Dentition and nutritional status of aged New Zealanders living in aged residential care.

BACKGROUND: Previous studies of the nutritional status of older individuals have used measures such as plasma vitamin and mineral levels, which can be difficult to interpret. The relationship between nutrition and dentition has been limited to studying exposures such as the number of posterior occluding pairs of teeth, edentulousness, and the number of natural teeth. OBJECTIVES: To investigate the association between dentition status and nutritional status in a national survey of older New Zealanders living in aged residential care facilities. MATERIAL AND METHODS: Secondary analysis of clinical oral status and nutrition data collected in 2012 in New Zealand's Older People's Oral Health Survey. The validated Mini Nutritional Assessment short format was used to categorize participants as "normal nutritional status," "at risk of malnutrition" or "malnourished." RESULTS: Just under half of older New Zealanders living in aged residential care facilities were classified as either at risk of malnutrition or malnourished (with about one in sixteen in the latter category). The prevalence of malnutrition was higher among those in hospital-level and psychogeriatric-level care, as well as in those of high socioeconomic status. Individuals who were at risk of malnutrition had the most untreated dental caries and untreated coronal caries. Relative to their counterparts in nursing-home-level care, dentate individuals in hospital-level care were 2.4 times-and those in psychogeriatric-level care were 2.8 times-as likely to be malnourished or at risk of it. CONCLUSIONS: Just under half of the New Zealanders living in aged residential care were at risk of malnutrition or were malnourished. Greater experience of untreated dental caries was associated with a higher rate of being malnourished or at risk of it. Poorer cognitive function and greater dependency were important risk indicators for malnutrition.

The residual dentition among New Zealanders in aged residential care.

BACKGROUND: Descriptions of the older population's dentition status are usually limited to indicators such as the edentulous proportion, the mean number of restored and missing teeth, and the proportion with a functional dentition, with very few reports describing in detail the nature of the residual dentition. OBJECTIVES: This study described the residual dentition among older New Zealanders living in residential aged care facilities. MATERIAL AND METHODS: Using national data from the Older People's Oral Health Survey, we determined the residual dentition arrangement and Kennedy classification for each dental arch. Individuals were categorised according to their maxillary-mandibular dental configuration. Data were weighted to make the estimates generalisable to the source population. RESULTS: Among the dentate 45% of the 987 clinically examined participants, the most prevalent configuration was maxillary tooth-bounded saddles against a partially dentate lower (24.7%; 95% CI: 20.4, 29.7). More younger participants generally had less tooth loss experience and had higher prevalence of Kennedy Classes II, III and IV. There were few sex differences, although more females had a fully dentate arch. Marked ethnic differences were observed: Maori were up to eight times as likely to have only mandibular anterior teeth remaining. Upper dentures were worn more than their lower counterpart. Age, sex and ethnic characteristics were associated with particular residual teeth configurations. CONCLUSIONS: Having various degrees of tooth loss was the norm, with the upper tooth-bounded saddles against any partially dentate lower combination most common, and limited to females. An edentulous maxilla opposed by some standing teeth was observed in over one-quarter of the population, and most common among Maori and those who were older. Maxillary prostheses were much more common than mandibular ones. Caring for dentate older people in aged residential care is likely to be complicated by the wide range of dentition configurations.

Oral status, cognitive function and dependency among New Zealand nursing home residents.

OBJECTIVES: To investigate clinical oral disease and its association with cognitive function and dependency among older New Zealanders in residential aged care. MATERIAL AND METHODS: National survey of oral health in aged residential care throughout New Zealand. We classified residents into 1 of 3 levels of care: "low dependency care (or assisted living)"; "high dependency care"; or "specialist dementia care/psychogeriatric care." The Abbreviated Mental Test characterised cognitive function as "unimpaired" (scores of 7-10), "moderately impaired" (4-6) or "severely impaired" (0-3). Intra-oral examinations were conducted, along with a computer-assisted personal interview. RESULTS: Most of the 987 clinically examined participants were either at low or high dependency care level, with another 1 in 6 in psychogeriatric care. Almost half overall had severely impaired cognitive function. Just under half of the sample had 1 or more natural teeth remaining. Negative binomial regression modelling showed that the number of carious teeth was lower among women and higher among those who were older, those with more teeth and in those with severely impaired cognitive function. Oral debris scores (representing plaque biofilm and other soft deposits on teeth) were higher in men, those with more teeth, and in those with severely impaired cognitive function. CONCLUSIONS: Impaired cognitive function is a risk indicator for both dental caries and oral debris in aged residential care.

