Leadership for health: developing a canny nanny state

Health leadership comes from government, non-governmental organisations (NGOs), commercial organisations, and the community as a whole. Government has an obligation to act to protect the health of its citizens, both in respect of traditional threats to health, such as infectious diseases, and in response to newer threats, such as diet. Leadership requires the recognition and rejection of strategies that attempt to replace evidence with rhetoric. We recommend that health policy decisions have a clear evidence base and equity rationale, where the proposed interventions have been balanced against the freedom of individuals to act on their own account without undue influence from marketing. We recommend that government draws on the experience and expertise of the NGO and public health sectors, and communities to promote responsiveness to local priorities and needs. We recommend that public health practitioners strengthen their links with communities and build constituencies so public health decision-making does not occur predominantly in the bureaucratic domain.

The Equity in Prescription Medicines Use Study: using community pharmacy databases to study medicines utilisation

PURPOSE

Pharmacy dispensing databases provide a comprehensive source of data on medicines use free from many of the biases inherent in administrative databases. There are challenges associated with using pharmacy databases however. This paper describes the methods we used, and their performance, so that other researchers considering using pharmacy databases may benefit from our experiences.

METHODS

Data were collected from all nine pharmacy dispensing databases in an isolated New Zealand town for the period October 2005-September 2006. Probabilistic record matching was used to link individuals across pharmacies. Patient addresses from the pharmacy data were geo-located to small areas so an area measure of socioeconomic deprivation could be assigned. Medicines were coded according to the ATC-DDD drug classification system.

RESULTS

Data on 619,264 dispensings were collected. Record matching reduced an initial pool of individuals from 54,484 to 38,027. Socioeconomic deprivation ranks were assigned for 30,972 (93%) of the 33,375 unique addresses identified, or 36,048 (95%) of individuals. ATC codes were assigned to 613,490 (99%) of the dispensings, with DDDs assigned to 561,223 (91%). Overall, 93% of dispensing records had complete demographic and drug information.

CONCLUSIONS

The methods described in this paper generated a rich dataset for medicines use research. These methods, while initially resource-intensive, can to a great extent be automated and applied to other locations, and will hopefully prove useful to other researchers facing similar challenges with using pharmacy databases. However, it is difficult to envisage these methods being viable on a long-term or national scale.

Ethnic differences in access to prescription medication because of cost in New Zealand

OBJECTIVES

This paper aims to examine ethnic differences in financial barriers to access to prescription medication in New Zealand.

METHODS

Data from SoFIE-Health (wave 3), which is an add-on to the Statistics New Zealand-led longitudinal Survey of Family, Income and Employment (SoFIE) (N=18 320), were analysed using logistic regression, adjusting for demographic, socioeconomic, health behaviour and health variables. Financial barriers to access to prescription items were measured by the following question: 'In the past 12 months, have there been any times when a doctor gave you a prescription, but you didn't collect one or more of these items because you could not afford the cost?'.

RESULTS

The odds of deferring buying a prescription at least once during the preceding 12 months because they could not afford the cost of the prescription were greater for Māori and Pacific people than for NZ Europeans (OR 2.98, 95% CI 2.56 to 3.47 vs OR 3.52, 95% CI 2.85 to 4.35). Adjusting for potential confounders attenuated the ORs to 1.31 (95% CI 1.08 to 1.58) for Māori people and to 2.17 (95% CI 1.68 to 2.81) for Pacific people. Deferring buying medications because of cost was also associated with increased odds of poor self-reported health status, high/very high psychological stress and the presence of two or more comorbid conditions.

CONCLUSION

Ethnicity plays a critical role in facilitating or impeding access to primary health care. This suggests that policy measures to further reduce financial barriers to buying medication may improve access to care for everyone including Māori and Pacific people and may have positive health implications.

Gender differences in general practice utilisation in New Zealand

INTRODUCTION

This paper aims to examine gender differences in general practice utilisation in New Zealand.

