The concentration of complexity: case mix in New Zealand general practice and the sustainability of primary care.

Introduction New Zealand general practice and primary care is currently facing significant challenges and opportunities following the impact of the coronavirus disease 2019 (COVID-19) pandemic and the introduction of health sector reform. For future sustainability, it is important to understand the workload associated with differing levels of patient case mix seen in general practice. Aim To assess levels of morbidity and concomitant levels of socio-economic deprivation among primary care practices within a large primary health organisation (PHO) and associated Maori provider network. Methods Routinely collected practice data from a PHO of 57 practices and a Maori provider (PHO) of five medical practices in the same geographical area were used to compare a number of population health indicators between practices that had a high proportion of high needs patients (HPHN) and practices with a low proportion of high needs patients (Non-HPHN). Results When practices in these PHOs are grouped in terms of ethnicity distribution and deprivation scores between the HPHN and Non-HPHN groups, there is significantly increased clustering of both long-term conditions and health outcome risk factors in the HPHN practices. Discussion In this study, population adverse health determinants and established co-morbidities are concentrated into the defined health provider grouping of HPHN practices. This 'concentration of complexity' raises questions about models of care and adequate resourcing for quality primary care in these settings. The findings also highlight the need to develop equitable and appropriate resourcing for all patients in primary care.

Quantifying the incidence and burden of herpes zoster in New Zealand general practice: a retrospective cohort study using a natural language processing software inference algorithm.

OBJECTIVE: To investigate the incidence of primary care presentations for herpes zoster (zoster) in a representative New Zealand population and to evaluate the utilisation of primary healthcare services following zoster diagnosis. DESIGN: A cross-sectional retrospective cohort study used a natural language processing software inference algorithm to identify general practice consultations for zoster by interrogating 22 million electronic medical record (EMR) transactions routinely recorded from January 2005 to December 2015. Data linking enabled analysis of the demographics of each case. The frequency of doctor visits was assessed prior to and after the first consultation diagnosing zoster to determine health service utilisation. SETTING: General practice, using EMRs from two primary health organisations located in the lower North Island, New Zealand. PARTICIPANTS: Thirty-nine general practices consented interrogation of their EMRs to access deidentified records for all enrolled patients. Out-of-hours and practice nurse consultations were excluded. MAIN OUTCOME MEASURES: The incidence of first and repeated zoster-related visits to the doctor across all age groups and associated patient demographics. To determine whether zoster affects workload in general practice. RESULTS: Overall, for 6 189 019 doctor consultations, the incidence of zoster was 48.6 per 10 000 patient-years (95% CI 47.6 to 49.6). Incidence increased from the age of 50 years to a peak rate of 128 per 10 000 in the age group of 80-90 years and was significantly higher in females than males (p<0.001). Over this 11-year period, incidence increased gradually, notably in those aged 80-85 years. Only 19% of patients had one or more follow-up zoster consultations within 12 months of a zoster index consultation. The frequency of consultations, for any reason, did not change between periods before and after the diagnosis. CONCLUSIONS: Zoster consultations in general practice are rare, and the burden of these cases on overall general practice caseload is low.

Childhood respiratory illness presentation and service utilisation in primary care: a six-year cohort study in Wellington, New Zealand, using natural language processing (NLP) software.

OBJECTIVES: To identify childhood respiratory tract-related illness presentation rates and service utilisation in primary care by interrogating free text and coded data from electronic medical records. DESIGN: Retrospective cohort study. Data interrogation used a natural language processing software inference algorithm. SETTING: 36 primary care practices in New Zealand. Data analysed from January 2008 to December 2013. PARTICIPANTS: The records from 77 582 children enrolled were reviewed over a 6-year period to estimate the presentation of childhood respiratory illness and service utilisation. This cohort represents 268 919 person-years of data and over 650 000 unique consultations. MAIN OUTCOME MEASURE: Childhood respiratory illness presentation rate to primary care practice, with description of seasonal and yearly variation. RESULTS: Respiratory conditions constituted 46% of all child-general practitioner consultations with a stable year-on-year pattern of seasonal peaks. Upper respiratory tract infection was the most common respiratory category accounting for 21.0% of all childhood consultations, followed by otitis media (12.2%), wheeze-related illness (9.7%), throat infection (7.4%) and lower respiratory tract infection (4.4%). Almost 70% of children presented to their general practitioner with at least one respiratory condition in their first year of life; this reduced to approximately 25% for children aged 10-17. CONCLUSION: This is the first study to assess the primary care incidence and service utilisation of childhood respiratory illness in a large primary care cohort by interrogating electronic medical record free text. The study identified the very high primary care workload related to childhood respiratory illness, especially during the first 2 years of life. These data can enable more effective planning of health service delivery. The findings and methodology have relevance to many countries, and the use of primary care 'big data' in this way can be applied to other health conditions.

