Cardiovascular disease preventive medication dispensing for almost every New Zealander 65 years and over: a preventive treatment paradox?

OBJECTIVE: To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes. METHODS: New Zealanders aged ≥65 years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither. RESULTS: Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79-87% were dispensed BPL and 73-79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65-69 years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65-69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26-31% across the 65-84 year age groups, falling to 17% at 85+ years. CONCLUSION: The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often.

Clinical learning environments: place, artefacts and rhythm.

CONTEXT: Health care practitioners learn through experience in clinical environments in which supervision is a key component, but how that learning occurs outside the supervision relationship remains largely unknown. This study explores the environmental factors that inform and support workplace learning within a clinical environment. METHODS: An observational study drawing on ethnographic methods was undertaken in a general medicine ward. Observers paid attention to interactions among staff members that involved potential teaching and learning moments that occurred and were visible in the course of routine work. General purpose thematic analysis of field notes was undertaken. RESULTS: A total of 376 observations were undertaken and documented. The findings suggest that place (location of interaction), rhythm (regularity of activities occurring in the ward) and artefacts (objects and equipment) were strong influences on the interactions and exchanges that occurred. Each of these themes had inherent tensions that could promote or inhibit engagement and therefore learning opportunities. Although many learning opportunities were available, not all were taken up or recognised by the participants. CONCLUSIONS: We describe and make explicit how the natural environment of a medical ward and flow of work through patient care contribute to the learning architecture, and how this creates or inhibits opportunities for learning. Awareness of learning opportunities was often tacit and not explicit for either supervisor or learner. We identify strategies through which tensions inherent within space, artefacts and the rhythms of work can be resolved and learning opportunities maximised.

Assessment of glucose meter performance at the antenatal diabetes clinic: exploration of patient-related and pre-analytical factors.

BACKGROUND: To assess glucose meter performance in a diabetes antenatal clinic, focussing on clinical and pre-analytical factors that might impact on the quantification of meter accuracy and precision. METHODS: The Freestyle Lite and the Performa glucose meters were assessed by trained researchers. Finger stick glucose was measured and compared with plasma venous glucose, obtained from a concomitantly collected antecubital fossa sample. Venous plasma was separated on-site then sent to the laboratory for measurement of glucose using the hexokinase method (comparative method). Additional data collected included: (i) timing of and also (ii) quantity of last carbohydrate intake; (iii) time periods between collection, preparation and analysis of the venous sample; (iv) the haemolysis index of the plasma sample and (v) haematocrit. RESULTS: There were 104 participants. Both meters fulfilled ISO 15197 standards, with 99% and 97% of Freestyle Lite and Performa results, respectively, falling within acceptable limits for this standard. Both meters showed minor proportional bias, reading low at higher glucose values. Consensus error grid analysis showed 100% of results from the Freestyle Lite and 99% from the Performa falling within Zone A, thus the observed differences in measured capillary and venous plasma glucose were sufficiently minor that they would have little effect on clinical action. No association was observed between [capillary-plasma] glucose difference and the five variables outlined above. CONCLUSIONS: The two glucose meters tested showed a reassuringly acceptable level of performance, when assessed by a research team in the setting of a diabetes antenatal clinic.