April 2022

Clinical Snippets April 2022

1.  Eating disorders

Some useful resources for parents while they wait include (Goodfellow Gem):

• F.E.A.S.T info for parents
• EDANZ 
• Eating disorders. Mental Health Foundation
• Eating disorders. Health Navigator NZ
• Centre for Clinical Interventions   https://www.cci.health.wa.gov.au/  

For clinicians: Regional clinical pathways.   Also links to multiple resources for patients and whanau together with advice on management and monitoring. 

Private options include:

New Zealand Eating Disorders Clinic (NZEDC)

2.  BPAC update on weight loss

BPAC has recently released an update on weight loss: the options and the evidence.   Some key practice points include:

• The overriding principle of weight loss is that energy intake needs to be less than energy expenditure; there is no consistent evidence that any one calorie-restricted diet is better than another at achieving weight loss
• At least 2.5 hours of moderate intensity physical activity per week should be included in all weight loss interventions
• Contrary to popular belief, rapid weight loss is not associated with an increased risk of weight regain compared to gradual weight loss
• Pharmacological interventions may be considered only after dietary, exercise and behavioural approaches have been initiated and evaluated for people who are obese or as an adjunct to diet and lifestyle interventions, after the potential harms and benefits of treatment have been reviewed

There are two new pharmacological interventions approved in New Zealand (but not funded) for weight management:

Liraglutide (a GLP 1 receptor agonist – Saxenda) – daily SC injection, cost about $500 per month

Naltrexone + bupropion (Contrave) – tablet uptitrated over 3 weeks, cost about $220 per month

Cost comparison:  phentermine Duromine (30mg caps) $100/month;  orlistat (Xenical)  $180/month

Indication:  BMI ≥30 or 27-30 if at least one weight-related co-morbidity

Recent Tools for Practice question:  Is naltrexone/bupropion (Contrave^®) effective for weight loss?

Bottom line:  Over 28-56 weeks, at best, ~50% of patients taking naltrexone/bupropion achieved a >5% loss in body weight, compared to ~20% in control. Naltrexone/bupropion adverse events (examples nausea, constipation) lead to withdrawal in 23% of patients versus 12% on placebo.

3.  Depo-Provera dose interval update

In the April 2022 NZF update a change to dosing recommendation for Depo-Provera is noted as: 

• Individuals should be advised to return every 13 weeks for a repeat injection of intramuscular DMPA (outside the product licence for intramuscular DMPA). Health practitioners should be aware that this is an evidence-based recommendation and signals a change in practice in New Zealand. This recommendation may differ from the Manufacturer data sheet.

• Good practice points:  An injection of DMPA can be administered up to 7 days late (up to 14 weeks after the last injection) without the need for additional contraceptive precautions (outside the product licence for intramuscular DMPA). If necessary, an early repeat injection of DMPA can be administered from 10 weeks. 

4.  Supply issues with smoking cessation treatments

All patients who smoke should be encouraged to stop and provided with cessation support, including both behavioural and pharmacological treatment. Currently, the options for pharmacological support are limited due to supply constraints.

•  Varenicline has been unavailable for almost 12 months due to a manufacturing safety issue, and bupropion supply is now being managed in New Zealand due to increased global demand and manufacturing constraints.
• This leaves nicotine replacement therapy (patches, gum or lozenges) as the remaining funded pharmacological option; note that this is usually the first-line recommended treatment for smoking cessation. Nortriptyline (funded) may also be an option for some patients. Read more about smoking cessation treatments here.
• Vaping is not an approved smoking cessation method, but health care professionals can provide information to help smokers make an informed choice: read more here.

5.  Chronic pain guideline for primary care 

A recent Goodfellow Gem looked at the work of a Canadian panel that filtered 74,000 papers to get a summary for chronic pain management of osteoarthritis, low back pain, and neuropathic pain.  The findings are summarised in a table that might be useful for discussion with patients.

Some findings of note include:

• Placebo is fairly effective 29% to 40%.
• Physical activity is essential for OA and back pain.
• For OA (NZ available drugs) – steroid injections, oral and topical NSAIDs are effective.
• Glucosamine and chondroitin are of uncertain benefit as the publicly funded trials found no benefit while the industry-sponsored ones did show benefit.
• For low back pain – spinal manipulation, oral NSAIDs, and TCAs.
• The authors felt cannabinoids and opiates showed that harms exceeded benefits.

