Concordance Between Biopsy and Radical Prostatectomy Gleason Scores: Evaluation of Determinants in a Large-Scale Study of Patients Undergoing RARP in Belgium.

To determine whether Gleason scores were concordant between prostate biopsies (bGS) and the definitive resection specimen (pGS) excised with robot-assisted radical prostatectomy (RARP); to identify clinical and pathological factors that might predict upgrading; and to evaluate how upgrading affected outcome. Between 2009 and 2016, 25 Belgian centers participated in collecting prospective data for patients that underwent RARP. We analyzed the concordance rate between the bGS and the pGS in 8021 patients with kappa statistics, and we compared concordance rates from different centers. We assessed the effect of several clinical and pathological factors on the concordance rate with logistic regression analysis. The concordance rate for the entire population was 62.9%. Upgrading from bGS to pGS occurred in 27.3% of patients. The number of biopsies was significantly associated with concordance. Older age (>60 y), a higher clinical T stage (≥cT2), a higher PSA value at the time of biopsy (>10 ng/ml), and more time between the biopsy and the radical prostatectomy were significantly associated with a higher risk of upgrading. Positive margins and PSA relapse occurred more frequently in upgraded patients. Center size did not significantly affect the concordance rate (p = 0.40).This prospective, nationwide analysis demonstrated a Gleason score concordance rate of 62.9%. Upgrading was most frequently observed in the non-concordant group. We identified clinical and pathological factors associated with (non)-concordance. Upgrading was associated with a worse oncological outcome. Center volume was not associated with pathological accuracy.

Issues in patient compliance.

Patient compliance refers to the willingness and ability of an individual to follow health-related advice, to take medication as prescribed, to attend scheduled clinic appointments and to complete recommended investigations. It is a major health issue, with outcomes related to levels of morbidity, mortality and cost utilisation. Poor compliance has been reported as the most common cause of nonresponse to medication, with evidence to show that patients who adhere to treatment recommendations have better health outcomes than those who do not adhere, even when taking a placebo. Evidence-based practice guidelines, founded on clinical, behavioural and educational concepts, provide a means of measuring outcomes related to health status, patient satisfaction and cost-benefit issues, and may help to ensure that responsibility for compliance is shared between the clinician and the patient.

Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access?

BACKGROUND: Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access. AIM: To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma. DESIGN OF STUDY: A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach. SETTING: Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland. METHOD: Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature. RESULTS: The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children. CONCLUSION: A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children.

Do general practice patients with heart failure understand its nature and seriousness, and want improved information?

This study describes the extent to which patients with heart failure in general practice understand the nature and seriousness of their condition, and want more or better information about it than they currently get. The study involved a random sample of 62 patients receiving care for chronic heart failure in 30 central Auckland, New Zealand, practices. The narrative texts of personal, semi-structured interviews in late 1999 were edited (explicitly and systematically reduced and reassembled) until their interpretation was complete. Approximately 40% of the patients interviewed appeared not to understand the nature and seriousness of their heart failure condition. Two patients had accidentally discovered the diagnosis from inappropriate sources. Eleven patients (18%) expressed wanting improved information about their condition. However, to avoid harm, we did not ask patients about wants for information relating to the seriousness of their heart failure. Through patient education and counselling, providers could help patients to produce an advance written directive of wants for information.

New Zealand and United Kingdom experiences with the RAND modified Delphi approach to producing angina and heart failure criteria for quality assessment in general practice.

