Gaps in primary care documentation of cardiovascular risk factors

BACKGROUND

New Zealand guidelines recommend that cardiovascular risk management should be informed by the absolute risk of a cardiovascular event. This requires knowledge of a person's age, sex, ethnicity, medical and family history, blood pressure, total and HDL cholesterol, diabetes, and smoking status.

AIM

To establish the extent of primary care documentation of cardiovascular risk factors.

METHODS

An audit of electronic patient records was conducted in practices affiliated with an Auckland primary care organisation (ProCare Health Ltd). The audited population were patients eligible for risk assessment (all Maori and a random sample of non-Maori) who had a consultation with their general practitioner during a four week study period (1 year before the doctor first used cardiovascular electronic clinical decision support software). Audit nurses searched for risk factors documented prior to the study period.

RESULTS

The records of 1680 individuals from 84 doctors were audited. The study periods prior to which the records were inspected ranged from August 2001 to June 2003. The proportions of records with risk factors documented were: blood pressure 81.8%, cholesterol 62.4%, smoking status 41.5%, diabetes status 16.1%, all these risk factors 6.8%. Recording of blood pressure and of cholesterol was higher in those with cardiovascular disease or diabetes. Recording of blood pressure increased with increasing age, then levelled off at about age 60 years. Documentation of cholesterol was lowest in the oldest and youngest age groups, and in women (at all ages) compared to men.

CONCLUSIONS

Primary care documentation of cardiovascular risk factors was incomplete. Whilst many doctors may know whether patients are smokers or have diabetes, systematic documentation of these factors in particular, is not occurring. In order to realise the large potential benefits associated with population-based cardiovascular risk assessment and management, a substantial investment by government, healthcare organisations, health professionals, and patients is required to collect and record this information.

The accuracy of ethnicity data in primary care

AIM

To investigate the accuracy of ethnicity data held in Primary Health Organisation (PHO) registers within the Waitemata district of Auckland, New Zealand.

METHOD

Ethnicity data of school-aged children on the National Immunisation Register (NIR) were compared to ethnicity data for those children on the PHO register. NIR data were collected from parents via a protocol-based informed consent process in the Meningococcal B Immunisation Campaign.

RESULTS

For children classified as Maori on the NIR, 62.9% were recorded as Maori on the PHO register, 23.3% were misclassified as European, and a further 9.6% were misclassified as Unknown. For children classified as Pacific on the NIR, 77.2% were recorded as Pacific on the PHO register, 9.4% were misclassified as European, and 6.2% were misclassified as Unknown. For children classified as Asian on the NIR, 81.4% were recorded as Asian on the PHO register, 9.9% were misclassified as Unknown, and 6.0% misclassified as European. For children classified as European on the NIR, 83.2% were recorded as European on the PHO register and 14.4% were misclassified as Unknown.

CONCLUSIONS

This study reveals that ongoing efforts to improve the accuracy of ethnicity data held in PHO registers within the Waitemata district are required. The study reinforces the need for a standardised, systematic and appropriate sector-wide approach to ethnicity data collection.

A blinded, randomised, controlled trial of stapled versus tissue glue closure of neck surgery incisions

INTRODUCTION

Cosmetic acceptability of scar and neck mobility are important outcomes after collar line incision for neck surgery. This randomised, controlled trial compares these parameters in closures using tissue glue (Dermabond, Ethicon, UK) and skin staples.

PATIENTS AND METHODS

Patients requiring a collar line incision were randomised to receiving tissue glue or staples for skin closure. Time for closure to be completed was recorded. Mobility of the neck was assessed using a visual analogue scale at 48 h and 1 week after surgery. At 6 weeks, cosmetic appearance was assessed using a linear 1-10 visual analogue scale by the patient, surgeon and an independent blinded assessor. Results were compared using appropriate statistical tests.

RESULTS

Glued (n = 14) and stapled (n = 15) closures were performed for hemithyroidectomy (n = 8 versus 6), sub-total thyroidectomy (n = 2 versus 4), total thyroidectomy (n = 1 versus 4) and parathyroidectomy (n = 3 versus 1). Closure with tissue glue took significantly longer than with staples (mean, 95 versus 28 s; P < 0.001). Neck mobility scores were comparable at 48 h and 1 week (mean, 4.8 versus 4.4; P = 0.552: and 2.7 versus 2.6; P = 0.886). Cosmetic appearance at 6 weeks was comparable when patient (mean, 1.7 versus 1.8; P = 0.898), surgeon (mean, 2.6 versus 2.3; P = 0.633) and independent assessment (mean, 1.4 versus 1.9; P = 0.365) was performed.

