Journal of primary health care最新文献

Introduction Fundus examination by direct ophthalmoscopy is widely used in general practice; however, it offers limited field of view, requires close approximation to the patient, has a steep learning curve and is a difficult skill to master and maintain. Non-mydriatic fundus photography (NMFP) offers an alternative with a wider field of view, ability for image analysis and transmission, and is able to be conducted by allied healthcare staff. Aim This study aimed to compare the use of direct ophthalmoscopy with smart-phone NMFP in a large rural general practice. It also aimed to analyse the number of adequate views and positive findings achieved with each instrument and the impact of NMFP on ophthalmology referral decisions. Methods Patients aged ≥16 years presenting to Dargaville Medical Centre (Dargaville, New Zealand) with visual disturbance, headache, hypertensive urgency (systolic blood pressure (BP) >200 mmHg or diastolic BP >120 mmHg), transient ischemic attack (TIA) or stroke were enrolled prospectively into an observational study of visualisation, diagnosis and management impact for a 1-year period (n = 152, 304 eyes). Direct ophthalmoscopy findings and management plans were documented by the attending general practitioner (GP), and then again following assessment of the NMFP. Results NMFP significantly improved visualisation of the fundal structures with an increase in adequate views achieved of both the optic disc and the retina. Inter-rater agreement between the referring GP and ophthalmologist was good. Discussion The use of NMFP in general practice might result in greater accuracy in diagnosing retina and optic disc disease. Routine transmission of NMFP images to specialist eye clinics as part of the referral might improve management and result in health system efficiencies.

Introduction Traditionally, grommet post-surgical follow-up care has been undertaken by otorhinolaryngologists (ORLs), but in a large public outpatient ORL service in Auckland, New Zealand (Counties Manukau), this responsibility has been partially devolved to general practitioners (GPs). Aim The purpose of this study is to explore the perspectives and experiences of families/whānau and GPs regarding grommet services for children. Methods A mixed methods approach was used with family/whānau comprising semi-structured interviews and a GP survey. Recruitment of families/whānau reflected the local demographic and all participants were primary carers of a child who had received grommet surgery between 2020 and 2021. All GPs were practising in clinics within the ORL service catchment area. Results Twenty-eight family/whānau interviews were conducted, and 22 GPs responded to the survey. Five main themes were identified: (1) awareness of child development; (2) challenges accessing health care; (3) responses to health information; (4) importance of aftercare; and (5) preference for service provision. Most (16) GP respondents reported they should not be responsible for post-surgical follow-up after grommet insertion. Lack of capacity and funding were identified as key barriers to GP-led follow-up. Discussion Families/whānau highly valued follow-up services and hearing evaluations after grommet insertion, and had a strong preference for clinicians with perceived expertise in ear and hearing care (ORLs and audiologists). They reported multiple barriers to receiving the desired care. Māori and Pacific families/whānau experienced additional delays for referrals into specialist services. GPs showed low support for primary care-led grommet follow-up care, with most not providing routine grommet checks after surgery.

Introduction Client-Led Integrated Care (CLIC) was implemented in general practices between 2018 and 2022 in the Southern region of New Zealand. It was envisaged to be an equitable, holistic and patient-centred inter-disciplinary framework of care for those with multiple long-term conditions; usually called multimorbidity. Aim This process evaluation aimed to determine whether CLIC supported self-management ability and assessed its alignment with current priorities for multimorbidity management. Method Mixed methods were used across four purposively selected general practices. At each practice interviews were undertaken together with participant observation over 3years. This was followed by analysis of annual self-report surveys. Results CLIC worked well for those patients who were engaged, but the implementation provided minimal consideration of the resources required for everyone to receive culturally competent integrated care. Staff reported structural difficulties and wondered if the right patients were targeted. Discussion CLIC did not address the needs of all participants, nor did it target those with the most ability to benefit. In all practices, despite increasing rates of multimorbidity and social complexity during a pandemic, the organisation of general practice and how it connected with the health system remained unchanged. Transitioning to a general practice system for complex multimorbidity will require changes in funding, strong leadership and clear communication. It requires all areas of the health system to provide an integrated health and social care system that is culturally competent and engages those most vulnerable in our community.

