View From the Canoe: Co-Designing Research Pacific Style.

In 2016, Rose Lamont and Tana Fishman were the first patient-clinician dyad from outside North America to attend the North American Primary Care Research Group (NAPCRG) Patient and Clinician Engagement Program workshop. They returned to New Zealand inspired and formed the Pacific People's Health Advisory Group and a Pacific practice-based research network (PBRN). They are guided by the principles of co-design, and the Samoan research framework fa'afaletui, which emphasizes a collective approach and importance of reciprocity and relationships. Their collective inquiry aims to reduce health inequalities experienced by Pacific people in South Auckland. Their community group members and PBRN are generating research questions being answered by university-based graduate students. When they embarked, they knew not the direction in which they headed. With guidance, their community members and clinicians have led the way. By giving everyone a say in where they are going and how they get there, they are modeling what they wish to achieve-an egalitarian approach which decreases disparities for Pacific people.

Legitimate participation of medical students in community attachments.

INTRODUCTION: Social theories of learning consider learning and thinking as social activities. These activities may occur within a community of practice. Communities of practice may position learners as legitimate peripheral participants. This study tests whether legitimate peripheral participation provides an overarching theory to assist in evaluating learning and teaching of medical students undertaking short primary care attachments. METHODS: A questionnaire was delivered to all Year 4 students at the University of Auckland in 2015. A deductive content analysis was undertaken on the data utilising a categorisation matrix. Legitimate peripheral participation theory was used to develop the categorisation matrix. RESULTS: Three broad themes explained legitimate peripheral participation by medical students undertaking a short primary care attachment. These three themes were 'hospitality,' 'collegiality' and 'responsibility.' CONCLUSION: Legitimate peripheral participation, in the context of undergraduate primary health care attachments, appears to depend upon positive social activities between students and health professionals and patients. Using legitimate peripheral participation as a theory to underpin evaluations of general practice attachments it is possible to determine improvements in the learning and teaching experience of medical students.

Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population.

PURPOSE: Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9. METHODS: Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed. RESULTS: There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999. CONCLUSIONS: We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

Antidepressants versus placebo for depression in primary care.

BACKGROUND: Concern has been expressed about the relevance of secondary care studies to primary care patients specifically about the effectiveness of antidepressant medication. There is a need to review the evidence of only those studies that have been conducted comparing antidepressant efficacy with placebo in primary care-based samples. OBJECTIVES: To determine the efficacy and tolerability of antidepressants in patients (under the age of 65 years) with depression in primary care. SEARCH STRATEGY: All searches were conducted in September 2007.The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Controlled Trials Register was searched, together with a supplementary search of MEDLINE, PsycINFO, EMBASE, LILACS, CINAHL and PSYNDEX. Abstracts of all possible studies for inclusion were assessed independently by two reviewers. Further trials were sought through searching the reference lists of studies initially identified and by scrutinising other relevant review papers. Selected authors and experts were also contacted. SELECTION CRITERIA: Studies were selected if they were randomised controlled trials of tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) versus placebo in adults. Older patients (over 65 years) were excluded. Patients had to be recruited from a primary care setting. For continuous outcomes the Hamilton Depression scale of the Montgomery Asberg Scale was requred. DATA COLLECTION AND ANALYSIS: Data were extracted using data extraction forms by two reviewers independently, with disagreements resolved by discussion. A similar process was used for the validity assessment. Pooling of results was done using Review Manager 5. The primary outcome was depression reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of depression symptoms, using the mean difference (MD), with 95% confidence intervals (CI). MAIN RESULTS: There were fourteen studies (16 comparisons) with extractable data included in the review, of which ten studies examined TCAs, two examined SSRIs and two included both classes, all compared with placebo. The number of participants in the intervention groups was 1364 and in the placebo groups 919. Nearly all studies were of short duration, typically 6-8 weeks. Pooled estimates of efficacy data showed an RR of 1.24, 95% CI 1.11-1.38 in favour of TCAs against placebo. For SSRIs this was 1.28, 95% CI 1.15 to 1.43.. The numbers needed to treat (NNT) for TCAs ranged from 7 to 16 {median NNT 9} patient expected event rate ranged from 63% to 26% respectively) and for SSRIs from 7 to 8 {median NNT 7} (patient expected event rate ranged from 48% to 42% respectively) . The numbers needed to harm (NNH for withdrawal due to side effects) ranged from 4 to 30 for TCAs (excluding three studies with no harmful events leading to withdrawal) and 20 to 90 for SSRIs. AUTHORS' CONCLUSIONS: Both TCAs and SSRIs are effective for depression treated in primary care.

Reliability of Mini-CEX Assessment of Medical Students in General Practice Clinical Attachments.

