Journal of primary health care最新文献

Introduction Melanoma is a serious type of skin cancer with a high burden in New Zealand. MelNet Quality Statements (2021) guide the timeliness of investigations and management for melanoma patients, who might experience long delays waiting for treatment. Aim To assess compliance of melanoma diagnosis and treatment timeliness with the MelNet Quality Statements at Waikato Hospital and in primary care for melanoma and melanoma in situ (MIS). Methods This is a retrospective clinical audit of patients referred via the Suspected Skin Cancer (SSC) teledermatology pathway between June 2020 and June 2022, and histologically confirmed as having melanoma or MIS. Time intervals between elements of service were analysed. Results For 43 melanomas and 105 MIS, compliance with MelNet Quality Statements across all melanoma services was poor, except for teledermatology response rates (100% compliance). From referral to first cancer treatment (Statement 2.1.1), compliance was 50% in general practice and 7.7% in Waikato Hospital. From teledermatologist response to biopsy (Statement 2.1.3), compliance was 65.2% in general practice and 7.7% in hospital plastics department. Histopathological reporting delays were also identified. Discussion Long delays for melanoma care in hospital likely reflect system failures (such as inadequate funding and human resources) and the increasing burden of skin cancer. In contrast, primary care provided quicker diagnostic biopsies and surgical treatments for melanoma.

Introduction Maternal vaccination against influenza and pertussis protects mothers and babies from severe disease and is recommended and funded in Aotearoa New Zealand. Despite this, maternal vaccination uptake is low, varies by region and is inequitable, with Māori and Pacific māmā (mothers) less likely to receive vaccination. Aim To determine what interventions currently exist to support and encourage maternal vaccination against influenza and pertussis and what changes and interventions could be implemented to improve coverage, with a focus on Māori and Pacific hapū māmā (pregnant mothers). Methods Interviews with six participants with diverse roles in the vaccination workforce were conducted. Participants were involved in education, certification and supporting vaccinators, high-level strategising, and vaccination. Interviews aimed to determine what interventions currently exist for hapū māmā, what changes need to be made to improve coverage and how Māori and Pacific people have been specifically engaged. Qualitative data analysis was used to determine themes. Results Participants identified that interventions must focus on prioritising and emphasising the importance of maternal vaccination, promoting collaboration and innovation, making interventions accessible, and empowering Māori- and Pacific-driven avenues to vaccination. To create positive foundations, participants identified the importance of building and maintaining trust and affording mothers' time and autonomy in vaccination. Discussion Healthcare professionals need to proactively engage hapū māmā about vaccination and collaborate in service delivery. Interventions must be suitably accessible and allow for the autonomy of hapū māmā over vaccination decisions. Equity should be considered at the foundation of vaccine interventions to improve the accessibility of vaccines to all communities.

Introduction Most New Zealanders experience low back pain (LBP) at least once throughout their lifetime and many seek help from the large range of health providers in primary care. Accident Compensation Corporation (ACC) funds a significant proportion of those claims, but which services are they funding and what are the costs? Method This was a retrospective audit and descriptive analysis of ACC-funded, non-public hospital healthcare service use by people with LBP in New Zealand (NZ). Outcome measures were the healthcare services accessed by people with ACC-funded LBP,the claims (all occurrences for a service that has generated a payment/year), single contact (with a service), and costs (NZ$) for services between 2009 and 2020. Results The number of claims for services were 129 000 for physiotherapy, 105 000 for general practitioner and 59 000 for radiology services. Per single contact, elective surgery and radiology services were the most expensive. During 2009-2020, there were 3.3 million ACC claims for LBP with a total cost of NZ$4 billion. Over this time, there was an increase in claims, costs and single contacts. Costs decreased slightly during 2010 due to changes in healthcare funding and in 2020 due to the COVID-19 pandemic. Discussion Consumers have considerable choice in where they access health care for ACC-funded LBP services. This study shows the services they use most frequently and the cost to NZ for those services. These data can inform service planning for ACC-funded LBP health care in NZ.

Introduction Low back pain (LBP) is common and a significant cause of morbidity. Many patients receive inappropriate imaging for LBP in primary care. Aim To explore the incidence and type of spinal imaging conducted for LBP patients referred from general practice for specialist surgical opinion, and evaluate whether imaging conformed to clinical guidelines. Methods Audit of a sequential cohort (n  = 100) of new LBP patients referred from primary care for specialist opinion at a suburban Australian capital city independent Spinal Centre. Results In the 6 months before referral, 90% (95% CI 83-95%) of patients underwent spinal imaging. Imaging was performed in 95% of those who did and 79% of those who did not meet guidelines for radiological investigation. 35% of patients were inappropriately imaged and 3% inappropriately not imaged. Spinal computed tomography (CT) imaging was used in 52% of patients, magnetic resonance imaging (MRI) in 42% and image-guided lumbar spinal interventional procedures in 28%. Discussion Most patients with LBP referred for surgical opinion have diagnostic radiological investigations whether or not it is indicated by clinical guidelines. The more frequent use of spinal CT compared to MRI may be due to idiosyncrasies of the Australian Medicare Benefits Schedule (MBS) rebate system. The findings of this pilot study provide support for the changes recommended by the 2016 MBS Review Taskforce on LBP that permit GP access to subsidised lumbar MRI, while constraining access to lumbar CT, and provide novel data about spinal imaging and practice in this cohort of patients.