Introduction Type 2 diabetes (T2D) is a significant health issue in New Zealand with a disproportionate effect for Māori. To address inequities and optimise care, Te Korowai Hauora o Hauraki, an Iwi Māori health provider, established the 'Piki te Ora service' to support its five rural clinics by providing culturally safe, multidisciplinary support for patients with T2D. Aim This study aimed to undertake a service review, describing and evaluating the available clinical data, of the Piki te Ora service. Methods Patients enrolled in the Piki te Ora service between January 2021 and March 2024 were invited to have their data (sociodemographic, HbA1c, cholesterol and blood pressure) included in the review. Frequency and mode of health care/patient contact were also explored. Results A total of 112 patients were contacted and 64 (mean age 58years, 62.5% Māori) consented to data review. Over 6months, patients in the Piki te Ora service were contacted an average of 9.5 times, with phone calls being the predominant mode of contact. Median HbA1c levels significantly decreased by 16.0mmol/mol at 6months post enrolment in the Piki te Ora service (P =0.011) but no significant changes were observed in cholesterol or blood pressure. Discussion The Piki te Ora service appears to provide effective support for T2D management, particularly glycaemic control, however more clinical data is needed to evaluate its effectiveness. Its flexible and accessible approach, including free consultations, may enhance care accessibility, especially for economically deprived patients.

Introduction There is increasing concern about the wellbeing of tertiary students, and this is likely to be further exacerbated by the COVID-19 pandemic. There is minimal information about what support is being provided. In New Zealand, there is even less information available on Pacific students in the tertiary environment. Aim This study explored the role of one tertiary institution in the provision of support for Pacific tertiary students during the COVID-19 pandemic. Methods Pacific students' perceptions of all the support they received from the University of Otago during the COVID-19 pandemic were obtained from a cross-sectional survey between April to June 2022. All Pacific students attending the University in 2022 were eligible to participate. An online survey was emailed to all students. Results There were 1277 Pacific students enrolled at the University in 2022. Of all eligible Pacific students, 358 (28%) completed the survey. Three quarters of students had to isolate since the start of the academic year, either because they had COVID-19, or they were a close contact of someone with the disease. Of all participants, 356 (99%) received a health pack. At least two-thirds (67.6%) had accessed other support from the University. A third (32.4%) accessed support through the Otago University Students' Association and some from the community and local Pacific health provider. The support was highly valued by students who utilised these services. Discussion Institutions can provide effective leadership in the coordination of support for their students through working together with student-led, government and non-governmental organisations in the community.

Introduction Clinical uncertainty is not uncommon; however, the current conception of the professional clinician has meant that discussion on uncertainty has focused on elimination rather than recognition. Uncertainty comes from an imbalance in knowledge, data, clinical experience, evidence-based guidelines, judgement, and decision-making. There is a strong argument for improving tolerance of clinical uncertainty, particularly in primary care where general practitioners might be especially vulnerable to uncertainty due to their exposure to undifferentiated illness. Aim This research aims to establish expert patient and general practitioners' perspectives on the clinical attributes needed to deal with uncertainty. Methods Two focus groups, consisting of three general practitioners and five expert patients, discussed uncertainty regarding restless legs syndrome. This topic was used as a rhetorical proxy to examine expert patient and general practitioner perspectives on the clinical attributes needed to deal with uncertainty. The qualitative data were then analysed to form overarching thematic areas. Results Four overarching professional attributes were identified: collaboration, compassion, insight, and unconventional thinking. These are all attributes that lie within a clinician's skillset, but the evidence here suggests that they need to be foregrounded in practice. Discussion In attempting to assess professional clinical practice in relation to uncertainty, this research recommends that clinicians work to adopt a holistic, patient-centred approach, where they explicitly share uncertainties, focus on a patient's emotional state during the diagnostic phases of treatment, and see the merits of challenging themselves to look beyond routine algorithms.

Introduction Improving the respiratory health of Māori and Pacific children in Aotearoa, New Zealand is a priority. Respiratory studies over the past decade have continued to highlight the ongoing inequities among Māori and Pacific children. Aim This systematic review aimed to explore the characteristics of respiratory research with Māori and Pacific children (0-14 years) living in New Zealand. Research objectives were to evaluate the types of study designs used, summarise participant demographics including ethnicity and evaluate whether culturally relevant frameworks were incorporated. Methods Studies were located across four databases: Medline, EBSCOHost, Scopus and PubMed, from 2010 to 2022. To qualify, studies needed to include (1) Māori or (2) Pacific children aged (3) 0-14 years and (4) describe a respiratory research project conducted in New Zealand. A narrative synthesis of the studies meeting the inclusion criteria was performed. Results Of the 539 studies identified, 29 met the inclusion criteria. Most studies were retrospective cohort studies with respiratory conditions focused mainly on asthma, group A streptococcus and lower respiratory tract infections. Four studies were qualitative, and only 2 of the 29 studies reported using a Kaupapa Māori framework. Discussion Despite the increased attention to the respiratory health of Māori and Pacific children, there is a lack of research on the lived experiences of whānau and their children who endure these conditions. Few studies incorporated culturally relevant approaches. Further research that incorporates culturally responsive approaches is urgently needed to enhance ourunderstanding of Māori and Pacific child respiratory health and to advance health equity.