6.  The dangers of psychosis induced violence

Findings of a recent Coronial inquest into the deaths of five people who were killed in 2015 and 2016 by patients who were in a florid psychotic state have been summarised in GP Pulse with learnings for GPs documented as:

• When you are concerned about a patient and refer them, be ASSERTIVE. Say what you think and if it is a phone call, identify exactly who you are talking to. 
• Insist on talking to a consultant psychiatrist if you have concerns.  
• If you have an expectation about the type of care required, you need to state it clearly. You should also state that if your recommendation is not to be acted upon, then you should be contacted (leave your contact number) and you may wish to speak to a more senior member of the mental health team.
  • These cases are monumentally complicated, and a peer-to-peer discussion is the safest form of communication. You may well be the person who has the greatest insight into the case.
• Once you have made a referral, document it carefully.
  • If something goes wrong, you may find that other health professionals have a very different interpretation of what you said/documented.
• Keep clinical antennae up with patients who are guarded in their communication. Despite being psychotic, some patients can be wary of health professionals who may insist on treatments that they find intolerable.
• When family members or indeed other members of the public report abnormal behaviour you need to talk to and listen to them. This is not breaking patient confidentiality and may be critical to everyone’s welfare. You need to interview these people often without the patient present.
• We have a duty of care to our patients and their families and better outcomes for both should be paramount in our thinking.

Clinical Snippets May 2022

Clinical Snippets – May 2022

1.  ACC Treatment Injury

• Refusal to provide or delays in lodging a Treatment Injury claim with ACC is not an uncommon source of patient complaints.  However, on average a third of Treatment Injury claims are declined each year

• ACC has a provider resource (to which a patient could also be referred) clarifying the process

• The principles of a claim are:
  • An injury has occurred that has resulted in physical harm or damage to the patient
  • The injury has been caused by the treatment (probability rather than possibility considered)
  • The injury is not a necessary part or an ordinary consequence of treatment, having regard to the clinical knowledge at the time of treatment and the underlying health condition of the patient

• A precipitating event can include when treatment has not been given by mistake or has been given unreasonably late

• Lack of evidence of physical injury caused by treatment is the most common reason for a claim to be declined

• If review of an ACC Treatment Injury claim results in concern there is a risk to the public, the details may be forwarded to HDC

2.  Concussion

BPAC has recently published a comprehensive overview of concussion management for primary healthcare professionals – audiovisual and written resources including a summary sheet.  Key practice points include:

• Recognising concussion in primary care can be challenging as symptoms and signs are often subtle, non-specific, and can progress over time.  Initial loss of consciousness only occurs in one in ten people with concussion
• The Brain Injury Screening Tool (BIST) is a standardised and validated assessment tool to evaluate patients with suspected concussion; this is specifically tailored for use in time-limited clinical consultations (takes 5-6 minutes to complete)
• Initial management of patients with concussion involves physical and mental rest for 24 – 48 hours; in most cases patients should then progressively re-engage in normal activities after this rest period, assuming the degree of engagement does not significantly worsen symptoms – excessive rest can prolong recovery.
• Patients who have sustained a sports-related concussion should be immediately removed from play, and not return until they have been medically cleared after completing a graduated return-to-play protocol
• Patients can be reassured that most people who experience a concussion will fully recover within two to four weeks. However, recovery is strongly influenced by the timeliness of clinical review and follow-up, effective education delivered at an appropriate level of health literacy (and whether the advice given is culturally appropriate/relevant), as well as other patient-specific factors, e.g. initial symptom burden, ‘yellow flags’
• On-line educational resources are available from ACC for adult patients (English and Te Reo Maori) and for carers of an affected child
• Post-concussion syndrome is no longer a recognised as a diagnosis in DSM-5. ICD-11 or by ACC.  The preferred term is ‘persistent concussion symptoms’ (beyond three months). 

The article covers all aspects of assessment, education, recovery and rehabilitation,  complications, return to work and sport advice etc. 

3.  Calcium for hypertension?

A recent PEARL published in NZ Doctor referenced a Cochrane review noting several studies have shown an inverse association between calcium intake and blood pressure, and small reductions in blood pressure have been shown to produce rapid reductions in cardiovascular disease risk even in individuals with normal blood pressure. A 2 mmHg lower systolic blood pressure is predicted to produce about 10% lower stroke mortality and about 7% lower mortality from ischaemic heart disease.

An increase in calcium intake slightly reduced both systolic and diastolic blood pressure in normotensive people. The effect was confirmed in multiple prespecified subgroups, including a possible dose–response effect (1500mg per day being more efficacious than 1000mg), reinforcing the efficacy of the intervention. The effects were observed after only 3.5 months of intervention and were more pronounced in younger patients.

Most of the studies used calcium supplements and there is some suggestion that the effect might be lost over time in populations with adequate calcium intake.

