Comparison of three targeted approaches to screening for abdominal aortic aneurysm based on cardiovascular risk.

BACKGROUND: Abdominal aortic aneurysm (AAA) continues to be a significant health burden yet few countries have implemented a comprehensive screening programme. Screening typically places emphasis on men aged over 65 years; however, there is concern that other at-risk groups may be underidentified. The present study examined three potential screening strategies based on cardiovascular risk. METHODS: The prevalence of AAA was determined by abdominal ultrasound imaging in over 50-year-olds of either sex undergoing coronary angiography, vascular laboratory assessment of peripheral arterial disease, or community-based cardiovascular disease (CVD) event risk assessment. A fourth group, consisting of volunteers aged over 60 years who had no symptoms or signs of cardiovascular disease, was used as a comparator group. RESULTS: A total AAA prevalence of 4·4 per cent was detected across all three strategies (137 of 3142 individuals), compared with 1·0 per cent in the CVD-free group. Male sex, age and smoking were all associated with greater AAA prevalence. Although AAA prevalence was lowest using the community-based strategy, those with an AAA detected were on average 7 years younger than those with AAAs detected with the other two strategies (P < 0·001). CONCLUSION: Different strategies, based on CVD risk, resulted in AAA prevalence rates that were significantly greater than that in CVD-free individuals. This may provide opportunities for a targeted approach to community AAA screening in parts of the world where more sophisticated national screening programmes do not exist.

Care plans for acutely deteriorating COPD: a randomized controlled trial.

INTRODUCTION: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for admission to hospital and are responsible for the majority of the direct economic costs of treating COPD. AIMS: To test whether an individualized care plan for patients experiencing acute exacerbations of COPD result in reduced health care utilization and improved quality of life for patients. METHODS: Ninety-two patients with confirmed COPD were selected by general practitioners or district nurses, and randomly assigned to care plan or usual care groups. The care plan was developed in collaboration with general practitioners, secondary care specialists, specialist nurses, ambulance service providers and the after hours clinic. Patients were followed for 12 months, and the primary end-points were frequency of use of primary care services and hospital admissions. RESULTS: There was no significant reduction in hospital admissions or improvement in quality of life in the group of patients who used the care plan compared to controls. The care plan group called out the ambulance service more frequently [2.8 (1.3, 4.3) versus 1.1 (0.7, 1.5) calls per 12 months; P = 0.03], and there was a trend towards greater use of oral prednisone [2.3 (1.4, 3.2) versus 1.3 (0.8, 1.8) courses per 12 months; P = 0.06]. CONCLUSION: In contrast to asthma, the provision of individualized self-management plans, whose content was enhanced to provide guidance to carers and health care professionals, did not reduce health care utilization or improve overall quality of life during acute exacerbations of COPD. Other strategies are required.

Creating a general practice national minimum data set: present possibility or future plan?

AIM: To assess the feasibility of implementing the recommendations of the New Zealand National Minimum Data Set working party in computerised general practices. METHOD: Doctors from 12 computerised general practices belonging to the Royal New Zealand College of General Practitioners' Dunedin Research Unit Computer Network participated in the study (five Dunedin practices, four in rural Otago and Southland, and three in Christchurch). A three-month sample of data was extracted from practice computers and evaluated for completeness and compliance to the national minimum data set structure. Rates of recording practice identifier, provider, patient identifiers, sex, ethnicity, government subsidy eligibility, consultation identifier and date, prescriptions and Read codes were calculated for each practice. RESULTS: Apart from data recorded automatically by computers, there was a wide range in the extent of missing data. Of the data requiring manual computer entry, patient demography and subsidy eligibility were most comprehensively recorded (date of birth 99.9%, sex 99.6%, eligibility to subsidies 98.5%). Data with little immediate clinical or management relevance were poorly recorded (Read codes 32.4% and ethnicity 5.0%). CONCLUSIONS: It is possible to derive a common minimum data set from different computerised general practices. However some data elements will be missing unless suitable education and support are provided for the doctors and other staff members who record patient information.

The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners.

OBJECTIVES: The purpose of this study was to determine whether written advice from general practitioners increases physical activity among sedentary people more than verbal advice alone. METHODS: Sedentary patients (n = 456) received verbal advice on increasing physical activity and were then randomized to an exercise prescription (green prescription) group or a verbal advice group. RESULTS: The number of people engaging in any recreational physical activity at 6 weeks increased substantially, but significantly more so in the green prescription group. Also, more participants in the green prescription group increased their activity over the period. CONCLUSIONS: A written goal-oriented exercise prescription, in addition to verbal advice, is a useful tool for general practitioners in motivating their parents to increase physical activity.