METHODS

The dataforthis research came from 10 506 visit records gathered from 246 general practitioners (GPs) who took part in the National Primary Medical Care Survey (NatMedCa), a nationally representative, multistage, probability sample survey of GPs and patient visits conducted in 2001/2002. The number of visits to a general practice in the last 12 months among those patients who visited the GP at least once during the past 12 months was used as the outcome variable. Poisson regression was used for analysis.

RESULTS

Women were more likely than men to visit a GP over the last 12 months (IRR = 1.13; 95% CI: 1.03-1.24). We also found significant female excess in utilisation of GP services even after excluding gynaecological and obstetric conditions and across all age groups. Asian were 39% less likely than European women to visit a GP (IRR = 0.61; 95% CI: 0.43-0.85); a result that was not reflected in men's utilisation of GP services. In addition, we found that women visiting GPs were 39% more likely to have reported life-threatening' problems as compared to 'self-limiting' problems (IRR = 1.39; 95% CI: 1.00-1.94).

CONCLUSION

Our results do not support the body of literature that suggests that women's excess in service use can largely be attributed to gynaecological and obstetrical conditions or that the female excess in visits is focussed in the childbearing years. Ethnicity and the severity of a problem contributed significantly to explaining women's, but not men's, utilisation of GPs.

The case for integrating oral health into primary health care

Severe disparities in oral health and inequities in access to oral health care exist globally. In New Zealand, the cost of oral health services is high. Physician services and medicines are heavily subsidised by the government -- however, in contrast, private financing, either as out-of-pocket payments or as private insurance, dominates dental care. Consequently, the use of services is often prompted by symptoms, and services are mostly oriented towards relief of pain. The high cost of dental care with insufficient emphasis on primary prevention of oral diseases, poses a considerable challenge for providing equitable access to health care as laid down by the Alma-Ata Declaration on Primary Health Care (PHC). While improving oral health is one of the health objectives of the New Zealand Health Strategy, providing accessible and affordable oral health services does not feature prominently in the current Primary Health Care Strategy. This paper discusses current knowledge regarding oral health in relation to general health and health care strategies and frameworks, in order to highlight that oral health care is an important component of primary health care. The authors also propose that oral health care should be integrated into primary health care in New Zealand. This could be achieved by placing oral health within the broader framework of PHC as encapsulated by the Alma-Ata Declaration and the New Zealand Primary Health Care Strategy.

Putting population health into practice through primary health care

The introduction of the Primary Health Care Strategy has offered opportunities to take a population health approach to the planning and delivery of primary health care. The lack of a common understanding of population health between primary care and public health has been the prompt for a group of academics and practitioners to join forces and produce this statement on a population health approach to primary care, through primary health care. This paper takes the position that the features of a population health approach (such as a concern for equity, community participation, teamwork and attention to the determinants of health) enhance general practice care rather than undermine it. We conclude that the contribution of the health sector towards population health goals can be achieved through collaboration between GPs, nurses, other primary health care workers, and communities, together with health promotion and public health practitioners. Finding common language and understanding is an important step towards improving that collaboration.

Gender differences in general practice utilisation in New Zealand

INTRODUCTION: This paper aims to examine gender differences in general practice utilisation in New Zealand. METHODS: The data for this research came from 10 506 visit records gathered from 246 general practitioners (GPs) who took part in the National Primary Medical Care Survey (NatMedCa), a nationally representative, multistage, probability sample survey of GPs and patient visits conducted in 2001/2002. The number of visits to a general practice in the last 12 months among those patients who visited the GP at least once during the past 12 months was used as the outcome variable. Poisson regression was used for analysis. RESULTS: Women were more likely than men to visit a GP over the last 12 months (IRR=1.13; 95% CI: 1.03–1.24). We also found significant female excess in utilisation of GP services even after excluding gynaecological and obstetric conditions and across all age groups. Asian were 39% less likely than European women to visit a GP (IRR=0.61; 95% CI: 0.43–0.85); a result that was not reflected in men’s utilisation of GP services. In addition, we found that women visiting GPs were 39% more likely to have reported ‘life-threatening’ problems as compared to ‘self-limiting’ problems (IRR=1.39; 95% CI: 1.00–1.94). CONCLUSION: Our results do not support the body of literature that suggests that women’s excess in service use can largely be attributed to gynaecological and obstetrical conditions or that the female excess in visits is focussed in the childbearing years. Ethnicity and the severity of a problem contributed significantly to explaining women’s, but not men’s, utilisation of GPs. KEYWORDS: Gender differences; health services utilisation; New Zealand