Conversely, a 2021 meta-analysis in the journal Nutrients reported that dietary calcium intake of 700–1000 mg per day or supplementary calcium intake of 1000 mg per day increased the risk of CVD by about 15% in healthy postmenopausal women.

4.  Dog bites

Starship Hospital has updated its guidance on management of dog bite injuries which are increasing in frequency.  Practice points include:

• In serious incidents police or animal management may require photos or DNA collection from the wound prior to washout or closure. Encourage patients to take their own photos of injuries to keep for future reference.

• Consider imaging (Xray/CT) in even seemingly simple dog-bite injuries. Significant force (>1000N) can be involved, with deep penetration or crush injuries not initially obvious.
• Examination and copious irrigation should be done if the dermis has been penetrated or if the wound is in the proximity of joints
• Primary wound closure is recommended if early presentation (<4-6hours) AND absence of non-viable/heavily damaged tissue/contamination.  Delayed wound closure or healing by secondary intention is recommended for all other wounds.
• There is evidence that prophylactic antibiotics are associated with a statistically significant reduction in infection in dog-bites to hands.  There is conflicting evidence for other wounds. Antibiotics are also indicated for any infected wound, or as prophylaxis for puncture wounds, bite-injuries to hands, feet, face or genitalia, immunocompromised patients, those requiring surgery or who have an underlying structural injury, or if presenting >8 hours after the bite. 
• Amoxicillin/clavulanic acid is the antibiotic of choice with alternative for penicillin allergic patients being metronidazole plus co-trimoxazole (≥1 month – 11 years) or metronidazole plus doxycycline ( ≥ 12 years)
• It is strongly recommended that health professionals notify all dog-bite and serious non-bite dog-related injuries to the Animal Management Service of the council where the dog bite occurred, and do not require patient consent. Dogs pose a serious health risk to vulnerable people, including children, who are more likely to receive serious bites to the head/face/neck, and the potential for significant psychological harm in any age group
•   Any serious risk to a child or the public also needs to be referred to Social Work, Oranga Tamariki and/or Police. Animal Management Officers have limitations on what they can do in situations where a dog has bitten a family member, and may require further input from these services to ensure safety measures are put in place.
• Offer psychological support to all victims, and to whānau who have witnessed an attack. ACC can provide support with counselling or therapy sessions. 
• The Starship website has a printable information sheet for carers of affected children which includes reference to notification to Animal Control Officers, and a Council Notification form (currently Auckland specific – Hamilton details are Ph 07 8386632, email: animalweb@hcc.govt.nz  ) 

5.  Avocados

• A recent BPAC update references a recent paper published in the Journal of the American Heart Association that has found higher avocado intake is associated with a significantly lower risk of cardiovascular disease (CVD) and coronary heart disease.

• In a study of almost 70,000 women and over 40,000 men who did not have a history of cancer, coronary heart disease or stroke at baseline, followed up for thirty years, it was found that those who had two or more servings of avocado per week had a 16% lower risk of CVD and 21% lower risk of coronary heart disease. There was no significant association with a lower risk of stroke.

• The authors concluded that CVD risk could be lowered by 16 – 22% by replacing half a serving per day of high fat content foods such as margarine, butter, egg, yoghurt, cheese or processed meat with the equivalent amount of avocado.

Clinical Snippets March 2022

https://anchor.fm/opotikigp/episodes/Clinical-Snippets-March-2022-e1i6ir6

Show notes :

Clinical Snippets March 2022

1.  Naloxone and non-intentional opioid overdose

• A recent NZ Doctor article noted concern from the NZ Drug Foundation at the limited availability of naloxone to selected patients with opioid dependence as a means of decreasing fatalities from accidental overdose (around 50 per year).

• In 2020, an emergency kit containing two naloxone (Nyxoid) nasal sprays was approved for sale without a prescription. However, because it is not funded, at $92 it is out of reach for many people. It is also difficult to source with few pharmacies contacted in the article actually stocking the kit and is not subsidised if prescribed.
• Naloxone ampoules (for injection) continue to be available by prescription-only (PSO – maximum of 5 ampoules) but are available as an emergency kit in some countries. 
• Health Navigator has resources regarding community initiated use of naloxone including pamphlets developed by Waitemata DHB for use of intramuscular and intranasal naloxone.
• The incidence of iatrogenic opioid use disorder is around 3% over 2 years but causation is uncertain.  The Prescription Opioid Misuse Index (POMI), a 6-point questionnaire with strong predictive ability for OUD, may be a reasonable case-finding tool.  Medsafe have recently published a pamphlet outlining the risks of opioid medications.
• The HQSC Atlas of Healthcare Variation (large PHO comparison) shows that in 2019 2.0 people/1000 enrolled with practices in the MHN Waikato PHO region were dispensed a strong opioid for more than six weeks – slightly below the national average of 2.1.  Rates ranged from 1.5 (Procare) to 2.9 (WellSouth PHO).