Introduction Polypharmacy is associated with potentially inappropriate medicine prescribing and avoidable medicine-related harm. Polypharmacy should not be perceived as inherently harmful. Instead, priority should be placed on reducing inappropriate prescribing. Aim The study aimed to develop and validate PolyScan, a primary care information technology tool, to triage older adults with polypharmacy who are prescribed potentially inappropriate medicines. Methods Twenty-one indicators from a New Zealand criteria of potentially inappropriate medicines to correct for older adults with polypharmacy were developed into a set of implementable definitions. The definitions were applied as algorithmic logic statements used to interrogate hospital and emergency department records and pharmaceutical collection data to classify whether each indicator was present at an individual patient level, and then triage individuals based on the number of indicators met. Validity was evaluated by comparing PolyScan's accuracy against a manual review of healthcare records for 300 older adults. Results PolyScan was successfully implemented as a tool that can be used to identify potentially inappropriate prescribing in older adults with polypharmacy at different levels of aggregation. The tool has utility for individual practitioners delivering patient care, primary care organisations undertaking quality improvement programmes, and policymakers considering system-level interventions for medicines-related safety. During the validity assessment, PolyScan identified nine individuals (3%) with polypharmacy and indicators of potentially inappropriate medicine. Five unique indicators were detected. PolyScan achieved 100% sensitivity, specificity, and positive and negative predictive values. Discussion PolyScan can support clinicians, clinics, and policymakers with allocation of resources, rational medicine campaigns, and identifying individuals prescribed potentially inappropriate medicines for review.

Introduction A handful of reports detail efforts to redesign traditional hospital gowns to address common concerns related to patient comfort and privacy for big bodied patients. Results suggest that improving gown design has the potential to improve both the patient and carer experience and satisfaction of care. Aim This study aimed to ascertain the utility of gowns purposely designed for big bodied patients (named Xcellent Gowns) from a staff perspective. Methods Qualitative semi-structured interviews were conducted in 2022 with 14 hospice staff members. Interview transcripts were uploaded to DedooseTM . Data were analysed utilising reflexive thematic analysis according to a six-phase process including data familiarisation, iterative data coding, and theme development and refinement. Results The qualitative analysis of the interview data identified four main themes: (1) the gown experience, (2) fit-for-purpose, (3) love and dignity, (4) design principles. Each theme is presented and discussed with illustrative quotes from participants' interview transcripts. Discussion The perspectives of the staff participants in this study confirm research findings from other healthcare settings, that the patient and carer experience may be improved through focused redesign of this vital item of patient clothing.

Introduction The term comprehensiveness was introduced into the literature as early as the 1960s and is regarded as a core attribute of primary care. Although comprehensive care is a primary care research priority encompassing patient and provider experience, cost, and health outcomes, there has been a lack of focus on consolidating existing definitions. Aim To unify definitions of comprehensiveness in primary care. Methods The PRISMA extension for scoping reviews was followed, hierarchically filtering 'comprehensiveness' MeSH terms and literature-defined affiliated terms. Snowballing methods were used to include additional literature from known experts. Articles were systematically reviewed with a three-clinician team. Results The initial search populated 679 607 articles, of which 25 were included. Identified key terms include: whole-person care (WPC), range of services, and referral to specialty care. WPC is the extent which primary care physicians (PCPs) consider the physical, emotional, and social aspects of a patient's health. It has been shown to positively impact clinical costs and outcomes, satisfaction, and trust. Range of services encompasses most health problems to reduce unnecessary spending on specialty care and promote continuity. Referral to specialty care is utilized when PCPs cannot provide the necessary services - balancing depth and breadth of care with the limitations of primary care scope. Discussion This scoping review unified the interrelatedness of comprehensiveness's main aspects - whole-person care, range of services, and referral to specialty care - framing a working, evidence-based definition: managing most medical care needs and temporarily complementing care with special integrated services in the context of patient's values, preferences, and beliefs.

Introduction Antimicrobial resistance is an infectious disease threat to public health globally, and antimicrobial stewardship among healthcare professionals is one key way to address this potential problem. Registered nurse designated prescribers are the newest group of health professionals to gain prescribing authority in Aotearoa New Zealand, yet little is known about their understanding of their antimicrobial stewardship role. Aim The aim of this study was to explore registered nurse designated prescribers' understanding of their antimicrobial stewardship role through their prescribing practices and approaches to clinical reasoning. Methods This exploratory descriptive qualitative study used individual semi-structured interviews with six registered nurse designated prescribers. Thematic analysis was used to analyse the interviews. Results Four themes were identified: antibiotic prescribing practices and antimicrobial resistance; clinical indicators for prescribing antibiotics, with the sub-themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. These themes provide insight into registered nurse designated prescribers' understanding of their antimicrobial stewardship role and prescribing of antibiotics. Discussion This research found that the registered nurse designated prescribers had an awareness of the importance of their antimicrobial stewardship role in relation to antibiotic prescribing and reducing antimicrobial resistance. Education about antimicrobial resistance and antimicrobial stewardship for this professional group can be effective, but further research is needed to understand their ongoing educational needs.