Potential unmet need for gout diagnosis and treatment: capture-recapture analysis of a national administrative dataset.

OBJECTIVE: To estimate the degree of undercount of people diagnosed with gout in administrative datasets using capture-recapture methods. METHODS: Hospitalization and drug dispensing claims (allopurinol or colchicine) data for all Aotearoa New Zealand were used to estimate the prevalence of gout in 2009 (n = 4 295 296). As a comparison, we calculated gout prevalence using a large primary care dataset using general practitioner diagnosis and prescribing records (n = 555 313). For each of these datasets, we estimated the undercount through capture-recapture analysis using a Poisson regression model. A two-list model was used, which included covariates such as age, gender, ethnic groups and New Zealand deprivation quintiles. RESULTS: The crude prevalence of diagnosed gout in the Aotearoa New Zealand population aged ≥ 20 years was 3.75%. The covariate-adjusted capture-recapture estimate of those not recorded but likely to have gout was 0.92%, giving an overall estimated prevalence of 4.67% (95% CI 4.49, 4.90%) for the population aged ≥ 20 years. This amounts to 80% of people with gout being identified by the algorithm for the Aotearoa New Zealand data-that is being recorded in either lists of dispensing of allopurinol or colchicine or hospital discharge. After capture-recapture, gout prevalence for all males aged ≥ 20 years was 7.3% and in older (≥ 65 years) Maori and Pacific men was >30%. CONCLUSION: Capture-recapture analysis of administrative datasets provides a readily available method for estimating an aspect of unmet need in the population-in this instance potentially 20% of those with gout not being identified and treated specifically for this condition.

National prevalence of gout derived from administrative health data in Aotearoa New Zealand.

OBJECTIVE: Previous small studies in Aotearoa New Zealand have indicated a high prevalence of gout. This study sought to determine the prevalence of gout in the entire Aotearoa New Zealand population using national-level health data sets. METHODS: We used hospitalization and drug dispensing claims for allopurinol and colchicine for the entire Aotearoa New Zealand population from the Aotearoa New Zealand Health Tracker (ANZHT) to estimate the prevalence of gout in 2009, stratified by age, gender, ethnicity and socio-economic status (n = 4 295 296). RESULTS: were compared with those obtained from an independent large primary care data set (HealthStat, n = 555 313). Results. The all-ages crude prevalence of diagnosed gout in the ANZHT population was 2.69%. A similar prevalence of 2.89% was observed in the HealthStat population standardized to the ANZHT population for age, gender, ethnicity and deprivation. Analysis of the ANZHT population showed that gout was more common in Maori and Pacific people [relative risk (RR) 3.11 and 3.59, respectively], in males (RR 3.58), in those living in the most socio-economically deprived areas (RR 1.41) and in those aged >65 years (RR >40) (P-value for all <0.0001). The prevalence of gout in elderly Maori and Pacific men was particularly high at >25%. CONCLUSION: Applying algorithms to national administrative data sets provides a readily available method for estimating the prevalence of a chronic condition such as gout, where diagnosis and drug treatment are relatively specific for this disease. We have demonstrated high gout prevalence in the entire Aotearoa New Zealand population, particularly among Maori and Pacific people.

Burden of illness in blood eosinophilic phenotype COPD patients in New Zealand.

BACKGROUND: Real-world data on eosinophilic chronic obstructive pulmonary disease (COPD)'s clinical burden, in exacerbating/stable states, and the stability of blood eosinophil count (BEC) measurements are limited. We described measured BEC distributions among general practice COPD patients in New Zealand (NZ). METHODS: This retrospective cohort study utilized the NZ-HealthStat primary care database. Participants were aged ≥40 years, with ≥1 BEC 6 months following a COPD diagnosis code during 2011-2012. Descriptive analyses included examinations of BEC stability and association with COPD exacerbations/treatments/comorbidities. RESULTS: The most frequent COPD comorbidity was asthma (n = 1180/2909, 40.56%). Among COPD patients: 65% had BECs >150 cells/µL; 35% had BECs >300 cells/µL (non-mutually exclusive threshold categories). Treatment patterns were similar, except for more frequent inhaled corticosteroid (ICS)/long-acting beta2-agonist use in COPD patients with asthma history (51%) than those without (31%). Factors associated with BECs >150 cells/µL in participants without ICS treatment included Maori/Pacific ethnicity, obesity, oral corticosteroid (OCS) use, and exacerbation history. When stratified by asthma history, ICS treatment, and neutrophil count above/below 5000 cells/µL, geometric mean BECs ranged from 136.70 to 398.52 cells/µL. Exploratory analyses showed a fair-good COPD/BEC measurement stability over 12 months. CONCLUSIONS: Asthma was a common COPD comorbidity in NZ, particularly in Maori/Pacific patients. No overall relationship was observed between BEC/COPD exacerbations, which may reflect background ICS confounding. However, analyses in non-ICS treated participants suggested that Maori/Pacific patients with obesity and COPD, OCS treatment, exacerbation history, and/or elevated BECs are at the highest risk of COPD exacerbations. One BEC measurement appears a good indicator of a patient's BECs over time.

