Gregor Coster

Physician-Patient Relationship and Medication Compliance: A Primary Care Investigation

PURPOSE We assessed the relationship between 4 attributes of the physician-patient relationship and medication compliance. METHODS We conducted a waiting room survey of patients consulting 22 general practitioners in 14 randomly selected practices in Auckland, New Zealand (81% response rate). A total of 370 consecutive patients (75% response rate) completed survey instruments about 4 attributes of the physician-patient relationship. Continuity of care (assessed from use of a usual physician, length of continuity, and perceived importance of continuity) and trust in the physician were ascertained before the consultation. After the consultation the Patient Enablement Index measured the physician’s ability to enable patients in self-care, and concordance between the patient and physician was measured by a 6-item inventory of perceived agreement about the presenting problem and management, were ascertained immediately after the consultation. Compliance with prescribed medication therapy was ascertained by telephone follow-up 4 days after the consultation. RESULTS Overall, 220 patients (61%) received a prescription, and 79% of these patients were taking the medication at follow-up. In a univariate analysis adjusted for clustering, only trust and physician-patient concordance were significantly related to compliance. In analysis further adjusted for health and demographic factors, physician-patient concordance was independently related to compliance (odds ratio = 1.34, 95% confidence interval, 1.04–1.72). CONCLUSIONS Primary care consultations with higher levels of patient-reported physician-patient concordance were associated with one-third greater medication compliance. An emphasis on understanding and facilitating agreement between physician and patient may benefit outcomes in primary care.

Issues in Patient Compliance

SummaryPatient compliance refers to the willingness and ability of an individual to follow health-related advice, to take medication as prescribed, to attend scheduled clinic appointments and to complete recommended investigations. It is a major health issue, with outcomes related to levels of morbidity, mortality and cost utilisation. Poor compliance has been reported as the most common cause of nonresponse to medication, with evidence to show that patients who adhere to treatment recommendations have better health outcomes than those who do not adhere, even when taking a placebo. Evidence-based practice guidelines, founded on clinical, behavioural and educational concepts, provide a means of measuring outcomes related to health status, patient satisfaction and cost-benefit issues, and may help to ensure that responsibility for compliance is shared between the clinician and the patient.

The General Practitioner-Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy.

Objectives  There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for ‘medication reviews’ there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine‐related therapeutic outcomes for patients.

The New Zealand Diabetes Passport Study: a randomized controlled trial of the impact of a diabetes passport on risk factors for diabetes-related complications.

Aims  To assess the efficacy (change in HbA1c) of a patient‐held communication, self‐empowerment and educational device for people with diabetes (the New Zealand Diabetes Passport) in patients with poor glycaemic control.

Do general practice patients with heart failure understand its nature and seriousness, and want improved information?

This study describes the extent to which patients with heart failure in general practice understand the nature and seriousness of their condition, and want more or better information about it than they currently get. The study involved a random sample of 62 patients receiving care for chronic heart failure in 30 central Auckland, New Zealand, practices. The narrative texts of personal, semi-structured interviews in late 1999 were edited (explicitly and systematically reduced and reassembled) until their interpretation was complete. Approximately 40% of the patients interviewed appeared not to understand the nature and seriousness of their heart failure condition. Two patients had accidentally discovered the diagnosis from inappropriate sources. Eleven patients (18%) expressed wanting improved information about their condition. However, to avoid harm, we did not ask patients about wants for information relating to the seriousness of their heart failure. Through patient education and counselling, providers could help patients to produce an advance written directive of wants for information.

Risk factors for community-acquired pneumonia in pre-school-aged children

Aim:  To identify risk factors for children developing and being hospitalised with community‐acquired pneumonia.

General practice and the New Zealand health reforms--lessons for Australia?

