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ABSTRACT: To describe the financial impact on practice owners of increased clinical task substitution between practice nurses and GPs in New Zealand (NZ) primary care settings.
Case studies of 9 primary health care centres involving: interviews; collation of service and financial information; and nurse and GP diaries covering 1826 consultations. Results were compared with previous NZ large N survey results to develop a model predicting the financial impact of task substitution.
The proportion of general practice primary care consultations undertaken by nurses varied from 4% to 46% of total recorded consultations. The actual financial impact for a practice owner of substituting more nursing time for GP time is highly dependent on the following variables: nurse cost per minute relative to GP cost minute; nurse consult duration relative to GP consult duration; nurse consult revenue relative to GP consult revenue; and the proportion of nurse consults also requiring GP time.
Practice nurses can (and in some practices in NZ, do) provide a broad set of primary care services, including undifferentiated general consultations. For some practices, increasing the proportion of nurse consults and reducing GP consults, would result in significantly improved profitability--for others, the opposite applies. Clinical task substitution is one option to address the forecast increase in demand associated with population aging.
The New Zealand medical journal 01/2011; 124(1342):59-65.
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ABSTRACT: To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety.
25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance.
19 high-quality studies that assessed outcomes were included.
All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives.
Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance.
The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.
The Medical journal of Australia 11/2010; 193(10):602-7. · 2.81 Impact Factor
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ABSTRACT: The Shipman Inquiry recommended mortality rate monitoring if it could be 'shown to be workable' in detecting a future mass murderer in general practice.
To examine the effectiveness of cumulative sum (CUSUM) charts, cross-sectional Shewhart charts, and exponentially-weighted, moving-average control charts in mortality monitoring at practice level.
Analysis of Scottish routine general practice data combined with estimation of control chart effectiveness in detecting a 'murderer' in a simulated dataset.
Practice stability was calculated from routine data to determine feasible lengths of monitoring. A simulated dataset of 405,000 'patients' was created, registered with 75 'practices' whose underlying mortality rates varied with the same distribution as case-mix-adjusted mortality in all Scottish practices. The sensitivity of each chart to detect five and 10 excess deaths was examined in repeated simulations. The sensitivity of control charts to excess deaths in simulated data, and the number of alarm signals when control charts were applied to routine data were estimated.
Practice instability limited the length of monitoring and modelling was consequently restricted to a 3-year period. Monitoring mortality over 3 years, CUSUM charts were most sensitive but only reliably achieved >50% successful detection for 10 excess deaths per year and generated multiple false alarms (>15%).
At best, mortality monitoring can act as a backstop to detect a particularly prolific serial killer when other means of detection have failed. Policy should focus on changes likely to improve detection of individual murders, such as reform of death certification and the coroner system.
British Journal of General Practice 05/2008; 58(550):311-7. · 1.83 Impact Factor
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ABSTRACT: In an attempt to make rationing of elective surgery in the publicly funded health system more explicit, New Zealand has developed a booking system for surgery using clinical priority assessment criteria (CPAC). This paper is based on research undertaken to evaluate the use of CPAC. To explore whether the goals of explicit rationing were being met 69 interviews were undertaken with policy advisors, administrators and clinicians in six localities throughout New Zealand. The aims of reforming policy for access to elective surgery included improving equity, providing clarity for patients, and achieving a paradigm shift by relating likely benefit from surgery to the available resources. The research suggests that there have been changes in the way in which patients access elective surgery and that in many ways rationing has become more explicit. However, there is also some resistance to the use of CPAC, in part due to confusion over whether the tools are decision-aids or protocols, what role the tools play in achieving equity and differences between financial thresholds for access to surgery and clinical thresholds for benefit from surgery. For many surgical specialties implicit rationing will continue to play a major part in determining access to surgery unless validated and reliable CPAC tools can be developed.
Health Policy 10/2005; 74(1):1-12. · 1.51 Impact Factor
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ABSTRACT: Complex systems have specific properties of robustness and self organisation which arise from interacting components within the overall system and which govern the system's behaviour. These are typically associated with a power law distribution of event sizes. Commentators have suggested that health systems are complex, but there has been limited quantitative investigation of this issue.
To test the hypothesis that consultation patterns in primary care follow a power law distribution typical of a complex system.