OBJECTIVES: (1) To describe the development of minimum review criteria for the general practice management in New Zealand (NZ) of two chronic diseases: stable angina and systolic heart failure, and (2) to compare the NZ angina criteria with a set produced in Manchester to assess the extent to which use of the same approach to criteria development yields similar criteria. METHODS: A modified Delphi approach, based on the RAND consensus panel method, was used to produce minimum criteria for reviewing the recorded management of heart failure and angina in NZ general practice. The criteria for angina were compared with those produced in the UK, including assessment of the extent to which each set describes actions that the other panel agrees are necessary to record. RESULTS: For each condition we report minimum criteria describing actions rated as (a) necessary to record and (b) inappropriate to take but, if taken, necessary to record. Although strong scientific evidence underpins approximately one quarter and one third, respectively, of the final sets of NZ and UK angina criteria for actions necessary to record, the NZ criteria agree strongly with the UK criteria (33 of 39 criteria, 85%) but there is less UK agreement with the NZ angina criteria (28 of 40 criteria, 70%). CONCLUSION: Despite the lack of scientific evidence for up to three quarters of angina care in general practice, the RAND based approach to criteria development was used in NZ to reproduce most of the UK angina criteria for actions rated as necessary to record in general practice. It is important to make explicit whether ratings of necessity and appropriateness apply to the recording of actions or to the actions themselves.

Quality improvement within Independent Practitioner Associations: lessons from New Zealand.

AIMS: To ascertain what quality improvement activities are being performed by associations of general practitioners (GPs) in New Zealand, to find out how they are supporting these activities, and learn about their experience of the process. METHOD: A cross sectional questionnaire study of 25 independent practitioner associations (IPAs) in New Zealand. RESULTS: All respondents (n=25) believed quality improvement was a responsibility of their organization, and for 48% it was their highest priority. All organizations carried out and supported a range of quality improvement activities. The major perceived barriers to quality improvement were negative attitudes and lack of time and money to support the process. Strategies to overcome these barriers included providing comparative data to staff in a peer group setting and providing financial incentives, management support and education. CONCLUSIONS: Considerable quality improvement activity is occurring in primary care in New Zealand. A variety of barriers to the process and methods of overcoming them have been identified by some, but not all IPAs.

Non-invasive methods for measuring data quality in general practice.

AIM: To develop non-invasive methods of measuring the quality of data recorded in general practice. METHODS: Laboratory and pharmaceutical claims data from fourteen practices (44 doctors) from the FirstHealth network of general practices were examined to determine the extent to which valid minimum bounds on expected rates of diagnosis coding could be established. These were compared with recorded rates in patient notes to measure completeness of diagnosis recording. Data completeness was measured for demographic data and a marker for the accuracy of gender coding was developed from diagnosis data. RESULTS: Minimum rates of diagnosis could be established for asthma, diabetes (NIDDM and IDDM), ischaemic heart disease, hypothyroidism, bipolar affective disorder and Parkinson's disease. Minimum bounds for the number of patients requiring monitoring of warfarin and digoxin levels were also established. These expected minimum rates were combined with measures of completeness of age, gender, ethnicity and smoking data, and a gender coding accuracy measure, to produce a set of fourteen data quality indicators. Pass/fail thresholds on each indicator were set and each of the fourteen practices was scored on the number of passes they achieved. The scores ranged from three to nine out of fourteen passses. CONCLUSIONS: Non-invasive data quality measures may be useful in providing feedback to general practitioners as part of a data quality improvement cycle. The sensitivity of this method will decline as data quality improves.

New Zealand general practice computerisation; attitudes and reported behaviour.

AIMS: To gather information from general practitioners regarding aspects of computerisation including whether certain tasks should be computerised and whether those tasks were in fact computerised at their practice. METHODS: Five hundred general practitioners randomly selected throughout New Zealand were sent a postal survey in May 1995. Results were then collated and analysed. RESULTS: The response rate was 54% (268). Computerisation is becoming a necessity according to 85% of responders and a computer was used for at least one task by 84% of doctors. Computer use during consultation interfered unduly with doctor-patient communication according to 43% of responders. Privacy issues had not been dealt with adequately for 33% of responders. The five most frequently computerised tasks were; maintaining an age-sex register (81% of responders), recalls (80%), administration (77%), making appointments (50%) and word processing (49%). The number of doctors in a practice and responders' RNZCGP membership status appeared predictive of task computerisation. Responders' gender, year of graduation and their membership on the Indicative General Practitioners Register were not statistically significant factors for determining attitudinal and behavioural responses. CONCLUSIONS: The low response rate limits generalisation but the trends in the results are important. Reported tasks with greatest potential for computerisation were doctor education; checking drug interactions/contraindications; patient education; tasks relating to interfacing with laboratories; and database enquires of patients. Significant concerns among responders were perceived interference with doctor patient communication and privacy issues. Eighty-four percent of responders use the computer for at least one task.