The association of gender concordance and primary care physicians' perceptions of their patients

In this article, we examined the effect of gender concordance on physicians' perception of their patients and of their medical condition, analyzing a data set of 8,258 visit questionnaires from the New Zealand National Primary Care Medical Care Survey conducted in 2001 2002. Multivariate analysis indicated that the concordant female patient/female physician dyad had a positive independent association with physicians' reporting high rapport and a negative independent association with reporting uncertainty about the diagnosis. The discordant female patient/male physician dyad had a positive independent association with physicians' perceptions of uncertainty of diagnosis and hidden agenda, and a negative independent association with rating the patient's condition of high severity. The findings suggest a need to raise male physicians' awareness to possible biases when treating female patients. The findings also suggest the need to empower female patients to take an active partnership role to improve their communication with male physicians.

Capitation funding of primary health organisations in New Zealand: are enrolled populations being funded according to need?

AIM

To determine whether the three main funding formulas for Primary Health Organisations achieved a stated aim of the Primary Health Care Strategy to fund enrolled populations according to need.

METHODS

National data were obtained from the Ministry of Health for a 12-month period beginning in April 2004: these included demographic characteristics of the enrolled Primary Health Organisation population, plus rates tables for: First-Contact Services, Services to Improve Access, and Health Promotion. Funding for Access and Interim practices for four-quarters was calculated for each of these three funding streams. Analysis of the demographic characteristics of Access and Interim practices was undertaken.

RESULTS

Maori and Pacific peoples made up a greater proportion of the Access population than the Interim, had higher rates of deprivation than the non-Maori/non-Pacific population, and demonstrated a younger age distribution. The first quarter (April 2004-June 2004) showed there was preferential funding for Access PHOs and in particular high-needs groups. In quarter two, this level of preferential funding had diminished, coinciding with the introduction of increased government funding for all Interim enrolees aged 65 and over.

CONCLUSIONS

The greater funding for Access enrolees was notably eroded with the introduction of Access-level funding for those aged 65+ in Interim PHOs. Since these data were analysed all remaining Interim age groups have shifted to Access-level funding, benefiting non-Maori /non-Pacific in Interim PHOs. The rapid shift to Access-level funding for First Contact Services has seen a continued erosion of the redistributive effect of the original needs-based formulas. A system cannot be considered equitable if some members of society are not realising their health potential, and financing of primary care should remain redistributive until such a time as this objective is attained.

Comparison of services provided by urban commercial, community-governed and traditional primary care practices in New Zealand

OBJECTIVES

New Zealand has experienced restructuring and reform of primary health care since the 1980s, including the introduction of commercial clinics and increasing numbers of practices run by community-governed organizations. Our aim was to compare commercial, community-governed and traditional practices in five key domains: access; coordination and continuity of care; communication and patient centredness; population health and preventive health; and chronic disease management.

METHODS

A nationally representative, multistage probability sample of private general practitioners, stratified by geographical location and practice type, was drawn. Representative samples of urban commercial clinics and of practices governed by community organizations were obtained for the same period (2001-02). All doctors were asked to provide data on themselves, their practice, and to report on a 25% sample of patients in two periods of one week.

RESULTS

Among the three practice types, commercial clinics differed most in their organization; they charged higher fees and employed more staff, although their doctors were less experienced. Community-governed practices were visited by more people from lower socioeconomic groups. Commercial clinic patients were more likely to be younger and less likely to have an ongoing relationship with the clinic. They frequently attended for self-limiting problems related to injuries or respiratory problems. Investigations, follow-up and referral rates were similar between the three practice types. Treatment rates were higher at traditional and community-governed general practices.

CONCLUSION

Rather than replicating traditional practices, new practice types provide complementary services and established services in innovative ways. The challenge is to achieve an appropriate mix of diverse providers.

Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys

OBJECTIVES

To compare mix of patients, scope of practice, and duration of visit in primary care physicians in Australia, New Zealand, and the United States.

DESIGN

Comparison of three comparable cross sectional surveys performed in 2001-2. Physicians completed a questionnaire on patients' demographics, diagnoses, and duration of visit.

SETTING

Primary care practice.

PARTICIPANTS

79,790 office visits in Australia, 10,064 in New Zealand, and 25,838 in the US.

MAIN OUTCOME MEASURES

Diagnostic codes were mapped to the Johns Hopkins expanded diagnostic clusters. Scope of practice was defined as the number of expanded diagnostic clusters accounting for 75% of all managed problems related to morbidity. Exposure to primary care was calculated from duration of visits recorded by the physician, and reports on rates of visits to primary care for each country.

RESULTS

In each country, primary care physicians managed an average of 1.4 morbidity related problems per visit. In the US, 46 expanded diagnostic clusters accounted for 75% of problems managed compared with 52 in Australia, and 57 in New Zealand. Correlations in the frequencies of managed health problems between countries were high (0.87-0.97 for pairwise comparisons). Though primary care visits were longer in the US than in New Zealand and Australia, the per capita annual exposure to primary care physicians in the US (29.7 minutes) was about half of that in New Zealand (55.5 minutes) and about a third of that in Australia (83.4 minutes) because of higher rates of visits to primary care in these countries.

CONCLUSIONS

Despite differences in the supply and financing of primary care across countries, many aspects of the clinical practice of primary care physicians are remarkably similar in Australia, New Zealand, and the US.

Exposure to primary medical care in New Zealand: number and duration of general practitioner visits

AIMS

To estimate (among different population groups and different practice types) average duration of visit to a general practitioner, average number of visits, and average population exposure to primary medical care in New Zealand.

METHODS

Observational study using a representative survey of visits to general practitioners in New Zealand. Average exposure to primary medical care for a particular class of patient (e.g. by age group) was calculated as the average of the product of number of visits over the past 12 months and duration of visit for the current visit. Comparisons were made across different demographic groups of patients and different practice types.

RESULTS

Annual exposure to primary medical care was highest amongst the elderly (65+ years), followed by adults (18-64 years). Adjusting for age, gender, NZDep2001, rural/urban, and organisation type, average annual exposure to primary medical care was higher in the European ethnic group than in the Maori, Pacific, and Asian ethnic groups. Exposure to primary medical care did not differ significantly across NZDep2001 quintiles after controlling for other co-variates.

CONCLUSIONS

Annual exposure to primary medical care is both a direct measure of utilisation of primary medical care and also an indicator of access. Primary medical care exposure measurement can be used to monitor equity of service provision across different population groups: groups with high identified health care needs should have relatively high exposure to primary medical care. The most obvious breach of this principle is for Maori and Pacific users of primary medical care and for those living in deprived areas. Similarly, the low overall exposure to primary medical care for the Asian ethnic group is concerning and warrants further exploration.

Warrior genes and risk-taking science

This article provides a summary of our ethical concerns regarding the so-called "warrior gene" line of research. Prompted by recent claims that there is a genetic explanation for negative social and health statistics for Māori, the article discusses issues related to informed consent of research participants, the validity of the underlying science related to the "warrior gene", and scientifically unfounded speculation regarding the causality of complex social issues. We conclude that in all science, and particularly where there is a highly charged social and political setting, the scientist has a responsibility for the way in which findings are disseminated and for ensuring a clear public understanding of the limitations of the work.

The Community-Referred Radiology scheme: an evaluation

AIMS

To evaluate the Community-Referred Radiology (CRR) scheme.

METHODS

The study involved: (1) interviews with local stakeholders; (2) analysis of the number, type, and cost of referrals as well as sociodemographic characteristics of patients using the CRR database (for the year October 2003-October 2004); and (3) review of referral criteria, by an independent radiologist, of a random sample of 100 referrals.

