general practice

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare , ,

Clinical Snippets February 2023

https://podcasters.spotify.com/pod/show/opotikigp/episodes/Clinical-Snippets-February-2023-e20l1hm
Shownotes

Clinical Snippets February 2023

1.  Post-partum screening for diabetes

  • A NZ retrospective study published recently sought to estimate the proportion of women with a first episode of gestational diabetes who received post-partum type 2 diabetes screening in accordance with local guidance. 
  • The study showed only 40% of women were screened within 3 months post-partum and that only improved to 61% after 12 months. Additional findings included that Māori women and those with higher deprivation were less likely to be screened, and there was extreme variation by postcode (15.3–67.5% screened by 12 months). 
  • HealthPathways notes the Increased risk of patients with gestational diabetes developing type 2 diabetes following the pregnancy:
  • The cumulative risk has been estimated to be as high as 50% within 5 years postpartum, depending on ethnicity and time from index pregnancy.
  • There is good evidence that the risk of developing type 2 diabetes can be reduced by either lifestyle or pharmacological interventions (e.g., metformin) in the non-pregnant population
  • Post-partum screening advice for women who developed gestational diabetes is to check HbA1c at 3 months and annually thereafter

2.  Referral guidelines and unmet need

The end of year BPAC bulletin commented on some criticism the agency had received that some referral criteria and advice documented in various articles aren’t realistic, there is no way that patient will be seen…”. 

The comments noted BPAC is presenting what should happen, based on clinical trial data and consensus guidelines to improve patient outcomes. If we don’t refer based on the presumption that the referral will be declined due to resource constraints, the health system cannot measure unmet need. Te Whatu Ora in the October, 2022 “Planned Care Taskforce – Reset and Restore Plan” acknowledges that there is “no current effective measure of unmet need” and there is also no ability to measure the “not to refer” decisions that are based on a presumption that the outcome of the referral will be a denial of access. “Decline rates” are the simplest measure of unmet need, until other tools are developed to assess this.

3.  EpiPen funded from February, 2023

A recent Pharmac decision means that EpiPen and EpiPen Jr will be funded from 1 February, 2023, for people who have previously experienced anaphylaxis or who are at high risk.

  • Funding restrictions include a maximum of two devices per prescription, and replacement of up to two devices prior to expiry or after a device is used
  • Special Authority eligibility criteria include previous anaphylactic reaction which has resulted in presentation to an emergency department, or assessed by a relevant practitioner (including general practitioners, nurse practitioners and pharmacist prescribers) as being at significant risk of anaphylaxis; renewals of approval are not required
  • Patients being prescribed an Epipen can register on the supplier’s website (Mylan EpiClub ) to order a free training pack and practice pen. There are also videos on how to use the pen and other resources.

4.  Meningococcal B vaccination wider funded access

Access to the meningococcal B vaccine, Bexsero, will be widened from 1 March, 2023, to include all children aged up to 12 months and people aged 13 to 25 years in their first year of a specified close-living situation.

Either:

  • Two doses for individuals who are entering within the next three months, or in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons; or
    • Two doses for individuals who are currently living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons, from 1 March 2023 to 28 February 2024. 
  • Existing eligibility criteria for patients over one year of age are: 
    • up to two doses and a booster every five years for patients pre- and post-splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre- or post-solid organ transplant; or
    • up to two doses for close contacts of meningococcal cases of any group; or
    • up to two doses for person who has previously had meningococcal disease of any group; or
    • up to two doses for bone marrow transplant patients; or
    • up to two doses for person pre- and post-immunosuppression (Immunosuppression due to corticosteroid or other immunosuppressive therapy must be for a period of greater than 28 days)

5.  Soft tissue ultrasound

(i)  A recent Te Whatu Ora Waikato newsletter commented on the significant volume of requests being received for non-specific soft tissue mass USS.  There is reference to national imaging guidelines which include standard indications for community imaging referral as:

  • Soft tissue mass with red flags; however, specialist assessment is preferred, so only request imaging if there is likely to be a delay before the patient is seen
  • suspicion of a foreign body where not covered by ACC.

(ii)  Red flags include a soft tissue mass with any of the following characteristics:

  • growing
  • >5 cm in size
  • deep to deep fascia (limited mobility, less mobile with muscle flexion)
  • painful (most malignant lumps are painless; pain suggests nerve or bone involvement)
  • recurring after a previous excision.

(iii)  Additional guidance is:

  • Apply caution in the use of ultrasound, as its ability to characterise solid mass lesions is limited and incorrect diagnosis can lead to significant treatment delays.
  • Consider requesting a plain X-ray as well.
  • If a sarcoma is suspected, reserve biopsy for an orthopaedic or sarcoma specialist.