2.  COC and VTE

Medsafe have recently published a Prescriber Update following reports of a fatal PE in a young woman taking a COC.  Points include:

• Prescribers are reminded to counsel patients about the symptoms and signs of venous thromboembolism (VTE) when prescribing combined oral contraceptives (COCs).
• VTE may occur at any time during use of a COC. However, the risk of VTE is highest during the first year after starting a COC and when restarting after a break of four weeks or more.
• Ensure COC users know to seek medical attention if they experience symptoms or signs of VTE.
• COC use is associated with a 3- to 3.5-fold increase in the risk of VTE compared with non-use although absolute risk is low.  Reassess the risk of VTE periodically during COC use as risk factors may change over time.
• Consider the possibility of VTE in COC users who present with non-specific symptoms.  Patients with VTE may be asymptomatic or present with non-specific symptoms such as calf tightness, chest pain or cough. Always be mindful of the possibility of VTE in COC users and follow local guidelines for the investigation and management of suspected VTE as necessary.

3.  Rosuvastatin funding

• From the end of last year the very high potency statin rosuvastatin has been funded using SA for selected patient groups: 

LDL-C level eligibility for rosuvastatin funding

• Note the NZ Guidelines give an LDL-C target of < 1.4 mmol/L in people at high risk
• Use the Dutch Lipid Clinic Network Score (DLCNS) to determine the likelihood of familial hypercholesterolaemia diagnosis if suspected
• Further information on rosuvastatin dosing, contraindications and precautions can be found in a recent BPAC article  

4.  Ovarian cancer

A recent NZ Doctor article included the following points regarding ovarian cancer: 

• Ovarian cancer is a significant health issue in New Zealand – incidence and mortality rates are higher in Pacific and Māori women and compared with Australia, 16 per cent fewer women survive five years in New Zealand.
• GPs have an essential role to rule out ovarian cancer in symptomatic women and diagnose those with cancer in a timely manner.  Practitioners in countries with better survival are more willing to order an ultrasound at first visit for the following scenario: a 53-year-old woman who had her last period six months ago and has experienced abdominal pain for the past three weeks; she has had no other symptoms and the same sexual partner for 20 years.
• On average, a GP with 2000 patients will see one patient with ovarian cancer every four and a half years.
• Ovarian cancer is much more common in the postmenopausal population. However, in New Zealand, it is worth noting that one in eight cases occur in women younger than 45 years, and in the 20–44 age group, ovarian cancer remains the fifth most common cause of female cancer death. Younger age is a risk factor for delayed diagnosis.
• The symptoms women present with are variable but can include one or more of: bloating/distension, early satiety, urinary frequency/urgency, abdominal/pelvic/back pain and bowel habit changes. Other symptoms are also possible, including indigestion, nausea, fatigue, abnormal vaginal bleeding/discharge, unexplained weight changes and painful intercourse.  While it’s true these symptoms are very common in general practice, in women without ovarian cancer, they are usually mild and occur on five or fewer days a month.  In contrast, symptoms in ovarian cancer occur more frequently.
• Investigation for ovarian cancer usually includes a pelvic exam, cancer antigen 125 (CA-125) blood test and transvaginal ultrasound (TVUS).  Though pelvic exam has a low sensitivity when used as screening, it remains an important part of assessment in symptomatic patients. DHBs report decreased wait times for TVUS when pelvic exam is positive.
• Further detail on local recommendations regarding interpretation of CA-125 levels and referral for ultrasound and gynaecological assessment or advice can be found in HealthPathways.   A downloadable symptom diary can be found here. 

5.  Methotrexate and trimethoprim

Key points in a recent Medsafe Prescriber Update following a death associated with co-prescribing of methotrexate and trimethoprim include: 

• Severe bone marrow suppression has been reported in patients on methotrexate who have received trimethoprim or co-trimoxazole (trimethoprim with sulfamethoxazole). Some cases have been fatal.
• Trimethoprim and co-trimoxazole should be avoided in patients taking methotrexate.
• If this drug combination cannot be avoided, warn patients about the symptoms of bone marrow suppression. Advise them to seek immediate medical attention should these symptoms occur.

6.  Supply issues affecting FundaPen2 rollout

EpiPen® auto-injectors have been available through the FundaPen2 initiative from Wednesday 9 February 2022.  However, Allergy New Zealand has hit supply issues with 300mg adult EpiPens® due to global COVID freight delays. To ensure as many people as possible benefit from FundaPen2, it is important to keep prescribing under the FundaPen2 protocols. Patients will receive their free EpiPen® as soon as the stock is available, April 2022 at the earliest.