A Real-World Analysis of Treatment Patterns and Clinical Characteristics Among Patients with COPD Who Initiated Multiple-Inhaler Triple Therapy in New Zealand.

Purpose: Real-world data on maintenance treatment and prescription patterns provide insights into healthcare management among patients with chronic obstructive pulmonary disease (COPD), which benefits our understanding of current COPD treatment patterns in New Zealand. Methods: We retrospectively analyzed real-world data from the HealthStat general practice database to evaluate treatment patterns among patients with COPD in New Zealand who initiated multiple-inhaler triple therapy (MITT): inhaled corticosteroid (ICS) + long-acting muscarinic antagonist + long-acting ß2-agonist (LABA). Our main objective described treatment patterns (class, duration, modification, persistence, and adherence) and characteristics of patients with COPD initiating MITT between 1 May 2016 and 30 April 2017, with 12-months' follow-up. We also assessed the number of patients receiving MITT between 2015 and 2017, among a larger patient population receiving long-acting bronchodilator and ICS-containing therapies. Results: Of 6249 eligible patients, 421 (mean age 67.3 years; mean number exacerbations at baseline 1.8) initiated MITT: 59.1% received combination ICS/LABA therapy prior to MITT initiation, and median treatment duration prior to MITT initiation was 350 days. Overall, 33.5% of patients remained on index treatment for 12 months. Of the remaining patients who modified treatment (on average at 144.4 days), those who had a direct switch (24.9%) or retreatment (13.5%) remained on MITT, 19.7% of patients stepped down to mono/dual therapy, and 8.3% discontinued treatment. Mean (standard deviation) persistence to any MITT over 12 months was 47.3 (50.0), and 53.4% of patients were considered adherent to MITT. Total proportions of patients receiving long-acting bronchodilator therapy and MITT increased between 2015 and 2017. Conclusion: Most patients with COPD in New Zealand who initiated MITT had characteristics appropriate for triple therapy prescription, suggesting prescription behavior among general practitioners was largely consistent with treatment guidelines. Our findings may help optimize treatment decisions, with a focus on improving long-term triple therapy persistence and adherence.

Long-Acting Bronchodilator Use in Chronic Obstructive Pulmonary Disease in Primary Care in New Zealand: A Retrospective Study of Treatment Patterns and Evolution Using the HealthStat Database.

PURPOSE: Long-acting bronchodilator (LABD) use is the mainstay of pharmacologic treatment for chronic obstructive pulmonary disease (COPD). Few studies describe evolving patterns of LABD use in the setting of changing inhaler availability and updated clinical guidelines. METHODS: A retrospective cohort study in New Zealand using the HealthStat general practice database (01/2014 to 04/2018). Eligible patients (aged ≥40 years) had COPD and ≥1 LABD prescription (long-acting muscarinic antagonist [LAMA] and/or long-acting ß2-agonist [LABA]) during the index period (05/2015 to 04/2016). Demographics and clinical characteristics of all LABD users (overall/by treatment) were described at baseline. Patients starting LABD treatment during the index period, termed "new" users, were also described, as was their treatment evolution over 24 months of follow-up. Yearly LABD initiation rates were assessed from 2015 to 2017, covering changes to Pharmaceutical Management Agency criteria and clinical guidelines. RESULTS: Across 2140 eligible patients, the most common index treatments were inhaled corticosteroid (ICS)/LABA (59.0%) and open triple therapy (LAMA+LABA+ICS; 26.7%). ICS/LABA therapy was highest in younger patients, with open triple therapy highest in older patients. Prior yearly exacerbation rates were lowest in those receiving monotherapy (LABA: 0.9/year; LAMA: 1.1/year) versus dual therapy (all 1.4/year) and open triple therapy (2.2/year). Of 312 new LABD users, ICS/LABA was the most common index treatment (69.6%), followed by LAMA monotherapy (16.0%). Continuous use with index treatment was 31.1% at 12 months and 13.5% at 24 months; mean time to treatment change was 175.5 and 244.1 days, respectively. Among patients modifying treatment at 24 months, 23.0% augmented, 7.0% switched, 45.6% re-started, and 24.4% discontinued/stepped down. Among patients initiating LABD each year from 2015 to 2017, LAMA prescription increased (17% to 46%) while ICS prescription remained stable (approximately 20%). CONCLUSION: Predominant use of ICS/LABA (05/2015 to 04/2016) reflects available LABDs and previous restrictions on LAMA use in New Zealand.