(iv)  A localised HealthPathway for Soft Tissue Lumps and Sarcoma has been recently published.  The pathway reiterates the limitations of ultrasound in determining whether or not a mass is likely to be malignant although it can determine  if a mass is present, superficial or deep to fascia, and solid or cystic.     

(v)  If a lump is not being investigated or referred:

  • advise the patient to report any changes promptly.
    • reassess at 3 months if any concern.
    • consider discussing with a general practitioner colleague for a second opinion.

6.  Ramadan and Diabetes

  • Ramadan 2023 is expected to run from the evening of Wednesday 22 March to the evening of Thursday 20 April.  The Research Review series has published an excellent guide on diabetes management during Ramadan.
  • Many Muslims with diabetes have a strong desire to participate in the Ramadan fast, even though they may be exempted due to their underlying condition.  Be proactive about asking Muslim patients about their intention to fast as they may not volunteer this information. A pre-Ramadan assessment is essential for patients with diabetes who wish to fast.
  • Individualised risk stratification forms the basis for shared-decision making and recommendations regarding lifestyle, blood glucose monitoring and dose adjustments for glucose-lowering therapies. Patients at low risk should be able to fast safely, while those at moderate risk may be able to fast safely with appropriate education and monitoring. Patients at high risk should be discouraged from fasting.
  • Reassure patients who are at high risk that there are alternatives ways of obtaining spiritual rewards if they do not fast; consider engaging with a local Iman if the patient is uncertain about any of the medical recommendations provided.
  • Education about the risks associated with fasting and the provision of individualised strategies to preventing adverse outcomes are essential for the safety of patients with diabetes. Avoiding dehydration by drinking adequate quantities between Iftar and Suhoor is important.
  • SMBG is important for all patients with diabetes who are fasting and doing so does not break the fast. Patients at low risk should SMBG at least once during the day and following Iftar, as well as whenever they feel unwell or have symptoms of hypoglycaemia or hyperglycaemia. Patients at higher risk should test more frequently.
  • All patients with diabetes should break the fast if at any stage:
    • Blood glucose <3.9 mmol/L
    • Blood glucose >16.6 mmol/L
    • Symptoms of hypoglycaemia or acute illness develop.
  • Information about dosing and/or timing adjustments should be provided to all patients taking glucose-lowering therapies, especially those using insulin.  It is recommended that patients be on a stable treatment regimen before beginning the Ramadan fast.
  • A post-Ramadan follow-up is recommended to review what went well for the patient and to discuss challenges to make any future fasts safer and more rewarding.

7.  Asymptomatic bacteriuria in the elderly

A recent Tools for Practice summary looked at the question:  In elderly, does asymptomatic bacteriuria (ASB) cause altered mental state and will treating ASB improve clinical outcomes?

The context:  Ordering urine culture is associated with antibiotic use.  ASB is common in elderly: 5-20% in community age>80 (females>males) and institutionalization (25-50% women/15-40% men).

ASB guidelines recommend:

  • Avoiding ASB treatment in elderly without clear infection signs/symptoms. 
  • Assessment for other causes; careful observation; attention to contributing factors like dehydration.

BOTTOM LINE:   Due to important evidence limitations, it is not confirmed that ASB, or even Urinary Tract Infection (UTI), is clearly associated with altered mental state. Treating ASB does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In elderly patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection, and alternative reasons for altered mental state should be considered. 

Church Street Surgery 2016 Strategic Planning

opotikigp family medicine, general practice, Healthcare, rural

How do you make a strategic plan a living document?

Our last plan 2013-2016 helped us to set values that we have stuck to and remembered for 3 years.

CARE – Compassion, Attitude, Respect and Excellence were linked to the local DHB values – we felt this would align us more closely with the DHB services in our region.

Last time we agreed goals around workplace improvements, process improvements, improved patient outcomes and improved services.

We have achieved a number of these goals and embedded them into our system – we have morning meetings, names on our doors, agendas for every meeting, reduced bad debt, expanded funding streams, and produced quarterly newsletters.

We now have an ecg and defibrillator as we planned, we have reduced waiting times and our waiting list, we have trialled nurse practitioner services and expanded our teaching opportunities.

Several issues we aimed for have not been achieved – we don’t have an USS and in retrospect most of our identified goals were achieved in the first 6 months after the plan was set.  Those we did not achieve were large projects that needed a long term focus – such as reducing teenage pregnancies in the town and running a community awareness programme on gout.