A reminder of the process:

1. The GP establishes that the patient is clinically eligible for FundaPen (doctor-diagnosed with an allergy that puts them at risk of anaphylaxis, and needing an EpiPen® as per prescribing guidelines)

2. The GP completes the patient’s prescription for ONE EpiPen® as usual and e-mails to Allergy Pharmacy info@queenstownpharmacy.co.nz .  Please include the patient’s weight on the prescription so that the correct Epipen® is dispensed. (As per ASCIA guidelines more than 20kg qualifies the patient for an Adult Epipen® auto-injector regardless of age).

3.  Additional Pharmacy details are:  Fax 03 441 0591;    Allergy Pharmacy, PO Box 157, Queenstown.

4.   Allergy Pharmacy assesses that the prescription meets the FundaPen qualification criteria and dispenses the EpiPen® to the prescribing GP. 

5. GP receives the EpiPen® and contacts the patient to return for training (if required) and dispensing. 

6. Only one FREE EpiPen® is available per eligible patient.  Once the available subsidised supply (fixed funding) has been exhausted, normal fees and charges will apply. 

February 2022

Clinical Snippets February 2022

1.  Peripheral artery disease and walking

From a recent Tools for Practice:  In patients with PAD, exercise therapy improves maximum walking distance and pain-free walking distance by up to ~200 meters over 2 to 78 weeks compared to usual care. No benefit has been demonstrated for amputation or mortality. The most commonly studied exercise is supervised walking 2-3 times per week for 30-60 minutes, although other supervised activities (example resistance training) may be beneficial in those who cannot tolerate walking.

• Patient understanding of physical activity for PAD should be explored:
• 63% identified walking as the primary aetiology for their pain, 90% thought walking would worsen symptoms.

2.  Electronic communication and the internet

Last year MCNZ released an updated statement on Use of the internet and electronic communication  which includes the following points (and I recommend reviewing the whole document):

• Inappropriate communication, including use of social media, can be considered unprofessional, whether this is directly related to a doctor’s work or not.
• Patients who get information from the internet may wish to discuss this with you. You should use this as an opportunity to talk about how sometimes the information obtained from these sources may be of poor quality, incorrect, or create unrealistic expectations. Provide sound reasons for the views you express and, where possible, provide documentation, to support the alternative advice or treatment that you are recommending.
• There are security issues specific to the use of email. It is difficult to verify a person’s identity from an email; some families and groups share a common email address; and computers (particularly family computers) may be accessed by a number of different people. For these reasons, check with the patient before sending them sensitive information by email.

3.  Aotearoa New Zealand STI Management Guidelines – Chlamydia

• There is growing evidence that sexually transmitted Chlamydia trachomatis establishes a persistent rectal reservoir that is refractory to treatment with azithromycin stat.
• The evidence is very strong for men who have sex with men, but is growing for women too.
• Contemporary guidelines are abandoning azithromycin stat and reverting to doxycycline 100mg BD for seven days with stat azithromycin only if doxycycline contraindicated or patient is highly likely to be non-adherent.
• Symptomatic anorectal infection generally requires specialist advice as further testing and management is complex

4.  Recurrent Bacterial Vaginosis (BV)

A recent article in NZ Doctor includes the following key points on recurrent BV:

• There have been no major advances in the treatment and cure of bacterial vaginosis, perhaps because the pathophysiology is complex, multifactorial and not fully understood.
• Standard therapy is seven days of twice-daily metronidazole, but many women are looking for alternative treatments that may provide longer duration between recurrences.
• Intravaginal boric acid capsules have been used historically and may be considered an alternative, though unfunded, treatment to use in conjunction with antibiotic therapy.

DermnetNZ lists a number of alternative treatments including gels to reduce vaginal pH and a vaginal antiseptic dequalinium.  It does not appear any of the recommended products are in NZF but Aci-Jel is available OTC (around $30 per 100g tube).    Boric acid vaginal pessaries can be bought on-line – eg pHD $199 for 72 caps (about five courses)

A 2009 Cochrane review concluded that research at that time research did not provide conclusive evidence that probiotics are superior to or enhance the effectiveness of antibiotics in the treatment of BV.  However, a 2019 meta-analysis concluded that probiotic regimes are safe and may exhibit a short-term and long-term beneficial effect for BV treatment.  There are many OTC preparations available.  Probiotics do not form part of HealthPathways or Aotearoa New Zealand STI Management Guidelines recommendations for management of BV. 