Analysis of 142,050 episodes of non-pathological back pain in routinely collected New Zealand national data. Calculation of the distribution of the duration and number of GP consultations for each illness episode. Secondary analysis of a published UK dataset of consultation rates for 44,000 patients in four general practices.
Number of consultations per episode of back pain demonstrated excellent fit with a power law in the full dataset (r2 = 0.96) and all but one subgroups (r2 = 0.90-0.99). The number of consultations per patient from four UK practices was suggestive of a power law distribution (r2 = 0.88-0.93).
Consultation patterns in general practice show measurable properties of a complex system. The consistency of the distribution across different population groups suggests that attempts to manage consultation patterns should focus on the whole system of patients, rather than upon individuals or subgroups of the patient population.
Family Practice 07/2005; 22(3):347-52. · 1.50 Impact Factor
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ABSTRACT: To describe patterns of variation in referral among general practitioners, and to establish whether variability among practitioners within a geographic area is associated with high levels of utilisation in an area.
Multilevel analysis of routinely collected primary care data. The four outcome measures were referral to physiotherapy, specialist assessment, radiology, and approval of earnings-related compensation.
The pattern of observed variability is not consistent for different referral activities: groups of general practitioners within one area may practice consistently in referral for one outcome, but be highly variable for another, while practitioners in other areas can show the reverse pattern. The degree of variability among GPs within geographic areas was not significantly correlated at the 95% level with the absolute level of referral to any of the referral options.
The mechanisms which drive variability operate at the level of the specific clinical management option, rather than at the level of the overall approach to management of the disease. Caution should be exercised about claims that reductions in variability will produce reductions in utilisation.
The New Zealand medical journal 05/2005; 118(1212):U1381.
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ABSTRACT: To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC).
A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC.
New Zealand.
A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars.
Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery.
Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.
ANZ Journal of Surgery 12/2004; 74(11):1003-9. · 1.25 Impact Factor
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ABSTRACT: To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians' perceptions of equity and the factors they consider when prioritising patients for elective surgery.
A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically.
General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians' perceptions of the 'value' that patients would receive from the surgery and patients' needs for public sector funding.
The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.
Journal of Health Services Research & Policy 11/2004; 9 Suppl 2:41-7. · 1.73 Impact Factor
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ABSTRACT: To describe the development and evaluation of a primary care service for a population of mental health consumers who had previously been predominantly cared for by a specialist service.
Consumers were interviewed at regular intervals after entry to the programme. The Health of the Nation Outcomes Scale (HoNOS) and the Life Skills Profile (LSP) outcomes measures were used with consumers at intervals of 0,3,6,12 and 18 months after entry to the programme. A cost comparison was made between services provided to consumers in the year before entry to the programme, and after entry.
Consumers reported no deterioration in their clinical condition while under the care of general practitioners, and they were largely satisfied with general practitioner care. Consumers' LSP scores were stable after entry to the programme. General practitioners were initially ambivalent about the programme, but were more supportive after 12 months had elapsed. The education provided to general practitioners, nurses, and receptionists was strongly welcomed.
With carefully designed training and support, general practice can provide high-quality community-based mental healthcare for consumers with enduring mental health disorders, and it can support the introduction of integrated mental health care initiatives.
The New Zealand medical journal 10/2004; 117(1202):U1077.
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ABSTRACT: To describe the attitudes of general practitioners and specialist clinical teachers toward teaching evidence based medicine (EBM).
Questionnaire survey of 114 general practitioner and 162 specialist university teachers teaching EBM.
Two hundred and six (80%) teachers responded; 196 regularly consulted with patients, 21% had received training, and 40% taught EBM. Those with formal training (68%) taught more often than without (32%) (p = 0.0001), 27% had taught EBM for over 5 years. More GPs (57%) than specialists (40%) asked students to assist in finding evidence (p = 0.036). Most welcomed EBM and were confident in teaching it. Barriers included antagonism to EBM philosophy, shortage of time, and a need for training in teaching EBM.
Although not all trained, GPs and specialists teach EBM, enjoy doing so, and want to increase their ability to teach it.
Australian family physician 06/2004; 33(5):376-8. · 0.73 Impact Factor
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ABSTRACT: To describe the ways patients access elective surgery in New Zealand, and to understand the use of, and attitudes to, clinical priority assessment criteria (CPAC) in determining access to publicly funded elective surgery.
A qualitative study in selected New Zealand localities. A purposive sample of general practitioners, surgeons and administrators in publicly funded hospitals were interviewed. Data were analysed by a process of thematic analysis.
