Socio-demographic profile of medical students in Aotearoa, New Zealand (2016-2020): a nationwide cross-sectional study.

OBJECTIVE: To determine the socio-demographic profile of all students enrolled to study medicine in Aotearoa New Zealand (NZ). DESIGN AND SETTING: Observational, cross-sectional study. Data were sought from the Universities of Auckland and Otago, the two NZ tertiary education institutions providing medical education, for the period 2016-2020 inclusive. These data are a subset of the larger project 'Mirror on Society' examining all regulated health professional enrolled students in NZ. VARIABLES OF INTEREST: gender, citizenship, ethnicity, rural classification, socioeconomic deprivation, school type and school socioeconomic scores. NZ denominator population data (18-29 years) were sourced from the 2018 census. PARTICIPANTS: 2858 students were enrolled to study medicine between 2016 and 2020 inclusive. RESULTS: There were more women (59.1%) enrolled to study medicine than men (40.9%) and the majority (96.5%) were in the 18-29 years age range. Maori students (rate ratio 0.92; 95% CI 0.84 to 1.0) and Pacific students (rate ratio 0.85; 95% CI 0.73 to 0.98) had lower overall rates of enrolment. For all ethnic groups, irrespective of rural or urban origin, enrolment rates had a nearly log-linear negative relationship with increasing socioeconomic deprivation. Enrolments were lower for students from rural areas compared with those from urban areas (rate ratio 0.53; 95% CI 0.46-0.61). Overall NZ's medical students do not reflect the diverse communities they will serve, with under-representation of Maori and Pacific students and students who come from low socioeconomic and rural backgrounds. CONCLUSIONS: To meaningfully address these issues, we suggest the following policy changes: universities commit and act to Indigenise institutional ways of knowing and being; selection policies are reviewed to ensure that communities in greatest need of doctors are prioritised for enrolment into medicine (specifically, the impact of low socioeconomic status should be factored into selection decisions); and the government fund more New Zealanders to study medicine.

Medication-related harm in New Zealand general practice: a retrospective records review.

BACKGROUND: The extent of medication-related harm in general practice is unknown. AIM: To identify and describe all medication-related harm in electronic general practice records. The secondary aim was to investigate factors potentially associated with medication-related harm. DESIGN AND SETTING: Retrospective cohort records review study in 44 randomly selected New Zealand general practices for the 3 years 2011-2013. METHOD: Eight GPs reviewed 9076 randomly selected patient records. Medication-related harms were identified when the causal agent was prescribed in general practice. Harms were coded by type, preventability, and severity. The number and proportion of patients who experienced medication-related harm was calculated. Weighted logistic regression was used to identify factors associated with harm. RESULTS: In total, 976 of 9076 patients (10.8%) experienced 1762 medication-related harms over 3 years. After weighting, the incidence rate of all medication-related harms was 73.9 harms per 1000 patient-years, and the incidence of preventable, or potentially preventable, medication-related harms was 15.6 per 1000 patient-years. Most harms were minor (n = 1385/1762, 78.6%), but around one in five harms were moderate or severe (n = 373/1762, 21.2%); three patients died. Eighteen study patients were hospitalised; after weighting this correlates to a hospitalisation rate of 1.1 per 1000 patient-years. Increased age, number of consultations, and number of medications were associated with increased risk of medication-related harm. Cardiovascular medications, antineoplastic and immunomodulatory agents, and anticoagulants caused most harm by frequency and severity. CONCLUSION: Medication-related harm in general practice is common. This study adds to the evidence about the risk posed by medication in the real world. Findings can be used to inform decision making in general practice.

Characteristics of a stratified random sample of New Zealand general practices.

INTRODUCTION Practice size and location may affect the quality and safety of health care. Little is known about contemporary New Zealand general practice characteristics in terms of staffing, ownership and services. AIM To describe and compare the characteristics of small, medium and large general practices in rural and urban New Zealand. METHODS Seventy-two general practices were randomly selected from the 2014 Primary Health Organisation database and invited to participate in a records review study. Forty-five recruited practices located throughout New Zealand provided data on staff, health-care services and practice ownership. Chi-square and other non-parametric statistical analyses were used to compare practices. RESULTS The 45 study practices constituted 4.6% of New Zealand practices. Rural practices were located further from the nearest regional base hospital (rural median 65.0 km, urban 7.5 km (P < 0.001)), nearest local hospital (rural 25.7 km, urban 7.0 km (P = 0.002)) and nearest neighbouring general practitioner (GP) (rural 16.0 km, urban 1.0 km (P = 0.007)). In large practices, there were more enrolled patients per GP FTE than both medium-sized and small practices (mean 1827 compared to 1457 and 1120 respectively, P = 0.019). Nurses in large practices were more likely to insert intravenous lines (P = 0.026) and take blood (P = 0.049). There were no significant differences in practice ownership arrangements according to practice size or rurality. CONCLUSION Study practices were relatively homogenous. Unsurprisingly, rural practices were further away from hospitals. Larger practices had higher patient-to-doctor ratios and increased nursing scope. The study sample is small; findings need to be confirmed by specifically powered research.

