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Introduction The value of family health history as a means to understanding health risk has been long known. Its value in a precision medicine context is also now becoming apparent. General practitioners (GPs) are considered to play a key role in the collection, and investigation, of family health history, but it remains widely reported as being both poorly and infrequently undertaken. Little is known about this practice in Aotearoa New Zealand (NZ). Aim This study aimed to explore current practices in relation to the ascertainment of family health history, with a view towards precision medicine. Methods Semi-structured interviews were conducted with 10 GPs recruited from one urban area of NZ. The interviews were subjected to a thematic analysis. Results Family health history information was used to varying degrees in four areas - risk ascertainment, patient engagement with a diagnosis, social context and building relationships. Patient cultural considerations were rarely mentioned. Reliability of information provided by patients, resource constraints, context driven consults and electronic health record limitations are potential indicators of current limits of family health history. Discussion Our findings present a baseline of current practice and echo larger studies from overseas. As precision medicine is not yet routine, a unique opportunity exists for consideration to be given to establishing specific roles within the NZ health system to enable equitable practice of, and subsequent health gains from, the use of family/whanau health history information as part of precision medicine.
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Medicina General , Médicos Generales , Humanos , Nueva Zelanda , Reproducibilidad de los Resultados , Medicina Familiar y Comunitaria , Investigación CualitativaRESUMEN
OBJECTIVE: To develop a natural language processing software inference algorithm to classify the content of primary care consultations using electronic health record Big Data and subsequently test the algorithm's ability to estimate the prevalence and burden of childhood respiratory illness in primary care. DESIGN: Algorithm development and validation study. To classify consultations, the algorithm is designed to interrogate clinical narrative entered as free text, diagnostic (Read) codes created and medications prescribed on the day of the consultation. SETTING: Thirty-six consenting primary care practices from a mixed urban and semirural region of New Zealand. Three independent sets of 1200 child consultation records were randomly extracted from a data set of all general practitioner consultations in participating practices between 1 January 2008-31 December 2013 for children under 18 years of age (n=754,242). Each consultation record within these sets was independently classified by two expert clinicians as respiratory or non-respiratory, and subclassified according to respiratory diagnostic categories to create three 'gold standard' sets of classified records. These three gold standard record sets were used to train, test and validate the algorithm. OUTCOME MEASURES: Sensitivity, specificity, positive predictive value and F-measure were calculated to illustrate the algorithm's ability to replicate judgements of expert clinicians within the 1200 record gold standard validation set. RESULTS: The algorithm was able to identify respiratory consultations in the 1200 record validation set with a sensitivity of 0.72 (95% CI 0.67 to 0.78) and a specificity of 0.95 (95% CI 0.93 to 0.98). The positive predictive value of algorithm respiratory classification was 0.93 (95% CI 0.89 to 0.97). The positive predictive value of the algorithm classifying consultations as being related to specific respiratory diagnostic categories ranged from 0.68 (95% CI 0.40 to 1.00; other respiratory conditions) to 0.91 (95% CI 0.79 to 1.00; throat infections). CONCLUSIONS: A software inference algorithm that uses primary care Big Data can accurately classify the content of clinical consultations. This algorithm will enable accurate estimation of the prevalence of childhood respiratory illness in primary care and resultant service utilisation. The methodology can also be applied to other areas of clinical care.
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Algoritmos , Registros Electrónicos de Salud/normas , Atención Primaria de Salud/estadística & datos numéricos , Derivación y Consulta/clasificación , Enfermedades Respiratorias/epidemiología , Programas Informáticos , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Procesamiento de Lenguaje Natural , Nueva Zelanda/epidemiología , Evaluación de Resultado en la Atención de Salud , Derivación y Consulta/normas , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: Depression is common post-TBI, yet has not been studied longitudinally, nor at a population level. This study examined prevalence of depression in a population-based sample across the first year post-TBI. DESIGN AND METHODS: Prospective follow-up of 315 adults (>16 years) with assessments (Hospital Anxiety Depression Scale, DSM-IV criteria) at 1-, 6- and 12-months post-TBI. Demographic and injury-related predictors of depression at 1-year post-TBI were also explored. RESULTS: The number of individuals identified as depressed reduced significantly between baseline and 12-months post-TBI from 21-12.4% using the HADS and 49-34% using DSM-IV criteria; with only 10 of the 28 individuals initially meeting criteria on the HADS continuing to do so at 12-month follow-up. Meeting HADS depression criteria was linked to pre-morbid depression and/or anxiety; while those meeting DSM-IV criteria were older, but not significantly so. CONCLUSIONS: The findings suggest depression is common post-TBI and that clinicians/researchers use caution in its diagnosis, as existing criteria have significant overlap with common TBI sequels.
