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Objective: Little is known about differences in hospital harm (injury, suffering, disability, disease or death arising from hospital care) when people from rural and urban locations require hospital care. This study aimed to assess whether hospital harm risk differed by patients' rural or urban location using general practice data., Design: Secondary analysis of a 3-year retrospective cross-sectional general practice records review study, designed with equal numbers of rural and urban patients and patients from small, medium and large practices. Hospital admissions, interhospital transfer and hospital harm were identified., Setting: New Zealand (NZ) general practice clinical records including hospital discharge data., Participants: Randomly selected patient records from randomly selected general practices across NZ. Patient enrolment at rural and urban general practices defined patient location., Outcomes: Admission and harm risk and rate ratios by rural-urban location were investigated using multivariable analyses adjusted for age, sex, ethnicity, deprivation, practice size. Preventable hospital harm, harm severity and harm associated with interhospital transfer were analysed., Results: Of 9076 patient records, 1561 patients (17%) experienced hospital admissions with no significant association between patient location and hospital admission (rural vs urban adjusted risk ratio (aRR) 0.98 (95% CI 0.83 to 1.17)). Of patients admitted to hospital, 172 (11%) experienced hospital harm. Rural location was not associated with increased hospital harm risk (aRR 1.01 (95% CI 0.97 to 1.05)) or rate of hospital harm per admission (adjusted incidence rate ratio 1.09 (95% CI 0.83 to 1.43)). Nearly half (45%) of hospital harms became apparent only after discharge. No urban patients required interhospital transfer, but 3% of rural patients did. Interhospital transfer was associated with over twice the risk of hospital harm (age-adjusted aRR 2.33 (95% CI 1.37 to 3.98), p=0.003)., Conclusions: Rural patient location was not associated with increased hospital harm. This provides reassurance for rural communities and health planners. The exception was patients needing interhospital transfer, where risk was more than doubled, warranting further research., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

INTRODUCTION Measurement of family medicine research productivity has lacked the replicable methodology needed to document progress. AIM In this study, we compared three methods: (1) faculty-to-publications; (2) publications-to-faculty; and (3) department-reported publications. METHODS In this cross-sectional analysis, publications in peer-reviewed, indexed journals for faculty in 13 US family medicine departments in 2015 were assessed. In the faculty-to-publications method, department websites to identify faculty and Web of Science to identify publications were used. For the publications-to-faculty method, PubMed's author affiliation field were used to identify publications, which were linked to faculty members. In the department-reported method, chairs provided lists of faculty and their publications. For each method, descriptive statistics to compare faculty and publication counts were calculated. RESULTS Overall, 750 faculty members with 1052 unique publications, using all three methods combined as the reference standard, were identified. The department-reported method revealed 878 publications (84%), compared to 616 (59%) for the faculty-to-publications method and 412 (39%) for the publication-to-faculty method. Across all departments, 32% of faculty had any publications, and the mean number of publications per faculty was 1.4 (mean of 4.4 per faculty among those who had published). Assistant Professors, Associate Professors, Professors and Chairs accounted for 92% of all publications. DISCUSSION Online searches capture a fraction of publications, but also capture publications missed through self-report. The ideal methodology includes all three. Tracking publications is important for quantifying the return on our discipline's research investment.