Research using electronic health records: Balancing confidentiality and public good.

General practitioners are increasingly approached to participate in research and share de-identified patient information. Research using electronic health records has considerable potential for improving the quality and safety of patient care. Obtaining individual patient consent for the use of the information is usually not feasible. In this article we explore the ethical issues in using personal health information in research without patient consent including the threat to confidentially and the doctor-patient relationship, and we discuss how the risks can be minimised and managed drawing on our experience as general practitioners and researchers.

Epidemiology of Patient Harms in New Zealand: Protocol of a General Practice Records Review Study.

BACKGROUND: Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety. OBJECTIVE: We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records. METHODS: "Harm" is defined as disease, injury, disability, suffering, and death, arising from the health system. The study design is a stratified, 2-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study's results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between 6 study groups (large, medium-sized, small; urban and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review 3 years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double-blinded reviews will check the concordance of reviewers' assessments. Study data will comprise demographic data of all 9000 patients and reviewers' assessments of whether patients experienced harm arising from health care. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 18.0. RESULTS: We have recruited practices and collected electronic records from 9078 patients. Reviews of these records are under way. The study is expected to be completed in August 2017. CONCLUSIONS: The design of this complex study is presented with discussion on data collection methods, sampling weights, power analysis, and statistical approach. This study will show the epidemiology of patient harms recorded in general practice records for all of New Zealand and will show whether this epidemiology differs by rural location and clinic size.

Using triggers in primary care patient records to flag increased adverse event risk and measure patient safety at clinic level.

AIM: Using triggers to identify adverse events is proposed as an efficient means of consistently measuring, and tracking events that result in harm to patients. We aimed to test whether using triggers in our large provincial general practice could provide meaningful directions for improving safety. METHOD: A literature review identified potential triggers and established the number of patients whose records we should review. Two teams independently reviewed 170 randomly selected patients' records for trigger presence and for evidence of harm relating to that trigger. All triggers were tested for sensitivity and specificity: triggers with low specificity were removed. Logistic regression was used on both initial and refined trigger sets to measure the odds ratio (OR) of harm occurring if a trigger was present. RESULTS: Initially 36 triggers were identified. Applying these to 109.6 patient-years of records for 170 patients, we identified harm in the records of 46 (27.1%) patients. There were 7 occurrences of harm per 100 consultations (harm rate per consultation=0.07 (95% confidence interval [CI] 0.05-0.09) and 41 per 100 consulting patient years (95%CI 29-55). All harms related to medication use. The initial triggers were sensitive (0.98) but non-specific (0.08): removing triggers with low specificity left only 8. The OR for harm occurring using the initial triggers was 4.0 (95% 0.5-30) and using the refined trigger set OR=6.3 (95%CI 2.7-14.8). CONCLUSION: 8 selected triggers are a useful way of measuring progress towards safer care for patients in primary care practice.

Systematic care to reduce ethnic disparities in diabetes care.

AIMS: We sought to determine whether systematic care can reduce the gap in diabetes control between Maori and non-Maori. METHODS: A Primary Health Organisation implemented a chronic care management programme for diabetes in 2005. The data constitute an open, prospective cohort followed for approximately two years. Data describing process were also collected. RESULTS: There were 1311 people with diabetes (354 Maori, 957 non-Maori). Maori started with higher HbA(1c) (mean 8.1%, SD 1.9) than non-Maori (7.1%, SD 1.4) but over about 2 years HbA(1c) for Maori improved to that of non-Maori. LDL and systolic blood pressure decreased for both groups. Improved glucose in Maori was not due to starting insulin or metformin, and rates of sulphonylurea prescription increased in both groups. Urinary albumin:creatinine ratio remained higher for Maori throughout. Smoking rates and Body Mass Index (both higher in Maori) did not change. There is no evidence of selective retention in the cohort. CONCLUSION: Likely essential components of the programme were that governance was equally shared between Maori and non-Maori; prolonged nurse consultations were free to the patient; nurses used a formal written wellness plan; nurses were formally trained to support patient self-management; and a computer template supported structured care.