Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand.

AIMS: Cervical cancer remains a burden within Aotearoa New Zealand, with 2022 screening rates sitting 12.7% below target. The National Cervical Screening Programme has changed to primary human papillomavirus (HPV) testing for all screen-eligible people, with the aim for home self-testing. Little is known about the readiness of primary care for the change to self-testing and its associated challenges. A pilot HPV cervical cancer screening programme is being conducted in 17 practice centres. The aim of this study is to explore smear-taker knowledge at these centres about the use of primary HPV testing for cervical cancer screening. METHODS: This is an ethically approved questionnaire study, with data from a structured web-based questionnaire sent to all smear-takers at the pilot centres. RESULTS: We achieved a total completion rate of 57.8%. The average score for "Knowledge of HPV" was 56.5% (range=20-100%). The challenges to patient home HPV self-testing were felt to be overall "not at all" to "mildly challenging". Up to 73.3% of participants identified ongoing needs for further education. CONCLUSIONS: The findings indicate knowledge deficits regarding HPV testing for cervical cancer screening and a desire for the provision of further education. Overall, respondents felt that no major barriers to implementing HPV self-testing would occur.

Developing a model for primary care quality improvement success: a comparative case study in rural, urban and Kaupapa Maori organisations.

Introduction Primary care is under pressure to achieve accessible, equitable, quality health care, while being increasingly under resourced. There is a need to understand factors that influence quality improvement (QI) to support a high-performing primary care system. Literature highlights the impact of context on QI but there is little primary care research on this topic. Aim This qualitative case study research seeks to discover the contextual factors influencing QI in primary care, and how the relationships between contextual factors, the QI initiative, and the implementation process influence outcomes. Methods The Consolidated Framework for Implementation Research was used to frame this qualitative study exploring primary care experiences in depth. Six sites were selected to provide a sample of rural, urban and Kaupapa Maori settings. Qualitative data was collected via semi-structured interviews and compared and contrasted with the organisational documents and data provided by participants. Results Cases reported success in achieving improved outcomes for patients, practices, and staff. Strong internal cultures of 'Clan' and 'Adhocracy' typologies supported teamwork, distributed leadership, and a learning climate to facilitate iterative sensemaking activities. To varying degrees, external network relationships provided resources, knowledge, and support. Discussion Organisations were motivated by a combination of patient/community need and organisational culture. Network relationships assisted to varying degrees depending on need. Engaged and distributed leadership based on teamwork was observed, where leadership was shared and emerged at different levels and times as the need arose. A learning climate was supported to enable iterative sensemaking activities to achieve success.

Primary care experiences in the 'Let's test for HPV' study: a qualitative analysis.

Introduction The National Cervical Screening Programme (NCSP) will switch from cervical cytology to Human Papillomavirus (HPV) testing as the primary cervical screening modality in 2023. To prepare for rollout an implementation study of HPV testing in primary care commenced in August 2022 in three different geographic regions in NZ. Aims This study explores Primary Care Staff's experience of using the HPV testing pathway in the 'Let's test for HPV' study so that recommendations can be made to improve the testing process before nationwide roll-out. Method Thirty-nine primary care staff were interviewed across all 17 practices in the Capital and Coast, Canterbury and Whanganui region participating in the 'Let's Test For HPV' study. In total 19 interviews took place which followed a semi-structured approach. These interviews were recorded and transcribed. Template analysis was carried out on transcripts to aid in identifying themes. Results Three key themes, with additional subthemes, were identified. Staff were strongly supportive of the new testing regime. Interviewees identified some issues with the new pathway. Educational needs for both patients and clinicians were identified. Conclusion Primary care staff described the experience of using the HPV testing pathway positively; however, there were requests for ongoing additional support and nationwide rollout to be supported by practitioner and patient education programmes. With the right support this new pathway for cervical cancer screening has the potential to improve access for previously underserved and unserved groups.

Contextual antecedents of quality improvement: a comparative case study in rural, urban and Kaupapa Māori general practice.