Sixty-five interviews were completed. General practitioners had a key role in determining which patients were seen in the public sector and, by utilising strategies to actively advocate for patients, influenced both waiting times for first assessment by surgeons and for surgery. CPAC had been developed as decision support guides with the intention that they would provide transparency and equity in determining access. However, there was variation in the way CPAC were being used both in score construction and in the influence of the score on access to surgery. The management of the hospital system also limited the extent to which CPAC could be used to prioritise patients for surgery.
Variability in the use of CPAC tools meant that at the time of the study they did not provide a transparent and equitable method of determining access to surgery. This highlights the difficulties in developing and implementing CPAC and suggests that further development is difficult in the absence of evidence to identify patients who will benefit the most from surgery.
Journal of Health Services Research & Policy 05/2004; 9(2):91-9. · 1.73 Impact Factor
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ABSTRACT: Health agencies frequently seek to develop indicators of the quality and performance of work done by clinicians. The validity of such indicators is a subject of debate among clinicians and health managers.
Our aim was to quantify the effects of chance and small caseload on an indicator of referral behaviour for GPs.
The study used random simulation of GP referral to physiotherapy and variance components analysis of routinely collected accident insurance data. It analysed 129 079 episodes of accident-related back pain in New Zealand which were managed by 2679 GPs. The main outcome measure was the percentage of back pain cases referred for physiotherapy and for specialist assessment and by each GP.
The observed number of GPs who refer to physiotherapy at high levels is satisfactorily accounted for by chance. The variability of practice among GPs within any one area is not related to the absolute level of referral.
The primary care setting, in which a low caseload for any one condition is the norm, presents challenges for measuring clinical performance. An emphasis upon changing the behaviour of GPs with extremely high levels on a performance indicator cannot necessarily be expected to have an impact upon the level of the indicator across a geographic area. Indicators for quality improvement should be used across whole populations of practitioners, rather than used to focus upon extremely high referring individuals.
Family Practice 05/2004; 21(2):160-5. · 1.50 Impact Factor
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The New Zealand medical journal 05/2004; 117(1191):U820.
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Informatics in primary care 02/2004; 12(1):1-2.
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ABSTRACT: Implementing the evidence base for the management of chronic disease is as challenging as discovering which interventions are effective. The HEARTS collaboration (Heart disease Evidence-based Audit and Research in Tayside Scotland) is achieving that goal for the secondary prevention of coronary heart disease (CHD by linking national databases to manually validated hospital and family practice electronic patient records. Specific data from the system is fed back to practices in a facilitated educational process and through the NHS intranet. This paper describes some of the key features of this strategic decision support system. All residents of the Tayside region of Scotland (n=484,013 mid year estimate 2002) are covered by the system. 9,828 patients who have suffered a myocardial infarction(MI) or who have undergone angioplasty or bypass surgery are registered on the system. Improvements in clinical status and prescribing of effective therapies are 5-10% greater than elsewhere in Scotland.
Studies in health technology and informatics 02/2004; 107(Pt 2):1227-9.
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ABSTRACT: The aims of this study were to measure baseline use of Ottawa ankle rules (OAR), validate the OAR and, if appropriate, explore the impact of implementing the Rules on X-ray rates in a primary care, after hours medical centre setting.
General practitioners (GPs) were surveyed to find their awareness of ankle injury guidelines. Data concerning diagnosis and X-ray utilisation were collected prospectively for patients presenting with ankle injuries to two after hours medical centres. The OAR were applied retrospectively, and the sensitivity and specificity of the OAR were compared with GPs clinical judgement in ordering X-rays. The outcome measures were X-ray utilisation and diagnosis of fracture.
Awareness of the OAR was low. The sensitivity of the OAR for diagnosis of fractures was 100% (95% CI: 75.3 - 100) and the specificity was 47% (95% CI: 40.5 - 54.5). The sensitivity of GPs clinical judgement was 100% (95% CI: 75.3 - 100) and the specificity was 37% (95% CI: 30.2 - 44.2). Implementing the OAR would reduce X-ray utilisation by 16% (95% CI: approx 10.8 - 21.3).
The OAR are valid in a New Zealand primary care setting. Further implementation of the rules would result in some reduction of X-rays ordered for ankle injuries, but less than the reduction found in previous studies.
The New Zealand medical journal 10/2002; 115(1162):U184.
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