RESULTS

The scheme was widely used, and was viewed as being highly satisfactory by general practitioners. There were 117 types of radiology investigation ordered. Chest X-ray was the most requested investigation. Women constituted 65.5% of users. Maori had a lower rate of referral compared with New Zealand (NZ) European. The average cost of investigation in the NZ European and the 'Not stated' groups was higher than in other ethnic groups. Six (6.1%) of referrals did not align with the National Radiology Referral Guidelines.

CONCLUSIONS

The CRR scheme is perceived as being a popular, well-run, and streamlined service. The comparatively low rate of radiology referral for Maori people and people living in the most deprived areas as well as the lower average cost of their tests warrant further investigation. A number of recommendations are made aimed at further enhancing the scheme.

Socio-economic deprivation and duration of hospital stay in severe mental disorder

Adults from South Auckland, New Zealand who required acute admission to hospital were followed from admission to discharge. After adjusting for demographic factors, diagnosis, chronicity, severity, consultant psychiatrist and involuntary admission, the length of stay for those from more deprived areas was significantly longer by 7 days than for those from less deprived areas. Information on socio-economic deprivation should be used in discharge planning and in optimising access to community care. Research is needed on group-level factors that may affect recovery from mental disorders.

Panning for gold: an evidence-based tool for assessment of performance indicators in primary health care

It is important that debate occurs between theorists, policy makers, clinicians and service end-users to develop agreement over suitable and appropriate indicators for primary health care. A formal accounting of the relative strengths and weaknesses of any proposed indicator will enable sector commentators from a variety of viewpoints to discuss the relative merits of individual indicators, to understand the political and pragmatic reasons for their inclusion in any set of indicators and to trace the likely organisational impact of any given indicator. This paper details the development of an indicator appraisal tool that combines the assessment of scientific evidence with contextual considerations from the perspective of both the policy environment and the primary health care sector. The use of the tool is discussed in the context of the proposed national implementation of a set of performance indicators in New Zealand.

The contribution of causes of death to socioeconomic inequalities in child mortality: New Zealand 1981-1999

BACKGROUND

Socioeconomic inequalities in all-cause child mortality exist in New Zealand; however the inequalities in cause-specific mortality have not been examined. This study examines child mortality inequality by household income between 1981 and 1999, by cause of death.

METHODS

Data was used from a record linkage study of census and mortality records of all New Zealand children aged 0-14 years on census night 1981, 1986, 1991, 1996 followed up for 3 years for specific causes of mortality between ages 1-14 years. All cohorts were combined to calculate mortality rates, rate ratios, and rates differences for each cause of death.

RESULTS

Socioeconomic differences in child mortality (low income compared to high income) were observed for injury (non road traffic) (RR 1.87, 1.35 to 2.58), road traffic injury (RR 1.36, 1.01 to 1.82), and 'other' causes of death (RR 1.81, 1.32 to 2.47). 'Other' and non-road traffic injury deaths together contributed 70% of the total gap in child mortality between the rich and the poor.

CONCLUSIONS

Socioeconomic differences existed across most broad causes of child death. The major contributors to mortality inequality are diverse, suggesting that the similar distal causes of inequality (e.g. poverty) play out through a myriad of proximal causes. Fortunately there appears to be some scope for policymakers to modify some of the proximal and distal causes of these inequalities.

Does community-governed nonprofit primary care improve access to services? Cross-sectional survey of practice characteristics

This study compared community-governed nonprofit and for-profit primary care practices in New Zealand to test two hypotheses: (1) nonprofits reduce financial and cultural barriers to access; and (2) nonprofits do not differ from for-profits in equipment, services, service planning, and quality management. Data were obtained from a nationally representative cross-sectional survey of GPs. Practices were categorized by ownership status: private community-governed nonprofit or private for-profit. Community-governed nonprofits charged lower patient fees per visit and employed more Maori and Pacific Island staff, thus reducing financial and cultural barriers to access compared with for-profits. Nonprofits provided a different range of services and were less likely to have specific items of equipment; they were more likely to have written policies on quality management, complaints, and critical events, and to carry out locality service planning and community needs assessments. The findings support the shift to nonprofit community governance occurring in New Zealand and elsewhere.

