Hauora Maori - Maori health: a right to equal outcomes in primary care.

BACKGROUND: For more than a century, Maori have experienced poorer health than non-Maori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by "failing to design and administer the current primary health care system to actively address persistent Maori health inequities". Many Maori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Maori-owned practices. We hypothesised patient health outcomes for Maori would differ between models of care. METHODS: Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes. PRIMARY OUTCOMES: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Regressions include only Maori patients, across all models of care. RESULTS: A total of 660,752 Maori patients were enrolled in 924 practices with 124,854 in 65 Maori-owned practices. Maori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Maori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Maori practice had 52% Maori patients compared to 12% across all practices. Maori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Maori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Maori patients were more likely to be dispensed antibiotics or tramadol. CONCLUSIONS: Maori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Maori, despite increased clinical input. Funding must support under-resourced Maori practices and ensure accountability for the health outcomes of Maori patients in all models of general practice.

Is there equity of patient health outcomes across models of general practice in Aotearoa New Zealand? A national cross-sectional study.

BACKGROUND: Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Maori and non-Maori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Maori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care. METHODS: We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response. RESULTS: The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Maori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Maori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Maori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes. CONCLUSIONS: Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care.

Do healthcare services behave as complex systems? Analysis of patterns of attendance and implications for service delivery.

BACKGROUND: The science of complex systems has been proposed as a way of understanding health services and the demand for them, but there is little quantitative evidence to support this. We analysed patterns of healthcare use in different urgent care settings to see if they showed two characteristic statistical features of complex systems: heavy-tailed distributions (including the inverse power law) and generative burst patterns. METHODS: We conducted three linked studies. In study 1 we analysed the distribution of number of contacts per patient with an urgent care service in two settings: emergency department (ED) and primary care out-of-hours (PCOOH) services. We hypothesised that these distributions should be heavy-tailed (inverse power law or log-normal) in keeping with typical complex systems. In study 2 we analysed the distribution of bursts of contact with urgent care services by individuals: correlated bursts of activity occur in complex systems and represent a mechanism by which overall heavy-tailed distributions arise. In study 3 we replicated the approach of study 1 using data systematically identified from published sources. RESULTS: Study 1 involved data from a PCOOH service in Scotland (725,000) adults, 1.1 million contacts) and an ED in New Zealand (60,000 adults, 98,000 contacts). The total number of contacts per individual in each dataset was statistically indistinguishable from an inverse power law (p > 0.05) above 4 contacts for the PCOOH data and 3 contacts for the ED data. Study 2 found the distribution of contact bursts closely followed a heavy-tailed distribution (p < 0.008), indicating the presence of correlated bursts. Study 3 identified data from 17 studies across 8 countries and found distributions similar to study 1 in all of them. CONCLUSIONS: Urgent healthcare use displays characteristic statistical features of large complex systems. These studies provide strong quantitative evidence that healthcare services behave as complex systems and have important implications for urgent care. Interventions to manage demand must address drivers for consultation across the whole system: focusing on only the highest users (in the tail of the distribution) will have limited impact on efficiency. Bursts of attendance - and ways to shorten them - represent promising targets for managing demand.

Changes in Acceleration and Deceleration Capacity Throughout Professional Soccer Match-Play.

Russell, M, Sparkes, W, Northeast, J, Cook, CJ, Love, TD, Bracken, RM, and Kilduff, LP. Changes in acceleration and deceleration capacity throughout professional soccer match-play. J Strength Cond Res 30(10): 2839-2844, 2016-As the acceleration and deceleration demands of soccer are currently not well understood, this study aimed to profile markers of acceleration and deceleration capacity during professional soccer match-play. This within-player observational study required reserve team players from a Premier League club to wear 10-Hz Global Positioning System units throughout competitive matches played in the 2013-14 competitive season. Data are presented for players who completed 4 or more games during the season (n = 11), and variables are presented according to six 15-minute intervals (I1-6: 00:00-14:59 minutes, 15:00-29:59 minutes, 30:00-44:59 minutes, 45:00-59:59 minutes, 60:00-74:59 minutes, and 75:00-89:59 minutes, respectively). During I6, the distance covered (total, per minute, and at high intensity), number of sprints, accelerations (total and high intensity), decelerations (total and high intensity), and impacts were reduced compared with I1 (all p ≤ 0.05). The number of high-intensity impacts remained unchanged throughout match-play (p > 0.05). These findings indicate that high-intensity actions and markers of acceleration and deceleration capacity are reduced in the last 15 minutes of the normal duration of match-play. Such information can be used to increase the specificity of training programs designed for soccer players while also giving further insight in to the effects of 90 minutes of soccer-specific exercise. Interventions that seek to maintain the acceleration and deceleration capacity of players throughout the full duration of a soccer match warrant investigation.