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Ansiedad/diagnóstico , Lesiones Encefálicas/psicología , Depresión/diagnóstico , Personas con Discapacidad/psicología , Adulto , Factores de Edad , Ansiedad/etiología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/fisiopatología , Estudios Transversales , Depresión/etiología , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Personas con Discapacidad/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pruebas Neuropsicológicas , Nueva Zelanda/epidemiología , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: The World Health Organization is revising the primary care classification of mental and behavioural disorders for the International Classification of Diseases (ICD-11-Primary Health Care (PHC)) aiming to reduce the disease burden associated with mental disorders among member countries. OBJECTIVE: To explore the opinions of primary care professionals on proposed new diagnostic entities in draft ICD-11-PHC, namely anxious depression and bodily stress syndrome (BSS). METHODS: Qualitative study with focus groups of primary health-care workers, using standard interview schedule after draft ICD-11-PHC criteria for each proposed entity was introduced to the participants. RESULTS: Nine focus groups with 4-15 participants each were held at seven locations: Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom. There was overwhelming support for the inclusion of anxious depression, which was considered to be very common in primary care settings. However, there were concerns about the 2-week duration of symptoms being too short to make a reliable diagnosis. BSS was considered to be a better term than medically unexplained symptoms but there were disagreements about the diagnostic criteria in the number of symptoms required. CONCLUSION: Anxious depression is well received by primary care professionals, but BSS requires further modification. International field trials will be held to further test these new diagnoses in draft ICD-11-PHC.
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Ansiedad/clasificación , Depresión/clasificación , Clasificación Internacional de Enfermedades , Trastornos Mentales/clasificación , Estrés Fisiológico , Adolescente , Adulto , Anciano , Ansiedad/diagnóstico , Actitud del Personal de Salud , Depresión/diagnóstico , Femenino , Grupos Focales , Humanos , Masculino , Trastornos Mentales/diagnóstico , Persona de Mediana Edad , Enfermeras y Enfermeros , Médicos de Atención Primaria , Síndrome , Organización Mundial de la Salud , Adulto JovenRESUMEN
BACKGROUND: It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population. METHODS: Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined. RESULTS: Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP. CONCLUSION: HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP.
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Actitud del Personal de Salud , Actitud , Conocimientos, Actitudes y Práctica en Salud , Dolor de la Región Lumbar/psicología , Dolor de la Región Lumbar/terapia , Manejo del Dolor/psicología , Pacientes , Quiropráctica , Cultura , Interpretación Estadística de Datos , Escolaridad , Medicina Basada en la Evidencia , Adhesión a Directriz , Personal de Salud , Humanos , Fisioterapeutas , Derivación y Consulta , Factores Socioeconómicos , Resultado del Tratamiento , TrabajoRESUMEN
OBJECTIVES: To describe menopause symptoms in postmenopausal Maori and non-Maori New Zealand women, and explore relationships between symptoms, sociodemographic profile and hormone replacement therapy (HRT) use. METHODS: Cross-sectional analysis of data collected during recruitment of women from 27 primary-care practices into an observational study and the international WISDOM trial of postmenopausal HRT. RESULTS: A total of 3616 women aged 49-70 years (mean 58.9 years) were recruited between 1999 and 2004. Maori and non-Maori participants differed in demographic and clinical characteristics, but few differences were observed in the frequency of menopause-related symptoms. Vasomotor symptoms (hot flushes and/or night sweats) were reported by 34.4% of women, with no statistically significant difference between Maori and non-Maori (controlling for demographic variables, p > 0.05). Compared to non-Maori, Maori were less likely to have ever used HRT (24% vs. 54%), and only 5% of Maori reported current HRT use compared to 30% of non-Maori (p < 0.05). CONCLUSIONS: Maori and non-Maori have the same rate of self-reported vasomotor symptoms despite differences in factors thought to influence the experience of menopause symptoms. Differences in HRT use between Maori and non-Maori need to be further explored to identify contributing factors and whether, in turn, these factors impact on quality of life.