Do social and economic reforms change socioeconomic inequalities in child mortality? A case study: New Zealand 1981-1999

BACKGROUND

Socioeconomic inequalities in child mortality are known to exist; however the trends in these inequalities have not been well examined. This study examines the trends in child mortality inequality between 1981 and 1999 against the background of the rapid and dramatic social and economic restructuring in New Zealand during this time period.

METHODS

Record linkage studies of census and mortality records of all New Zealand children aged 0-14 years on census night 1981, 1986, 1991, 1996, each followed up for three years for mortality between ages 1-14 years. Socioeconomic position was measured using maternal education, household income, and highest occupational class in the household. Standardised mortality rates, rate ratios, and rates differences as well as regression based measures of inequality were calculated.

RESULTS

Mortality in all socioeconomic groups fell between 1981 and 1999. Socioeconomic inequality in child mortality existed by all measures of socioeconomic position, however only trends by income suggested a change over time: the relative index of inequality increased from 1.5 in 1981-84 to 1.8 in 1996-99 (p trend 0.06), but absolute inequality remained stable (slope index of inequality 15/100 000 in 1981-84 and 14/100 000 in 1996-99.

CONCLUSIONS

Dramatic changes in income in New Zealand possibly translated into increasing relative inequality in child mortality by income, but not by education or occupational class. The a priori hypothesis that socioeconomic inequalities in child mortality would have increased in New Zealand during a period of rapid structural reform and widening income inequalities was only partly supported.

The ownership elephant: ownership and community-governance in primary care

Ownership of primary care is an often neglected but important health systems design parameter. The New Zealand Primary Health Care Strategy has established Primary Health Organisations (PHOs) as non-profit umbrella organisations, however in most instances their constituent general practices are for-profit small businesses. This viewpoint paper aims to: (a) define ownership and community participation; (b) summarise some of the evidence from the NatMedCa study pertaining to ownership-related differences; and (c) discuss the policy implications of different ownership forms in primary care, and the implications of merging different ownership forms under the umbrella of PHOs. Ownership confers governance responsibility (ultimate control) for an organisation, and accountability for its actions. Community governance involves vesting overall control of resources in users and the community, rather than with health service managers or health professionals. Results from three studies using the NatMedCa survey indicate that community-governed non-profits in New Zealand differ in a number of respects from their for-profit counterparts. As non-profit and for-profit ownership forms have different social roles, and as meaningful community participation in governance is determined in large part by ownership structures, there is a need for ownership frameworks to be used more widely in health policy making. Because of the ownership boundary that exists between non-profit community-governed PHOs and their constituent for-profit general practices PHOs may have little real ability to effectively govern their practices.

NZiDep: a New Zealand index of socioeconomic deprivation for individuals

The aim of this research was to identify a small set of indicators of an individual's deprivation that is appropriate for all ethnic groups and can be combined into a single and simple index of individual socioeconomic deprivation in New Zealand. The NZiDep index of socioeconomic deprivation was derived using the same theoretical basis as the national census-based small-area indices of relative socioeconomic deprivation. The index has been created and validated from the analysis of representative sample survey data obtained from approximately 300 Maori, 300 Pacific, and 300 non-Maori, non-Pacific adults. Twenty-eight deprivation-related characteristics, derived from New Zealand and overseas surveys, were analysed by standard statistical techniques (factor analysis, Cronbach's coefficient alpha, item-total correlations, principal component analysis). The index was validated using information on tobacco smoking, which is known to be strongly related to deprivation. The NZiDep index is based on eight simple questions which take 2-3 min to administer. The index is a significant new (non-occupational) tool for measuring socioeconomic position for individuals. We argue that the index has advantages over existing measures, including a specific focus on deficits, applicability to all adults (not just the economically active), and usefulness for all ethnic groups. Its strengths include focus, simplicity, utility, acceptability across ethnic groups, construct validity, statistical validity, criterion validity (measured with reference to tobacco smoking), and relevance to the current New Zealand context. The index is indicative of deprivation in general, and is designed for use as a variable in research, and for elucidating the relationships between socioeconomic position and health/social outcomes.