DermnetNZ also discusses cytolytic vaginosis as a cause of possible of persistent vaginal discharge.  This is the result of a hyperacidic vaginal environment due to overgrowth of lactic acid producing bacilli, with management aiming to reduce vaginal pH (baking soda douching). 

5.  Extended use of intrauterine devices

Tools for Practice examined the evidence around effectiveness of intrauterine devices for prevention of pregnancy when used beyond the manufacturer recommended use period.  The conclusion was:

If it is not possible or desirable to replace a levonorgestrel 52mg or copper-T380A intrauterine device (IUD) at the end of the approved duration of use, small observational studies demonstrated similar efficacy and safety for up to two additional years, with little evidence afterwards. Guidelines suggest that with patient-informed discussion, deferral of IUD replacement for up to twelve months is reasonable.

6.  Antipsychotic switching tool

A useful tool is available from NPS Australia that assists prescribers when changing a patient’s antipsychotic treatment. Using the interactive tool, the prescriber enters the formulation (oral or depot), the current medicine the patient is prescribed and the medicine they want to switch the patient to. This then generates prescribing information about how to stop one medicine and start the next, along with key clinical issues to be aware of. All antipsychotic medicines currently funded in New Zealand are included in the tool.

7.  Serotonin syndrome – a reminder

A relatively common prescribing complaint I see relates to patients concerned they were not warned of the risk of serotonin syndrome, or that they experienced serotonin syndrome, usually secondary to co-prescribing of two serotonergic agents.  The most common combinations I see are tramadol and SSRI, SNRI or TCA, or when a TCA is added to an existing antidepressant regime.  A 2015 communication from Medsafe discusses the issue in more detail and is worth a quick review. 

podcasts.apple.com/nz/podcast/the-new-zealand-general-practice-podcast/id1457506728

Lucy O’Hagan is the latest contributor to the podcast, sharing her story of dealing with the pressures of General Practice.

Being in roles that focus on advocacy and service improvement naturally starts with conversations about problems.

I started this project to balance the negative noise that inevitably accompanies a desire to do things better.

I hope that listeners will gain an understanding of their GPs, knowing what makes your gp tick will I hope improve doctor patient relationships.

I hope that GPs listening will be inspired to reflect on what brings them most pleasure from their work, and find some tips and tricks to enhance the joy of General Practice.

Jo

There are plenty of reasons that face to face consultations are valuable, not only to provide examinations and procedures. The limbic link that connects people and that is so important in communication is dramatically filtered when made through a screen.

“Virtual first” processes allow for better infection control, and as a minimum patients and staff will expect excellent infection control in health services.

It will never again be acceptable to sit next to a coughing patient in a waiting room, or to be sneezed on when you are doing a diabetes check.

“Virtual first” also provides opportunities for improved access through the wider open door afforded by virtual systems and for efficient service delivery through planned consultations and direction to the best source of help.

To me, it’s a no-brainer. I know the concept of change is hard, and many GPs and hospital services just want everything to be back the way it was.

Unfortunately the way it was was not working for the most disadvantaged.

The way it was was not working for many primary care services and clinicians who were over worked, under paid, and frustrated with the quality of care they were able to provide because of poor access.

The way it was was not working for many rural communities.

Let’s see if virtual first approaches can make the way it was into the way it can be.

More reading on limbic connections here : https://www.goodreads.com/book/show/35711

Evidence that “virtual first” approaches can improve access and outcomes can be found here: https://www.healthcarehome.org.nz/

The “New Normal” – looking forward to the next phase in healthcare.

The impact of the pandemic is going to be with us for the next 18-36 months if not longer, and whilst this is a challenge it is also an opportunity.

Moving backwards is rarely the right choice in medicine, and in this situation not an option.

We need to look forward to what is now becoming the “new normal” way we do things.   

What won’t change ?

Primary care has been described as  “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” 

It is measured as “good” against four elements:

1. First-contact access for each need;
2. Long-term person- (not disease) focused care;
3. Comprehensive care for most health needs; and
4. Coordinated care when it must be sought elsewhere

In some measures the degree of family or community care is also included. [1]

None of this is changing.

Nor is the fact that primary care is all about relationships.

General Practice team members are experts in relationships.  We are experts in communication. We are experts in risk management. We are experts in healthcare.

Why do we need to change ?

For the foreseeable future we will be swabbing a large proportion of those who have respiratory symptoms for covid19, we will need to keep our other patients, and our staff safe from this disease.

There will be local and regional and potentially national outbreaks over this time.

This will be happening on the background of a world in economic crisis, challenges to businesses in all sectors, and a high level of patient and provider anxiety.

