcome measures: chlamydia testing and chlamydia diagnosis (adjusting for potential covariates of age, ethnicity, past chlamydia infection, pregnancy history) in year one and two of follow up. RESULTS: Two thousand seven hundred and twenty nine women (44%) received a LARC and 1764 (28.6%) were prescribed oral contraception. Adjusted testing rates differed by contraceptive method only in year one (P < 0.01): with higher rates among copper intrauterine device users (relative risk (RR) 1.2, 95% CI 1.06-1.35), and lower rates for implant users (RR 0.84, 95% CI 0.72-0.99) compared with oral contraceptive users (reference group). No significant differences were observed in chlamydia diagnosis rates by contraceptive method (P > 0.05). Younger age, past chlamydia infection, Maori and Pacific ethnicity were associated with higher rates of chlamydia diagnosis (P < 0.01). CONCLUSIONS: Known STI-related risk factors (age, ethnicity, past infection) but not contraceptive method were independently related to rates of subsequent chlamydia diagnosis. This suggests that increased LARC uptake would not occur at the expense of chlamydia control. Regular screening and risk reduction advice (including condom use) are important chlamydia control measures for at-risk groups.

Retesting and repeat positivity following diagnosis of Chlamydia trachomatis and Neisseria gonorrhoea in New Zealand: a retrospective cohort study.

BACKGROUND: Testing for reinfection at 3 to 6 months following treatment for Chlamydia Trachomatis or Neisseria gonorrhoea is recommended in best practice sexual health management guidelines. This study aimed to describe rates of retesting and repeat positivity following diagnosis of chlamydia or gonorrhoea in a defined geographic region of New Zealand. METHODS: Retrospective cohort study in Wellington, New Zealand involving analysis of laboratory data for chlamydia and gonorrhoea tests performed in primary care and sexual health clinics (July 2012-July 2015). OUTCOME MEASURES: rate of retesting and rate of repeat positivity 6 weeks to 6 months after a positive result (index event). Kaplan-Meier curves were used to plot time from first index event to retest. Logistic regression modelling was used to determine the odds of retesting and repeat positivity between 6 weeks and 6 months of follow-up, adjusting for potential confounders (age, gender, ethnicity and socioeconomic deprivation). RESULTS: Overall 29.4% (1919/6530) of the cohort was retested between 6 weeks and 6 months, with 18% (347/1919) of those retested returning positive results. Lower odds of retesting were observed for males (OR 0.4, 95% CI 0.34-0.48), and individuals of NZ Maori (OR 0.72, 0.61-0.85) and Pacific ethnicities (OR 0.49, 0.39-0.62, reference European). Factors associated with higher odds of repeat positivity on retesting included male gender (OR 2.0, 1.14-2.82), age 15-19 years (OR 1.78, 1.32-2.41, reference 20-24 years), chlamydia/gonorrhoea co-infection (OR 2.39, 1.32-4.35, reference chlamydia only), Maori (OR 1.6, 1.18-2.17) and Pacific ethnicities (OR 1.88, 1.22-2.9, reference European). CONCLUSIONS: We observed low adherence to STI retesting guidelines, and marked gender and ethnic disparities in rates of retesting and repeat positivity. Low retesting rates are suggestive of low levels of awareness of this aspect of patient management, and an absence of a systematic approach to retesting. High rates of repeat positivity reinforce the importance of advising patients about reducing their risk of reinfection, including notification and treatment of all recent sexual partners. Greater priority needs to be placed on increasing retesting and reducing rates of reinfection, with strategies implemented to improve these important aspects of patient care and population STI control.

Overcoming challenges associated with partner notification following chlamydia and gonorrhoea diagnosis in primary care: a postal survey of doctors and nurses.

INTRODUCTION Sexual health guidelines recommend that partner notification and testing for reinfection are undertaken when individuals are diagnosed with bacterial sexually transmitted infections (STIs). AIM To understand factors influencing the effective delivery of partner notification and follow up after diagnosis of STIs in primary care, and to identify strategies that might facilitate these processes. METHODS A postal survey was sent to 216 primary care doctors and nurses working in 72 Wellington primary care settings. Eligible clinicians were identified from laboratory testing data, and included clinicians who had diagnosed relatively high numbers of chlamydia and/or gonorrhoea cases during a 12-month period. Response frequencies were tabulated and chi-squared testing was used to test for significant differences between doctor and nurse responses for selected items. RESULTS In total, 121 surveys were completed (56% response rate) by 78 doctors and 43 nurses, from 55 primary care settings (76% of sites surveyed). Responding health professionals thought that patients were open to partner notification discussion, but appreciated that this sometimes raised difficult issues for patients. Lack of time or resources to follow up, and difficulty getting hold of patients, were cited as key factors that limit assessment of partner notification success. Factors deemed likely to facilitate partner notification included readily available patient resources, training to upskill practice team members, guidance on what to say and record, and access to external advice and assistance. DISCUSSION This study provides insight into provider- and patient-level factors perceived to be hindering successful partner notification. Strategies that could facilitate partner notification were identified, and suggestions made as to how these could be integrated into practice.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus.

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin's 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.

Interprofessional undergraduate students talk about nurses and nursing: A qualitative study.

OBJECTIVES: To understand the discourse amongst a range of health professional students, including nursing, talking about nurses and nursing. DESIGN: A qualitative descriptive study which employed the use of focus groups. SETTINGS: A rural and residential interprofessional immersion programme in a rural location in New Zealand. The participants were final year undergraduates drawn from seven different degrees (dentistry, dietetics, medicine, nursing, occupational therapy, pharmacy and physiotherapy). METHODS: Data were collected from separate and sequential group interviews; each of which comprised a different mix of students and always included nursing students. Each student participated once. Data were analysed by comparing datum with datum until recurrent themes emerged. RESULTS: The discourse in relation to nurses and nursing identified two overarching themes 'constrained conversations' and 'the benefit of IPE: what nursing might become'. Within those themes there were four contributing sub themes; 'nursing as doing', 'limiting our vocabulary', 'becoming part of the conversation 'and 'moving from the present to the future what nursing might become'. CONCLUSIONS: The interprofessional experience for student nurses not only enabled them to learn about other professions but was a forum in which they were able to articulate the role of the nurse. This was an unintended and positive by-product of the IPE programme.