Search

Background/objectives: To determine the effect of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people., Design: Controlled before and after, and controlled after only quasi-experimental studies, with a comparison group created via propensity score matching. One-year follow-up., Setting: Nine general practices in Auckland, New Zealand., Participants: Community-dwelling people aged 75 and older identified as at increased risk of hospitalization. One thousand and eighty five patients are compared with 3750 comparison patients matched by propensity score based on known risks., Intervention: Primary healthcare based, registered nurse-led, comprehensive geriatric assessment, goal-setting, care planning, and regular follow-up. Patients were also provided self-management education, health and social care navigation, and transitional care for hospital discharges. Practices received program support, workforce development, and mentoring of primary healthcare nurses by gerontology nurse specialists., Measurements: Outcomes from routinely collected administrative data. Primary: aged-residential care placement., Secondary Outcomes: acute hospitalization, mortality, and other health service utilization., Results: Aged-residential care placement (odds ratio [OR] 0.66, 95% confidence interval (CI) = 0.48-0.91) and mortality (OR 0.66, 95% CI = 0.49-0.88) were significantly lower over the first year in Kare patients compared with matched controls. There was no difference in acute hospitalization (+0.06 admissions per year, 95% CI = -0.01-0.13). Support service use (allied health therapists and assessment for social support) was increased, and emergency department use decreased., Conclusion: The Kare participants had lower aged-residential care placement and mortality in the first year, but no decrease in acute hospitalization. Because the design is nonexperimental caution is required in interpreting these results., (© 2021 The American Geriatrics Society.)

Objective: To describe the type and level of non-pharmacological management offered by general practitioners for essential hypertension., Design: An open-ended interviewer-administered survey using a standard case of a 60-year-old man with essential hypertension. Seventy interviews were conducted face-to-face and 30 by telephone., Setting: Auckland general practices., Subjects: A random sample of 100 Auckland general practitioners., Main Outcome Measures: Aspects of the medical histories of patients, physical examination, laboratory testing and treatment relevant to non-pharmacological management., Results: There was an 84% response rate. Most general practitioners reported offering non-pharmacological management at the first consultation before prescribing medication. However, few offered detailed programmes. Dietary therapy, restriction of alcohol consumption and exercise were suggested by most general practitioners. Restriction of sodium intake and behavioural therapy were less popular non-pharmacological interventions. The median number of visits of patients to a general practitioner before drugs were prescribed was five, which is in keeping with guidelines. The median number of days from the first visit to prescription of drug therapy was 42 (range 2-341). The clinical advice given by the majority of participants was consistent with current guidelines on the treatment of hypertension but the range of advice given was wide., Conclusions: The results suggest that general practitioners are aware of non-pharmacological interventions for the management of hypertension. They report making routine use of non-pharmacological therapies for blood pressure reduction and other health benefits early in the clinical process before considering pharmacological therapy. These non-pharmacological therapies are not delivered with well-defined and detailed programmes.

Aims: The paper uses coronary heart disease risk factor prevalence data from a defined urban population to assess the potential impact of implementing the New Zealand National Heart Foundation "Guidelines for detection and management of dyslipidaemia" on the treatment of dyslipidaemia in New Zealand., Methods: Coronary heart disease risk factor data was collected on an age stratified random sample of Auckland residents aged 35-74 years. The 10 year absolute risk of coronary heart disease was calculated for each participant aged between 35-64 years and management options determined from the National Heart Foundation guidelines. The Framingham equation used in these guidelines was used to extrapolate the 10 year risk of a coronary event in the 65-74 year age group. The proportions of participants potentially requiring treatment with lipid modifying medication were identified and extrapolated to the New Zealand European population. A sensitivity analysis was undertaken to assess the impact of 5% and 10% reductions in total cholesterol following dietary intervention on numbers meeting the drug treatment criteria., Results: The proportion of participants potentially requiring lipid modifying treatment based on the guidelines was considerably higher than estimates of current treatment rates in each age group. The number meeting the treatment criteria increased dramatically with age. By the age of 65-74 years one in five participants met the drug treatment criteria. A 5% and 10% reduction in total cholesterol following dietary intervention reduced the proportion of participants potentially requiring drugs by almost one quarter and one half respectively., Conclusion: The approach taken by the New Zealand National Heart Foundation guidelines appropriately gives highest priority to patients at highest risk of a coronary event. If this high risk approach is extrapolated to older age groups, it will lead to more drug treatment among the elderly. Further evidence from randomised controlled trials on benefits of using cholesterol modifying medication in older age groups is required. Future guidelines need to address specifically criteria for use of lipid modifying medications in older age groups. Reductions in the numbers meeting drug treatment criteria following 5% and 10% reductions in total cholesterol reinforces the importance of dietary management.