Introduction The impact of contextual factors on primary health-care quality improvement is significant. In-depth research is required to identify the key contextual factors that influence quality improvement initiatives to develop high-performing primary health-care systems. Aim This research seeks to answer two questions; what are the contextual factors influencing primary care improvement initiatives?; and how do contextual factors, the quality improvement initiative and the implementation process influence one another and the overall improvement outcomes? Methods A multi-case study methodology was used to explore the complexities of the phenomena in situ . Three sites where successful quality improvement had occurred were selected by purposeful theoretical sampling to provide a sample of rural, urban and Kaupapa Maori general practice settings typical of the New Zealand environment. Semi-structured interviews were conducted with team members and triangulated with secondary data provided by the organisations. Results The quality improvement topic and the approach taken were intrinsically linked to context. Sites reported success in achieving the desired outcomes benefitting the patients, practice and staff. Teams did not use formal improvement methods, instead relying on established relationships and elements of change management methods. The culture in all three cases was a large component of why and how these initiatives were successful. Discussion Intrinsic motivation was generated by community connections and networks. This combined with a learning climate generated by distributed leadership and teamwork enabled success. Iterative reflection and sensemaking processes were able to deliver quality improvement success in primary care without the use of formal improvement methods.

Developing a national primary care research network: a qualitative study of stakeholder views.

Introduction Primary care research is critical to address Aotearoa New Zealand's (NZ) health sector challenges. These include health inequities, workforce issues and the need for evaluation of health system changes. Internationally, primary care data are routinely collected and used to understand these issues by primary care research and surveillance networks (PCRN). NZ currently has no such infrastructure. Aim To explore health sector stakeholders' views on the utility of, and critical elements needed for, a national PCRN in NZ. Methods Twenty semi-structured interviews and a focus group were conducted with key stakeholders, representing different perspectives within the health sector, including Hauora Maori providers. Data were analysed thematically. Results Six themes were identified that included both challenges within current primary care research and ideas for a future network. The themes were: disconnection between research, practice and policy; desire for better infrastructure; improving health equity for Maori and other groups who experience inequity; responding to the research needs of communities; reciprocity between research and practice; and the need for data to allow evidence-informed decision-making. Improving health equity for Maori was identified as a critical function for a national PCRN. Discussion Stakeholders identified challenges in conducting primary care research and translating research into practice and policy in NZ. Stakeholders from across the health sector supported a national PCRN and identified what its function should be and how it could operate. These views were used to develop a set of recommendations to guide the development of a national PCRN.

Electronic transmission of prescriptions in primary care: transformation, timing and teamwork.

INTRODUCTION During the coronavirus disease 2019 (COVID-19) pandemic lockdown in New Zealand in March 2020, there was a rapid shift to virtual consultations in primary care. This change was supported by system adjustments to enable electronic transmission of prescriptions without a handwritten signature if they met certain security criteria. International research suggests potential for unintended consequences with such changes, so it is important to understand the effect on professional practice in New Zealand general practice and community pharmacy. AIM The purpose of this study was to undertake a preliminary exploration of the experiences of New Zealand general practitioners and community pharmacists when prescriptions are transmitted electronically directly from prescriber to pharmacy. METHODS Semi-structured interviews with a purposive sample of four pharmacists and four general practitioners gathered qualitative data about their experiences of the shift to electronic transmission of prescriptions. Participants' perceptions of effect on professional workflow, interprofessional interactions between general practitioners and pharmacists, and interactions with patients were explored. Interviews were audio-recorded, and the data analysed thematically using an inductive approach. RESULTS Four themes were identified: workflow transformation; mixed impact on interactions with patients; juggling timing and expectations; and new avenues for interprofessional communication (with some cul-de-sacs). DISCUSSION Both general practitioners and pharmacists experienced transformational changes to workflow. This was positive for general practitioners due to saved time and increased work flexibility. Pharmacists noted potential benefits but also some challenges. To fully reap teamwork benefits, more work is needed on managing the timing issues and patient expectations, and to refine the new modes of communication between health-care practitioners.

Simulating 'that jaw drop moment': challenging heteronormative assumptions in a novel clinical consultation skills session with undergraduate medical students.

This article was migrated. The article was marked as recommended. Introduction This paper discusses the design and impact of a clinical consultation skills session for undergraduate medical students in context of diverse sexual orientation, gender identity and expression, and sex characteristics. Existing teaching approaches omit opportunities for application and skills practice. This innovation seeks to address this gap. Methods Senior medical undergraduate students participated in actor-facilitated standardized simulated patient role-play. The scenarios utilized a structure akin to the end of year final observed objective structured clinical examination. Plan-do-study-act cycles involving facilitator observation, verbal and written feedback from students and actors, confidential student evaluations, and peer evaluation contributed to session modification and improvement. Findings The teaching session offered students the opportunity to practice exam-style simulated patient consultations, communication and empathy skills. Improvements made following the first iteration were reflected in positive student evaluations in the second iteration. Discussion and Conclusion Simulated consultations using standardised scenarios represent an accepted format for medical education. We demonstrated it is possible to include topics that frequently give rise to discrimination and stigma from medical professionals whilst maintaining expected learning outcomes. Student evaluations identify the acceptability and value of the topics for medical education. We present a viable option for integration into medical education.

Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles.

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.

Quantifying the incidence and burden of herpes zoster in New Zealand general practice: a retrospective cohort study using a natural language processing software inference algorithm.

OBJECTIVE: To investigate the incidence of primary care presentations for herpes zoster (zoster) in a representative New Zealand population and to evaluate the utilisation of primary healthcare services following zoster diagnosis. DESIGN: A cross-sectional retrospective cohort study used a natural language processing software inference algorithm to identify general practice consultations for zoster by interrogating 22 million electronic medical record (EMR) transactions routinely recorded from January 2005 to December 2015. Data linking enabled analysis of the demographics of each case. The frequency of doctor visits was assessed prior to and after the first consultation diagnosing zoster to determine health service utilisation. SETTING: General practice, using EMRs from two primary health organisations located in the lower North Island, New Zealand. PARTICIPANTS: Thirty-nine general practices consented interrogation of their EMRs to access deidentified records for all enrolled patients. Out-of-hours and practice nurse consultations were excluded. MAIN OUTCOME MEASURES: The incidence of first and repeated zoster-related visits to the doctor across all age groups and associated patient demographics. To determine whether zoster affects workload in general practice. RESULTS: Overall, for 6 189 019 doctor consultations, the incidence of zoster was 48.6 per 10 000 patient-years (95% CI 47.6 to 49.6). Incidence increased from the age of 50 years to a peak rate of 128 per 10 000 in the age group of 80-90 years and was significantly higher in females than males (p<0.001). Over this 11-year period, incidence increased gradually, notably in those aged 80-85 years. Only 19% of patients had one or more follow-up zoster consultations within 12 months of a zoster index consultation. The frequency of consultations, for any reason, did not change between periods before and after the diagnosis. CONCLUSIONS: Zoster consultations in general practice are rare, and the burden of these cases on overall general practice caseload is low.

Renal function monitoring in patients prescribed dabigatran in the Compass Health Primary Health Organisation: a quality improvement audit.

AIM: To assess annual renal function monitoring and clinical indications for use in patients prescribed dabigatran. METHOD: A quality improvement activity included all patients in the Compass Health Primary Health Organisation (PHO) prescribed dabigatran. Information recorded: demographics; indication for use; daily dose; height; weight; serum creatinine; and estimated glomerular filtration rate (eGFR). The first audit occurred during July 2013 - May 2014, the second during May 2014 - October 2016. RESULTS: Across the PHO, all patients prescribed dabigatran were reviewed: 941 patients and 1,564 respectively. At the time of the second pass audit, renal function monitoring improved from 88% to 90%, and 96% were prescribed dabigatran for an approved indication. CONCLUSION: Results showed a continuing high level of renal function monitoring across the PHO in 90% of patients prescribed dabigatran. Practitioners were reminded to use creatinine clearance as a marker of renal function. Dabigatran was prescribed for an approved indication in 96% of patients. Our results are in line with recommended best practice and clinical guidelines.

Development of a structured diabetes self-management education program specific to the cultural and ethnic population of New Zealand.

AIM: To develop and pilot a diabetes self-management education (DSME) program specific to the needs of New Zealanders with type 2 diabetes mellitus (T2DM). METHODS: There were two parts in the present study. The first was the development of the program. This involved a literature review, consultation with end-user groups and drafting the content of the program. In the second part, the program was tested and modified according to feedback provided by both participants and facilitators. RESULTS: The present study achieved its primary goal of developing, piloting and modifying a DSME program specific to the New Zealand population. The DSME program was developed using concepts and content of international DSME programs. The content and concept was extensively tested via discussion groups with 71 individuals with T2DM and practice nurses to ensure the program met the unique cultural needs of New Zealanders with T2DM. Twenty-seven participants with T2DM were recruited into the pilot, of which 13 attended four of six sessions. Feedback from participants, observing nurses and facilitators was incorporated into the final program. CONCLUSIONS: DSME programs are an effective vehicle for providing individuals with T2DM the initial information and support to start self-managing their diabetes. However, to ensure DSME programs help individuals with the highest rates of diabetes and diabetes-related complications, it is important end-users participate in the development of the program. This DSME program now requires longitudinal trial to determine if in the New Zealand context it is able generate the same improvements in both clinical and qualitative outcomes as seen in similar international programs.