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Actitud Frente a la Salud/etnología , Sofocos/etnología , Menopausia/etnología , Nativos de Hawái y Otras Islas del Pacífico/estadística & datos numéricos , Sudoración , Anciano , Estudios Transversales , Terapia de Reemplazo de Estrógeno/estadística & datos numéricos , Femenino , Salud Holística , Humanos , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Calidad de Vida , Autoeficacia , Factores SocioeconómicosRESUMEN
Between April 1999 and March 2004, metabolic profile analyses were performed on individual blood samples from 35,506 dairy cattle in the UK. Assessment of the cows' energy status by the analysis of plasma samples for beta-hydroxybutyrate, glucose and non-esterified fatty acids showed that 70.4 per cent of the cows in early lactation (10 to 20 days calved), 57.1 per cent of the cows in mid-lactation (51 to 120 days calved) and 57.7 per cent of the dry cows within 10 days of their predicted calving date had one or more energy metabolites outside the optimum range; in addition, 16 per cent of the cows in early lactation, 5.6 per cent of those in mid-lactation and 20.5 per cent of the dry cows within 10 days of their predicted calving date had a low plasma urea nitrogen concentration, indicating poor intakes of effective rumen-degradable protein. Abnormalities in the concentrations of magnesium, inorganic phosphate, copper, selenium and iodine were relatively uncommon. The transitional period, particularly in late pregnancy, was commonly identified as a constraint on productivity. Nutritional problems were most commonly associated with poor feed intakes and poor feed management, rather than with the formulation of the rations.
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Fenómenos Fisiológicos Nutricionales de los Animales , Bovinos/sangre , Lactancia/sangre , Preñez/sangre , Alimentación Animal , Animales , Análisis Químico de la Sangre , Bovinos/metabolismo , Bovinos/fisiología , Proteínas en la Dieta/administración & dosificación , Proteínas en la Dieta/sangre , Proteínas en la Dieta/metabolismo , Metabolismo Energético/fisiología , Femenino , Lactancia/metabolismo , Lactancia/fisiología , Necesidades Nutricionales , Estado Nutricional , Embarazo , Preñez/metabolismo , Preñez/fisiología , Oligoelementos/administración & dosificación , Oligoelementos/sangre , Oligoelementos/metabolismoRESUMEN
The neuropeptide substance P (SP), encoded by the preprotachykinin-A (PPTA) gene, is expressed in the central and medial amygdaloid nucleus, where it plays a critical role in modulating fear and anxiety related behaviour. Determining the regulatory systems that support PPTA expression in the amygdala may provide important insights into the causes of depression and anxiety related disorders and will provide avenues for the development of novel therapies. In order to identify the tissue specific regulatory element responsible for supporting expression of the PPTA gene in the amygdala, we used long-range comparative genomics in combination with transgenic analysis and immunohistochemistry. By comparing human and chicken genomes, it was possible to detect and characterise a highly conserved long-range enhancer that supported tissue specific expression in SP expressing cells of the medial and central amygdaloid bodies (ECR1; 158.5 kb 5' of human PPTA ORF). Further bioinformatic analysis using the TRANSFAC database indicated that the ECR1 element contained multiple and highly conserved consensus binding sequences of transcription factors (TFs) such as MEIS1. The results of immunohistochemical analysis of transgenic lines were consistent with the hypothesis that the MEIS1 TF interacts with and maintains ECR1 activity in the central amygdala in vivo. The discovery of ECR1 and the in vivo functional relationship with MEIS1 inferred by our studies suggests a mechanism to the regulatory systems that control PPTA expression in the amygdala. Uncovering these mechanisms may play an important role in the future development of tissue specific therapies for the treatment of anxiety and depression.
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Amígdala del Cerebelo/metabolismo , Elementos de Facilitación Genéticos/fisiología , Regulación del Desarrollo de la Expresión Génica/fisiología , Precursores de Proteínas/genética , Sustancia P/metabolismo , Taquicininas/genética , Amígdala del Cerebelo/embriología , Animales , Ansiedad/genética , Ansiedad/metabolismo , Secuencia de Bases , Células Cultivadas , Pollos , Biología Computacional , Secuencia Conservada/genética , Elementos de Facilitación Genéticos/genética , Femenino , Proteínas de Homeodominio/genética , Proteínas de Homeodominio/metabolismo , Humanos , Ratones , Ratones Transgénicos , Datos de Secuencia Molecular , Proteína 1 del Sitio de Integración Viral Ecotrópica Mieloide , Proteínas de Neoplasias/genética , Proteínas de Neoplasias/metabolismo , Precursores de Proteínas/metabolismo , Homología de Secuencia de Ácido Nucleico , Sustancia P/genética , Taquicininas/metabolismo , Factores de Transcripción/genética , Factores de Transcripción/metabolismoRESUMEN
This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based Mäori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.