 As a minimum we have to adapt to the “new normal” by :  

1. Providing virtual triage for all patients to identify the potential covid19 from the non-potential covid19.
2. Having systems that keep infectious people away from others when we are seeing them face to face.
3. Providing safe systems to protect staff.
4. Having the ability to scale up a local response to manage an outbreak  
5. Having systems for monitoring covid19 disease progress in the community and clear referral and management pathways

What is the New Normal ?

In the “new normal” general practice will continue to do what it does best with more virtual care, in cleaner environments with better infection control mechanisms, and with staff with more flexible working conditions.

In the new normal practices will need to either be “green zones” and have nothing to do with anyone with a respiratory infection or ‘flu like illness , or to have “green” and “red” zones and processes that allow them to continue to manage patients with respiratory infections and ‘flu like illness safely.

In the new normal “virtual first” becomes the primary point of contact for patients who need to use the health system. This will impact on the working conditions of all staff, as we shift our ability to provide effective efficient home based care.

In the new normal, personal protective equipment is worn, not kept in box in case of emergencies.

Community Based Assessment Centres (CBACs) have a role in supporting communities whose practices cannot provide “green” and “red” safe zoning, and to provide covid19 services to communities that have low GP penetration / poor access.

CBACs in the future have a role in stepping up to support practices dealing with an outbreak in a locality that threatens to overwhelm the local service.  They will need to be able to be rapidly set up within 24-48 hrs, and to be in place for at least 28 days.

And the future ?

We have already demonstrated our ability to adapt to the new normal, as practices and as networks.

The new normal brings with it challenges and opportunities to do much more than just the bare minimum.

There have been palpable improvements in access to services through the switch to virtual care, yes with inequities evident; the digital divide is shown to be wider than was thought – but that’s just a problem, it’s not insurmountable.

There have been palpable improvements in working conditions for practice teams – yes, with challenges to the business model and income expectations, change in working patterns, and different stressors but these are just issues, they are not insurmountable.

Yes, we are worried that patient outcomes may be compromised somehow- but we have never been very good at measuring them and this is an opportunity for that to change.

Let’s embrace the new normal, look forward, learn from each other, build on the power of networks, and collaborate to provide better first contact, comprehensive, coordinated, person-centred care. 

To be honest, it’s not like we have much choice.

Jo Scott-Jones   

1. Contribution of Primary Care to Health Systems and Health, Starfield, Shi, Macinko 2005.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/

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Change is hard.

The commonest end point of a significant pivot in the way we do things is for us to return to our original behaviour over time.

Look at every new year’s resolution, every idea you bring back from a conference, even the range of medications you prescribe.

We don’t like change.

We lose focus on change that must happen over time, we don’t review and embed change.

We need others to help us, and we often rely on people who don’t really understand what needs to happen.

We lack commitment ourselves to see change through, we fail to inspire others to commit to change.

We lose energy and find it hard to maintain the effort required to embed change.

So why is the change caused by COVID19 going to be different?

1. SARS-Cov2 is not a short-lived phenomenon.

It emerged only in December 2019, NZ’s first case was in February, just 2 months ago. The graphs usually show an exaggerated bell curve, with a rapid fall in cases after a peak.

The rhetoric describes this as a fight. Wars are fought, battles are won and lost but eventually we will defeat this. We will “get through.” 

The reality is that the only infectious disease that the world has managed to eradicate is smallpox.

Discussed from 1945, completed in 1979 this relied on a determined global campaign over 13 years, an effective vaccine, case identification, contract tracing and quarantine.

It is unlikely this illness will “burn itself out” as appears to have happened to SARS-Cov-1, this virus is much more infectious, and unlike SARS-Cov-1 does not appear to be limited in who it can affect.    

“Herd immunity” (if achievable) is not a cure, it is an acceptance of prevalence.      

• Societal attitudes have changed.

Doctor’s waiting rooms have long been seen as a source of infection.

I am certain that every GP has had a patient in the past express that they don’t like sitting in the waiting room because it’s full of sick people.

This was usually dismissed with a shrug of the shoulders, a smile, a “What can you do, eh?”

Some of us would have apologised for keeping the patient waiting, assuming that was the underlying reason for stating of the blinking obvious.

There was an acceptance that risk was low enough, that consequences were minor, hidden or infrequent enough for us to dismiss.

We are now facing a “Semmelweis Moment.”

In 1847 Semmelweis recognised that handwashing reduced maternal mortality [1]. We have recognised that separating out infectious from non-infectious patients reduces transmission of COVID19 disease.

This isn’t new science.

What is new is our understanding of the need to change and we now need to act.