Characterization and burden of severe eosinophilic asthma in New Zealand: Results from the HealthStat Database.

BACKGROUND: This retrospective cohort study aimed to characterize epidemiology, medication use and healthcare resource utilization (HCRU) of patients diagnosed with severe eosinophilic asthma (SEA) compared to other patients with asthma in New Zealand. METHODS: Adult patients with asthma with no concurrent diagnosis of Chronic Obstructive Lung Disease (COPD) were identified from the HealthStat primary care database and the National Minimum Dataset using asthma diagnosis, hospital codes and prescriptions. Patients with SEA were identified using a 1-year baseline period (2011) and were those with: inhaled corticosteroid prescription above medium dose (including high dose) plus controller medication, ≥2 exacerbations, and eosinophils ≥300 cells/µl (or ≥150 in 6 weeks prior to index date); patients were followed for 1 year (2012). RESULTS: 160/3,276 (4.9%) asthmatics with available eosinophil counts met SEA criteria. Patients with SEA were more likely to be Maori, former smokers, have more comorbidities, higher mean BMI and higher neutrophil counts compared with other patients with asthma. In the follow up period, SEA patients had over 4 times as many exacerbations; incidence of exacerbations of the same frequency was highest in Maori patients. CONCLUSIONS: Compared with other patients with asthma, SEA patients had over 1.5 times as many respiratory treatment prescriptions and higher all-cause HCRU and total healthcare costs; asthma-related healthcare costs were 3.6 times greater.

Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand.

Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease (RHD), have largely disappeared from high-income countries. However, in New Zealand (NZ), rates remain unacceptably high in indigenous Maori and Pacific populations. The goal of this study is to identify potentially modifiable risk factors for ARF to support effective disease prevention policies and programmes. A case-control design is used. Cases are those meeting the standard NZ case-definition for ARF, recruited within four weeks of hospitalisation for a first episode of ARF, aged less than 20 years, and residing in the North Island of NZ. This study aims to recruit at least 120 cases and 360 controls matched by age, ethnicity, gender, deprivation, district, and time period. For data collection, a comprehensive pre-tested questionnaire focussed on exposures during the four weeks prior to illness or interview will be used. Linked data include previous hospitalisations, dental records, and school characteristics. Specimen collection includes a throat swab (Group A Streptococcus), a nasal swab (Staphylococcus aureus), blood (vitamin D, ferritin, DNA for genetic testing, immune-profiling), and head hair (nicotine). A major strength of this study is its comprehensive focus covering organism, host and environmental factors. Having closely matched controls enables the examination of a wide range of specific environmental risk factors.

Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

BACKGROUND: In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005. RESULTS: Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices. CONCLUSION: The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.

Attendance for general practitioner asthma care by children with moderate to severe asthma in Auckland, New Zealand.

Attendance for general practitioner (GP) care of childhood asthma varies widely in New Zealand (NZ). There is little current research to account for the variations, although groups such as Maori and Pacific peoples have traditionally faced barriers to accessing GP care. This paper aims to describe and account for attendance levels for GP asthma care among 6-9 year-olds with moderate to severe asthma in Auckland, NZ. During 2002, randomly selected schools identified all 6-9 year-olds with possible breathing problems. Completion of a questionnaire by each parent/guardian indicated which children had moderate to severe asthma, and what characteristics influenced their access to GP asthma care. A multilevel, negative binomial regression model (NBRM) was fitted to account for the number of reported GP visits for asthma, with adjustment for clustering within schools. Twenty-six schools (89.7 percent) identified 931 children with possible breathing problems. Useable questionnaires were returned to schools by 455 children (48.9 percent). Results indicated 209 children with moderate to severe asthma, almost one in every three reportedly making 5 or more GP visits for asthma in the previous year. Maori, Pacific and Asian children were disproportionately represented among these 'high attendees'. Low attendees (0-2 visits) were mainly NZ Europeans. The NBRM (n=155) showed that expected visits were increased by perceived need, ill-health, asthma severity and, in particular, Maori and Pacific child ethnicity. It may be that Maori and Pacific children no longer face significant barriers to accessing GP asthma care. However, more likely is that barriers apply only to accessing routine, preventative care, leading to poor asthma control, exacerbations requiring acute care, and paradoxically an increase in GP visits. That barriers may increase total numbers of visits challenges the assumption, for all health systems, that access can be defined in terms of barriers that must be overcome to obtain health care.

