An evaluation of diagnostic tests in a case series of suspected leptospirosis patients seen in primary care.

AIMS: This study describes 47 presentations of suspected leptospirosis in general practice in New Zealand. Our primary aim was to assess the laboratory diagnosis of leptospirosis in these patients, by comparing polymerase chain reaction (PCR) tests, microscopic agglutination test (MAT) and culture results. METHODS: Patients suspected of leptospirosis were recruited from general practices in the Waikato (n=17) and Wairoa (n=30) between August 2011 and June 2015. Blood and urine samples were tested for leptospirosis at two diagnostic laboratories and one research laboratory using PCR tests, MAT and culture. RESULTS: Forty-seven patients were recruited for this study: 37 during the acute phase of the illness (within 10 days of symptom onset) and 10 after the acute phase. Eleven of the acute phase patients (11/37, 30%) and two of the later phase patients (2/10, 20%) returned positive leptospirosis test results. The 11 acute phase leptospirosis positive patients had the following positive diagnostic tests: PCR and paired MAT (+/- blood culture) (n=3), PCR only (+/- blood culture) (n=4), paired MAT only (n=3) and blood culture only (n=1). Urine PCR (performed only on Wairoa patients) was the only positive test for two of these patients. CONCLUSION: About a quarter of farm workers and meat workers presenting to general practice with flu-like symptoms will have leptospirosis, but they will not be diagnosed unless appropriately tested, and then they may only test positive for some of the tests available. To increase the likelihood of making a diagnosis, clinicians should order multiple laboratory tests, including blood and urine PCR and a paired MAT.

Improving gout education from patients' perspectives: a focus group study of Maori and Pakeha people with gout.

INTRODUCTION Gout is a common form of arthritis that is typically managed in primary care. Gout management guidelines emphasise patient education for successful treatment outcomes, but there is limited literature about the educational experiences of people living with gout in New Zealand, particularly for Maori, who have higher gout prevalence and worse gout outcomes than Pakeha. AIM To explore gout patient education in primary care from the perspectives of Maori and Pakeha people with gout. METHODS In total, 69 people with gout were recruited through primary care providers in three locations across New Zealand. Nine semi-structured focus groups were run with Maori and Pakeha participants in separate groups. RESULTS Thematic analysis yielded two themes in relation to gout education: (i) 'Multiple sources of gout education'; and (ii) 'Gaps in gout knowledge'. Participants received education from general practitioners, educational resources, family and friends, and their own experiences. Maori participants preferred information to be kanohi-ki-te-kanohi (face-to-face) and with significant others present where necessary. Participants disclosed gaps in gout's epidemiology and management. Pakeha and Maori participants reported limited understanding of the genetic basis of gout or the biological underpinnings of the condition and its treatments, but learned treatment adherence through experience. DISCUSSION Despite improved gout patient education, knowledge gaps remain and may contribute to poor medication adherence. Gout patient education interventions need to be tailored to culture and incorporate suitable methods of disseminating information about gout management.

Rural New Zealand health professionals' perceived barriers to greater use of the internet for learning.

INTRODUCTION: The purpose of this research was to investigate rural North Island (New Zealand) health professionals' attitudes and perceived barriers to using the internet for ongoing professional learning. METHODS: A cross-sectional postal survey of all rural North Island GPs, practice nurses and pharmacists was conducted in mid-2003. The questionnaire contained both quantitative and qualitative questions. The transcripts from two open questions requiring written answers were analysed for emergent themes, which are reported here. The first open question asked: 'Do you have any comments on the questionnaire, learning, computers or the Internet?' The second open question asked those who had taken a distance-learning course using the internet to list positive and negative aspects of their course, and suggest improvements. RESULTS: Out of 735 rural North Island health professionals surveyed, 430 returned useable questionnaires (a response rate of 59%). Of these, 137 answered the question asking for comments on learning, computers and the internet. Twenty-eight individuals who had completed a distance-learning course using the internet, provided written responses to the second question. Multiple barriers to greater use of the internet were identified. They included lack of access to computers, poor availability of broadband (fast) internet access, lack of IT skills/knowledge, lack of time, concerns about IT costs and database security, difficulty finding quality information, lack of time, energy or motivation to learn new skills, competing priorities (eg family), and a preference for learning modalities which include more social interaction. Individuals also stated that rural health professionals needed to engage the technology, because it provided rapid, flexible access from home or work to a significant health information resource, and would save money and travelling time to urban-based education. CONCLUSIONS: In mid-2003, there were multiple barriers to rural North Island health professionals making greater use of the internet for learning. Now that access to broadband internet is available in all rural towns in New Zealand, there is a clear need to address the other identified barriers, especially the self-reported lack of IT skills, which are preventing many in the rural health workforce from gaining maximum advantage from both computers and the internet.

