Sharon Leitch

Epidemiology of Patient Harms in New Zealand: Protocol of a General Practice Records Review Study

Background Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety. Objective We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records. Methods “Harm” is defined as disease, injury, disability, suffering, and death, arising from the health system. The study design is a stratified, 2-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study’s results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between 6 study groups (large, medium-sized, small; urban and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review 3 years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double-blinded reviews will check the concordance of reviewers’ assessments. Study data will comprise demographic data of all 9000 patients and reviewers’ assessments of whether patients experienced harm arising from health care. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 18.0. Results We have recruited practices and collected electronic records from 9078 patients. Reviews of these records are under way. The study is expected to be completed in August 2017. Conclusions The design of this complex study is presented with discussion on data collection methods, sampling weights, power analysis, and statistical approach. This study will show the epidemiology of patient harms recorded in general practice records for all of New Zealand and will show whether this epidemiology differs by rural location and clinic size.

Characteristics of a stratified random sample of New Zealand general practices

INTRODUCTION Practice size and location may affect the quality and safety of health care. Little is known about contemporary New Zealand general practice characteristics in terms of staffing, ownership and services. AIM To describe and compare the characteristics of small, medium and large general practices in rural and urban New Zealand. METHODS Seventy-two general practices were randomly selected from the 2014 Primary Health Organisation database and invited to participate in a records review study. Forty-five recruited practices located throughout New Zealand provided data on staff, health-care services and practice ownership. Chi-square and other non-parametric statistical analyses were used to compare practices. RESULTS The 45 study practices constituted 4.6% of New Zealand practices. Rural practices were located further from the nearest regional base hospital (rural median 65.0 km, urban 7.5 km (P < 0.001)), nearest local hospital (rural 25.7 km, urban 7.0 km (P = 0.002)) and nearest neighbouring general practitioner (GP) (rural 16.0 km, urban 1.0 km (P = 0.007)). In large practices, there were more enrolled patients per GP FTE than both medium-sized and small practices (mean 1827 compared to 1457 and 1120 respectively, P = 0.019). Nurses in large practices were more likely to insert intravenous lines (P = 0.026) and take blood (P = 0.049). There were no significant differences in practice ownership arrangements according to practice size or rurality. CONCLUSION Study practices were relatively homogenous. Unsurprisingly, rural practices were further away from hospitals. Larger practices had higher patient-to-doctor ratios and increased nursing scope. The study sample is small; findings need to be confirmed by specifically powered research.

New Zealand needs a Practice Based Research Network

Practice Based Research Networks (PBRNs) are groups of general practices collaborating to produce research. Contemporary New Zealand health information technology systems are ideal for electronic data extraction for PBRN research. Stakeholders have a valuable, but typically underutilised, part to play in research. Development of an e-participation platform will facilitate stakeholder engagement. New Zealand is in a unique position to create an innovative, low cost, stakeholder-engaged PBRN. This type of PBRN would offer unparalleled research opportunities, and would strengthen New Zealands general practice research capacity. The more research information we have based on our New Zealand population, the more appropriate care we can provide. Establishing a stakeholder-engaged PBRN in New Zealand will promote and support transformational change within our health system.

Comparison of Psychosocial Variables Associated With Loneliness in Centenarian vs Elderly Populations in New Zealand

Key Points Questions Are centenarians less lonely than elderly people, and if so, are there any demographic and psychosocial differences that may account for this? Findings This cross-sectional study of 73 286 community-dwelling New Zealanders 65 years and older found that centenarians were more likely to be female, widowed, living alone or with relatives, receiving family support, and not depressed compared with those aged 65 to 99 years. Loneliness was significantly less common with older age, and living arrangements, race/ethnicity, marital status, family support, and depression were significantly associated with loneliness. Meaning Knowing the variables associated with loneliness may help our society address risk factors to reduce loneliness in older people.