CONCLUSIONS

The use of glued skin closure may increase the duration of surgery but acceptable neck mobility and wound cosmesis can be achieved by the more rapid application of stapled skin closure in cervicotomy incisions.

Will a web-based cardiovascular disease (CVD) risk assessment programme increase the assessment of CVD risk factors for Maori?

BACKGROUND

Maori suffer disproportionately from cardiovascular disease despite the national priority of reducing inequalities. National guidelines on the clinical management of CVD risk recommend a comprehensive risk assessment be completed as a prerequisite for identifying patients most likely to benefit from treatment.

METHODS

A retrospective audit of GPs using PREDICT-CVD (an electronic risk assessment and management tool) was designed with adequate explanatory power for Maori to determine if it could increase CVD risk assessment without increasing inequalities. 1680 electronic medical records (EMRs) prior to implementation and 1884 after implementation of PREDICT were audited.

RESULTS

Documentation of CVD risk increased from 3.2% of EMRs to 14.7% of EMRs in Maori, and from 2.8% to 10.5% in non-Maori. The documentation of individual CVD risk factors also increased post-implementation of the tool.

CONCLUSIONS

The implementation of PREDICT-CVD was as likely to increase documentation of CVD risk assessment and risk factors in Maori as in non-Maori. However documentation was still low in Maori despite known high prevalence of CVD risk factors. A comprehensive quality-driven implementation programme is recommended, including targeting risk assessment for those most in need.

Cardiovascular risk factors and their associations with alcohol consumption: are there differences between Maori and non-Maori in Aotearoa (New Zealand)?

AIMS

To describe the relationship between indicators of alcohol consumption and major known cardiovascular risk factors, and to test whether these relationships are different for Maori and non-Maori.

METHODS

Data from five New Zealand studies (national and population specific) conducted since 1988 were made available to the investigators and were re-analysed by Maori and non-Maori classification using multivariate modelling adjusting for sex and age. Three indicators of alcohol consumption were used: frequency of drinking, volume drunk on a typical or usual occasion, and average daily consumption. Interaction terms were used to test for differences between Maori and non-Maori in the associations between alcohol consumption and cardiovascular risk factors (tobacco smoking, systolic and diastolic blood pressure, high density lipoprotein (HDL), the ratio of total cholesterol to HDL, serum glucose, reported diagnosis of diabetes, and body mass index).

RESULTS

There were a total of 44,830 people in the combined study populations of whom 6926 (15.4%) were Maori. For the risk factors examined, in general Maori had higher levels of risk compared to non-Maori. The pattern of associations between each of the three indicators of alcohol consumption and lipid factors, diabetes, serum glucose level, and obesity were not shown to be different in Maori and non-Maori. However for systolic blood pressure and tobacco smoking, the patterns of association were different.

CONCLUSION

There are clear associations for most of the cardiovascular risk factors examined and alcohol consumption. These associations are consistent for Maori and non-Maori, except for blood pressure and cigarette smoking. As the study is hypothesis-generating, further investigation is required for confirmation.

Coronary artery bypass graft surgery in New Zealand's Auckland region: a comparison between the clinical priority assessment criteria score and the actual clinical priority assigned

AIMS

To describe the cohort of patients waiting for Coronary Artery Bypass Graft (CABG) surgery in the Auckland region; compare the Clinical Priority Assessment Criteria (CPAC) score with the actual priority assigned; and to assess the impact of a patient's demographic characteristics on the CPAC score and the assigned priority.

METHODS

An electronic register was developed to capture all patients who had a CPAC form completed for isolated CABG surgery during the period June 2002 to September 2004 in the Auckland region. CPAC scores and clinical priority assigned were collected from the CABG booking form. Demographic characteristics came from the booking form (age, gender) or linkage via the National Health Index (NHI) number (ethnicity, deprivation score).

RESULTS

The cohort displayed severe coronary artery disease and symptoms: 70% had class 3 or class 4 angina; 89% had their ability to work, live independently, or care for dependents threatened; 65% had three-vessel coronary disease; and 26% had left-main coronary disease. The CPAC score correlated only modestly with the actual clinical priority assigned, with an extremely wide range of scores for any given clinical priority. The mean CPAC score varied by the age of the patient, level of deprivation, and ethnicity--with higher mean scores among male patients who were Maori, Pacific, or more socioeconomically deprived. Clinical priority varied less by demographic characteristics than did the CPAC score, except more women than men were assigned the 'emergency' category. Despite higher CPAC scores for Maori and Pacific men, these did not translate to greater urgency in clinical priority.