This year our strategic planning process was an opportunity to revisit our team culture and to revitalise our values , to find out what our community think of us and set some short term achievable goals, the start of a cycle of 3 monthly improvement plans.

Executive Summary:

Our New Values

Integrity Compassion Excellence Teamwork

ICE –T

 

Our Next Goals

Weekly Clinical Meetings

Expand the uptake of MMH – 300 by May 2016

Expand use of technology to educate patients – students to produce a MMH promotion video

Reduce waiting times for patients – expand the doctor workforce

Increase patient numbers to 3600 by May 2016

 

 

Detailed Report

VALUES

On Wed March 2nd we closed the surgery for the afternoon and after a shared lunch reminded ourselves of our #my3words for 2016 – a personal values exercise we had undertaken the week before.

For me those values for 2016 are Centre, Connect, Create. I need to remind myself to “centre” and look after myself physically and emotionally, if I can “connect” with others I will be more effective, and I will enjoy life more if I “create” new things.

We then moved onto a values exercise –

The instructions were to silently organise ourselves into a hierarchy of values (we had words posted on our backs) – once we had silently agreed an order we had to then speak to the value we had been assigned and argue for why it should be in our top 4.

We chose

integrity – because without integrity we have nothing

compassion – because you cannot do this job without compassion

excellence – because this encompasses a passion for quality, effectiveness, and great patient outcomes and

teamwork – because we need each other, our patients, and our colleagues to achieve our goals.

 

COMMUNITY INPUT:

We then headed out into the community to find out the community and patient view of our service:

In pairs we went out into the street and shops and spoke to at least 3 people and asked what they thought the surgery does, what it should do more of and what it should do less of.

We posted the findings on facebook and will continue to reflect on comments we get from our facebook followers.

FINDINGS:

What’s the most important things to you about your health ? Eating properly, keeping fit, lifestyle issues , be healthy for my kids and myself, having support, being well informed, being able to make decisions about your health, mental health, being given the tools to make my own decisions, Knowing my doctor is approachable and knowledgeable Making sure I am trying to help myself, Keeping informed and knowing my options

What are the most important things about a good GP surgery? Showing interest, thorough examinations, approachable, seeing the same doctor, familiarity Having good staff getting an appointment when needed, flexible times, reasonable price, affordable, good communication and openness – never rushed Care about the bigger picture – holistic health Being understood, people who listen On time Appointment availability friendly service Confidentiality

What would you like to your GP to do more of in the next 3 years ? Less waiting times, longer consultation times, after hours, educational sessions – smears and breast screening etc More doctors , after hours clinics. Push the antismoking – clean up the street education Use the whanau ora services to support wider families, one day late night clinic a week, Home visits Develop a formal engagement with the police More follow ups with the hospital – it is very hard to see a specialist Our next exercise was to reflect on these comments – and to use a set of craft materials to develop a model structure that described our ideal surgery in the next 3 years – we broke into two groups and thought about  what we should do more of as a team, what we should do less of as a team, and built our ideal worlds :

The “Whare Waka” model was based on Mason Durie’s Te Whare Tapa Wha model and “The Blue Path” was based on the materials in the box !

The Blue Path

The Whare Waka

The ideal world exercise was fun and creative and it also made concrete our values and started us thinking about the bigger and longer term picture for the surgery.

The videos can be viewed on Vimeo.com

The Blue Path – https://vimeo.com/157862107

The Whare Waka – https://vimeo.com/157812550

Each group then further explored the things we should do more of, the things we should do less of and 3 achievable goals for the next 3 months.

BRAINSTORM :

 

More of:

  • time availability to interact between staff – we need to be able to see more of each other to discuss clinical cases
  • awareness of how long people have been waiting in the book – protect your time for other patients
  • involvement of reception if the appointment is going to blow out in time
  • planning for unexpected patients.
  • longer opening hours
  • education training for staff
  • doctors
  • MMH – expanding the uptake

Less of:

  • chasing up patients – we can go round in circles chasing up things for patients
  • short staff days
  • bullying from patients
  • phone calls
  • bad debt
  • outstanding debt
  • people not using MMH even though they are signed up

Goals

Increase patient numbers to 3600 by May

Increase MMH numbers to 300 by May

MED students to do a video to promote health

Waiting time improvement.

Clinical time set aside every week

Our New Values

Integrity Compassion Excellence Teamwork

ICE–T

Our Next Goals

Weekly Clinical Meetings

Expand the uptake of MMH – 300 by May 2016

Expand use of technology to educate patients – students to produce a MMH promotion video

Reduce waiting times for patients – expand the doctor workforce

Increase patient numbers to 3600 by May 2016

WE WILL REVISIT THIS IN MAY 2016

 

The Importance of Training in Rural Areas

opotikigp family medicine, general practice, Healthcare, rural ,

The recent Rural Health Conference in Gramado gave us time to reflect on a number of important issues facing rural communities across the world – along with the pressures of climate change, population growth and increasing burdens of chronic disease the “perfect storm” is compounded by the continued problem of access to the quality medical services.