Green prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise.

BACKGROUND: This qualitative study was part of a broader randomized controlled trial which showed that written exercise advice (green prescription) from a general practitioner (GP) increased physical activity levels among sedentary patients more than verbal advice alone over a 6-week period. AIM: To assess the attitudes and perceptions of GPs towards the practice of writing green prescriptions. METHOD: Participating GPs (n = 25) discussed attitudes and perceptions towards green prescriptions through structured focus groups within 2 weeks of the end of recruitment for the main study. RESULTS: The GPs felt comfortable discussing and prescribing exercise with and to patients. They preferred giving green prescriptions to giving verbal advice alone, and felt they were a valuable tool to formalize and document mutually agreed exercise goals. Time constraints were identified as a major barrier to the widespread implementation of green prescriptions. Appropriate training, resource materials, and patient follow-up mechanisms were identified as important elements for successful implementation of the strategy. CONCLUSION: Overall, the GPs were very positive about the green prescription concept, believing it to be beneficial for patients and achievable within general practice.

Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women.

OBJECTIVE: To assess the effectiveness of a home exercise programme of strength and balance retraining exercises in reducing falls and injuries in elderly women. DESIGN: Randomised controlled trial of an individually tailored programme of physical therapy in the home (exercise group, n = 116) compared with the usual care and an equal number of social visits (control group, n = 117). SETTING: 17 general practices in Dunedin, New Zealand. SUBJECTS: Women aged 80 years and older living in the community and registered with a general practice in Dunedin. MAIN OUTCOME MEASURES: Number of falls and injuries related to falls and time between falls during one year of follow up; changes in muscle strength and balance measures after six months. RESULTS: After one year there were 152 falls in the control group and 88 falls in the exercise group. The mean (SD) rate of falls was lower in the exercise than the control group (0.87 (1.29) v 1.34 (1.93) falls per year respectively; difference 0.47; 95% confidence interval 0.04 to 0.90). The relative hazard for the first four falls in the exercise group compared with the control group was 0.68 (0.52 to 0.90). The relative hazard for a first fall with injury in the exercise group compared with the control group was 0.61 (0.39 to 0.97). After six months, balance had improved in the exercise group (difference between groups in change in balance score 0.43 (0.21 to 0.65). CONCLUSIONS: An individual programme of strength and balance retraining exercises improved physical function and was effective in reducing falls and injuries in women 80 years and older.

Abdominal pain in New Zealand general practice.

AIM: To describe the clinical management of patients presenting with abdominal pain to New Zealand general practitioners. METHODS: A study sample was drawn from a computer database of general practice consultation records. Over the 12 month period 1 July 1993 to 30 June 1994, 4606 consultations for abdominal pain were analysed. RESULTS: Of patients seen in general practice 2.1% consulted with abdominal pain. The majority of patients were women aged 16-45, who presented within one week of onset of symptoms. A diagnosis was recorded in only 55% of cases but management did not appear to be dependent on a diagnosis being made. Treatment was offered in 75% of consultations, though only 34.9% resulted in a prescription. CONCLUSIONS: Abdominal pain is a common presentation in general practice. We should be aware that it is often of indeterminate aetiology and often resolves spontaneously.

Otitis media treatment in New Zealand general practice.

AIMS: To compare incidence and general practice treatments for acute (AOM), serous (OME), and recurrent (ROM) otitis media in New Zealand. METHODS: A retrospective analysis of 2901 consultations for otitis media was undertaken. Specific diagnostic groups were compared for antibiotic treatments offered, duration of therapy, and treatment success. Twenty New Zealand general practices contributed 290100 computerised consultation records generated between 1 July 1993 and 30 June 1994. Records from 2089 otitis media patients were examined to determine incidence and treatment success. RESULTS: Most initial acute otitis media and recurrent otitis media presentations resulted in antibiotic treatment (96.6% and 94.9%): fewer otitis media with effusion presentations (77.6%) were initially treated with antibiotics. Age and treatment success were significantly associated for patients with acute otitis media: patients < 2 years were least likely to be successfully treated (p < 0.0001). There was no difference in success rates between antibiotic and no antibiotic therapies. Antibiotic therapy duration ranged from < 6 days to 40 days. Shorter courses were as likely as longer courses to be successful for all diagnoses. CONCLUSIONS: The outcome of otitis media episodes is more closely related to patients' age than to specific diagnosis, type or duration of therapy.