Problem gamblers: do GPs want to intervene?

AIM: To survey GPs' attitudes towards problem gamblers and knowledge to successfully intervene. METHODS: 100 GPs, randomly selected for gender and geographical distribution, were anonymously surveyed by questionnaire through the Royal New Zealand College of General Practitioners. RESULTS: 80 GPs responded (80% of those surveyed). There was strong support (85%) for problem gambling being within a GP's mandate, for involvement in treatment of problem gambling (72%) and for their having a role in supporting a family where a member has a gambling problem (80%). There was less confidence in: raising the issue of gambling with patients (53%), in knowledge of resources (38%) and in having the necessary training to intervene (19%). CONCLUSIONS: GPs see problem gambling as a legitimate role for their intervention, however, they have concerns around their competency and knowledge of resources. The provision of undergraduate and postgraduate training may assist to remove barriers to an accepted role in primary health.

A future for primary health care in New Zealand.

The attempt to implement a health market in New Zealand by separating funders and providers in 1992 has not delivered improved health outcomes. Indeed there is increasing concern that deprived populations are not accessing appropriate health care. This article describes the models of primary care that have evolved in the new environment and suggests that these new structures, given appropriate support, are ideally placed to increase the focus of primary care on population health. A capitation funding model with patient enrolment and low fee-for-service barriers is proposed as the most promising model for delivering improved health outcomes. The model incorporates a needs-based funding formula, locality health needs assessment, an increased role for primary care nurses and improved responsiveness to local communities, especially Maori.

Why do children hospitalised with pneumonia not receive antibiotics in primary care?

BACKGROUND: Although antibiotics are recommended for the primary care management of community-acquired pneumonia, a recent UK study reported that most children admitted to hospital had not received antibiotics. OBJECTIVE: To describe primary care antibiotic use for children subsequently hospitalised with community-acquired pneumonia. DESIGN/METHODS: A case series of 280 children <5 years old hospitalised with pneumonia in Auckland, New Zealand. Pneumonia was defined as an acute illness with cough or respiratory distress, the presence of tachypnoea or indrawing and an abnormal chest radiograph. Receipt of antibiotics was determined by parental report and medical record review. RESULTS: Fewer than half (108, 39%) of the children had received an antibiotic before hospital admission. For 60 children (21%) there had been no opportunity to prescribe because the illness evolved rapidly, resulting in early hospital admission. For the remaining 112 children (40%) an opportunity to receive antibiotics was missed. The parent failed to obtain the antibiotic prescribed for 23 children (21% of 112), but in 24 children (21%) pneumonia was diagnosed but no antibiotic prescribed and in a further 28 children (25%) the diagnosis was not made despite parental report of symptoms suggesting pneumonia. Missed opportunities to prescribe were not associated with increased overall severity of symptoms at hospital presentation but were associated with an increased risk of: focal chest radiological abnormalities (rate ratio (RR)=2.14; 95% CI 1.49 to 2.83), peripheral leucocytosis >15×10(9)/l (RR=2.29; 95% CI 1.61 to 2.98) and bacteraemia (RR=6.68, 95% CI 1.08 to 58.44). CONCLUSIONS: Young children with community-acquired pneumonia may not receive an antibiotic before hospital admission because the illness evolves rapidly or the prescribed medicine is not given by parents. However, missed opportunities for appropriate antibiotic prescribing by health professionals in primary care appear to be common.

Coping strategies in the self-management of chronic heart failure.