New Zealands health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:1. Loss of autonomy2. Inadequate management funding and support3. Inconsistency and variations in contracting processes4. Lack of publicity and advice around enrolment issues5. Workforce and workload issues6. Financial risksOn the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealands latest health sector and primary health care reforms.The key lessons concern:• the need for a national primary health care strategy• active engagement of general practitioners and their professional organisations• recognition of implementation costs• the need for infrastructural support, including information technology and quality systems• robust management and governance arrangements• issues related to critical mass and population/distance trade offs in service delivery models

Why do children hospitalised with pneumonia not receive antibiotics in primary care

Background Although antibiotics are recommended for the primary care management of community-acquired pneumonia, a recent UK study reported that most children admitted to hospital had not received antibiotics. Objective To describe primary care antibiotic use for children subsequently hospitalised with community-acquired pneumonia. Design/methods A case series of 280 children <5 years old hospitalised with pneumonia in Auckland, New Zealand. Pneumonia was defined as an acute illness with cough or respiratory distress, the presence of tachypnoea or indrawing and an abnormal chest radiograph. Receipt of antibiotics was determined by parental report and medical record review. Results Fewer than half (108, 39%) of the children had received an antibiotic before hospital admission. For 60 children (21%) there had been no opportunity to prescribe because the illness evolved rapidly, resulting in early hospital admission. For the remaining 112 children (40%) an opportunity to receive antibiotics was missed. The parent failed to obtain the antibiotic prescribed for 23 children (21% of 112), but in 24 children (21%) pneumonia was diagnosed but no antibiotic prescribed and in a further 28 children (25%) the diagnosis was not made despite parental report of symptoms suggesting pneumonia. Missed opportunities to prescribe were not associated with increased overall severity of symptoms at hospital presentation but were associated with an increased risk of: focal chest radiological abnormalities (rate ratio (RR)=2.14; 95% CI 1.49 to 2.83), peripheral leucocytosis >15×109/l (RR=2.29; 95% CI 1.61 to 2.98) and bacteraemia (RR=6.68, 95% CI 1.08 to 58.44). Conclusions Young children with community-acquired pneumonia may not receive an antibiotic before hospital admission because the illness evolves rapidly or the prescribed medicine is not given by parents. However, missed opportunities for appropriate antibiotic prescribing by health professionals in primary care appear to be common.

An investigation of three injections techniques in reducing local injection pain with a human papillomavirus vaccine: A randomized trial

BACKGROUND Previous research suggests vaccine injection technique can influence local reactogenicity. OBJECTIVE To identify characteristics of vaccination technique and individual vaccinees associated with frequency and severity of pain on injection and local reactogenicity following immunisation with quadrivalent human papillomavirus vaccine. DESIGN Randomised cross-over trial of three injection techniques. Data were collected on health history, perceived stress and social support using a 10 item perceived stress scale and a single item social support question. Pain on injection was measured using a visual analogue scale and reactogenicity data was collected using participant-held diaries. SETTING Clinic rooms at the University of Auckland. PARTICIPANTS Females aged 14-45 years and males aged 14-26 years recruited to the study. MAIN OUTCOME MEASURES Primary outcome measures were perceived pain on injection and the local injection site reactions pain, erythema, swelling and induration. RESULTS The three injection techniques did not affect injection site reactogenicity. Females tended to experience more reactogenicity. Perceived stress, social support and atopy were not associated with reactogenicity outcomes and exercise showed little effect. No variables, including injection technique, were associated with wide variation in perceived pain in injection. Case by case observational data suggest some variations in anatomical site may be important. CONCLUSIONS Most injection site reactions in this study were mild. The three injection techniques used in this study were equivalent in their reactogenicity and pain profiles and could be recommended for use in this population.

Key informant representations of Maori and other patient fears of accessing general practitioner care for child asthma in Auckland, New Zealand

Fear is seldom reported in the research literature on barriers to accessing general practitioner (GP) care. One reason may be that some patients are unwilling to admit to fear of this care. This is especially so for patients who, for social, cultural and historical reasons, have a poor sense of self, or do not wish to challenge professionals, or both. In New Zealand, the Maori and Pacific peoples are disproportionately characteristic of these patients and have poor access to GP care, including asthma in children. This paper contributes to the literature on using key informants to interpret another group’s needs, and integrates and adds to known patient attitudes that can hinder access to GP services.