The computer research network of the Royal New Zealand College of General Practitioners: an approach to general practice research in New Zealand.

Computers are now in widespread use by general practitioners (GPs) in many countries. In New Zealand this development has advanced general practice research by enabling collaboration among a small population of doctors practising in geographically diverse locations. This paper reviews the establishment of the Computer Research Network of the Royal New Zealand College of General Practitioners (RNZCGP) and its development between 1990 and 1995. The Network consists of 181 general practices (approximately 450 GPs) from throughout urban and rural New Zealand. All participants use computers in their practices to record consultation notes and to generate prescriptions, investigations and referral forms. Computer programs developed in the RNZCGP Research Unit are run on commercial software in doctors' surgeries to provide anonymous, individual data. In addition to the routine analysis of utilization for feedback to participants, 13 research projects have been completed. These include investigations of access to general practice care, use of health services by individuals and families, surveillance of immunization uptake, epidemiology of common conditions, and the use of pharmaceuticals in general practice. The RNZCGP Computer Research Network is an example of a computerized general practice research network that has been productive without receiving significant financial resources or having a formal management structure.

Changes in payments for general practice consultations 1989-93.

AIMS: Information generated by the computer systems of general practitioners was examined to determine whether general practitioners fee structures during 1993 were different from those reported in 1989. METHODS: Copies of the general medical services (GMS) claims and actual consultation charges to patients were examined to determine whether patients had been charged the doctors' regular fee or an amount greater or less than this, in 1993. These data were compared with results from a previous study describing charging data in 1989. RESULTS: Information on 59,215 consultations was collected in 1993 and compared with information on 97,869 consultations collected in 1989. The proportion of consultations which resulted in a regular fee being charge had reduced from 47.0% in 1989 to 34.1% in 1993 (p < 0.001). The proportion of cases in which a less than normal fee was charged had risen 7.9 times from 3.5% in 1989 to 27.5% in 1993 (p < 0.001). The contribution of Accident Compensation (ACC) funding for general practitioner consultations had reduced from 17.5% of consultations in 1989 to 10.1% of 1993 consultations (p < 0.001). Excluding consultations in which a maternity or immunisation claim was made, 19.4% of consultations in 1993 generated no fee to the patient. CONCLUSION: In the 4 years between these two data collections, changes in the contribution of different agencies funding general practice care is marked. Public agencies have diminished input and both patients and practitioners are carrying more of the financial burden for access to primary care.

Differences between prescribed and dispensed medications.

AIMS: To describe differences between general practice prescribed and dispensed medications in terms of patient characteristics and category of drug. METHODS: Computerised prescribing records and prescriptions presented to pharmacies were retrospectively reviewed. All prescriptions generated from the computers of 13 practices over a 12 week period in 1992 were compared with prescriptions dispensed. Data from the two sources were matched and unmatched items were analysed to determine whether patient demography or category of drug prescribed influenced the rate of prescription dispensing. The nine most commonly prescribed drug categories were examined in detail. RESULTS: A total of 49 756 items were prescribed to 19 299 people and 43 302 (87.0%) of these were dispensed. Antibiotics were the most commonly prescribed category of the drug accounting for 17.6% of nondispensed items. There was no significant difference by gender in the proportion of people (9.8%) failing to claim prescribed items, nor in the number of items (13.0%) prescribed but not dispensed. Differences in dispensing rates by community services card (CSC) status of patients were statistically significant for both numbers of people failing to uplift their medications and for numbers of items not dispensed (p<0.001). There were also significant differences by high user health card (HUH) eligibility (p<0.005) and age (p<0.001). CONCLUSIONS: There is a high rate of nondispensing of medicines prescribed in general practice. Patients eligible for government subsidies are more likely than other patients to have their prescriptions filled. Current pharmaceutical subsidies may be inadequately targeted. There are no gender differences, while increasing age is associated with lower nondispensing rates. General practitioners need to be aware of these factors when making prescribing decisions.

Biases in estimates from the RNZCGP computer research group.