Identifying influenza-like illness presentation from unstructured general practice clinical narrative using a text classifier rule-based expert system versus a clinical expert.

BACKGROUND: We designed and validated a rule-based expert system to identify influenza like illness (ILI) from routinely recorded general practice clinical narrative to aid a larger retrospective research study into the impact of the 2009 influenza pandemic in New Zealand. METHODS: Rules were assessed using pattern matching heuristics on routine clinical narrative. The system was trained using data from 623 clinical encounters and validated using a clinical expert as a gold standard against a mutually exclusive set of 901 records. RESULTS: We calculated a 98.2 % specificity and 90.2 % sensitivity across an ILI incidence of 12.4 % measured against clinical expert classification. Peak problem list identification of ILI by clinical coding in any month was 9.2 % of all detected ILI presentations. Our system addressed an unusual problem domain for clinical narrative classification; using notational, unstructured, clinician entered information in a community care setting. It performed well compared with other approaches and domains. It has potential applications in real-time surveillance of disease, and in assisted problem list coding for clinicians. CONCLUSIONS: Our system identified ILI presentation with sufficient accuracy for use at a population level in the wider research study. The peak coding of 9.2 % illustrated the need for automated coding of unstructured narrative in our study.

Towards a national equitable and sustainable clinical research infrastructure for Aotearoa New Zealand.

Clinical trials are a critical element of a modern, high-functioning, learning healthcare system. Clinical trials provide access to novel, as yet unfunded treatments, and deliver cutting-edge healthcare. Evidence from clinical trials ensures appropriateness of healthcare, allows disinvestment from practices that are found not to improve outcomes or be cost-effective, and supports the introduction of new approaches, all of which leads to improvement in health outcomes. In 2020, Manatu Hauora - Ministry of Health and The Health Research Council of New Zealand funded a project to understand the current state of clinical trial activity in Aotearoa New Zealand and to propose the infrastructure required to support equitable clinical trial activity, in order to ensure that trials benefiting from publicly funded infrastructure are responsive to the needs of New Zealanders and ultimately enable equitable delivery of the best healthcare we can achieve to all New Zealanders. This viewpoint reports the process that was undertaken to develop the final proposed infrastructure and the rationale for the approach. The restructuring of the Aotearoa New Zealand health system into Te Whatu Ora - Health New Zealand and Te Aka Whai Ora - Maori Health Authority that will both operate hospital services and commission primary and community healthcare at a national level provides the ideal opportunity to integrate and embed research into Aotearoa New Zealand's healthcare system. Integration of clinical trials and research more broadly into the public healthcare system will require a significant shift in the culture within our healthcare system. Research must be recognised and promoted as a core activity for clinical staff at all levels of the healthcare system, rather than something to be tolerated or even hindered. Strong leadership will be required from the top of Te Whatu Ora - Health New Zealand down to ensure the required cultural shift to recognise the value of clinical trials to all aspects of the healthcare system, and to grow capability and capacity of the health research workforce. The investment required by the Government to implement the proposed clinical trial infrastructure will be substantial, but now is the ideal time for investment in clinical trials infrastructure in Aotearoa New Zealand. We urge the Government to be bold and invest now to ensure the benefits can be reaped for all New Zealanders in years to come.

The societal cost of unintentional childhood injuries in Aotearoa.

AIMS: To estimate the burden and inequity of unintentional childhood injury for children in Aotearoa. METHODS: We used administrative data from the Accident Compensation Corporation (ACC) and the Ministry of Health to estimate the direct, indirect and intangible costs of unintentional injuries in children aged under 15 and the inequity of the impact of childhood injury on discretionary household income. We used an incidence approach and attributed all costs arising from injuries to the year in which those injuries were sustained. RESULTS: 257,000 children experienced unintentional injury in 2014, resulting in direct and indirect costs of almost $400 million. The burden of lost health and premature death was the equivalent of almost 200 full lives at perfect health. Pacific children had the highest incidence rates. Maori had the lowest rates of ACC claims but the highest rate of emergency department attendance. Children living with the highest levels of socioeconomic deprivation had the highest rate of hospital admission following injury. The proportional loss in discretionary income arising from an injury was higher for Maori and Pacific compared to non-Maori, non-Pacific households. CONCLUSION: The burden of unintentional childhood injury is greater than previously reported and has a substantial and iniquitous societal impact. There should be a focus on addressing inequities in incidence and access to care in order to reduce inequities in health and financial impact.