BACKGROUND: A patient's psychological adaptation to heart failure can influence its impact on his or her life. However, attempts to understand how patients cope mentally with severe emotional strain have led to inconsistent use of a plethora of concepts, making communication and clinical care difficult. OBJECTIVES: The aim of the present study was to develop a framework for conceptualizing how patients with chronic heart failure cope mentally with their illness, and then use the framework to suggest how GPs can facilitate patient self-care. METHODS: We systematically reduced and reassembled the narrative texts of personal, semi-structured interviews until their interpretation was complete. The interviews were conducted during late 1999 with 62 heart failure patients under GP care in 30 practices across central Auckland, New Zealand. RESULTS: Our framework describes four coping strategies: avoidance, disavowal, denial and acceptance. Disavowal provides a distinct coping strategy through which patients, who basically understand the threat to their life situations, seek hope through positively reconstructing this threat. Use of this strategy was highly salient regardless of patients' age, the length of time since their recorded diagnosis or the degree of self-reported limitation of recent physical function due to heart failure. Only over age 70 were avoidance and acceptance also highly salient among patients whose heart failure was diagnosed at least 3 years previously and had mildly limited their recent physical function. CONCLUSION: Many different heart failure patients use disavowal to palliate the emotional strain and find hope. Disavowal is not a problem to deal with but a process GPs can facilitate by implementing a range of suggested strategies through methods such as story telling.

Are vocationally trained general practitioners better GPs? A review of research designs and outcomes.

Implicit and explicit in reviews of and changes to vocational education for general practitioners in the 1990s is the challenge to defend the assumption that vocationally trained GPs are better GPs. This paper provides a review of the international literature which has reported on outcomes of general practice vocational training programmes. Through the review we identify both the types of research methodologies used (including a brief discussion of their strengths and limitations) and the outcomes reported of vocational training. Twenty-five studies on the outcomes of vocational training are reviewed. These studies used multiple data sources and one of four methodologies: pre- and post-training comparisons, analysis of learners' or teachers' accounts, audits of general practice or analysis of examination pass rates. When collated, the following range of outcomes from vocational training were identified: improved quality of patient care, increased knowledge, improved general practice skills, increased confidence and desirable GP attitudes and personality traits, increased adherence to practice guidelines and higher examination pass rates. The paper concludes with a summary of research and education issues which arise when we examine the question posed at the outset: are trained GPs better GPs?

The New Zealand Diabetes Passport Study: a randomized controlled trial of the impact of a diabetes passport on risk factors for diabetes-related complications.

AIMS: To assess the efficacy (change in HbA1c) of a patient-held communication, self-empowerment and educational device for people with diabetes (the New Zealand Diabetes Passport) in patients with poor glycaemic control. RESEARCH DESIGN AND METHODS: A 12-month, multicentre, general practice-based randomized controlled trial in urban, provincial and rural New Zealand involving 398 people with poorly controlled Type 1 or Type 2 diabetes. The intervention included a specifically designed and piloted New Zealand Diabetes Passport including information relating to diabetes knowledge, self-assessments, and guidance concerning how to engage with diabetes health professionals. The primary end point was change in HbA1c. Assessments were made at 0, 6 and 12 months. RESULTS: Two hundred and twenty-two patients received the Passport, 176 the control booklet, coming from 69 and 66 general practitioners, respectively. Use of the Passport was associated with a relative reduction in HbA1c of 0.4% (P = 0.017) and a relative increase in weight of 1.0 kg/m2 (P = 0.028), but no changes in diabetes knowledge, attitudes to diabetes or risk factors for diabetic tissue damage. CONCLUSIONS: The dissemination of the New Zealand Diabetes Passport, in isolation, was not associated with improvements in either diabetes knowledge or self-empowerment. While a small improvement in glycaemic control occurred, this was probably due to changes in insulin therapy in the intervention group. It is possible that linking the use of the Passport with other behavioural and educational interventions may make the Passport more useful. Further study is required to confirm the effect of such multifaceted interventions.