Doctors and pharmacists provision and opinions of medicines information leaflets in New Zealand

Background Providing verbal medicines information to patients may be insufficient. Providing medicine information leaflets could support verbal information, however New Zealand health professionals’ opinions or use of leaflets is unknown. Objective To examine self-reported provision and health professionals’ views about medicine information leaflets and to determine their support for tailoring patient leaflets. Setting A cross sectional survey of general practitioners (GPs) and community pharmacists in New Zealand primary care. Method GPs and pharmacists completed validated questionnaires. Data was collected using SurveyMonkey® and where applicable, Chi squared analysis was carried out. Main outcome measures Frequency of leaflet provision, how leaflets are used in practice and why, likes and dislikes of available leaflets, and opinions on providing tailored information. Results 143 GPs and 126 pharmacists responded. For new medicines, significantly more pharmacists than GPs reported providing leaflets all or most of the time. For repeat medicines, leaflets were more likely to be given only on request. Leaflets were given to ensure patients are well-informed. Most GPs and pharmacists report discussing sections of leaflets with patients. The likes and dislikes of leaflets were mostly about design and content. Both professions support tailoring leaflets to meet individual’s requirements. Conclusions Provision of medicines information needs to be re-evaluated. Relying on verbal communication is inadequate and leaflet provision appears to be suboptimal. Making leaflets more patient-centred and accessible could improve health professionals’ perceptions and use of them. Automated creation and provision of tailored summary leaflets would be beneficial. Further advantage could be gained by digital patient access.

Do health professionals tell patients what they want to know about their medicines

Background: Discussing medicines with patients is the responsibility of prescribers and pharmacists. However, it is not well known whether patients are given the information they want or whether information provision continues when medicines are taken long-term. Objective: To determine how often general practitioners (GPs) and pharmacists provide verbal information to patients about their medicines, and compare the information given with what patients want to know. Design: Cross-sectional surveys. Setting: New Zealand primary healthcare. Method: Two questionnaires were developed and sent to a sample of pharmacists and GPs, and chi-squared analysis was carried out. Open responses were analysed qualitatively to detect further ideas. Results: A total of 119 pharmacists and 150 GPs responded. For new medicines, significantly more GPs than pharmacists reported giving verbal information all of the time. Significantly more GPs than pharmacists reported discussing most counselling points all or most of the time. Pharmacists were more likely than GPs to discuss counselling points only when requested to by patients. For repeat medicines, significantly more GPs than pharmacists were likely to consider counselling points very important. Conclusion: Patients may not be receiving the information they want to know about their medicines, and there may be an overall lack of verbal communication about medicines with patients. Some information will only be discussed if the patient actively requests it; the likelihood of this increases with repeat medicines. The use of counselling aids and tools, such as a medicine information leaflet, could help healthcare providers provide patients with the information they need.

Identifying Hoarding Disorder in the Elderly using the interRAI

OBJECTIVES Hoarding disorder (HD) is prevalent in older adults and contributes to morbidity and mortality. We attempted to estimate rates of hoarding amongst the elderly using the international Residential Assessment Instrument - Home Care (interRAI-HC). SETTING The interRAI is a mandatory prerequisite in New Zealand (NZ) for government-funded community support or for entry into aged residential care. PARTICIPANTS All 50 years and older people who were assessed using the interRAI in the southern district health board of NZ. MEASUREMENTS The age, gender, socially inappropriate or disruptive behaviour and squalor interRAI-HC items were analysed. RESULTS During the 3 years study period (Jan., 2015 to Dec., 2017) 6655 people, mean age 81.4 + 7.6 years, 56% female, were assessed. The interRAI socially inappropriate behaviour (includes hoarding as one of its descriptors) was present in 233 people (3.5%), herein defined as suspected HD. Squalid conditions were present in 98 additional people (1.5%). Mean age for suspected HD group was significantly younger [76.1 + 6.3 years (p < 0.001)] and there were more males [57% (p < 0.05)] compared with the general interRAI group. CONCLUSIONS Rates of HD estimated by using the interRAI are in line with published international data. As identification of HD with the interRAI is not straightforward its use as a screening tool for identifying HD should be validated in future studies.

Triggering safer general practice care

We know for sure that healthcare does good things for a lot of people and that for some, it harms—sometimes concurrently with providing benefits. Quite likely doctors have known this for millennia, inspiring the caution in the Hippocratic oath to ‘first do no harm’. Clinically grounded medical researchers know that medicine is complicated and that things can sometimes go wrong despite the best efforts of conscientious and well-intentioned clinicians. To minimise peoples exposure to healthcare that harms them, while maximising their exposure to healthcare that helps, a diverse armamentarium has developed that includes tools such as alarms and alerts built in to equipment, postmarketing medicines surveillance, incident reporting systems, check lists, fish plots, run charts and many other things. Concern over healthcare safety became increasingly widespread in the closing years of the 20th century but came relatively lately to primary care. Trigger tools are now part of the safety armoury of primary care clinicians.1 ,2 In this context, ‘triggers’ are a somewhat different …