Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand.

Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for 'at risk' patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not 'at risk' waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist. SLEEP DISORDERS: MORE ASSESSMENTS, SHORTER WAITS WITH COMMUNITY SLEEP SERVICE: A community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region's largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital's sleep unit.

The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery.

In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.

Self-management plans in the primary care of patients with chronic obstructive pulmonary disease.

OBJECTIVE AND BACKGROUND: The role of COPD self-management plans in improving health outcomes remains unclear. The objective of this study was to assess whether self-management plans administered in primary care have beneficial effects on quality of life, self-care behaviour and health outcomes in the long term for patients with COPD. MATERIAL, PATIENTS AND METHODS: The study was a prospective, unblinded, randomized controlled trial of usual care vs. usual care plus structured education on the use of a written self-management plan and patient-initiated short courses of antibiotics and oral corticosteroids. The study was conducted in general practice, in Christchurch, New Zealand. Participants were 159 patients with COPD randomized by general practice site into control or intervention groups. The primary outcome measure was change in St. George's Respiratory Questionnaire. Secondary variables were frequency of hospital and primary-care attendance, frequency of use of courses of antibiotics and oral corticosteroids over 12 months, and change in Hospital Anxiety and Depression Scale. Self-management knowledge was assessed using a structured interview, the COPD Self-Management Interview. RESULTS: Self-management plans and structured education were associated with higher levels of self-management knowledge at 12 months, but had no effect on change in St. George's Respiratory Questionnaire, health utilization, mental health or self-reported outcomes of patients with COPD managed in general practice. CONCLUSIONS: Self-management knowledge was higher in the intervention group but there was no difference in quality of life or health outcomes due to self-management plans.

Home management of mild to moderately severe community-acquired pneumonia: a randomised controlled trial.

OBJECTIVE: To determine whether community management of mild to moderate community-acquired pneumonia (CAP) is as effective and acceptable as standard hospital management of CAP. DESIGN: Randomised controlled trial. SETTING: Christchurch, New Zealand, primary and secondary care. PARTICIPANTS: 55 patients presenting or referred to the emergency department at Christchurch Hospital with mild to moderately severe pneumonia, assessed using a validated pneumonia severity assessment score, from July 2002 to October 2003. INTERVENTIONS: Hospital treatment as usual or comprehensive care in the home delivered by primary care teams. MAIN OUTCOME MEASURES: Primary: days to discharge, days on intravenous (IV) antibiotics, patient-rated symptom scores. Secondary: health status measured using level of functioning at 2 and 6 weeks, patient satisfaction. RESULTS: The median number of days to discharge was higher in the home care group (4 days; range, 1-14) than in the hospital groups (2 days; range, 0-10; P = 0.004). There was no difference in the number of days on IV antibiotics or on subsequent oral antibiotics. Patient-rated symptom scores at 2 and 6 weeks, median change in symptom severity from baseline to 6 weeks, and general functioning at 2 and 6 weeks did not differ between the groups. Patients in both groups were satisfied with their treatment, with a clear preference for community treatment (P < 0.001). CONCLUSIONS: Mild to moderately severe CAP can be managed effectively in the community by primary care teams. This model of comprehensive care at home can be implemented by primary care teams with suitable funding structures.

Antibiotic resistance in uncomplicated urinary tract infection: problems with interpreting cumulative resistance rates from local community laboratories.

AIMS: To determine the resistance rates and patterns in bacteria causing uncomplicated urinary tract infections (UTIs) presenting to general practitioners (GPs) in Christchurch. METHODS: 82 randomly selected GPs in Christchurch participated in the study. Midstream urine (MSU) samples were prospectively collected for standard microbiological analysis on all women between the ages of 16 and 50 years presenting with symptoms of dysuria and frequency and who had positive dipstick testing to either (or both) nitrites or leucocytes. MSUs were submitted for bacterial colony counts and resistance testing of isolates present in adequate numbers. RESULTS: 374 specimens were collected. 299 filled the inclusion criteria, of which 94 fulfilled criteria for significant infection. Trimethoprim resistance was found in 8, (8.5%) (95%CI 2.8,14.2) overall with a resistance rate for Escberichia coli (E. coli) to trimethoprim of 11.5%. This compared with cumulative resistance rates from local community laboratories for E. coli to trimethoprim of 19%. For a woman in this age group presenting with symptoms of UTI we estimated that her probability of having a trimethoprim resistant organism was 2.7%. CONCLUSION: Trimethoprim remains a reasonable first line treatment for uncomplicated UTI in Christchurch. Actual resistance rates are significantly less than those derived from routine pooled laboratory specimens, and when used in an intention to treat calculation to inform empiric prescribing, become even less significant. While collection of these routine data is essential to provide early warning of emergent resistance, a truly representative rate should be determined to inform prescribing decisions if resistance appears to be increasing.