How much variation in clinical activity is there between general practitioners? A multi-level analysis of decision-making in primary care.

OBJECTIVES: There is considerable policy interest in medical practice variation (MPV). Although the extent of MPV has been quantified for secondary care, this has not been investigated adequately in general practice. Technical obstacles to such analyses have been presented by the reliance on ecological small area variation (SAV) data, the binary nature of many clinical outcomes in primary care and by diagnostic variability. The study seeks to quantify the extent of variation in clinical activity between general practitioners by addressing these problems. METHODS: A survey of nearly 10 000 encounters drawn from a representative sample of general practitioners in the Waikato region of New Zealand was carried out in the period 1991-1992. Participating doctors recorded all details of clinical activity for a sample of encounters. Measures used in this analysis are the issuing of a prescription, the ordering of a laboratory test or radiology examination, and the recommendation of a future follow-up office visit at a specified date. An innovative statistical technique is adopted to assess the allocation of variance for binary outcomes within a multi-level analysis of decision-making. RESULTS: As expected, there was considerable variability between doctors in levels of prescribing, ordering of investigations and requests for follow up. These differences persisted after controlling for case-mix and patient and practitioner attributes. However, analysis of the components of variance suggested that less than 10% of remaining variability occurred at the practitioner level for any of the measures of clinical activity. Further analysis of a single diagnostic group--upper respiratory tract infection--marginally increased the practitioner contribution. CONCLUSIONS: The amount of variability in clinical activity that can definitively be linked to the practitioner in primary care is similar to that recorded in studies of the secondary sector. With primary care doctors increasingly being grouped into larger professional organisations, we can expect application of multi-level techniques to the analysis of clinical activity in primary care at different levels of organisational complexity.

Quality of care indicators for population-based primary care in New Zealand.

AIM: To develop a set of non-invasive, evidence-based, population-based quality of care indicators for primary care in New Zealand and to test their feasibility. METHODS: New Zealand, British and Australian publications were reviewed and a set of quality of care indicators was constructed. These were trialed on data collected from seventeen fully computerised practices from the FirstHealth network of general practices. RESULTS: 28 indicators are proposed in five categories: smoking cessation, preventive health activities, prescribing quality, chronic disease management and data quality. We were able to calculate ten indicators from data already collected routinely, a further twelve could be calculated now with more sophisticated data queries and six would require the trial practices to collect further data. CONCLUSIONS: While any set of indicators is arbitrary there are sufficient research data to support a set of evidence-based, population-focused, quality of care indicators in New Zealand primary health care. In computerised practices these indicators can be calculated from routinely collected data.

Integrated disease management pilot for diabetes.

A New Zealand diabetes program integrates management systems for hospitals and physician practices through a shared integrated care server (ICS), which supports collaborative patient management, virtual consults, and clinical feedback.

The incidence of acute otitis media in New Zealand children under five years of age in the primary care setting.

INTRODUCTION: Acute otitis media (AOM) is a common childhood infection. Baseline data are required to evaluate potential changes in the epidemiology of AOM with new public health measures. AIM: To estimate the incidence of AOM in children under five years of age in primary care in New Zealand. METHODS: Using a cohort study design, consultation notes from 1 November 2008 to 31 October 2009 from 63 primary care facilities were analysed for new and recurrent episodes of AOM, complications, antimicrobial use and outcome. RESULTS: There were 19 146 children in the sample. The raw incidence of AOM was 273 per 1000 children (27.3%; 95% CI 216-330). Of the 3885 children, 2888 (74%) had one episode of AOM and 152 (4%) of these children developed recurrent AOM. Incidence declined with age. There was no difference in incidence between Maori, Pacific and 'Other' ethnicities. Antibiotics were used to treat 2653 (51%) AOM episodes and 113 (4.3%) of these children re-presented within three days of antibiotic therapy for persistent symptoms. Tympanic membrane perforation was the only complication noted, observed in 62 (1%) episodes. DISCUSSION: These data indicate that AOM is an important and frequent childhood infection in New Zealand. The show a significant decline in the use of antibiotics to manage AOM in concordance with accepted best practice. The complication rate of AOM is likely under-represented. This study enables future research into the effectiveness of current and future immunisations and changing management practices in New Zealand.