BACKGROUND AND OBJECTIVES: Mini Clinical Evaluation eXercise (mini-CEX) involves observation of routine clinical encounters, initially developed to assess clinical competencies of postgraduate doctors. This study aimed to measure its inter-rater reliability in assessment of medical students in general practice settings. METHODS: General practitioners (GPs) supervising medical students were invited to complete online teaching on how to conduct a mini-CEX. This included three randomly presented scripted films of clinical scenarios representing different levels of student performance. Consenting participants completed an online mini-CEX. Mean marks were calculated for each case, Intraclass Correlation Coefficients (ICC) for overall clinical and four individual competencies, one-way analysis of variance to compare scores, and internal consistency measured by Cronbach's alpha. RESULTS: RESULTS were collated for the first 100 completing GPs, majority aged 40-59 years (71%), male (59%), New Zealand European (58%). Forty-four percent were in rural practice, with 21 mean years in practice. Mean mini-CEX grades increased as standardized performance increased, indicating that GPs reliably agreed about ranking of student performance from poor to very good. The intraclass correlation coefficient (ICC) for overall clinical competency was 0.78 (95% confidence interval 0.48-0.99), indicating good reliability regarding their agreement with each other. A Cronbach's alpha calculated with the overall scores was 0.85, indicating good internal consistency. CONCLUSIONS: Mini-CEXs in undergraduate general practice attachments provide a reliable measure of assessing performance. However, they may be less useful in identifying exceptional performance or weaknesses in key competencies. In addition, caution must be applied in relying upon mini-CEXs to supply a summative assessment.

Effectiveness of simulated clinical teaching in general practice: randomised controlled trial.

INTRODUCTION: There are shortages in community-based general practice placements for medical students. Innovative ways to teach the skills required in general practice are needed. AIM: To assess the effectiveness of 'simulated' general practice clinics using actors, compared with standard community-based general practice attachments in medical undergraduate education. METHODS: Randomised controlled trial involving medical students. Outcome measures included self-reported knowledge, clinical confidence, communication skills, and attitudes within general practice assessed at baseline and after one week. Intervention students participated in 24 simulated consultations with actor-patients over four days. Control students spent four days working with community-based general practitioners and real patients. RESULTS: Of 138 eligible medical students in the first clinical year, 128 (93%) participated and 106/128 (82%) completed the study. Those participating in simulated clinics improved in confidence in history-taking (p=0.03), communication skills (p=0.04), and ability to detect depression (p<0.001) compared with those undertaking community attachments. Those in community-based attachments felt more confident in managing upper respiratory tract infections (p<0.001), giving injections (p<0.001), screening in general practice (p=0.03) and managing illness in the patient's home (p=0.04). There was no difference between the groups in other measures. DISCUSSION: Simulated clinics may assist with development of communication skills within the general practice consultation and may also be used to supplement community-based attachment with real patients. Even so, confidence in the management of common conditions and procedures improves more with real patients.

The prevalence of depression among Maori patients in Auckland general practice.

INTRODUCTION: There has been concern over high rates of mental illness in Maori. Previous studies in general practice have had small sample sizes. AIM: To determine the prevalence of major depression among Maori patients in Auckland general practice using the CIDI and the PHQ as measurement tools. METHODS: This prevalence study is part of a larger randomised trial. The patients were recruited from 77 general practitioners from around Auckland who could provide a private room for interviewing. The patients were invited to participate in the waiting room and all consecutive patients were approached. For this study all patients received a computerised CIDI examination and one third received a PHQ assessment prior to getting the CIDI. The interviewer was blind to the questionnaire results when the patient did the CIDI. RESULTS: There were 7994 patients approached from whom there were data on 7432. The prevalence of Maori in the study was 9.7%. The overall 12-month prevalence of major depression based on the CIDI was 10.1% 95% CI (8.8 to 11.4). For Maori the prevalence was 11.5% 95% CI (8.8 to 14.2) and for non-Maori 10.1% 95% CI (8.6 to 11.3). For Maori men and Maori women the prevalence was 8.5% and 13.4% and for non-Maori men and non-Maori women it was 8.3% and 11.1%. The prevalence of depression over at least the previous two weeks on the PHQ > or = 9 for all participants was 12.9% 95% CI (11.2 to 14.5). DISCUSSION: The prevalence of depression among Maori is high, but not as high as earlier studies. This may be due to the bigger sample size of this study.

A new case-finding tool for anxiety: a pragmatic diagnostic validity study in primary care.

OBJECTIVE: Anxiety is common in the community and in family practice (FP) patients. It is a treatable condition but often not diagnosed. The aim of this study was to determine the validity of two written questions to aid family physicians in the identification of anxiety. The first question asks the patient whether they have been worrying a lot during the past month; and the second question asks whether the patient would like help with this problem. METHODS: The study was a pragmatic cross sectional validity study conducted with 19 family physicians in six clinics in New Zealand. The outcomes were the sensitivity, specificity, and likelihood ratios compared with the HADS anxiety score > or = 11 as a gold standard. RESULTS: The study recruited 982 consecutive patients receiving no psychotropic drugs. The FP diagnosis had a sensitivity of 58% (95% CI 45% to 69%) and a specificity of 87% (95% CI 85 to 89). The worry question alone had a sensitivity of 76% (95% CI 64% to 85%) and a specificity of 82% (95% CI 79% to 84%). The positive likelihood ratio for patients wanting help today was 9.29 (95% CI 5.62 to 15.36). The likelihood ratio for patients worrying but not wanting help was 2.29 (95% CI 1.48 to 3.55). The likelihood ratio (negative) for those not worrying was 0.29 (95% CI 0.18 to 0.46). CONCLUSIONS: The use of a case-finding question for anxiety and a question asking whether help is wanted increases the positive likelihood ratio indicating that the use of the two questions may aid family physicians in identifying cases of anxiety.