Background: The purpose of this study is to describe associations between a number of standard cardiovascular risk factors and all-cause mortality., Method: Mortality data were collected for a randomly selected cohort of 1029 New Zealand men aged 35-64 years, followed up over a 9-year period. A proportional hazards regression model was used to estimate the relative risks (RR) for all-cause mortality associated with a number of cardiovascular risk factors., Results: In all, 96 deaths occurred over the 9-year period, of which 50% were due to cardiovascular causes. All-cause mortality was positively associated with cigarette smoking (age-adjusted RR = 2.01, 95% CI:1.15-3.53, current versus never), systolic blood pressure (age-adjusted RR = 2.18, 95% CI:1.23-4.44, upper versus lower tertile), and body mass index (age-adjusted RR = 1.59, 95% CI:0.94-2.66, upper versus lower tertile) and inversely associated with high density lipoprotein (HDL)-cholesterol (age-adjusted RR = 0.45, 95% CI:0.25-0.80, upper versus lower tertile). All-cause mortality was only weakly associated with serum total cholesterol (age-adjusted RR = 1.19, 95% CI:0.70-1.99, upper versus lower tertile), and there was no evidence of a U-shaped relationship for this risk factor. There was an inverse association between all-cause mortality and socioeconomic status (age-adjusted RR = 1.70, 95% CI:1.03-2.80, lower versus upper). Light alcohol consumption was associated with reduced all-cause mortality (age-adjusted RR = 0.63, 95% CI:0.37-1.05, light versus teetotal), but this benefit did not persist for alcohol consumption above about three standard drinks per day., Conclusions: The findings of this study indicate that the standard cardiovascular risk factors are likely to have a beneficial impact on all-cause mortality as well as cardiovascular disease in middle-aged and older men.

Aim: To determine if the management of a hypothetical case of essential hypertension by general practitioners conforms with the Report to the National Advisory Committee on Core Health and Disability Services guidelines on the Management of Raised Blood Pressure in New Zealand (Core Services Report on Hypertension) sent to all general practitioners in November 1992., Method: A cross-sectional survey of a random sample of 100 Auckland general practitioners using a standard case of a 60 year old man with essential hypertension. Seventy interviews were conducted by a face-to-face interview and 30 by telephone interview. The main outcome measures were. Initial choice of medication and levels at which blood pressure would require treatment., Results: Forty one percent of the interviewed doctors had read the Core Services report on hypertension. Fifty percent of the doctors indicated they would use the recommended first line antihypertensive medication (ie, diuretic or beta blocker). Doctors who prescribed beta blockers had been graduated a significantly longer time than those who did not. The majority of doctors indicated that they would initiate pharmacological treatment at lower blood pressures in younger patients than older patients contrary to the recommendation of the report., Conclusions: Current reported practice is only partially consistent with that suggested by the Core Services report on hypertension. Approximately half of the doctors interviewed were prescribing the recommended first line medication. Treatment was more likely to be initiated at lower levels in younger patients than in older patients in spite of the higher absolute risk and potential absolute benefit in the latter group. Adherence to the guidelines could see a shift from overtreatment of younger patients to an increase in treatment for older patients who are at higher risk of blood pressure related disease. More specific graduate educational measures will be needed if the Core Services report on hypertension are to be implemented.