Using the patient-centred medicine clinical framework to better appreciate and explore the many barriers to care in type 2 diabetes.

There are many barriers to diabetes care. This paper explores whether organising these barriers to Type 2 diabetes care within the clinical framework of patient-centred medicine (PCM) enables a better appreciation and conceptualisation of these barriers. The terms 'diabetes', 'barriers to care', 'self-management', 'patient-centred care' and 'outcome assessment' were used to identify 28 articles describing multiple barriers (minimum of three) to care in Type 2 diabetes. Identified barriers were organised within the clinical framework of PCM. Barriers to diabetes care were numerous and diverse, but all could be accommodated within the PCM framework, except for one, that of patient non-compliance (non-adherence). This paternalistic concept contradicts patient autonomy, a key component of the PCM paradigm. Accepting non-adherence as a plausible barrier stops providers from recognising the actual barriers to diabetes self-management. Clinicians need to stop attributing blame for poor disease outcomes on patients, and instead to become partners in identifying and addressing their patients' real barriers to better health by using the practical clinical framework of PCM.

Understanding barriers to glycaemic control from the patient's perspective.

INTRODUCTION: To better understand barriers to glycaemic control from the patient's perspective. METHODS: An interpretative phenomenological approach was used to study the experiences of 15 adults with Type 2 diabetes. Participants each gave a semi-structured interview of their experiences of living with diabetes. Interviews were transcribed, and themes extracted and organised using a patientcentred framework. FINDINGS: Participants' stories confirmed many of the barriers in the literature, particularly those related to context, such as family, finances, work. Barriers also related to negative emotional reactions to diabetes: fear of new events (diagnosis, starting pills/insulin); guilt about getting diabetes and not controlling it; and shame about having diabetes. Barriers also related to unscientific beliefs and personal beliefs. There were additional barriers related to poor clinician-patient relationships. Overall, participants had a poor understanding of diabetes, and complained that their clinician simply 'told them what to do'. CONCLUSION: Using a patient-centred approach, this study identified many barriers to glycaemic control. We suggest that a key barrier is clinician ignorance of their patients' fears, beliefs, expectations, context; of what constitutes a positive therapeutic relationship; and of the limitations of a biomedical approach to patient non-adherence. Faced with both a worsening diabetes epidemic and increasing health care workforce shortages, clinicians urgently need to understand that it is they, not their patients, who must change their approach if diabetes care is to be improved.

Latrodectism: case report of a katipo spider (Latrodectus katipo) bite and review of the literature.

We describe the case of a 29-year-old man who was bitten on the leg by a katipo spider, a relative of the Australian redback and American black widow spiders, while camping in sand dunes at Mahanga Beach, Mahia (North Island of New Zealand). Symptoms of latrodectism developed within hours, and were not diminished until two doses of the antivenom had been administered. This is only the second case report of a katipo spider bite in the recent literature. The katipo spider bite produces significant symptoms, however an antivenom is available in some hospital pharmacies.

New Zealand rural primary health care workforce in 2005: more than just a doctor shortage.

OBJECTIVE: To obtain a 2005 snapshot of New Zealand (NZ) rural primary health care workforce, specifically GPs, general practice nurses and community pharmacists. DESIGN: Postal questionnaires, November 2005. SETTING: NZ-wide rural general practices and community pharmacies. PARTICIPANTS: Rural general practice managers, GPs, nurses, community pharmacy managers and pharmacists. MAIN OUTCOME MEASURES: Self-reported data: demographics, country of training, years in practice, business ownership, hours worked including on-call, intention to leave rural practice. RESULTS: General practices: response rate 95% (206/217); 70% GP-owned, practice size ranged from one GP/one nurse to 12 GPs/nine nurses. PHARMACIES: Response rate 90% (147/163). Majority had one (33%) or two (32%) pharmacists; <10% had more than three pharmacists. GPs: response rate 64% (358/559), 71% male, 73% aged >40, 61% full-time, 79% provide on-call, 57% overseas-trained, 78% male and 57% female GPs aged >40; more full-time male GPs (76%) than female (37%) . Nurses: response rate 65% (445/685), 97% female, 72% aged >40, 31% full-time, 28% provide on-call, 84% NZ-trained, 45% consulted independently in 'nurse-clinics' within practice setting. Pharmacists: response rate 96% (248/258), 52% male, 66% aged >40, 71% full-time, 33% provide on-call, 92% NZ-trained, 55% sole/partner pharmacy owners. Many intend to leave NZ rural practice within 5 years: GPs (34%), nurses (25%) and pharmacists (47%). CONCLUSION: This is the first NZ-wide rural workforce survey to include a range of rural primary health care providers (GPs, nurses and pharmacists). Ageing rural primary health care workforce and intentions to leave herald worsening workforce shortages.