Men living with obesity in New Zealand: What does this mean for health care in general practice?

INTRODUCTION: More men than women live with overweight and obesity in New Zealand, yet we know little about their everyday lives or their weight management experiences in primary care. This study sought to link the weight management experiences of these men in primary care, with their experiences of life in general as big men. METHODS: Semi-structured interviews with participants selected purposively based on a priori criteria were conducted. Interviews were either face to face or via telephone. Interviews were digitally recorded and transcribed and text coded into a priori codes where established. RESULTS: Fourteen men were interviewed. Analysis of text data revealed three overarching themes. The first, social experience of life as a big man highlighted the significance of social transitions as times of weight gain. The second theme related to experiences of weight management in primary care, with communication the largest sub-theme. Finally, stigma materialised as a key and widespread issue. CONCLUSION: Scant attention has been paid to the experiences of overweight and obese men in primary care or the impact of their size on their daily lives. Effective, tailored communication by health professionals in primary care is sorely needed. Times of social transition can be exploited as appropriate instances to offer advice on effective strategies to reduce the risk of weight gain. Men also need to be made aware of their vulnerability for weight gain at these times through effective, gender specific health promotion messages. The widespread nature of stigmatising experiences within personal networks was a concerning finding.

Routine mortality monitoring for detecting mass murder in UK general practice: test of effectiveness using modelling.

BACKGROUND: The Shipman Inquiry recommended mortality rate monitoring if it could be 'shown to be workable' in detecting a future mass murderer in general practice. AIM: To examine the effectiveness of cumulative sum (CUSUM) charts, cross-sectional Shewhart charts, and exponentially-weighted, moving-average control charts in mortality monitoring at practice level. DESIGN OF STUDY: Analysis of Scottish routine general practice data combined with estimation of control chart effectiveness in detecting a 'murderer' in a simulated dataset. METHOD: Practice stability was calculated from routine data to determine feasible lengths of monitoring. A simulated dataset of 405,000 'patients' was created, registered with 75 'practices' whose underlying mortality rates varied with the same distribution as case-mix-adjusted mortality in all Scottish practices. The sensitivity of each chart to detect five and 10 excess deaths was examined in repeated simulations. The sensitivity of control charts to excess deaths in simulated data, and the number of alarm signals when control charts were applied to routine data were estimated. RESULTS: Practice instability limited the length of monitoring and modelling was consequently restricted to a 3-year period. Monitoring mortality over 3 years, CUSUM charts were most sensitive but only reliably achieved >50% successful detection for 10 excess deaths per year and generated multiple false alarms (>15%). CONCLUSION: At best, mortality monitoring can act as a backstop to detect a particularly prolific serial killer when other means of detection have failed. Policy should focus on changes likely to improve detection of individual murders, such as reform of death certification and the coroner system.

Explicit rationing of elective services: implementing the New Zealand reforms.

In an attempt to make rationing of elective surgery in the publicly funded health system more explicit, New Zealand has developed a booking system for surgery using clinical priority assessment criteria (CPAC). This paper is based on research undertaken to evaluate the use of CPAC. To explore whether the goals of explicit rationing were being met 69 interviews were undertaken with policy advisors, administrators and clinicians in six localities throughout New Zealand. The aims of reforming policy for access to elective surgery included improving equity, providing clarity for patients, and achieving a paradigm shift by relating likely benefit from surgery to the available resources. The research suggests that there have been changes in the way in which patients access elective surgery and that in many ways rationing has become more explicit. However, there is also some resistance to the use of CPAC, in part due to confusion over whether the tools are decision-aids or protocols, what role the tools play in achieving equity and differences between financial thresholds for access to surgery and clinical thresholds for benefit from surgery. For many surgical specialties implicit rationing will continue to play a major part in determining access to surgery unless validated and reliable CPAC tools can be developed.

Equity of access to elective surgery: reflections from NZ clinicians.

OBJECTIVES: To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians' perceptions of equity and the factors they consider when prioritising patients for elective surgery. METHODS: A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically. RESULTS: General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians' perceptions of the 'value' that patients would receive from the surgery and patients' needs for public sector funding. CONCLUSIONS: The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.

Use of, and attitudes to, clinical priority assessment criteria in elective surgery in New Zealand.