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Redes Comunitarias/organización & administración , Propiedad , Atención Primaria de Salud/organización & administración , Sector Privado/organización & administración , Redes Comunitarias/economía , Humanos , Nueva Zelanda , Política , Atención Primaria de Salud/economíaRESUMEN
CONTEXT: Cultural factors in health and illness, and an awareness of community health needs analysis, are important issues for medical education. Both have received relatively little recognition in the medical education literature. This paper describes the development of an educational attachment to remote predominantly Maori rural communities in New Zealand. The twin purposes of the programme were to encourage students to adopt broad public health approaches in assessing the health needs of defined communities, and to increase their awareness of the importance of cultural issues. METHODS: During a one week attachment, 51 students from the Wellington School of Medicine were hosted in six small communities in the East Cape region of New Zealand. Students gained an insight into the health needs of the communities and were encouraged to challenge their own attitudes, assumptions and thinking regarding the determinants of health and the importance of cultural factors in health and illness. The programme included both health needs assessment and cultural immersion. Students made visits with primary health care professionals and were also introduced to Maori history and cultural protocol, and participated in diverse activities ranging from the preparation of traditional medicines to performing their own songs in concert. CONCLUSIONS: The students evaluated the course extremely highly. Attachments of this sort provide an opportunity for students to appreciate how cultural values have an impact on health care, and how they also make the teaching and learning of topics such as community health needs analysis an enjoyable and dynamic experience.
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Planificación en Salud Comunitaria/métodos , Educación de Pregrado en Medicina/organización & administración , Evaluación de Necesidades , Salud Rural/normas , Competencia Clínica , Cultura , Humanos , Nueva Zelanda , Calidad de la Atención de Salud , Servicios de Salud Rural/normasRESUMEN
AIM: To assess job satisfaction, job-related stress and psychological morbidity among New Zealand physicians, surgeons and community pharmacists and provide a comparison with New Zealand general practitioners (GPs). METHODS: 411 physicians, 330 surgeons and 400 randomly sampled community pharmacists, were surveyed. Psychological morbidity was assessed by the General Health Questionnaire (GHQ-12) and job satisfaction by the Warr Cook Wall scale. RESULTS: Response rates were 70.5% for physicians, 69% for surgeons and 76% for community pharmacists. Job satisfaction scores for surgeons were similar to scores for GPs. Pharmacist and physicians scores were lower. Job satisfaction varied according to gender, the relative amount of time spent in public practice and the perceived ill effects of work on health. Pharmacists had the highest number of cases with significant scores on the GHQ-12 scale, with physicians and surgeons scoring similar to GPs. In each of these health professional groups approximately 10% described a level of symptoms that is associated with more severe psychological disturbance. CONCLUSIONS: All three groups were generally satisfied with their jobs. Pharmacists were significantly less so. Physicians and surgeons reported similar levels of psychological morbidity to GPs, which have been previously reported as a cause for concern.
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Satisfacción en el Trabajo , Farmacéuticos/psicología , Médicos/psicología , Estrés Psicológico/epidemiología , Adulto , Actitud del Personal de Salud , Femenino , Humanos , Masculino , Medicina , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Prevalencia , Especialización , Estadísticas no Paramétricas , Encuestas y CuestionariosRESUMEN
AIMS: To obtain current information about New Zealand rural general practitioners (GPs) and their localitites. METHODS: An anonymous postal questionnaire was mailed out to 559 rural and semi-rural GPs in November 1999, and non-responders were sent three reminders. RESULTS: Of the 417 completed questionnaires returned (response rate 75%), 338 were from rural GPs(Rural Ranking Scale score > or = 35 points) and these formed the study group. The mean age was 44 years, 72% were male, and 93% were of New Zealand European ethnicity. Less than 50%had graduated from a New Zealand medical school with Britain (30%) and South Africa (11%) providing most of the foreign- trained rural GPs. Only 59% had received vocational training in general practice. The majority worked fulltime (79%) and owned their practice (78%), while 133 (39%) worked part time as rural hospital doctors and 72 (21%) provided intra-partum obstetric care. Over two thirds rated lack of locum relief, onerous oncall,and rural GP shortages as 'important' or 'very important' problems, with one third stating that more rural GPswere needed in their locality. CONCLUSIONS: This, only the second national survey of rural GPs, provides a comprehensive overview of New Zealand rural general practice in November 1999. It confirms that the major current problem is an under supply of rural GPs, causing overwork and stress in those remaining.
