Accessing primary care Big Data: the development of a software algorithm to explore the rich content of consultation records.

OBJECTIVE: To develop a natural language processing software inference algorithm to classify the content of primary care consultations using electronic health record Big Data and subsequently test the algorithm's ability to estimate the prevalence and burden of childhood respiratory illness in primary care. DESIGN: Algorithm development and validation study. To classify consultations, the algorithm is designed to interrogate clinical narrative entered as free text, diagnostic (Read) codes created and medications prescribed on the day of the consultation. SETTING: Thirty-six consenting primary care practices from a mixed urban and semirural region of New Zealand. Three independent sets of 1200 child consultation records were randomly extracted from a data set of all general practitioner consultations in participating practices between 1 January 2008-31 December 2013 for children under 18 years of age (n=754,242). Each consultation record within these sets was independently classified by two expert clinicians as respiratory or non-respiratory, and subclassified according to respiratory diagnostic categories to create three 'gold standard' sets of classified records. These three gold standard record sets were used to train, test and validate the algorithm. OUTCOME MEASURES: Sensitivity, specificity, positive predictive value and F-measure were calculated to illustrate the algorithm's ability to replicate judgements of expert clinicians within the 1200 record gold standard validation set. RESULTS: The algorithm was able to identify respiratory consultations in the 1200 record validation set with a sensitivity of 0.72 (95% CI 0.67 to 0.78) and a specificity of 0.95 (95% CI 0.93 to 0.98). The positive predictive value of algorithm respiratory classification was 0.93 (95% CI 0.89 to 0.97). The positive predictive value of the algorithm classifying consultations as being related to specific respiratory diagnostic categories ranged from 0.68 (95% CI 0.40 to 1.00; other respiratory conditions) to 0.91 (95% CI 0.79 to 1.00; throat infections). CONCLUSIONS: A software inference algorithm that uses primary care Big Data can accurately classify the content of clinical consultations. This algorithm will enable accurate estimation of the prevalence of childhood respiratory illness in primary care and resultant service utilisation. The methodology can also be applied to other areas of clinical care.

A structured, group-based diabetes self-management education (DSME) programme for people, families and whanau with type 2 diabetes (T2DM) in New Zealand: an observational study.

BACKGROUND: Group-based diabetes self-management education (DSME) programmes have been shown to be effective. A programme tailored for the unique social and ethnic environment of New Zealand (NZ) was developed using concepts from internationally developed programmes. AIM: To assess the effectiveness of a 6 week New Zealand specific DSME programme. METHODS: In this observational study people with type 2 diabetes (aged 18-80 years) from diverse cultural backgrounds were recruited from primary care. Seventeen groups of six education sessions were run. Clinical data were collected from primary care at baseline, 3, 6 and 9 months. Participants also completed a self-administered questionnaire on diabetes knowledge, and self-management behaviours. RESULTS: 107 participants, mean age 56.7±11.3 years and mean duration of diabetes 7.5±7 years (NZ European (44%), Maori (24%), Pacific (16%) and Indian (16%)), were enrolled. Confidence in self-managing diabetes, regular examination of feet, physical activity levels and smoking rates all improved. Glycaemic control improved between baseline and 6 months (HbA1C 64.9±20.0 mmol/mol to 59.9±13.9 mmol/mol (p<0.05) (baseline 8.07%±1.80, 6 months 7.62%±1.25)), but was no different to baseline at 9 months. Systolic BP reduced from 131.9±16.4 to 127.4±18.2 mmHg (p<0.05) at 6 months, but increased to baseline levels by 9 months. Diastolic BP, triglycerides and urine microalbumin:creatinine ratio were significantly reduced at 3, 6 and 9 months. CONCLUSION: A group-based DSME programme designed specifically for the NZ population was effective at improving aspects of diabetes care at 6 months. The attenuation of these improvements after 6 months suggests a refresher course at that time may be beneficial.

New Zealand general practice nurses' roles in mental health care.

AIM: To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions. BACKGROUND: Supporting mental health and well-being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government-funded, time-limited projects using different service delivery models. METHODS: An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29-month external evaluation. FINDINGS: Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles. CONCLUSIONS: Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.

Teaching and learning about chronic conditions management for undergraduate medical students: utilizing the patient-as-teacher approach.

OBJECTIVES: This study was undertaken to evaluate the impact on medical student learning of a revised chronic conditions teaching programme based on the chronic care model utilizing patients-as-teachers. METHODS: A qualitative questionnaire was completed by students at the start of a primary healthcare rotation to determine existing impressions/understandings about chronic conditions. Following the revised teaching programme, a reflective essay about a home-visit to a person with chronic conditions was completed by students at the end of the rotation. RESULTS: Analysis of the questionnaire at the start of the rotation showed students have some knowledge of the differences between acute and chronic care, have rather negative impressions of what it means to have chronic conditions and know little of overall patient management including the work of an interdisciplinary team. Analysis of the reflective essays completed by students at the end of the rotation showed an increased understanding of chronic conditions, what it means to have a chronic condition and who supports management. DISCUSSION: A structured chronic conditions teaching programme including patient-as-teacher is an effective way of building knowledge and changing students' impressions of what it means to have a chronic condition.

A prospective study of immunisation for a cohort of children.

AIMS: To determine rates of immunisation by 24 months of age, the number of times children were recalled and the cost of immunisation for a cohort of children in general practices in Wellington. METHODS: A prospective study of 979 children registered with 27 general practices. Children in the cohort were followed from 9-24 months old. Data collected included immunisation status, the number of times children were recalled and demographic data. RESULTS: At the end of the study period (when children reached 24 months of age) 803 (82%) remained with the practices and 176 (18%) had left. At 24 months 724 (74%) of the total cohort and 685 (85.3%) of registered children who stayed with the practice were fully immunised for the early childhood vaccinations. 54% of the cohort were fully immunised after a standard recall process. The average cost per child immunised was $13.33. CONCLUSION: It is possible to achieve high rates of full immunisation in children registered with a general practice using an effective system of facilitation and support.

Nursing and native peoples in Northern Saskatchewan: 1930s-1950s.

The aim of this research is to investigate the role of nurses in northern Saskatchewan Aboriginal communities in Canada between 1930 and the 1950s. During and after the war, the federal government began sharing its responsibilities for delivering health services to Indian communities with a growing system of provincial Public Health nursing stations. In northern Saskatchewan, interaction between Aboriginal peoples and the state health care system occurred primarily through provincial Public Health nurses permanently stationed at these outpost clinics. What was the role of nurses in these communities? How did federal Indian health policy influence nurses' behaviour? Based on the record available for Saskatchewan, it appears the outpost clinics delivered standard nursing care. It also appears that the federal government was eager to devolve its responsibilities for Indian health care to the province, and that its tenuous commitment to providing health care caused confusion in the treatment of patients.