Attention deficit and hyperactivity disorder and use of psychostimulants in Aotearoa, New Zealand: exploring the treatment gap.

Introduction Attention deficit and hyperactivity disorder (ADHD) is a common neurodevelopmental disorder affecting about 7% of those aged up to 12 years, 5% of teenagers and 3% of adults. It is associated with poor academic performance, substance abuse, criminality, poor social functioning and other negative outcomes. Psychotherapeutic treatment is moderately successful, whereas pharmacotherapy with stimulant medication is more efficacious and is recommended in many international guidelines. Anecdotal evidence suggests underuse of these medications in Aotearoa, New Zealand. Aim To estimate how many patients with ADHD are prescribed psychostimulants in Aotearoa, New Zealand. Methods National prescribing data for dexamphetamine and methylphenidate in 2022 were obtained and matched against estimated prevalence of ADHD by age. Results There is a significant treatment gap for which inability to access first-line medication is likely to be the predominant explanation. Discussion The data suggest failure of our health system to provide reasonable health care for a significant number of people with ADHD, and results in inequity in outcomes. New approaches are needed that will increase access to first-line medication, yet maintain appropriateness of diagnosis and limit risk of medication diversion.

Treatment Harms in Paediatric Primary Care.

The aim of this study was to describe the epidemiology in children of harms detectable from general practice records, and to identify risk factors. The SHARP study examined 9076 patient records from 44 general practices in New Zealand, with an enrolled population of 210,559 patients. "Harm" was defined as disease, injury, disability, suffering, and death, arising from the health system. The age group studied was ≤20 years of age. There were 193 harms to 141 children and adolescents during the 3-year study period. Harms were reported in one (3.5%) patient aged <2 years, 80 (6.6%) aged 2 to <12 years, 36 (4.9%) aged 12 to <18 years, and 24 (7.5%) aged 18 to ≤20 years. The annualised rates of harm were 36/1000 child and adolescent population for all harms, 20/1000 for medication-related harm (MRH), 2/1000 for severe MRH, and 0.4/1000 for hospitalisation. For MRH, the drug groups most frequently involved were anti-infectives (51.9%), genitourinary (15.4%), dermatologicals (12.5%), and the nervous system (9.6%). Treatment-related harm in children was less common than in a corresponding adult population. MRH was the most common type of harm and was related to the most common treatments used. The risk of harm increased with the number of consultations.

The end of general practice as we know it.

Among the many changes in general practice over the last 30 years, loss of continuity of relationship between a health professional and patient in the general practice context has occurred in many areas. There has been little discussion or consultation over this change, yet the consequences on people working in general practice and patients who come for the services is significant. Without continuity of relationship, general practice will evolve into something quite different from what it has traditionally represented.

What stops Korean immigrants from accessing child and adolescent mental health services?

BACKGROUND: Access to child and adolescent mental health services by ethnic minorities has been poorly studied. Despite rapid growth of the immigrant Korean population, evidence indicates that few Korean families utilise these services in New Zealand. Those that do tend to present late and with significant morbidity. We sought to understand barriers to service access from Korean parents' perspectives. METHOD: Seven focus groups were undertaken with 31 Korean parents of children aged 18 and under. The focus groups were semi-structured, held in the Korean language and utilised two case scenarios of common childhood/adolescent mental illnesses around which a set of broad, open-ended questions were posed. All conversations were audiorecorded, transcribed and translated into English. Thematic analysis was conducted using NVivo software. RESULTS: Both attitudinal and structural barriers were identified. Attitudinal barriers included attribution of mental illness to external stressors or parenting problems, social stigma, denial or normalization of children's behaviour, fear of family disempowerment, and mistrust of public mental health services. Structural barriers included parents' lack of information regarding available services, logistical difficulties in access, communication difficulties, concerns over the quality of translators, and cultural competence of service providers. CONCLUSION: Significant barriers prevent Korean immigrant families from accessing child and adolescent mental health services in New Zealand. Measures to improve access, for example by countering stigma, are urgently required.

Bullying in the New Zealand general practitioner workforce.

INTRODUCTION In recent years, there has been growing acknowledgment of problematic unprofessional behaviours such as bullying in the health workforce. AIM The purpose of this research is to investigate how bullying manifests in general practice, responses to bullying and the impact of this behaviour. METHODS Qualitative research using semi-structured interviews or focus groups was conducted. Twenty-four doctors working in the scope of general practice in New Zealand participated: 21 by interview and three by focus group. Participants had been accused of bullying or subject to bullying. RESULTS Results are reported in three categories: people who have experienced being bullied, people accused of bullying, and the cycle of bullying. Participants experienced a range of negative behaviours and had varied responses to bullying, yet the impact of the behaviour was the same. There was considerable overlap in experiences of participants experiencing and accused of bullying, and these categories were not static. DISCUSSION Bullying has a substantial negative impact on the general practice workforce. Responses to bullying often fail to consider the complexities of the behaviour and are premised on simple notions of bully and victim, failing to consider the wider work environment.

Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study.

OBJECTIVES: To determine the epidemiology of healthcare harm observable in general practice records. DESIGN: Retrospective cohort records review study. SETTING: 72 general practice clinics were randomly selected from all 988 New Zealand clinics stratified by rurality and size; 44 clinics consented to participate. PARTICIPANTS: 9076 patient records were randomly selected from participating clinics. INTERVENTION: Eight general practitioners examined patient records (2011-2013) to identify harms, harm severity and preventability. Analyses were weighted to account for the stratified sampling design and generalise findings to all New Zealand patients. MAIN OUTCOME MEASURES: Healthcare harm, severity and preventability. RESULTS: Reviewers identified 2972 harms affecting 1505 patients aged 0-102 years. Most patients (82.0%, weighted) experienced no harm. The estimated incidence of harm was 123 per 1000 patient-years. Most harms (2160; 72.7%, 72.4% weighted) were minor, 661 (22.2%, 22.8% weighted) were moderate, and 135 (4.5%, 4.4% weighted) severe. Eleven patients died, five following a preventable harm. Of the non-fatal harms, 2411 (81.6%, 79.4% weighted) were considered not preventable. Increasing age and number of consultations were associated with increased odds of harm. Compared with patients aged ≤49 years, patients aged 50-69 had an OR of 1.77 (95% CI 1.61 to 1.94), ≥70 years OR 3.23 (95% CI 2.37 to 4.41). Compared with patients with ≤3 consultations, patients with 4-12 consultations had an OR of 7.14 (95% CI 5.21 to 9.79); ≥13 consultations OR 30.06 (95% CI 21.70 to 41.63). CONCLUSIONS: Strategic balancing of healthcare risks and benefits may improve patient safety but will not necessarily eliminate harms, which often arise from standard care. Reducing harms considered 'not preventable' remains a laudable challenge.

Medication-related harm in New Zealand general practice: a retrospective records review.

BACKGROUND: The extent of medication-related harm in general practice is unknown. AIM: To identify and describe all medication-related harm in electronic general practice records. The secondary aim was to investigate factors potentially associated with medication-related harm. DESIGN AND SETTING: Retrospective cohort records review study in 44 randomly selected New Zealand general practices for the 3 years 2011-2013. METHOD: Eight GPs reviewed 9076 randomly selected patient records. Medication-related harms were identified when the causal agent was prescribed in general practice. Harms were coded by type, preventability, and severity. The number and proportion of patients who experienced medication-related harm was calculated. Weighted logistic regression was used to identify factors associated with harm. RESULTS: In total, 976 of 9076 patients (10.8%) experienced 1762 medication-related harms over 3 years. After weighting, the incidence rate of all medication-related harms was 73.9 harms per 1000 patient-years, and the incidence of preventable, or potentially preventable, medication-related harms was 15.6 per 1000 patient-years. Most harms were minor (n = 1385/1762, 78.6%), but around one in five harms were moderate or severe (n = 373/1762, 21.2%); three patients died. Eighteen study patients were hospitalised; after weighting this correlates to a hospitalisation rate of 1.1 per 1000 patient-years. Increased age, number of consultations, and number of medications were associated with increased risk of medication-related harm. Cardiovascular medications, antineoplastic and immunomodulatory agents, and anticoagulants caused most harm by frequency and severity. CONCLUSION: Medication-related harm in general practice is common. This study adds to the evidence about the risk posed by medication in the real world. Findings can be used to inform decision making in general practice.

Repeat prescribing policy in New Zealand general practice: making it better.

INTRODUCTION Repeat prescribing is common in New Zealand general practice. Research also suggests that repeat prescribing is a process prone to error. All New Zealand general practices have to comply with requirements to have a repeat prescribing policy, with the details of the policy to be designed by the practice. AIM To inform the development of practice policy, research was undertaken with experienced general practitioners to identify and mitigate risk in the process. METHODS At the 2019 annual conference of the Royal New Zealand College of General Practitioners, a workshop was held with 58 experienced general practitioner participants. The group was divided into six small groups, each with the task of discussing one aspect of the repeat prescribing process. The results were then discussed with the whole group and key discussion points were transcribed and analysed. RESULTS Issues identified included: improving patient education on appropriateness of repeat prescribing; having protected time for medicine reconciliation and the task of repeat prescribing; reducing the number of personnel and steps in the process; and clarity over responsibility for repeat prescribing. DISCUSSION This research can inform the local development of a repeat prescribing policy at the practice level or be used to critique existing practice policies. Attention was also drawn to the increasing administrative burden that repeat prescribing contributes to in general practice.