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Actitud del Personal de Salud , Medicina Familiar y Comunitaria/estadística & datos numéricos , Ubicación de la Práctica Profesional/estadística & datos numéricos , Salud Rural/estadística & datos numéricos , Adulto , Anciano , Etnicidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Ubicación de la Práctica Profesional/tendencias , Encuestas y CuestionariosRESUMEN
AIM: To assess levels of psychological distress and job satisfaction among New Zealand general practitioners. METHODS: A random sample of general practitioners (GPs) in the central region of the North Island were surveyed using a postal questionnaire. Job satisfaction and psychological distress (twelve-item General Health Questionnaire, GHQ-12) were assessed and compared with personal, practice and workload characteristics. Qualitative statements about work conditions sources of stress and ill health were also collected. RESULTS: The response rate was 391/480 (81.5%). Job satisfaction scores were generally high. Rural GPs were less satisfied than urban practitioners and solo practitioners less satisfied than those in group practice. Work was perceived as affecting the physical health of 177 GPs (46%) and 220 (57%) often contemplated leaving general practice. 121 GPs (31.4%) scored >3 on the GHQ-12 showing high levels of psychological symptoms and 39 (9.9%) scored greater than eight, indicating significant psychological distress. Major causes of stress and lack of job satisfaction were: excessive paperwork, health reforms and bureaucratic interference, excessive hours and on-call work. CONCLUSIONS: Overall, GPs were satisfied with their jobs. Levels of psychological symptoms were of concern, particularly in the 10% showing very high levels of psychological distress, and in rural and solo practitioners.
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Satisfacción en el Trabajo , Médicos de Familia/estadística & datos numéricos , Estrés Psicológico/epidemiología , Carga de Trabajo/psicología , Adulto , Anciano , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Población Rural , Estrés Psicológico/psicología , Encuestas y Cuestionarios , Población UrbanaRESUMEN
BACKGROUND: Infection with Helicobacter pylori is the main cause of peptic-ulcer disease. Treatment of this infection might lower the prevalence of dyspepsia in the community and improve quality of life. We investigated this possibility in a double-blind randomised controlled trial. METHODS: Individuals aged 40-49 years were randomly selected from the lists of 36 primary-care centres. A researcher interviewed participants with a validated dyspepsia questionnaire and the psychological general wellbeing index (PGWB). H. pylori status was assessed by the carbon-13-labelled urea breath test. Infected participants were randomly assigned active treatment (omeprazole 20 mg, clarithromycin 250 mg, and tinidazole 500 mg, each twice daily for 7 days) or identical placebo. Participants were followed up at 6 months and 2 years. FINDINGS: Of 32,929 individuals invited, 8455 attended and were eligible; 2324 were positive for H. pylori and were assigned active treatment (1161) or placebo (1163). 1773 (76%) returned at 2 years. Dyspepsia or symptoms of gastro-oesophageal reflux were reported in 247 (28%) of 880 in the treatment group and 291 (33%) of 871 in the placebo group (absolute-risk reduction 5% [95% CI 1-10]). H. pylori treatment had no significant effect on quality of life (mean difference in PGWB score between groups 0.86 [-0.33 to 2.05]). INTERPRETATION: Community screening and treatment for H. pylori produced only a 5% reduction in dyspepsia. This small benefit had no impact on quality of life.