CONCLUSIONS

The CPAC scoring system is used to limit access onto the CABG surgery waiting list in Auckland, but is not used to prioritise patients as to the urgency of surgery once on the list. The challenge is to determine why clinicians do not consider that the CPAC score is adequate to prioritise the urgency of surgery and to build in a process whereby any such score can be continuously evaluated and improved. We have demonstrated that the establishment of an electronic register of such patients can provide timely analysis of patterns of practice and could be used on a national scale to improve future CPAC scoring systems.

Tension empyema as a reversible cause for cardiac arrest

Empyema is a well recognised complication of pneumonia.1 We report a case of pulseless electrical activity (PEA) treated in the emergency department (ED) with intercostal tube drainage based on clinical findings, where a tension empyema was found to be the cause. To our knowledge, this is the first report of actual cardiac arrest from this cause.

Do u smoke after txt? Results of a randomised trial of smoking cessation using mobile phone text messaging

OBJECTIVES

To determine the effectiveness of a mobile phone text messaging smoking cessation programme.

DESIGN

Randomised controlled trial

SETTING

New Zealand

PARTICIPANTS

1705 smokers from throughout New Zealand who wanted to quit, were aged over 15 years, and owned a mobile phone were randomised to an intervention group that received regular, personalised text messages providing smoking cessation advice, support, and distraction, or to a control group. All participants received a free month of text messaging; starting for the intervention group on their quit day to assist with quitting, and starting for the control group at six months to encourage follow up. Follow up data were available for 1624 (95%) at six weeks and 1265 (74%) at six months.

MAIN OUTCOME MEASURES

The main trial outcome was current non-smoking (that is, not smoking in the past week) six weeks after randomisation. Secondary outcomes included current non-smoking at 12 and 26 weeks.

RESULTS

More participants had quit at six weeks in the intervention compared to the control group: 239 (28%) v 109 (13%), relative risk 2.20 (95% confidence interval 1.79 to 2.70), p < 0.0001. This treatment effect was consistent across subgroups defined by age, sex, income level, or geographic location (p homogeneity > 0.2). The relative risk estimates were similar in sensitivity analyses adjusting for missing data and salivary cotinine verification tests. Reported quit rates remained high at six months, but there was some uncertainty about between group differences because of incomplete follow up.

CONCLUSIONS

This programme offers potential for a new way to help young smokers to quit, being affordable, personalised, age appropriate, and not location dependent. Future research should test these findings in different settings, and provide further assessment of long term quit rates.

Smoking cessation using mobile phone text messaging is as effective in Maori as non-Maori

AIMS

To determine whether a smoking cessation service using mobile phone text messaging is as effective for Maori as non-Maori.

METHODS

A single-blind randomised controlled trial was undertaken with recruitment targeted to maximise the participation of young Maori. The intervention included regular, personalised text messages providing smoking cessation advice, support, and distraction. Maori text messages related to Maori language, support messages (in Maori and English) and information on Maori traditions. Text messaging was free for 1 month. After 6 weeks, the number of messages reduced from 5 per day to 3 per week until the 26-week follow-up.

RESULTS

Participants included 355 Maori and 1350 non-Maori. Maori in the intervention group were more likely to report quitting (no smoking in the past week) at 6 weeks (26.1%) than those in the control group (11.2%) RR 2.34, 95% CI: 1.44-3.79. There was no significant difference between the RR for Maori and that for non-Maori (RR: 2.16, 95%CI: 1.72-2.71).

CONCLUSIONS

A mobile phone-based cessation programme was successful in recruiting young Maori, and was shown to be as effective for Maori as non-Maori at increasing short-term self-reported quit rates. This shows clear potential as a new public health initiative.

Indigenous disparities in disease-specific mortality, a cross-country comparison: New Zealand, Australia, Canada, and the United States

AIMS

To compare the disease-specific mortality rates of the indigenous populations of New Zealand, Australia, Canada, and the United States with the non-indigenous populations in each country.

METHODS

For New Zealand, Australia, Canada, and the United States, we compiled and calculated (from crude data) ethnic-specific mortality rates by primary cause of death in 1999 for the indigenous and non-indigenous populations in each country. We calculated age-adjusted mortality rates, using direct standardisation and weights based on the World Health Organization world population.