Background and Objectives: In Bahrain, maintaining life support at all costs is a cultural value considered to be embedded in the Islamic religion. We explore end-of-life decision making for brain dead patients in an Arab country where medical cultures are dominated by Western ideas and the lay culture is Eastern., Methods: In-depth interviews were conducted from February to April 2018 with 12 Western-educated Bahraini doctors whose medical practice often included end-of-life decision making. Discussions were about who should make withdrawal of life support decisions, how decisions are made and the context for decision making. To develop results, we used the inductive method of thematic analysis., Results: Informants considered it difficult to engage non-medical people in end-of-life decisions because of people's reluctance to talk about death and no legal clarity about medical responsibilities. There was disagreement about doctors' roles with some saying that end-of-life decisions were purely medical or purely religious but most maintaining that such decisions need to be collectively owned by medicine, patients, families, religious advisors and society. Informants practised in a legal vacuum that made their ethics interpretations and clinical decision making idiosyncratic regarding end-of-life care for brain dead patients. Participants referred to contrasts between their current practice and previous work in other countries, recognising the influences of religious and cultural dimensions on their practice in Bahrain., Conclusions: End-of-life decisions challenge Western-trained doctors in Bahrain as they grapple with aligning respect for local culture with their training in the ethical practice of Western medicine., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Goals: Many patients with transient ischemic attack (TIA) receive initial assessments by general practitioners (GPs) who may lack TIA management experience. In a randomized controlled trial (RCT), we showed that electronic decision support for GPs improves patient outcomes and guideline adherence. Some stroke services prefer to improve referrer expertise through TIA/stroke education sessions instead of promoting TIA decision aids or triaging tools. This is a secondary analysis of whether a GP education session influenced TIA management and outcomes., Materials and Methods: Post hoc analysis of a multicenter, single blind, parallel group, cluster RCT comparing TIA/stroke electronic decision support guided GP management with usual care to assess whether a pretrial TIA/stroke education session also affected RCT outcomes., Findings: Of 181 participating GPs, 79 (43.7%) attended an education session and 140 of 291 (48.1%) trial patients were managed by these GPs. There were fewer 90-day stroke events and 90-day vascular events or deaths in patients treated by GPs who attended education; 2 of 140 (1.4%) and 10 of 140 (7.1%) respectively, compared with those who did not; 5 of 151 (3.3%), and 14 of 151 (9.3%), respectively. Logistic regression for association between 90-day stroke and 90-day vascular events or death and education, however, was nonsignificant (odds ratio [OR] .42 (.08 to 2.22), P = .29 and .59 (95% confidence interval [CI] .27 to 1.29), P = .18 respectively. Guideline adherence was not improved by the education session: OR .84 (95% CI .49 to 1.45), P = .54., Conclusion: In the described setting, a GP TIA/stroke education session did not significantly enhance guideline adherence or reduce 90-day stroke or vascular events following TIA., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

INTRODUCTION Since 1991 the University of Otago, Dunedin, New Zealand has offered postgraduate qualifications specifically designed to educate general practitioners (GPs) about their unique work environment. AIM To determine motivations and impacts of postgraduate education for practising GPs. METHODS Survey of the 100 graduates of the University of Otago, Dunedin postgraduate general practice programme. Ninety five living graduates were approached and 70 (73.7%) responded. Quantitative data about disposition of respondents before enrolling and after completion of the programme were analysed using chi-square and paired t-tests. Free text responses about motivations, impacts and outcomes of the program were thematically analysed. RESULTS 64 GPs graduated with a postgraduate diploma and 36 with a masters degree in general practice. Although the mean number of graduates was 3.5 and 2.0 (respectively), annual enrolments averaged 25.1. Most graduates (60.9%) were aged in their 40s when they started studying and most (94.3%) had a spouse and/or children at home. DISCUSSION This voluntary postgraduate medical education complements traditional medical training but has low external value despite personal, practising and professional benefits. Graduates valued engagement above completion of a qualification. KEYWORDS Medical education; general practitioners; scholarship; professionalism.

Background: Variation in prescription costs between general practices and within practices over time is poorly understood., Methods: From New Zealand's national health data collections, we extracted dispensed medicines data for 1045 general practices in 2011 and 917 practices continuously existing 2008-11. Using indirect standardization to account for patient demographics and morbidity, a standardized prescribing cost ratio (SPR: the ratio of actual : expected prescription costs) was calculated for each practice in each year. Case studies of three outlier clinics explored reasons for their status., Results: SPRs ranged from 0.53 to 2.28 (median = 0.98). Of 469 practices with higher than expected costs (SPR > 1.0) in 2011, 204 (43.5%) had a single medicine or therapeutic drug class accounting for >15% of total costs. Case studies contrasted practices with overall pharmaceutical expenditure influenced strongly by a few patients needing high-cost medicines, more patients using medicines in one high-cost therapeutic drug class (antiretrovirals), and high medicine use across all therapeutic drug classes., Conclusions: Routine data collections can measure inter-practice variation in prescription costs, adjusted for differences in the demography and morbidity profile of each practice's patients. Small groups of patients using high-cost medicines influence general practices' expenditure on pharmaceuticals., (© The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To describe the reasons for socially vulnerable patients at Dunedin's Free Clinic visiting their general practitioner, using the International Classification of Primary Care, Second Edition (ICPC-2)., Method: An audit of electronic medical notes at Dunedin's Free Clinic for a 13-week period, to profile the health needs of patients and associated general practice activity, Results: There were 9.0 visits per patient over 12 months at the Free Clinic. An average of 1.2 presenting complaints or requests was made per visit. The most frequent "reasons for encounter" (RFE) at the Free Clinic were requests for prescriptions and Sickness Benefit medical certificates. An average of 1.9 diagnostic or therapeutic procedures was recorded per consultation at the Free Clinic., Conclusion: Patients at Dunedin's Free Clinic had a high rate of prescription and Sickness Benefit medical certificate requests. However, they brought on average fewer RFEs and received fewer than expected "processes of care" than patients in the NatMedCa study.