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Antiulcerosos/uso terapéutico , Dispepsia/tratamiento farmacológico , Infecciones por Helicobacter/tratamiento farmacológico , Helicobacter pylori , Tamizaje Masivo , Úlcera Péptica/tratamiento farmacológico , Calidad de Vida , Adulto , Antiulcerosos/efectos adversos , Claritromicina/efectos adversos , Claritromicina/uso terapéutico , Método Doble Ciego , Quimioterapia Combinada , Dispepsia/diagnóstico , Dispepsia/psicología , Femenino , Estudios de Seguimiento , Infecciones por Helicobacter/diagnóstico , Infecciones por Helicobacter/psicología , Humanos , Masculino , Persona de Mediana Edad , Omeprazol/efectos adversos , Omeprazol/uso terapéutico , Úlcera Péptica/diagnóstico , Úlcera Péptica/psicología , Perfil de Impacto de Enfermedad , Tinidazol/efectos adversos , Tinidazol/uso terapéuticoRESUMEN
AIMS: To describe key organisational characteristics of selected third sector (non-profit and non-government) primary health care organisations. METHODS: Data were collected, in 1997 and 1998, from 15 third sector primary care organisations that were members of a network of third sector primary care providers, Health Care Aotearoa (HCA). Data were collected by face-to-face interviews of managers and key informants using a semi-structured interview schedule, and from practice computer information systems. RESULTS: Overall the populations served were young: only 4% of patients were aged 65 years or older, and the ethnicity profile was highly atypical, with 21.8% European, 36% Maori, 22.7% Pacific Island, 12% other, and 7.5% not stated. Community services card holding rates were higher than recorded in other studies, and registered patients tended to live in highly deprived areas. HCA organisations had high patient to doctor ratios, in general over 2000:1, and there were significant differences in management structures between HCA practices and more traditional general practice. CONCLUSIONS: Third sector organisations provide services for populations that are disadvantaged in many respects. It is likely that New Zealand will continue to develop a diverse range of primary care organisational arrangements. Effort is now required to measure quality and effectiveness of services provided by different primary care organisations serving comparable populations.
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Programas Controlados de Atención en Salud/organización & administración , Organizaciones sin Fines de Lucro/organización & administración , Atención Primaria de Salud/organización & administración , Adolescente , Adulto , Anciano , Niño , Preescolar , Relaciones Comunidad-Institución , Grupos Diagnósticos Relacionados , Humanos , Lactante , Recién Nacido , Área sin Atención Médica , Persona de Mediana Edad , Nueva Zelanda , Administración de Personal , Pautas de la Práctica en MedicinaRESUMEN
INTRODUCTION: Helicobacter pylori screening and treatment has been proposed as a cost-effective method of preventing gastric cancer. AIM: To assess, in a randomized controlled trial, the efficacy of therapy in eradicating H. pylori as part of a screening programme, and to report the adverse events associated with this strategy. METHODS: Subjects between the ages of 40-49 years were randomly selected from the lists of 36 primary care centres. Participants attended their local practice and H. pylori status was determined by 13C-urea breath test. Infected subjects were randomized to receive omeprazole 20 mg b.d., clarithromycin 250 mg b.d. and tinidazole 500 mg b.d. for 7 days (OCT) or identical placebos. Eradication was determined by a 13C-urea breath test 6 months and 2 years after the first visit. Successful eradication was defined as two negative 13C-urea breath tests or one negative and one missing test. Adverse events and compliance were assessed at the 6-month visit. RESULTS: A total of 32 929 subjects were invited to attend, 8407 were evaluable, and 2329 (28%) of these were H. pylori-positive. A total of 1161 subjects were randomized to OCT and 1163 to placebo; over 80% returned for a repeat 13C-urea breath test on at least one occasion. The eradication rates in those allocated to OCT were as follows: intention-to-treat, 710 out of 1161 (61%; 95% confidence interval: 58-64%); evaluable 710 out of 967 (73%; 95% CI: 71-76%); took all medication 645 out of 769 (84%; 95% CI: 81-87%). Adverse events occurred in 45% of the treatment group and in 18% of the placebo group (relative risk 2.5; 95% CI: 2.1-2.9). Compliance, male gender, no antibiotic prescription in the subsequent 2 years and experiencing a bitter taste with the medication were independently associated with treatment success. CONCLUSIONS: The OCT regimen has an eradication rate of 61% in intention-to-treat analysis and is therefore less successful in treating H. pylori as part of a screening programme compared with hospital studies in dyspeptic patients.