Using the Multiple Mini Interview for selection into vocational general practice training.

INTRODUCTION Interviews for selection into post graduate training courses are an accepted method of selection. There is the presumption that such interview processes are fair to both candidates and the training scheme. AIM Due to concerns over unconscious bias and a desire to move to best practice, the Royal New Zealand College of General Practitioners introduced the Mini Multiple Interview (MMI) process as the selection process for doctors wishing to enter vocational training in general practice. METHODS Aspects assessed during the interviews were developed through wide consultation and included: reason for wanting to undertake training, managing poor compliance, addressing issues of equity, managing complaints, insight and understanding the role of general practitioners in chronic care. There were 218 applicants who took the MMI. Demographic data as well as scores were collected. RESULTS The MMI process has good reliability and performs well in several aspects of validity. All three interview venues had similar results. There was no gender difference in overall result or scores. New Zealand graduates scored higher than overseas graduates. Of the 218 candidates, 12 were considered not yet ready to enter training. DISCUSSION The MMI process appears to have acceptable reliability and good validity. The structure of the MMI is likely to have reduced unconscious bias. Further research will study the predictive validity of the MMI for this cohort of candidates.

Repeat prescribing safety survey.

INTRODUCTION Repeat prescribing is an accepted part of general practice activities in New Zealand and in many developed countries. However, there has been little research on how this service is used in New Zealand, or on clinicians' attitudes towards it. AIM To discover the opinions of vocationally registered general practitioners (GPs) and general practice registrars regarding repeat prescribing, availability of practice policy and mechanisms for issuing such prescriptions. METHODS A survey was developed by an expert group and shared through the Royal New Zealand College of General Practitioners' (the College) weekly newsletter, epulse, inviting members to participate in the survey. The survey was also emailed to registrars. RESULTS In total, 144 vocationally registered GPs and 115 registrars responded (n=259), giving a response rate of 3.2% for GPs and 12.7% for registrars. Patient convenience and time efficiency for the practice were the most commonly cited reasons for repeat prescribing. Registrars had low awareness of practice policy on repeat prescribing and only one-quarter of practices had an orientation pack that contained advice on repeat prescribing. DISCUSSION Better practice systems are likely to improve the safety profile of repeat prescribing and should be addressed. There is substantial unwanted variability currently in these practice systems.

Characteristics of a stratified random sample of New Zealand general practices.

INTRODUCTION Practice size and location may affect the quality and safety of health care. Little is known about contemporary New Zealand general practice characteristics in terms of staffing, ownership and services. AIM To describe and compare the characteristics of small, medium and large general practices in rural and urban New Zealand. METHODS Seventy-two general practices were randomly selected from the 2014 Primary Health Organisation database and invited to participate in a records review study. Forty-five recruited practices located throughout New Zealand provided data on staff, health-care services and practice ownership. Chi-square and other non-parametric statistical analyses were used to compare practices. RESULTS The 45 study practices constituted 4.6% of New Zealand practices. Rural practices were located further from the nearest regional base hospital (rural median 65.0 km, urban 7.5 km (P < 0.001)), nearest local hospital (rural 25.7 km, urban 7.0 km (P = 0.002)) and nearest neighbouring general practitioner (GP) (rural 16.0 km, urban 1.0 km (P = 0.007)). In large practices, there were more enrolled patients per GP FTE than both medium-sized and small practices (mean 1827 compared to 1457 and 1120 respectively, P = 0.019). Nurses in large practices were more likely to insert intravenous lines (P = 0.026) and take blood (P = 0.049). There were no significant differences in practice ownership arrangements according to practice size or rurality. CONCLUSION Study practices were relatively homogenous. Unsurprisingly, rural practices were further away from hospitals. Larger practices had higher patient-to-doctor ratios and increased nursing scope. The study sample is small; findings need to be confirmed by specifically powered research.

A qualitative exploration of student perceptions of the impact of progress tests on learning and emotional wellbeing.