AIM: This study aimed to determine whether conclusions drawn in studies using data from the computer research group of the Royal New Zealand College of General Practitioners (RNZCGP) could be extrapolated to other New Zealand general practices. METHOD: Retrospectively collected data on doctor, practice, and consultation variables form the study database. The control group comprised a random sample of 106 New Zealand general practitioners. The study group were 67 general practitioners participating in the RNZCGP computer research group. Comparisons between groups were based on doctor and practice variables, patient demography and morbidity, and number and type of service items observed. RESULTS: Study group doctors were more likely to have received post graduate training in general practice (p < 0.01) and saw more patients entitled to government subsidised health care (p < 0.01). The geographical distribution of the study group was skewed with more located in the south of New Zealand. Wide variability on most other study parameters was seen among doctors in both groups although overall patient morbidity was similar for both groups in the 8612 consultations analysed. Computer research group general practitioners reported lower rates of patient referral and laboratory investigations, and higher immunisation rates than the control group (p < 0.01). CONCLUSION: Although the profile of study group general practitioners was different from that of the control group, data collected by both groups provided a similar reflection of the morbidity and services of New Zealand general practice. Adjustments will be needed for extrapolating the results of research from the RNZCGP computer research group where the focus of the investigation is referrals from primary care, investigations, or immunisations.

The prescribing and adverse reactions of nonsteroidal antiinflammatory drugs in general practice: a Dunedin study.

AIMS: The aims of this study were to describe the prescribing of nonsteroidal antiinflammatory drugs (NSAIDs) by some general practitioners and to assess the information recorded on computer records on their use in individual patients so that techniques could be developed for a broader investigation of the topic in general practice. METHODS: All prescribing and consulting data from five Dunedin practices was reviewed for a 6 month period. From all consultations generating a prescription for NSAIDs, data was collected relating to the name of the drug, dosage, strength and length of treatment and patient demographic and morbidity details. Recorded adverse drug reactions were classified into six groups and four age groups were used for the analysis. RESULTS: Prescriptions for NSAIDs accounted for 2.6% of all items prescribed. Diclofenac was the most commonly prescribed NSAID, for most conditions, but menstrual problems were more likely to be treated with mefenamic acid. Coprescription of possibly contraindicated medications (usually antihypertensive medicines) occurred for 20.8% of patients. Gastric adverse reactions were reported in 3% of cases while 0.9% of prescriptions resulted in no change in condition, leading to a change in therapy. Aspirin, fenbufen, ketoprofen, sulindac and flurbiprofen were never prescribed for patients under 20 years old. CONCLUSION: Routinely recorded patient and prescribing information from general practice permits an assessment of the use of NSAIDs which includes the conditions for which they are prescribed, the total numbers prescribed, concurrent medications prescribed and their recorded adverse effects. This is not possible from any other source. Data from clinical trials provides an incomplete assessment of the use of these medications in general practice.

Skeletal muscle mechanics in osteoporotic and nonosteoporotic postmenopausal women.

The purpose of this study was to evaluate single-joint, dynamic muscle function of osteoporotic (OST) and nonosteoporotic (N-OST) women. Knee flexor and extensor function in postmenopausal women (6th decade OST, n = 15; 7th decade OST, n = 10; 6th decade N-OST, n = 6; 7th decade N-OST, n = 5) were evaluated at five angular velocities from 60 degrees.s-1 to 300 degrees.s-1. All subject groups had similar anthropometric measurements, but the 6th decade N-OST group were more physically active than the age-matched OST group. The OST and N-OST women produced peak torque at similar knee angles. The 6th decade N-OST women produced significantly greater knee extensor mean peak torque and angle specific torque, and mean work than any of the other three groups (P < 0.05). However, knee flexor function was equivalent throughout the groups for most comparisons, except those between the 6th decade N-OST and 7th decade OST. While previous research has shown an early loss of flexor muscle function in aging women, our data indicated that women with osteoporosis also experience a deterioration in quadriceps muscle function not encountered within the N-OST subjects. It is possible that such a change is precipitated by reduced physical activity, and may mirror deterioration in bone mineral content.

New Zealand general practitioner referral patterns.