RESULTS

Australia experienced the largest relative and absolute disparities in life expectancy between indigenous and non-indigenous populations. For specific causes of death, New Zealand Maori, and Australian Aboriginals and Torres Strait Islanders experienced the highest levels of disparities when compared to their respective non-indigenous population group. Large disparities exist for indigenous peoples in all four countries for diabetes mortality. CONCLUSION The indigenous peoples of New Zealand and Australia suffer from high disease-specific mortality rates. The relative size of indigenous/non-indigenous mortality disparities are highest in New Zealand and Australia. There appears to be a number of common issues that adversely affect the quality of the mortality data that is available in the four countries. Action is required to address indigenous health disparities and to improve the quality of indigenous mortality data.

Differences in patterns of alcohol consumption between Maori and non-Maori in Aotearoa (New Zealand)

AIM

To describe relative differences in alcohol consumption patterns in Maori and non-Maori from all available large-scale New Zealand surveys.

METHODS

Data from five New Zealand surveys (national and population specific) conducted since 1988 were made available to the investigators and were re-analysed by sex and age group in Maori and non-Maori using multivariate modelling.

RESULTS

There was a total of 44 830 people in the combined study populations, of whom 6926 (15.4%) were Maori. There was significant variation in the populations sampled and instruments used for measuring alcohol; however, the relative differences in consumption patterns between Maori and non-Maori were similar across all studies. In all age groups, and in men and women, non-Maori were more likely to be drinkers. The strength of this relationship increased with age. In all age groups, frequency of alcohol consumption (days a year) was higher for non-Maori, though the relative volume drunk on a usual drinking occasion was consistently around 40% less than for Maori. The averaged daily volume of alcohol consumed was similar between Maori and non-Maori.

CONCLUSIONS

Maori have markedly different alcohol consumption patterns from non-Maori, which are not apparent when averaged daily alcohol consumption is compared. Frequency of drinking and amount consumed on a typical drinking occasion should be considered when determining the relationship between Maori alcohol consumption and health-related problems.

The cost effectiveness of universal antenatal screening for HIV in New Zealand

OBJECTIVE

To model the incremental costs and benefits of a universal antenatal HIV screening programme in New Zealand (NZ).

DESIGN

Cost effectiveness analysis, including only health service costs, using secondary data sources and expert opinion. Uncertainty assessed in multi-way sensitivity analyses.

SETTING

The NZ Health Care System.

SUBJECTS

Antenatal population of NZ.

INTERVENTION

Universal antenatal HIV screening programme.

MAIN OUTCOME MEASURES

Incremental cost per true-positive HIV case detected in mothers; incremental cost per HIV case avoided in babies; and incremental cost per discounted life-year gained, for mothers and babies, due to screening.

RESULTS

Using base case values the application of universal screening would cost an additional $NZ 723 607 ($US 307 917) and would lead to the identification of an additional 6.25 true-positive women. After terminations have been excluded, the screening programme would detect five HIV exposed babies. There would be 1.15 avoided cases of HIV infection in babies and a net gain of 41.97 discounted life-years, for mothers and babies combined. The cost per incremental HIV-positive woman detected was $NZ 115 859 ($US 49 301), HIV infected baby avoided $NZ 629 669 ($US 267 944) and discounted life-year gained $NZ 17 241 ($US 7336).

CONCLUSION

The discounted cost per life gained in NZ compares favourably to estimates reported in studies of similar interventions in other developed countries and other health care interventions in NZ. The decision of whether to implement universal screening in NZ would be clarified if the prevalence of antenatal HIV infection was known and policy makers identified their willingness to pay for an additional life-year gained.

The acceptability of chronic disease management programmes to patients, general practitioners and practice nurses

AIM

To evaluate the perceived effectiveness and acceptability of a disease management programme for patients with congestive heart failure (CHF) in South Auckland.

METHODS

Focus groups were held with patients, and practice nurses (PNs) and general practitioners (GPs) interviewed to develop the questionnaires. Questionnaires were posted to the 150 patients, 14 GPs and 6 PNs involved in the programme.

RESULTS

The programme was reported as changing patient lifestyle behaviours and patient understanding of medications and CHF. GP management was also seen as having improved. All aspects of the programme were seen as important: clinical review with a GP, educational sessions with a PN, patient-held care plan and educational material. The main issues were lack of time for practice staff to be involved, and payment for their time.

CONCLUSIONS

Disease management programmes such as this are of value and are acceptable to both patients and providers.