BACKGROUND: Progress testing was introduced to the MBChB programme at the University of Auckland in 2013. As there has been a focus in published literature on aspects relating to the format or function of progress tests, the purpose of this study was to explore a qualitative student perspective on the introduction of progress testing and its impact on approaches to learning and perceived stress. METHODS: This article presents the qualitative aspects of a longitudinal evaluation study. The qualitative data were derived from eight focus groups of Year 2-5 medical students in the University of Auckland medical programme. RESULTS: Two themes, 'Impact on Learning' and 'Emotional Wellbeing' and their subthemes offered insight into student perceptions and behaviour. Students described a variety of learning responses to progress testing that clustered around the employment of a range of learning strategies based on their experience of sitting progress tests and their individualised feedback. A range of emotional responses were also expressed, with some finding progress tests stressful, while others enjoyed not needing to intensively cram before the tests. CONCLUSIONS: Progress tests appear to influence the approach of students to their learning. They employ a mix of learning strategies, shaped by their performance, individualised feedback and the learning environment. While students expressed some stress and anxiety with respect to sitting progress tests, this form of testing was viewed by these students as no worse, and sometimes better than traditional assessments.

Epidemiology of Patient Harms in New Zealand: Protocol of a General Practice Records Review Study.

BACKGROUND: Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety. OBJECTIVE: We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records. METHODS: "Harm" is defined as disease, injury, disability, suffering, and death, arising from the health system. The study design is a stratified, 2-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study's results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between 6 study groups (large, medium-sized, small; urban and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review 3 years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double-blinded reviews will check the concordance of reviewers' assessments. Study data will comprise demographic data of all 9000 patients and reviewers' assessments of whether patients experienced harm arising from health care. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 18.0. RESULTS: We have recruited practices and collected electronic records from 9078 patients. Reviews of these records are under way. The study is expected to be completed in August 2017. CONCLUSIONS: The design of this complex study is presented with discussion on data collection methods, sampling weights, power analysis, and statistical approach. This study will show the epidemiology of patient harms recorded in general practice records for all of New Zealand and will show whether this epidemiology differs by rural location and clinic size.

Ageing doctors.

Doctors are neither more nor less susceptible than the general population to the effects of ageing. The relevance of deterioration with age depends on the nature of the work undertaken. Reduced muscle strength and visual and auditory deterioration can compromise clinical ability. Accumulation of chronic disease further reduces capacity. Cognitive decline is of particular importance, as good medical care requires considerable cognitive function. Patient safety is paramount, yet older doctors are an important part of the medical workforce and their value should be recognised. Changes in patient case mix, work place support systems and individual adjustments can assist safe practice. Deterioration in health should be acknowledged and requires proactive management. Current methods of ensuring competence are inadequate for supporting ageing doctors. A new initiative is recommended comprising collaboration between regulators, colleges and employing institutions to support the ageing doctor in providing safe and effective practice.

Workplace-based assessment for vocational registration of international medical graduates.

INTRODUCTION: Medical regulatory authorities need efficient and effective methods of ensuring the competence of immigrating international medical graduates (IMGs). Not all IMGs who apply for specialist vocational registration will have directly comparable qualifications to those usually accepted. As general licensure examinations are inappropriate for these doctors, workplace-based assessment (WBA) techniques would appear to provide a solution. However, there is little published data on such outcomes. METHODS: All cases of WBA (n = 81) used for vocational registration of IMGs in New Zealand between 2008 and 2013 were collated and analyzed. RESULTS: The successful completion rate of IMGs through the pathway was 87%. The majority (64%) undertook the year of supervised practice and the final assessment in a provincial center. For those unsuccessful in the pathway, inadequate clinical knowledge was the most common deficit found, followed by poor clinical reasoning. DISCUSSION: A WBA approach for assessing readiness of IMGs for vocational registration is feasible. The constructivist theoretical perspective of WBA has particular advantages in assessing the standard of practice for experienced practitioners working in narrow scopes than traditional methods of assessment. The majority of IMGs undertook both the clinical year and the assessment in provincial hospitals, thus providing a workforce for underserved areas.

Progress of successful New Zealand Registration Examination (NZREX Clinical) candidates during their first year of supervised clinical practice in New Zealand.

AIM: To determine the frequency and nature of clinical difficulties faced in the first year of supervised clinical practice by international medical graduates (IMGs) who have successfully passed NZREX Clinical in order to be able to practise in New Zealand. METHOD: All doctors who successfully passed NZREX Clinical and who registered with the Medical Council of New Zealand (the Council) from 2005 to 2013 were identified. Supervisor reports for each of the four runs in the first year of practice were obtained and reports where concerns were raised over clinical performance analysed. RESULTS: Of 353 IMGs successful in NZREX Clinical, 316 (89.6%) completed the subsequent clinical year with no adverse reports. Those requiring more than one attempt to pass NZREX Clinical had an incremental increase in number of unsatisfactory reports, where areas of the IMGs' performance were rated as 'below the expected standard'. Less than 2% of IMGs had more than one unsatisfactory report. The majority of unsatisfactory reports were generated in the first half of the clinical year. Areas of concerns found were Clinical Knowledge and Skills (28%), Clinical Judgment (35%), Patient Communication (28%) and Professional Attitudes and Behaviour (9%). CONCLUSION: Most IMGs who were successful in NZREX Clinical performed well in the subsequent year of clinical practice. NZREX Clinical would appear to have acceptable criterion validity.