Asunto(s)
Antibacterianos/uso terapéutico , Antiulcerosos/uso terapéutico , Antitricomonas/uso terapéutico , Infecciones por Helicobacter/tratamiento farmacológico , Helicobacter pylori/efectos de los fármacos , Neoplasias Gástricas/prevención & control , Administración Oral , Adulto , Antibacterianos/administración & dosificación , Antibacterianos/efectos adversos , Antiulcerosos/administración & dosificación , Antiulcerosos/efectos adversos , Antitricomonas/administración & dosificación , Antitricomonas/efectos adversos , Claritromicina/administración & dosificación , Claritromicina/efectos adversos , Claritromicina/uso terapéutico , Análisis Costo-Beneficio , Quimioterapia Combinada , Femenino , Infecciones por Helicobacter/complicaciones , Helicobacter pylori/patogenicidad , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Omeprazol/administración & dosificación , Omeprazol/efectos adversos , Omeprazol/uso terapéutico , Cooperación del Paciente , Factores Sexuales , Neoplasias Gástricas/etiología , Neoplasias Gástricas/microbiología , Tinidazol/administración & dosificación , Tinidazol/efectos adversos , Tinidazol/uso terapéutico , Resultado del TratamientoRESUMEN
AIM: To measure utilisation rates in capitated primary care organisations serving low income populations with low or zero co-payments, and to examine the relationship between utilisation rates and organisation, age group, sex, ethnicity, community services card (CSC) holding rates, high use health card (HUHC) holding rates and deprivation of area of residence (NZDep96). METHODS: Data were collected during 1997/98, from eleven primary care organisations. Utilisation data were collected from practice computer information systems. RESULTS: 53.9% of registered patients were recorded as having consulted in a twelve-month period. Utilisation rates for doctor, nurse and midwife combined were higher amongst the young, elderly, and CSC holders. For males, they were higher amongst those living in the most socioeconomically deprived areas, but not for females. Utilisation rates were highest amongst the 'other' ethnic group, and lowest in the Pacific Island ethnic group. Organisation, age group, sex, ethnicity, CSC, HUHC and NZDep96 were independently predictive of total utilisation. CONCLUSIONS: Utilisation rates in capitated practices tended to be lower than those in fee-for-service practices. If equitable needs-based capitation funding formulas are to be developed, utilisation data from capitated practices in a range of cultural and socioeconomic settings is urgently required.
Asunto(s)
Capitación , Centros Comunitarios de Salud/estadística & datos numéricos , Áreas de Pobreza , Atención Primaria de Salud/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Anciano , Niño , Preescolar , Centros Comunitarios de Salud/economía , Deducibles y Coseguros , Femenino , Encuestas de Atención de la Salud , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Análisis Multivariante , Evaluación de Necesidades , Nueva Zelanda , Atención Primaria de Salud/economía , Análisis de Regresión , Características de la Residencia/estadística & datos numéricos , Factores Sexuales , Revisión de Utilización de RecursosRESUMEN
AIMS: To describe the advice and support New Zealand general practitioners (GPs) reported providing to patients about smoking cessation, to explore barriers encountered in providing this advice, and to compare reported practice with recommended best practice. METHODS: 450 GPs were surveyed from four different localities using a structured postal questionnaire. RESULTS: Questionnaires were returned by 283 GPs, giving a response rate of 63%. Approximately one-third of GPs asked every adult patient about their smoking status. Fewer recorded this information in the patient's notes. GPs, based on their own experience, considered nicotine replacement therapy (NRT) and their own advice to quit to be the two most useful smoking cessation strategies. They perceived patient resistance and time pressures as the main barriers limiting their ability to give advice to patients about smoking cessation. CONCLUSIONS: GPs provide smoking cessation advice to many patients, but this needs to be viewed in the context of the New Zealand fee-for-service primary care system and competing demands placed on the limited time available within a consultation. There is potential to increase the practice nurse's involvement in providing smoking cessation advice.