Teenage use of GP care for moderate to severe asthma in Auckland, New Zealand.

OBJECTIVES: To describe and understand teenagers' frequency of attendance for General Practitioner (GP) care of moderate to severe asthma in the Auckland region. METHODS: Ten Auckland schools identified 510 children aged 13-14 years with breathing problems, who were invited to complete a screening questionnaire. 271 children participated, of whom 114 had moderate to severe asthma. RESULTS: 39% of the 114 had made 0-1 GP visit for asthma, and 17% made 'greater than and equal to' 5 visits. Low attendees (0-1 visit) were disproportionately New Zealand European. High attendees ('greater than and equal to' 5 visits) tended to be Maori and/or Pacific Islanders. Half of the teenagers attended GP asthma care as often as it wanted, independently of ethnicity; 62% tell their parents when they cannot manage their asthma; and 29% must pay for GP care. Expected attendance was increased for Maori and Pacific students versus others by 77% (p=0002), and by asthma of increased severity (p<0.001). Teenager resistance to accessing GP asthma care reduced expected attendance by 24% (p=0.003). CONCLUSIONS: Maori and Pacific peoples have traditionally faced barriers to accessing GP care, but their their more frequent attendance (than New Zealand Europeans) in this case, challenges whether such barriers persist, at least for acute care of moderate to severe asthma.

General practitioners' assessments of the primary care caseload in Middlemore Hospital Emergency Department.

AIM: To estimate the proportion of Middlemore Hospital Emergency Department (ED) attendances that GPs thought could be handled in primary care. METHODS: A retrospective review of 300 randomly selected discharge summaries of non-admitted patients by 12 GPs. RESULTS: Data were available from 278 discharges. Agreement between GP reviewers was "fair" (kappa = 0.34, Kendall's W = 0.48). In 50 cases, the GPs were unanimous that the case was a primary care case (18%). In two cases, there was unanimity that the case was an ED case (<1%). The 12 GPs assessed that an average of 56% (range 38-81%) of the cases they reviewed could have been handled in their surgeries yesterday with no extra resources. This suggests that 34% of the total ED caseload (ie, including admitted patients) could be managed in primary care. CONCLUSIONS: A significant proportion of ED attendances at Middlemore Hospital could be handled in primary care; however, there is considerable variation in GP estimates of this proportion.

Establishing a Maori case management clinic.

AIMS: The Maori Case Management Clinic Project aims to improve Maori health outcomes by establishing low cost, high quality, culturally appropriate primary care facilities in targeted areas, with a focus on the management of chronic illness. Further, the project aims to evaluate this 'by Maori for Maori' model of community healthcare delivery. METHODS: Working in partnership with local Maori health providers, we analysed the available health utilisation and demographic data to choose the three best sites to establish new primary care facilities. We established the facilities with initial start-up funding from Counties Manukau District Health Board. Rigorous evaluation processes have been built into the project. RESULTS: Enrollments at the first of the three clinics exceeded expectations. Client satisfaction as reported by independent evaluators was very high, with cost, cultural acceptability and convenience of location being the three most common reasons given for high satisfaction. CONCLUSIONS: The model adopted has been positively received by the targeted population. Further evaluation will reveal whether this resulted in improved health outcomes.

Integrating healthcare: the Counties Manukau experience.

In 1998, Counties Manukau District Health Board (CMDHB) was experiencing rapidly increasing demands on its secondary services. It was finding it increasingly difficult to meet the health needs of its relatively deprived population. There was widespread evidence of "systems failure", with poor coordination of primary and secondary services. A strategic plan was devised to meet identified priorities and this was subsequently implemented with extensive community involvement. A "disruptive change" model was utilised. Thirty separate projects were undertaken to improve coordination and integration of health services. Brief summaries of all projects are presented, and full evaluations were performed of major projects. Factors critical to project success were: dedicated and effective leadership; involvement of clinical staff; early engagement of the Maori and Pacific community; careful selection of stakeholders; reassurance for providers about privacy issues; close monitoring of project progress; realistic timeframes; and adequate initial funding. CMDHB believes that the critical factor to success in improving the performance of the health sector will be the ability of our key leaders in primary and secondary care, in both management and clinical roles, to adopt a systems view to problem analysis and solution building