Long-term outcomes of a remedial education program for doctors with clinical performance deficits.

INTRODUCTION: Medical regulatory authorities need reliable methods of assessing and remediating doctors where there are concerns over competence. There's a small but growing literature describing remediation programs and documenting their effectiveness. This article adds to that literature by describing a program associated with the Medical Council of New Zealand (MCNZ) and reporting outcomes for 24 consecutive doctors required to undergo remediation. METHODS: Over the 18-month period covered in this study, 24 doctors were required by the MCNZ to enter remediation after a performance assessment. The data set used in this study was drawn from these 24 consecutive cases and included the nature of concerns, severity of concerns, results of remediation and outcome of a second assessment when such an assessment was ordered. RESULTS: Of 24 doctors who underwent initial assessment, 5 failed to engage with remediation and withdrew from clinical work. A 12-month education remediation program was completed by all remaining 19 doctors. Of these, 13 were considered to be practicing at an acceptable standard at the end of remediation on the basis of sequential supervisor reports. Six doctors were required to have a second performance assessment. Of these, only 1 was considered to be functioning at an acceptable standard. Concurrent health concerns were common among this cohort of doctors. DISCUSSION: Seventy-five percent of doctors who entered remedial education were considered to be practicing at an acceptable standard at the end of remediation. This accords well with international data. A small number of doctors appear to be unresponsive to remediation.

Does the order of presentation and number of online resources affect the frequency of access by learners?

INTRODUCTION: Provision of web-based resources is a valuable addition to face-to-face teaching in a blended learning environment. AIM: To understand how both order of presentation and number of online resources impacts on the frequency of access by learners in postgraduate vocational training in general practice. METHODS: Information was collected on how many times individual online resources were accessed. Data regarding access rates for 15 separate topics used in postgraduate general practice vocational training were aggregated. Analysis was on the basis of order of presentation where the mean of percentages of hits by order of presentation with standard deviations was calculated. RESULTS: The first four listed resources were accessed at a higher rate than the remainder of the resources. All resources after the first four were accessed at a relatively uniform low rate. DISCUSSION: It would appear that providing more than four resources per topic is associated with learner overload. The number of online resources to support face-to-face teaching should be limited to four. Resource material needs to be carefully considered in terms of how it adds educational value. The ability of resource material to present a different perspective on a topic and adherence to both curriculum and assessment objectives are important considerations.

New Zealand Registration Examination (NZREX Clinical): 6 years of experience as an Objective Structured Clinical Examination (OSCE).

The NZREX Clinical pathway is one of several methods by which international medical graduates (IMGs) may enter the New Zealand medical workforce. The NZREX Clinical is the clinical component of the pathway and consists of a 16-station OSCE. The examination has previously been held twice a year, however due to applicant numbers NZREX Clinical is now held 4 to 5 times a year and 28 candidates are examined in each cohort. A comprehensive range of methods are used to promote validity and reliability of the examination. The mean pass rate over the last 5 years is 60%.

The educational value of peer groups from a general practitioner perspective.

INTRODUCTION: Peer review groups are compulsory for New Zealand (NZ) general practitioners (GPs) but little is known about how they function. This study aimed to understand the educational value of peer group meetings to general practitioners and explore methods of increasing value. METHODS: A qualitative study was undertaken comprising a single meeting involving 22 NZ GPs with an interest in education and subsequent thematic analysis on the raw data. FINDINGS: Respondents indicated a strong belief in the educational value of peer groups. Pastoral care was also perceived as a valuable outcome of peer groups that was somewhat separate from the educational value. It would appear that the majority of peer groups work on the basis of internally driven contemporaneous learning needs based on difficult work experiences. There was limited concern over the wide interpretation of what constitutes acceptable topics for discussion as well as the informal nature of training and structuring the meetings. DISCUSSION: The interactive nature of peer group learning with subject matter of 'real life' problems would suggest peer groups have the potential to make significant change in the performance of doctors. A broad and differing range of experience in the group is more likely to generate an educationally valuable environment. It would appear that there may be a limited role for assisting peer groups with methods of structuring content and increasing effectiveness.