Graham McGeoch

Self-management plans in the primary care of patients with chronic obstructive pulmonary disease

Objective and background:  The role of COPD self‐management plans in improving health outcomes remains unclear. The objective of this study was to assess whether self‐management plans administered in primary care have beneficial effects on quality of life, self‐care behaviour and health outcomes in the long term for patients with COPD.

Plasma brain natriuretic peptide after long-term treatment for heart failure in general practice.

Plasma brain natriuretic peptide (BNP) concentrations are known to have high sensitivity and specificity in the diagnosis of heart failure in newly symptomatic patients. The relationship of plasma BNP to cardiac function in stable patients on long‐term established treatment for heart failure is unknown. Plasma BNP was assessed for its ability to predict echocardiographic abnormality in 100 patients receiving long‐term treatment in general practice for a provisional diagnosis of heart failure.

Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand

Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for ‘at risk’ patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not ‘at risk’ waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist.Sleep disorders: More assessments, shorter waits with community sleep serviceA community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region’s largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital’s sleep unit.

Unmet need for referred services as measured by general practice

INTRODUCTION Unmet needs are a key indicator of the success of a health system. Clinicians and funders in Christchurch, Canterbury, New Zealand were concerned that unmet health need was hidden. AIM The aim of this survey was to estimate the proportion of patients attending general practice who were unable to access clinically indicated referred services. METHODS The survey used a novel method to estimate unserviced health needs. General practitioners (GPs, n = 54) asked their patients (n = 2135) during a consultation about any health needs requiring a referred service. If both agreed that a service was potentially beneficial and not available, this was documented on an e-referral system for review. The outcomes of actual referrals were also reviewed. RESULTS The patient group was broadly representative of the Canterbury population, but over-sampled female and middle-aged people and under-sampled Māori. Data adjusted to regional demographics showed that 3.6% of patients had a GP-confirmed unserviced health need. Elective orthopaedic surgery, general surgery and mental health were areas of greatest need. Unserviced health needs were significantly (P ≤ 0.05) associated with greater deprivation, middle-age, and receiving high health-use subsidies. DISCUSSION To our knowledge, this is the first survey of GP and patient agreement on unserviced referred health needs. Measuring unserviced health needs in this way is directly relevant to service planning because the gaps identified reflect clinically indicated services that patients want and need. The survey method is an improvement on declined referral rates as a measure of need. Key factors in the method were using a patient-initiated GP consultation and an e-referral system to collect data.

Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding

This observational case series in 65 premenopausal women with abnormal uterine bleeding evaluated whether transvaginal ultrasound followed by saline infusion sonohysterography (SIS) prevented unnecessary hysteroscopy. Although SIS indicated that hysteroscopy was unnecessary in eight women, this benefit was offset by the invasive nature of the scan, the number of endometrial abnormalities falsely detected by SIS and the cost of the additional investigation.

The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery

In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.

Reducing hospital admissions for COPD: perspectives following the Christchurch Earthquake

The devastating 2011 earthquake in Christchurch destroyed or badly damaged healthcare infrastructure, including Christchurch Hospital. This forced change in management of exacerbations of chronic obstructive pulmonary disease (COPD), which until that point had frequently led to admission to hospital and focused attention on providing safe community options for care. This paper describes the process of understanding factors contributing to high admission frequency with exacerbations of COPD and also describes a process of change, predominantly to healthcare delivery systems and philosophies, and the subsequent outcomes. What became clear in understanding admissions with COPD to Christchurch Hospital was that the behaviour of the patient, in the context of exacerbations, and the subsequent response of the system to the patient, led to admission being the default option, in spite of low severity of the exacerbation itself. By altering systems’ responses to exacerbations, with a linked care process between ambulances, community care and hospitals, we were able to safely reduce admissions for COPD, with a sustained overall reduction in bed-day occupancy for COPD of ~48%. We would encourage these discussions and changes to occur without the stimulus of an earthquake in your healthcare environment!