Asunto(s)
Medicina Familiar y Comunitaria , Pautas de la Práctica en Medicina , Cese del Hábito de Fumar , Adolescente , Adulto , Actitud del Personal de Salud , Recolección de Datos , Adhesión a Directriz , Humanos , Nueva Zelanda , Guías de Práctica Clínica como Asunto , Estadísticas no ParamétricasRESUMEN
OBJECTIVE: To assess the effect of doctor ethnicity and country of qualification on prescribing patterns. DESIGN: Ecological study. SETTING: 90 Family Health Services Authorities in the U.K. RESULTS: Being an Asian doctor and qualifying from the Indian subcontinent contributes to 5% of the observed variation seen in the frequency of prescribing, but not the cost. The major determinant of variation in prescribing is deprivation, which accounts for 14% of the cost and 32% of the frequency of prescribing. CONCLUSIONS: Being an Asian doctor and qualifying from the Indian subcontinent contributes to the frequency, but not the cost of prescribing variation. As this study was at the FHSA level, 'ecological fallacy' exists and further research is advocated at the individual doctor level.
Asunto(s)
Prescripciones de Medicamentos , Etnicidad , Médicos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Asia/etnología , Costos de los Medicamentos/estadística & datos numéricos , Prescripciones de Medicamentos/economía , Femenino , Médicos Graduados Extranjeros , Humanos , India/etnología , Masculino , Clase SocialRESUMEN
We report a transient drop in plasma Hcy and Cys following a single oral dose of PteGlu. The thiol change was concomitant with both the peak plasma 5CH3H4PteGlu1 level (by HPLC) and the maximum plasma Lactobacillus casei activity which reflects absorption of unmodified PteGlu. The significant reciprocal association of Hcy with radioassay RBC folate (r = -0.28, 99% CI -0.48, -0.05, P = 0.0016), serum folate (r = -0.37, 99% CI -0.56, -16, P = 0.0001), and vitamin B12 (r = -0.42, 99% CI -0.59, -21, P = 0.0001) is shown and reflects the long-term nutritional effect of B vitamins on this important, potentially atherogenic thiol. These are now well-established associations. We extend the potential for investigation of folate metabolism in health and disease by evaluating a range of new folate indices which are based on erythrocyte coenzymes. These have been looked at independently and in association with established parameters. Erythrocyte methylfolates (mono- to hexaglutamate-5CH3H4PteGlu1-6), formylfolates (tri- to pentaglutamate-5CHOH4PteGlu3-5),formiminotetrahydrofolate (formiminoH4PteGlu1), unsubstituted tetrahydrofolate (H4PteGlu1), andpara-aminobenzoylglutamate (P-ABG) have been measured by HPLC with fluorescence detection. A positive linear association exists between (i) H4PteGlu1 and radioassay RBC folate (r = 0.50, 99% CI 0. 07, 0.77, P = 0.0036), and (ii) H4PteGlu1 and tetraglutamates of both formyl- and methylfolate (r = 0.52, 99% CI 0.10, 0.78, P = 0. 0022, and r = 0.56, 99% CI 0.15, 0.80, P = 0.0009, respectively). Since, in addition, a reciprocal linear association exists between Hcy and tetraglutamyl formylfolate (r = -0.41, 99% CI -0.73, 0.05, P = 0.0206), erythrocyte tetraglutamates may be a good reflection of the bodies' active coenzyme pools. Pentaglutamyl formylfolate, the longest oligo-gamma-glutamyl chain form of this coenzyme may be a good indicator of folate depletion. The abundance of this coenzyme both increases with increasing Hcy (r = 0.55, 99% CI 0.13, 0.80, P = 0.0014) and increases as H4PteGlu1, the principle folate congener, decreases (r = -0.59, 99% CI -0.82, -0.20, P = 0.0004). Furthermore, the apparent equilibrium between substrate (5CH3H4PteGlu1) and product (H4PteGlu1) of methionine synthase is significantly associated with the abundance of 5CHOH4PteGlu5 (r = -0.53, 99% CI -0. 79, -0.11, P = 0.0018). This suggests that low methionine synthase activity for whatever reason (metabolic or dietary) may lead to an increase in the relative abundance of 5CHOH4PteGlu5. Like 5CHOH4PteGlu5, evidence is given that 5CH3H4PteGlu6, the longest oligo-gamma-glutamyl chain form of this particular coenzyme pool, may also be a good indicator of folate depletion. This is shown by a change in the relative proportion of erythrocyte methylfolate polyglutamates following supplementation with 400 microg/day PteGlu. Short-chain polyglutamates of methylfolate (5CH3H4PteGlu1--> 5CH3H4PteGlu4) increase in proportion to the total methylfolate pool, while long-chain polyglutamates of methylfolate (5CH3H4PteGlu5 and particularly 5CH3H4PteGlu6) decrease in their relative abundance.