This study examines the validity of self-reported hospital admission data obtained by telephone interview from a sample of 563 participants in a follow-up study in Auckland, New Zealand. The personal recall of hospital admissions over a 4-year period between 1988 and 1991 was compared with a national computerized record of all hospital admissions. Only two admissions were recalled by participants but not recorded on the hospital record. However, the study found significant underreporting of admissions by participants. Of those participants who could be contacted, 58% recalled all their admissions recorded on the computerized database. Additionally, 26% recalled some of the admissions, and 16% recalled none of the admissions. The age, sex, and social class status of the participants did not appear to significantly influence recall ability. A greater proportion of "first" admissions (68%) was recalled than that of "readmission" (45%). Follow-up studies that rely on similar methods for collecting self-reported hospital admission data may significantly underestimate admission rates, particularly those of readmissions for the same condition.

Aim: This analysis aims to identify the direct costs of rheumatic fever and its sequelae to the Auckland Area Health Board and to describe the indirect and intangible costs to patients., Methods: The annual cost was estimated using primarily 1987 data costed in 1991 dollars. The cost analysis was undertaken in five sections: (1) acute rheumatic fever admissions; (2) surgical admissions; (3) rheumatic heart disease related admissions (nonsurgical); (4) outpatient clinic appointments; and (5) secondary prophylaxis programme. Non hospital board direct costs and indirect and intangible costs are described. Ethnic distribution and subsequent economic burden were analysed for each section., Results: The total cost to the health board was estimated to be $3.60M. The management of chronic rheumatic heart disease accounts for 71% of the cost. Rheumatic heart disease related nonsurgical admissions cost $1,228,495 (34%), surgical admissions $846,235 (23%) and outpatient clinic appointments $490,060 (14%) respectively. Both Maori (30% of costs, $1.1M) and Pacific Island people (36% of costs, $1.3M) are disproportionately affected by this largely preventable disease. Of the total cost 13% is spent on coordinated secondary prevention programmes., Conclusion: An energetic secondary prevention programme over 10 years to prevent recurrences and the development of carditis has only partially reduced the rate of rheumatic heart disease. A targeted primary prevention pilot programme should be actively considered.

Aims: The aim of this study was to describe benzodiazepine use in a general practice., Methods: A prevalence study in an Auckland general practice was undertaken to describe the benzodiazepines prescribed, patterns of use and compliance. An associated case control study compared benzodiazepine users and nonusers., Results: The age standardised prevalence rate of benzodiazepine use in this Auckland general practice was 3.4% for patients over 20 years of age. The benzodiazepine users described were predominantly elderly (70% over 60 years of age) and female (62.5%). They had significantly more medical and psychiatric complaints than matched controls. Triazolam and diazepam accounted for 60.9% of the benzodiazepines prescribed. Over one-third of the patients using benzodiazepines were concurrently prescribed other psychotropic medications, primarily tricyclic antidepressants., Conclusion: This rate suggests an overall decline in benzodiazepine use since previous studies. Benzodiazepines continue to be prescribed predominantly in the elderly, a group at considerable risk from side effects. Doctors should continue to inform their patients about the side effects of benzodiazepines, the risks of dependence and difficulties of withdrawal.

The demographic features and contraceptive practices of 1000 women attending Parkview clinic of Wellington Hospital for termination of pregnancy were studied over an eight month period in 1988-9. Comparisons were made with a previous study at the same clinic in 1980-1. The overall abortion rate has increased from 6.8/1000 women in the Wellington statistical area in 1981 to 9.8 in 1989. The proportion of Pacific Island and Asian women presenting for abortions is high and has increased disproportionately between 1981 and 1989. The abortion rate has also increased in lower socioeconomic groups in 1989. The proportion of women using contraception at the time of conception increased from 50% in 1981 to 68.5% in 1989. The methods used by women presenting for abortion have changed significantly. There has been an increase in the proportion of women using condoms (from 13.3% to 36.2%) and the oral contraceptive pill from (14% to 21.4%).