OBJECTIVES: To describe the ways patients access elective surgery in New Zealand, and to understand the use of, and attitudes to, clinical priority assessment criteria (CPAC) in determining access to publicly funded elective surgery. METHODS: A qualitative study in selected New Zealand localities. A purposive sample of general practitioners, surgeons and administrators in publicly funded hospitals were interviewed. Data were analysed by a process of thematic analysis. RESULTS: Sixty-five interviews were completed. General practitioners had a key role in determining which patients were seen in the public sector and, by utilising strategies to actively advocate for patients, influenced both waiting times for first assessment by surgeons and for surgery. CPAC had been developed as decision support guides with the intention that they would provide transparency and equity in determining access. However, there was variation in the way CPAC were being used both in score construction and in the influence of the score on access to surgery. The management of the hospital system also limited the extent to which CPAC could be used to prioritise patients for surgery. CONCLUSIONS: Variability in the use of CPAC tools meant that at the time of the study they did not provide a transparent and equitable method of determining access to surgery. This highlights the difficulties in developing and implementing CPAC and suggests that further development is difficult in the absence of evidence to identify patients who will benefit the most from surgery.

Clinicians' reported use of clinical priority assessment criteria and their attitudes to prioritization for elective surgery: a cross-sectional survey.

OBJECTIVES: To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). DESIGN: A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. SETTING: New Zealand. PARTICIPANTS: A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. RESULTS: Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. CONCLUSIONS: Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.

Whole population secondary prevention of coronary heart disease in Scotland: the HEARTS database.

Implementing the evidence base for the management of chronic disease is as challenging as discovering which interventions are effective. The HEARTS collaboration (Heart disease Evidence-based Audit and Research in Tayside Scotland) is achieving that goal for the secondary prevention of coronary heart disease (CHD by linking national databases to manually validated hospital and family practice electronic patient records. Specific data from the system is fed back to practices in a facilitated educational process and through the NHS intranet. This paper describes some of the key features of this strategic decision support system. All residents of the Tayside region of Scotland (n=484,013 mid year estimate 2002) are covered by the system. 9,828 patients who have suffered a myocardial infarction(MI) or who have undergone angioplasty or bypass surgery are registered on the system. Improvements in clinical status and prescribing of effective therapies are 5-10% greater than elsewhere in Scotland.

Attitudes of teachers to evidence based medicine.

AIM: To describe the attitudes of general practitioners and specialist clinical teachers toward teaching evidence based medicine (EBM). PARTICIPANTS AND METHODS: Questionnaire survey of 114 general practitioner and 162 specialist university teachers teaching EBM. RESULTS: Two hundred and six (80%) teachers responded; 196 regularly consulted with patients, 21% had received training, and 40% taught EBM. Those with formal training (68%) taught more often than without (32%) (p = 0.0001), 27% had taught EBM for over 5 years. More GPs (57%) than specialists (40%) asked students to assist in finding evidence (p = 0.036). Most welcomed EBM and were confident in teaching it. Barriers included antagonism to EBM philosophy, shortage of time, and a need for training in teaching EBM. DISCUSSION: Although not all trained, GPs and specialists teach EBM, enjoy doing so, and want to increase their ability to teach it.

The financial impact of clinical task substitution between practice nurses and GPs in New Zealand primary care centres.

AIM: To describe the financial impact on practice owners of increased clinical task substitution between practice nurses and GPs in New Zealand (NZ) primary care settings. METHOD: Case studies of 9 primary health care centres involving: interviews; collation of service and financial information; and nurse and GP diaries covering 1826 consultations. Results were compared with previous NZ large N survey results to develop a model predicting the financial impact of task substitution. RESULTS: The proportion of general practice primary care consultations undertaken by nurses varied from 4% to 46% of total recorded consultations. The actual financial impact for a practice owner of substituting more nursing time for GP time is highly dependent on the following variables: nurse cost per minute relative to GP cost minute; nurse consult duration relative to GP consult duration; nurse consult revenue relative to GP consult revenue; and the proportion of nurse consults also requiring GP time. CONCLUSION: Practice nurses can (and in some practices in NZ, do) provide a broad set of primary care services, including undifferentiated general consultations. For some practices, increasing the proportion of nurse consults and reducing GP consults, would result in significantly improved profitability--for others, the opposite applies. Clinical task substitution is one option to address the forecast increase in demand associated with population aging.

Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence.

OBJECTIVES: To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety. DATA SOURCES: 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance. STUDY SELECTION: 19 high-quality studies that assessed outcomes were included. DATA EXTRACTION: All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives. DATA SYNTHESIS: Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance. CONCLUSIONS: The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.