Better, Sooner, More Convenient? The reality of pursuing greater integration between primary and secondary healthcare providers in New Zealand.

OBJECTIVES: This article focuses on the results of evaluations of two business plans developed in response to a policy initiative which aimed to achieve greater integration between primary and secondary health providers in New Zealand. We employ the Consolidated Framework for Implementation Research to inform our analysis. The Better, Sooner, More Convenient policy programme involved the development of business plans and, within each business plan, a range of areas of focus and associated work-streams. METHODS: The evaluations employed a mixed method multi-level case study design, involving qualitative face-to-face interviews with front-line staff, clinicians and management in two districts, one in the North Island and the other in the South Island, and an analysis of routine data tracked ambulatory sensitive hospitalisations and emergency department presentations. Two postal surveys were conducted, one focussing on the patient care experiences of integration and care co-ordination and the second focussing on the perspectives of health professionals in primary and secondary settings in both districts. RESULTS: Both evaluations revealed non-significant changes in ambulatory sensitive hospitalisations and emergency department presentation rates and slow uneven progress with areas of focus and their associated work-streams. Our evaluations revealed a range of implementation issues, the barriers and facilitators to greater integration of healthcare services and the implications for those who were responsible for putting policy into practice. CONCLUSION: The business plans were shown to be overly ambitious and compromised by the size and scope of the business plans; dysfunctional governance arrangements and associated accountability issues; organisational inability to implement change quickly with appropriate and timely funding support; an absence of organisational structural change allowing parity with the policy objectives; barriers that were encountered because of inadequate attention to organisational culture; competing additional areas of focus within the same timeframe; and consequent overloading of front-line staff which led to workload stress, fatigue and disillusionment. Where success was achieved, this largely hinged on the enthusiasm of a small pool of front-line workers and their initial buy-into the idea of integrated care.

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.

The effect of spatial barriers on realised accessibility to heath services after a natural disaster.

The closure of the Manawatu Gorge in New Zealand in August 2011 caused a change in the travel time for patients living in the east of the MidCentral Health District to their health services located in Palmerston North. This presented an opportunity to study the effect a change in spatial access had on a population before and after such an event. We used a retrospective cohort design with routinely collected data from general practice and hospital services. Realised accessibility was calculated for 101,456 patients over 3.5 years. General practice utilization appeared to be the only service affected negatively during the gorge closure (rate ratio 1.106). Outpatient attendances had an increase in use by those with increased travel time (rate ratio 0.922). There was evidence of other unidentified factors that impacted the use of services across both intervention and control groups between the gorge open and closed periods. These results were more conservative than those produced by a traditional uncontrolled travel time category analysis which suggested a correlation in non-urgent ED attendance and general practice and boundary effects in all ED attendances and hospital admissions.

Patients consulting outside of funded practices within primary health organisations: implications for utilisation reporting.

AIM: To consider two definitions for utilisation reporting in primary care in New Zealand and to assess the affect of two reporting methods on volumes of utilisation in four primary health organisations (PHOs). METHODS: Utilisation data was analysed for a 6-month period from 60 practices across four PHOs. Analysis was based on comparing the expected volumes from two alternative collection and reporting methods, named "matched" and "unmatched" reporting. The "unmatched" method is potentially sensitive to patients consulting outside of the practice in which they are funded. Volumes were grouped into categories based on those used for reporting. RESULTS: There was up to 25% difference in volumes in some reporting groups depending on the matching method used. Several of these were for high deprivation, New Zealand Maori, Pacific Islanders, and Community Service Card (CSC) holders--all potentially target populations within PHOs. Two PHOs were more affected having a total of 7.6% and 6.4% fewer reported encounters using the "unmatched" method. Data implies that some groups of patients may not be receiving continuity of care. CONCLUSIONS: There were differences in reporting volumes between the two methods. The Ministry of Health (MOH), district health boards (DHBs), and PHOs should be aware of how these results may potentially apply to them, especially where they have after-hours services or target groups as minorities.