Semmelweis found it hard to ensure that cleaning hands between patients became the new normal, perhaps because change was imposed rather than developed through collaboration and engaging the hearts and minds of colleagues.

We are less likely to repeat that mistake because the general public will not let us.  

More people across the world are contemplating routinely wearing face coverings, people are interested in the difference between aerosols and droplets, and the distance and speed at which viruses spread after a cough or a sneeze, they are asking questions about the length of time infectious particles can survive on plastic, metal, wood and paper.

It is never going to be acceptable again to sit in a place where lots of sick people have gathered and not to be provided with assurance that everything is being done to reduce transmission of disease between people.

• It is unlikely there will ever be a cure.  

History tells us that viruses and bacteria develop resistance to any “cure” we have created in the past, SARS-Cov2 is not going to be any different.

There may be medications that mitigate the impact of the disease, remdesivir and antiretroviral agents may interfere with viral replication, hydroxychloroquine and chloroquine may reduce the ability of the virus to enter cells, “convalescent plasma” containing antibodies generated by a person who has survived the disease may “boost” the immune system.

There is no doubt that we will develop better ways of intervening that will improve outcomes for people needing hospital care.

But it is very unlikely that we are going to be able to “cure” people of this illness with medication.

• It is unknown if we develop or can induce long lasting immunity.

We hope that when we reach “herd immunity” either through a vaccine or natural immunity of 80% of the population, we will have reduced the risks to an acceptable level.

The fact is that immunity, whether vaccine induced or naturally gained is an unknown quantity.

If this coronavirus is like the others that cause 2o% of common colds, immunity may last 2-4 weeks, if it has similar properties to SARS-Cov-1 immunity it may last 2-3 years.

We don’t think the virus mutates as frequently as the influenza virus.

We don’t know if a safe vaccine will be found, or how long-lasting a vaccine will be.

What is clear is that vaccine development is not going to be quick.

• The public response

Each year in New Zealand we accept that around 10 people will die from HIV, 20 people die from TB, we may not like it, but we accept that 2-3% of deaths in this country are due to lower respiratory tract infections.

COVID19 will become another blip in the numbers eventually, and its impact on healthcare will become part of the way we do things ‘round here.    

People at high risk of other viral illnesses with no cure and no immunity, like Herpes and HIV, have changed behaviour to reduce the risk of catching and transmitting the virus.

This illness is going to gradually settle in the mind of the public into one of the risks that we take when we interact with others, but its global impact is not going to quickly go away in the mind of the public.

Although we rationalise the numbers of people who die each day from poverty, malaria, road traffic accidents, and medical errors the personal impact of seeing mass graves being dug in New York, the dying in hospital corridors in Italy, bodies in the street in Turkey that feels like this will stick.

The case load of SARs-Cov2 is following the same pattern of other respiratory infectious diseases.

We have seen a surge of known cases settle into a background incidence as a result of public health measures. It seems likely that this level of disease will flare and settle over time, both in the public consciousness and in the pressure,  it causes on the health system.

How well we cope as a system will depend on the ability, we must keep that case load within the limits of the what the health system can cope with.

We may drift back to an acceptance of the risk when gathering to watch sports, concerts and theatre, to party and carnival, but the acceptance of risk is not going to extend to health care services.

Nor should it. 

Dr Jo Scott-Jones FRNZCGP MMSc DipClinED DipSports DipObs DipGerMed

More reading on:  

Change management

HBR item on DICE scoring (duration, integrity, commitment and effort.)

https://hbr.org/2005/10/the-hard-side-of-change-management

Smallpox

WHO archives https://www.who.int/archives/fonds_collections/bytitle/fonds_6/en/

What medical students are now taught about the immune system? 

Immunology from osmosis.org (https://www.youtube.com/watch?v=wHCJUMBKgyo&vl=en)

and:

COVID specific information from “Ninja Nerd Science”

Epidemiology, pathophysiology and diagnosis.

(https://www.youtube.com/watch?v=PWzbArPgo-o)

Monitoring, treatment, prognosis and prevention. 

View at Medium.com

View at Medium.com

More scholarly reading on immune response to SARS-Cov2

Coronavirus infections and immune responses Geng Li et al Journal of Medical Virology 

https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25685

Coronavirus infections: Epidemiological, clinical and immunological features and hypotheses

Raoutl et al in Cell Stress

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146059/

Global Burden of Disease

http://www.healthdata.org/data-visualization/gbd-compare

For a public explanation of the current understanding of immunity and covid19

Wired magazine and Dr Seema Yazmin from Stanford

https://www.wired.com/story/covid-19-immunity/

View at Medium.com

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[1] https://www.ncbi.nlm.nih.gov/books/NBK144018/