New Zealand began life as a rural nation, and our national identity takes pride in our ‘can-do’ approach to life. It is a fundamental human right that people living in all regions have access to high quality health services, perhaps especially in regions at distance from main population centres, regions that are often the backbone of a country’s economic wealth, and centre of leisure activities (1).

Having a healthy, engaged and well educated health workforce is important to the wellbeing of all communities. Attracting health professionals to live and work in rural areas is an international problem familiar to all WONCA members (2).

It may be a little confusing why this is a problem for those of us that have made this lifestyle choice, but it may be more prevalent in areas where there is a high demand, especially on after hours care, low reward and professional isolation and where family and social issues put pressure on rural providers (3).

In New Zealand year after year GP workforce surveys have detailed the on-going problems of recruitment and retention into rural practice (4-6), and the shortage of providers in rural areas continues, with over 25% of practices currently seeking full time GPs and Nurses (Rural General Practice Network unpublished data 2014.)

The medical workforce is the best studied example of a need that is widely reported to affect rural nurses, pharmacists, midwives, dentists and physiotherapists (7).

New Zealand needs 50% of its medical graduates to choose General Practice as a career, currently only 29% have a “strong interest” in doing so at the end of the medical degree offered by Auckland University, (8) and it is unclear how many NZ graduates actually become GPs and even less is known about how many of them to choose rural practice.

We do know that currently only 9.2% of doctors working in rural areas are NZ trained, and only 16.4% of NZ trained GPs choose to work in rural areas (9). We do know that as a proportion of the workforce the number of GPs is falling compared to specialists (10).

Rural workforce statistics show that the average age of rural General Practitioners continues to age and these communities rely heavily on international medical graduates to provide services. This leads to a continuing need for recruitment as we are failing to “grow our own” health workforce (9).

If we are to “grow our own” workforce it is very clear from international studies that choosing students with rural interests and backgrounds, exposing undergraduates to positive training experiences in rural areas, and providing well supported career pathways in rural practice increases the intention of medical students to work in rural communities once they graduate (2, 11).

We know that the career decisions of students and young professionals in the future will be affected by the way health career choices are viewed by society, available financial incentives, appropriate professional development and career opportunities, the availability of locums, a good quality of life ability to achieve balance, and the lifestyle choices of their spouses and family needs (2).

Many of us involved in education will be aware of the idea of “constructive alignment” of intended learning outcomes – what we hope to achieve – and the assessment and learning activities that are planned. The same theory applies to issues that face us in our rural communities.

We want to see an improvement in the health outcomes for rural communities, “Health for All Rural People”, we need our governments, colleges and colleagues to be measuring these outcomes – because of it is not measured it won’t be changed – and then we need our recruitment and retention and service delivery model thinking to be focused on achieving these outcomes.

This may seem bigger than Ben Hur but from what we do know it is clear that in order to meet the needs of our current and future population, in order to achieve equity and fairness or health outcomes for rural communities, in order to support and further develop the economic health of our rural sector, government needs to further support and expand initiatives that that increase exposure of training health professionals to positive rural experiences.

Dr Jo Scott-Jones

REFERENCES:

1. Ministry for Primary Industries : Rural Communities 2014 [09/05/2014]. Available from:http://www.mpi.govt.nz/agriculture/rural-communities.
2. WHO. Increasing access to health workers in remote and rural areas through improved retention:global policy recommendations. Geneva: World Health Organisation, 2010.
3. Burton J. Rural Health Care In New Zealand. Wellington: Royal New Zealand College of General Practitioners, 1999.
4. London M. New Zealand Annual Rural Workforce Survey 2000. Christchurch: Centre For Rural Health; 2001.
5. Mel Pande M, Fretter J, Stenson A, Webber C, Turner J. Royal New Zealand College Of General Practitioners Workforce Survey 2005 part 3: General Practitioners In Urban and Rural New Zealand. 2006.
6. The New Zealand Medical Workforce 2007. New Zealand Medical Council; 2008.
7. Health Workforce Development: An Overview. In: Health Mo, editor. Wellington, New Zealand2006.
8. Poole P, Bourke D, Shulruf B. Increasing medical student interest in general practice in New Zealand: where to from here? The New Zealand medical journal. 2010;123(1315):12.
9. Garces-Ozanne A, Yow A, Audas R. Rural practice and retention in New Zealand: an examination of New Zealand-trained and foreign-trained doctors. The New Zealand Medical Journal (Online). 2011;124(1330):14-23.
10. Medical Council of New Zealand: The New Zealand Medical Workforce in 2012 Wellington, New Zealand2013.
11. Walker JH, DeWitt DE, Pallant JF, CE. C. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural and Remote Health. 2012;12(1908):Online.
12. Farry P, Hill D, Isobel Martin I. What would attract general practice trainees into rural practice in New Zealand? NZMJ. 2002;115(1161).
13. Worley P, Strasser R, D. P. Can medical students learn specialist disciplines based in rural practice: lessons from students’ self reported experience and competence. Rural and Remote Health. 2004;4(338):Online.
14. Ministry of Health: Voluntary Bonding Scheme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.health.govt.nz/our-work/health-workforce/voluntary-bonding-scheme.
15. Rural Health Interprofessional Immersion Programme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.rhiip.ac.nz/.
16. University of Otago: Rural Medical Immersion Programme Otago University, New Zealand2014 [09/05/2014]. Available from: http://rmip.otago.ac.nz/.
17. P Poole, W Bagg, B O’Connor, A Dare, J McKimm, K Meredith, et al. The Northland Regional-Rural program (Pukawakawa): broadening medical undergraduate learning in New Zealand. Rural and Remote Health. 2010;10(1254):Online

 

(published in Wonca News June 2014)

Wonca World Rural Health Conference Gramado April 2014

opotikigp family medicine, general practice, Healthcare, rural , , , ,

The WONCA WORKING PARTY on RURAL PRACTICE is the rural working group of the world organisation of academic associations and national colleges.
Amongst other work it runs regular conferences and Gramado in Brazil was host to the 12 th WWPRP conference.

The picture above is of Carlos Grossman and his wife Doris, he was heralded during the conference as the father of family medicine in Brazil, I spoke to him about why as a cardiologist in the 1970s he had decided to set up a family medicine programme.

His response was both simple and profound : ” We need to be close to the people.”

Is there a better explanation ?

Rural people are disadvantaged from the outset because of distance, Carlos Grossman recognised it is essential to have health care that is provided close to the people, by a professional trained to engage closely with them in their work and family life, a professional who shares the closeness of the community. This shared experience, also identified by McWhinney as a essential part of family practice, brings with it opportunities for fantastic work in supporting people to live happier and healthier lives.

It is a phenomenal thing to come to a realisation that the culture you work in as a GP is substantially different from that of other GPs, and the question of what it means to be a “rural” GP is worth a later exploration, suffice to say being able to spend time with like minded but different people, with a richly diverse way of dealing with a common set of challenges was not only interesting but I suspect will prove useful in the New Zealand context.

My task now is to share some of the ideas that were shared with me during the event.

For those of you who “twitter” searching through my recent tweets using #nzrgpn you will be able to find slides and comments from the main speakers.

Consider following me @opotikigp and @ruralwonca for future links and conversations about rural health.

First Post -Truth develops over Time

opotikigp family medicine, general practice, Healthcare, rural , ,

Don’t shoot the messenger.

The purpose of taking this step into bloggersphere is to provide another outlet for my own opinions about the state of healthcare, in particular how rural communities, and in particular rural communities in New Zealand, fare.

I suspect that when Don Berwick and his colleagues delivered their Don Berwick’s report for the UK NHS they felt a bit like Phiddepides the apocryphal first marathon runner.

Phiddepides bore bad news of invasion, and of the failure of the government of the day to respond.

Berwick et al told the bad news to the UK government of the need for systematic and widespread change to address the failures of the health system, to develop a culture of learning and patient safety, and the letters he wrote, to management, staff and the public exhort a response. They not only challenge the system in England, but internationally. Have we responded?

Famously Phideppides died at the end of his courier run, conveniently I suspect, since the bearers of bad news often did not fare too well in ancient times.

Many bearers of bad news are still “shot down” at least metaphorically, and perhaps in an effort to avoid this people who challenge the status quo will couch their approaches as “solutions” spinning the bad news to assuage the anxieties of leading political parties.

The problem is it is almost impossible to keep everyone happy all the time whilst maintaining the feeling of freedom of expression.

I have been told that you need to play the game if you are to have influence, to treat the powerful like they are children in a sandpit, fighting for the bucket that makes the sandpies.

It seems to me that a regular personal viewpoint, expressed clearly and with the acknowledgement that it is often through expressing ideas and debate that opinions form, could help to get the message through to the children in the sandpit.

Here’s hoping they don’t shoot….