When should I do rural general practice? A qualitative study of job/life satisfaction of male rural GPs of differing ages in New Zealand.

AIMS: There is a shortage of rural general practitioners in New Zealand (NZ), and many are approaching retirement. This qualitative study was undertaken to investigate the perceived advantages and disadvantages of rural general practice at various stages of family life of male NZ-trained GPs. METHODS: Semi-structured interviews were conducted with 12 male NZ-trained rural GPs from the Waikato and Northland regions during December 2006. Major themes relating to rural general practice as a career were identified and analysed with respect to the family life cycle: no children yet, pre-school children, high school children, or 'empty nest'. RESULTS: Trends in the frequency of themes, and changes in the sentiments within each theme across different stages of family life were noted. CONCLUSION: Based on the frequency of themes and sentiments, a conceptual picture of the influences of stages of a male rural GP's family life on the GP are discussed.

Why don't some women return for cervical smears? A hermeneutic phenomenological investigation.

To enhance understanding of how having a cervical smear can lead some women not to keep up-to-date with this test, a hermeneutic (interpretative) phenomenological study was undertaken. Participants were six purposively selected New Zealand women -- predominantly Maori -- at least 6 months overdue for a follow-up cervical screen in the previous 6 years. Each woman gave an in-depth interview. Transcribed and analyzed via a general inductive approach, the interviews suggested that the smears can violate women's positive aloneness with their bodies, and magnify aloneness as a negative state. Overdueness for the test avoids these effects. To minimize such effects, primary health care needs to acknowledge and address these issues, for example by providing an opportunity to connect the aloneness to trusted others.

New Zealand rural general practitioners 1999 survey part 4: analysis of specific sub-groups.

AIMS: To compare and contrast the demographics, working characteristics, and computer usage of 5 sub-groups of rural general practitioners (GPs) using data from the New Zealand Rural GPs 1999 Survey. METHODS: Anonymous postal questionnaires were mailed out to 559 rural and semi-rural GPs in November 1999. RESULTS: Of the 417 completed questionnaires returned (response rate = 75%), 338 were from GPs scoring >or= 35 points on the Rural Ranking Scale (RRS), and these 'rural' GPs formed the study group. Analysis of sub-groups showed that a significantly higher percentage of younger doctors (<45 years old) were vocationally trained, doing accreditation, working in group practices, or working part-time. A higher percentage of the more isolated rural GPs (RRS >or= 55) were working on the South Island, in solo practice, in areas with 3 or less GPs, working as rural hospital doctors, or doing intra-partum obstetrics. Of the vocationally trained GPs, a higher percentage expected to be in their current practice in 3 years, were doing accreditation or re-accreditation, were members of an Independent Practitioners' Association (IPA), or had email at the surgery. Compared to overseas graduates, New Zealand graduates were more likely to have been working in NZ rural general practice for >or= 10 years. CONCLUSIONS: The trend of younger doctors wanting to work part-time, in group practices, and not own their practice, has significant implications for the rural workforce shortage - especially as older, predominantly male rural GPs retire. This may be especially problematic for the South Island, where rural isolation appears to be a greater problem.

Few rural general practitioners use the Internet frequently in regard to patient care.