Childhood respiratory illness presentation and service utilisation in primary care: a six-year cohort study in Wellington, New Zealand, using natural language processing (NLP) software.

OBJECTIVES: To identify childhood respiratory tract-related illness presentation rates and service utilisation in primary care by interrogating free text and coded data from electronic medical records. DESIGN: Retrospective cohort study. Data interrogation used a natural language processing software inference algorithm. SETTING: 36 primary care practices in New Zealand. Data analysed from January 2008 to December 2013. PARTICIPANTS: The records from 77 582 children enrolled were reviewed over a 6-year period to estimate the presentation of childhood respiratory illness and service utilisation. This cohort represents 268 919 person-years of data and over 650 000 unique consultations. MAIN OUTCOME MEASURE: Childhood respiratory illness presentation rate to primary care practice, with description of seasonal and yearly variation. RESULTS: Respiratory conditions constituted 46% of all child-general practitioner consultations with a stable year-on-year pattern of seasonal peaks. Upper respiratory tract infection was the most common respiratory category accounting for 21.0% of all childhood consultations, followed by otitis media (12.2%), wheeze-related illness (9.7%), throat infection (7.4%) and lower respiratory tract infection (4.4%). Almost 70% of children presented to their general practitioner with at least one respiratory condition in their first year of life; this reduced to approximately 25% for children aged 10-17. CONCLUSION: This is the first study to assess the primary care incidence and service utilisation of childhood respiratory illness in a large primary care cohort by interrogating electronic medical record free text. The study identified the very high primary care workload related to childhood respiratory illness, especially during the first 2 years of life. These data can enable more effective planning of health service delivery. The findings and methodology have relevance to many countries, and the use of primary care 'big data' in this way can be applied to other health conditions.

GPs' views and experiences of prescribing non-steroidal anti-inflammatory drugs: a qualitative study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in primary care despite being a high-risk drug group causing significant adverse events, yet little is known about GPs' perceptions of NSAID risks and benefits. AIM: To explore GPs' experiences with NSAID prescribing and views about the risks and benefits of this group of medicines. DESIGN & SETTING: A qualitative, inductive study in general practice. METHOD: Individual interviews with 15 GPs using a semi-structured interview guide. Interviews were audiorecorded and transcribed. An inductive, thematic approach was used for analysis. Sampling continued until data saturation was achieved. RESULTS: Three main themes illustrate GPs' key concerns with managing NSAID risks. The first theme was perceptions of risks and benefits of NSAIDs: GPs expressed differing attitudes towards prescribing medication generally. GPs were aware of the general risks of NSAIDs but weighed these up against specific risk factors and potential benefits for particular patients. They were most concerned about long-term use, risks for children, older people, and patients with comorbidities. The second theme was assessing and mitigating risks when prescribing NSAIDs: GPs considered gastric, cardiac, and renal risks of patients as well as drug interactions. Mitigation strategies included alternative treatment, choice and dose of NSAID, and use of gastroprotective agents. The final theme was other factors impacting on NSAID risks: particularly patient expectations and over-the-counter (OTC) availability. CONCLUSION: NSAID prescribing is a complex balance between pragmatism and potential adverse events. Given the costs of morbidity, hospitalisation, and patient demand there is an urgent need to secure a more detailed evidence base and develop practical pathways to support safer prescribing.

Rheumatologists fail to advise people with RA to get immunised, which matters if you are under 65: An audit in a New Zealand rheumatology service.

AIM: To assess if yearly-influenza and five-yearly pneumococcal vaccines are recommended to people with rheumatoid arthritis (RA) in a New Zealand rheumatology service in accordance with guidelines and determine patient immunisation status for these respiratory pathogens. METHODS: Retrospective review of electronic health records of all outpatients with RA attending a regional rheumatology centre in New Zealand over a one-month period immediately after the release of the 2015 influenza vaccination. RESULTS: The 232 people with RA in the sample had a mean age of 60.4 years with 59% having RA for more than five years. Documented advice was infrequent (<5%) at the index visit and other clinically relevant time points. Despite this, many patients were immunised. People with RA over 65 years of age were more likely to receive influenza vaccination, however, the vaccination rate was similar to the general population over 65 years of age. CONCLUSIONS: People with RA receive recommended respiratory vaccinations despite infrequent advice for immunisation from rheumatology specialist services. However, immunisation rate in people with RA, particularly those under 65 years, remains suboptimal and multi-level interventions are required to improve this.