AIM: The aim of this study was to describe the referral patterns of general practitioners in New Zealand, for a defined list of medical conditions. METHODS: A postal questionnaire was sent to a random sample of 200 general practitioners, selected from the Medical Council of New Zealand list. Responses were made on five point scales to indicate general practitioners' views on the appropriateness of referral. For each medical condition, derived from An Educational Guide for General Practice, respondents also indicated favoured agencies for referral. Cluster analysis was used on an SPSSX dataset. RESULTS: A response rate of 87% (91.5% of eligible contacts) was achieved. The conditions for which referrals were least often made included mild hypertension, rheumatoid arthritis not requiring second line therapy, hypothyroidism, and obesity. Referral was common for rheumatoid arthritis requiring second line therapy, insulin dependent diabetes mellitus, altered bowel habit with rectal bleeding, multiple sclerosis, and postmenopausal bleeding. Seventy seven different referral agencies were indicated by respondents: the most common was the general physician (13% of all agencies indicated). CONCLUSIONS: Although there are a large number of conditions which are routinely managed only in general practice, general practitioners need to be able to refer patients to other health carers, even if only occasionally. There is a high degree of consensus as to the conditions for which referral is usually appropriate. They tend to be conditions requiring well defined investigation, treatment or management procedures which are commonly provided by centralised secondary or tertiary institutions.

Roxithromycin versus cefaclor in lower respiratory tract infection: a general practice pharmacoeconomic study.

An economic evaluation comparing roxithromycin 150mg twice daily and cefaclor 250mg thrice daily in the treatment of lower respiratory tract infections (LRTI) was undertaken as part of a randomised clinical trial in New Zealand general practice. The observed statistically significant difference in adverse events, withdrawal rates and extra treatment courses in favour of roxithromycin in the clinical study was translated into medical cost savings. Treatment failures, withdrawals or adverse events resulted in additional costs for 11 of 120 (9%) patients receiving roxithromycin and 19 of 118 (16%) patients receiving cefaclor. In these cases (treatment failures, withdrawals, adverse effects) additional antibiotics and general practitioner visits were required 3 times more often and the cost of additional medication for treating failure or adverse effects was 3 times higher for patients treated with cefaclor than for patients receiving roxithromycin. The total direct medical cost per patient treated with roxithromycin was $NZ9.37 lower (on an incremental basis) than for patients treated with cefaclor, despite a higher drug acquisition cost. An estimate of $NZ656 000 per year in total savings in direct medical costs could be made in New Zealand if roxithromycin were to replace all cefaclor prescriptions in the treatment of LRTI.

General practitioners' views on the role of the community pharmacist.

AIM: to determine the views of general practitioners on the roles and activities of community pharmacists. METHOD: the views of 137 general practitioners in Otago and Southland were canvassed by postal questionnaire. RESULTS: one hundred and three completed questionnaires were returned. All of the general practitioners reported that their professional contact with pharmacists was useful. Seventy-five percent expressed a desire for greater cooperation. Nearly all respondents (99%) accepted that pharmacists have a role in screening prescriptions for possible problems and preparing and dispensing medicines. They also accepted that pharmacists were capable of treating and advising in the management of minor illnesses. Providing drug information to general practitioners, information about previously diagnosed conditions to patients, and advice on personal and home hygiene were less widely accepted activities. The majority indicated that they considered it inappropriate for pharmacists to undertake screening programmes (blood pressure (70.6%), cholesterol (70.6%), glucose (60.8%), haemoglobin (72.5%)). Younger general practitioners objected more often than older general practitioners to reclassification of Acetopt eye drops from prescription only to availability through pharmacies (p < 0.05). Female general practitioners were more often in favour of reclassification of Gyno-Daktarin than their male colleagues (p < 0.05). CONCLUSION: this study shows that general practitioners accept several aspects of the current role of pharmacists in providing primary health care. However, there is room for improved communication between general practitioners and pharmacists to ensure optimum patient care.

A comparison of tiaprofenic acid, mefenamic acid and placebo in the treatment of dysmenorrhoea in general practice.

The efficiency and side-effects of tiaprofenic acid, mefenamic acid and placebo were compared in the treatment of primary dysmenorrhoea. The trial was a double-blind prospective randomized 3-way crossover study during 6 successive menstrual cycles following a 2-cycle run-in period and involved 50 women with primary dysmenorrhoea selected from 96 volunteers between 16 and 35 years of age. Overall pain was significantly less (p less than 0.05) on treatment with tiaprofenic acid than on treatment with mefanemic acid, placebo, or the women's usual treatments. Both active treatments were well tolerated but more side-effects were reported during treatment with mefenamic acid.