AIMS: To benchmark North Island rural general practitioner (GP) access to computers and the Internet, both at work and home, and assess whether rural GPs are using the Internet in regard to patient care. METHODS: Cross-sectional postal survey of all North Island rural GPs in mid-2003. RESULTS: 175 of 289 GPs (60.6%) returned useable questionnaires. Most (89.0%) reported computer availability at work when consulting, but even more had access to a computer at home (97.1%, p<0.01). Access to the Internet was also lower at work (68.6%) than at home (98.8%, p<0.01). Fewer GPs (p<0.05) reported ever using the Internet at work in regard to patients (56.5%) than at home (71.9%). Less than 10% of all GPs used the Internet three or more times a week at work (6.9%) or home (8.6%) in regard to patients. Of those with Internet access at work, 27.0% had broadband (fast Internet) access. Predictors of having (versus not having) work Internet access were computer availability in consultations (p=0.04). CONCLUSIONS: Few North Island rural GPs use the Internet frequently in regard to patient care, despite increasing access to computers and the Internet, both at work and home.

New Zealand Rural General Practitioners 1999 Survey--Part 3: rural general practitioners speak out.

AIMS: To describe themes about rural general practice from the written responses in the 'New Zealand Rural GPs 1999 Survey'. METHODS: A postal questionnaire surveyed all rural general practitioners (GPs) in New Zealand (NZ), who were asked for comments or suggestions about rural general practice. These responses were explored for themes about rural practice. RESULTS: Of 338 completed questionnaires (response rate--75%), 138 contained written responses. The positive themes of rural general practice included: forming strong relationships with patients and the community, and practising the full spectrum of general practice, including emergency medicine. The negative themes included: heavy workloads, frequent on-call, inability to get time off, and feeling undervalued and underpaid by funders. Retention solutions included: better pay to adequately reflect the skills and workload, more salaried positions with guaranteed working conditions, and better rural continuing education. Recruitment solutions included: reducing barriers for foreign doctors to enter NZ, establishing a rural GP career pathway, and increasing the number of rural registrars. CONCLUSIONS: This study highlights both the positive and negative features of NZ rural general practice, and makes it clear that further concerted and sustained action is required to improve retention and recruitment. The GPs' written comments provide detail on the challenges facing rural general practice, as well as informed comment about potential solutions.

New Zealand Rural General Practitioners 1999 Survey--Part 2: gender issues.

AIMS: To compare and contrast the demographic and working characteristics of female and male rural general practitioners (GPs) in New Zealand, and to highlight issues specific to female rural GPs. METHODS: Anonymous postal questionnaires were sent to 559 rural GPs in November 1999. RESULTS: Completed questionnaires were returned by 417 rural GPs (75%). Of the 338 rural GPs who fulfilled the inclusion criteria, 93 (28%) were female. Eighty percent of female rural GPs were younger than 45 years of age compared with 53% of male rural GPs (p < 0.01). Women were less likely to be in full-time practice (45% vs 90%) or own their own practice (63% vs 83%) (p < 0.01). Concerns about locum scarcities, overwork, excessive on-call, bureaucratic demands, and GP shortages were equally important to both genders--while issues of security, accreditation, and combining work and family were mentioned by female GPs. CONCLUSIONS: Most of the quantitative gender differences could be explained by the female rural GPs being younger (80% in their child-bearing years). Recognising and addressing the specific difficulties faced by part-time female rural GPs, such as by providing more flexible work options, would create a more favourable environment, likely to retain and recruit more women.

Lifestyle screening: development of an acceptable multi-item general practice tool.

AIMS: To develop a short screening tool for lifestyle and mental-health risk factors that adults can self-administer, and to determine acceptability and feasibility of use of this tool in primary care settings. METHODS: The multi-item tool was designed to screen patients in rural and urban New Zealand general practices for smoking, alcohol and drug misuse, problem gambling, depression, anxiety, abuse, anger, sedentary lifestyle, and weight issues. Patients were offered help for identified risk factors. Fifty consecutive adult patients per practice (n=2,543) were recruited to participate from 20 randomly-selected urban general practitioners; 20 general practice nurses and 11 rural general practitioners. RESULTS: Patients came from diverse ethnic, geographical, and socioeconomic backgrounds. The sample prevalence of positive responses identified ranged from 2.8% (gambling) to 42.7% (depression). The number of patients requesting immediate assistance with these responses (0.5 to 13.5%) did not overwhelm clinicians. The tool was well accepted by patients, with few objections to specific questions (0.1-0.8%). Most practitioners stated they will use the screening tool once available. CONCLUSIONS: Screening for lifestyle and mental health risk factors is becoming increasingly important in primary health care. This screening tool was acceptable to patients and was not considered overly burdensome by practitioners.