Genital examination training: assessing the effectiveness of an integrated female and male teaching programme.

BACKGROUND: Learning to undertake intimate female and male examinations is an important part of medical student training but opportunities to participate in practical, supervised learning in a safe environment can be limited. A collaborative, integrated training programme to provide such learning was developed by two university teaching departments and a specialist sexual health service, utilising teaching associates trained for intimate examinations in a simulated clinical educational setting. The objective of this research was to determine changes in senior medical students' self- reported experience and confidence in performing male and female genital examinations, before and after participating in a new clinical teaching programme. METHODS: A quasi-experimental mixed methods design, using pre and post programme questionnaires and focus groups, was used to assess the effectiveness of the programme. RESULTS: The students reported greatly improved skill, confidence and comfort levels for both male and female genital examination following the teaching programme. Skill, confidence and comfort regarding male examinations were rated particularly low on the pre-teaching programme self- assessment, but post-programme was rated at similar levels to the female examination. CONCLUSIONS: This integrated female-male teaching programme (utilising trained teaching associates as simulated patients in a supervised clinical teaching environment) was successful in increasing senior medical students' skills and levels of confidence in performing genital examinations. There were differences between female and male medical students in their learning. Suggestions for improvement included providing more detailed instruction to some clinical supervisors about their facilitation role in the session.

Continuity of cancer patient care in New Zealand; the general practitioner perspective.

AIM: As cancer treatments become more effective, increasing numbers of cancer patients seek long-term support from general practice. This study aimed to canvass the perspective of GPs on issues around continuity of care for these patients. METHODS: In this qualitative study purposive sampling was used to invite a range of New Zealand GPs from urban and rural communities in the Greater Wellington and Otago/Southland areas to participate. A total of 34 GPs took part in three semi-structured individual interviews and six focus groups. RESULTS: Six main themes emerged; the participating GPs noted they wanted more involvement in their patients' cancer journeys but were not always clear of their place in relation to cancer specialists and other health care providers. They saw cancer as a chronic condition to be managed long term. They mentioned the breast cancer and palliative care models as examples to be followed. Poor communication and barriers for patients in accessing GP care were seen as areas for improvement. CONCLUSION: Participating GPs felt that the current cancer care pathway could be improved with a better understanding of their own role and through improved communication with patients, cancer specialists and other health professionals.

"I wanted to communicate my feelings freely": a descriptive study of creative responses to enhance reflection in palliative medicine education.

BACKGROUND: The recent growth of arts and humanities in medical education shows recognition that these disciplines can facilitate a breadth of thinking and result in personal and professional growth. However creative work can be a challenge to incorporate into a busy curriculum. Offering the option of creative media as a way of reflecting is an example of how this can occur. This study aimed to examine the medical student response to being given this option to explore a visit to a patient in a hospice. METHODS: This was a mainly qualitative study. In the 2012 academic programme, the class of 86 students were given the option of using a creative medium to explore their responses to both the visit and their developing communication skills. Students were required to write an accompanying commentary if submitting the creative work option. Sixty-four percent of the class chose a creative medium e.g. poetry, visual art, narrative prose, music. These students were asked to take part in research including completing a short on-line survey and consenting for their creative work and commentaries to be further examined. The creative works were categorised by genre and the commentaries analysed using inductive thematic analysis. RESULTS: Seventeen students completed the on-line survey and fifteen consented to their work being used for this research. Thematic analysis of the student commentaries revealed the following themes: effectiveness for expressing emotion or ideas that are difficult to articulate; engaging and energising quality of the task; time for reflection; flexibility for individual learning styles and therapeutic value. CONCLUSIONS: Teaching the art of communicating at end-of-life is challenging especially when it involves patients, and teachers want to ensure students gain as much as possible from the experience. Offering the option to use creative media means that students can choose a medium for reflection that best suits them as individuals and that can enable them to benefit as much as possible from their experience.