Introduction: Several methods of reducing the cost barrier to primary health care have been implemented in New Zealand, but research about free primary health care and the patients who use such services is scarce., Aim: To compare the characteristics of patients at Dunedin's free clinic with those at a traditional general practice clinic., Methods: A written survey was distributed to waiting room patients at the Free Clinic and a fee-charging clinic in close proximity. Patient records were accessed to determine health services utilisation rates at both clinics and the discounting rate at the traditional clinic., Results: There were 126 patient surveys returned at the Traditional Clinic and 65 at the Free Clinic. There was a significantly greater proportion of Maori respondents at the Free Clinic than at the Traditional Clinic (24.1% versus 9.2%, p=0.011). The difference in deprivation profiles of Free Clinic and Traditional Clinic respondents was more marked for the individual deprivation measure (five or more NZiDep deprivation characteristics: 65.5% versus 13.3%, p<0.001) than for residential area deprivation (NZDep2006 quintile 5: 41.4% versus 15.8%, p<0.001). Emergency department presentation rates were high for Free Clinic patients, despite free primary care access and high general practitioner consultation rates. Among Traditional Clinic respondents, 31.7% reported deferring health care because of cost in the previous 12 months. The equivalent figure for Free Clinic respondents was 63.8%., Discussion: This survey suggests that Dunedin's Free Clinic serves a vulnerable population, in whom levels of unmet health need and health service usage are high.

Most secondary care health services in New Zealand, including computed tomography (CT) scanners, are concentrated in urban centres. Little is known about the access rural patients have to these services. The aim of this research was to determine whether there was geographic variation in the utilisation of CT across the southern part of the South Island and if present to measure the magnitude. Quantitative analysis of public hospital data for CTs over two twelve month periods (2007/08 and 2010) showed that residents of urban base hospital catchment areas were 1.6 times more likely to access CT services than residents of the catchment areas of remote rural hospitals. Similar disparities were present when the analysis was limited to the ≥70 yrs age group. The disparities were present regardless of the referral source or the type of scan but were greatest for emergency department referrals, head scans and CT pulmonary angiograms. Further research is needed to determine the causes of these differences and whether they result in differences in health outcomes., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Aim: Using triggers to identify adverse events is proposed as an efficient means of consistently measuring, and tracking events that result in harm to patients. We aimed to test whether using triggers in our large provincial general practice could provide meaningful directions for improving safety., Method: A literature review identified potential triggers and established the number of patients whose records we should review. Two teams independently reviewed 170 randomly selected patients' records for trigger presence and for evidence of harm relating to that trigger. All triggers were tested for sensitivity and specificity: triggers with low specificity were removed. Logistic regression was used on both initial and refined trigger sets to measure the odds ratio (OR) of harm occurring if a trigger was present., Results: Initially 36 triggers were identified. Applying these to 109.6 patient-years of records for 170 patients, we identified harm in the records of 46 (27.1%) patients. There were 7 occurrences of harm per 100 consultations (harm rate per consultation=0.07 (95% confidence interval [CI] 0.05-0.09) and 41 per 100 consulting patient years (95%CI 29-55). All harms related to medication use. The initial triggers were sensitive (0.98) but non-specific (0.08): removing triggers with low specificity left only 8. The OR for harm occurring using the initial triggers was 4.0 (95% 0.5-30) and using the refined trigger set OR=6.3 (95%CI 2.7-14.8)., Conclusion: 8 selected triggers are a useful way of measuring progress towards safer care for patients in primary care practice.

Aim: The after-hours or on-call component of a paediatrician's work has implications for their spouse and family. Little is known about the specifics and extent of this impact. We aimed to understand the potential positive and negative impacts of this important aspect of a paediatrician's work., Methods: The spouses (nine female and one male) of 10 practising paediatricians, who are providing care in a variety of hospital settings within New Zealand, were interviewed using an open-questioning technique. Interviews were analysed by a qualitative line-by-line thematic method in order to categorise the perceived impact of their spouses' on-call work on themselves and their families., Results: Participants reported multiple effects of after-hours on-call on themselves, their paediatrician partners and their families. Negative themes included sleep deprivation, restrictions on life-style and living location (specifically home proximity to hospital), spousal sacrifice, intimacy and communication challenges, and diminished quality time with children. Positive themes highlighted professional rewards, financial security and adaptability. Themes were consistent across age, length of relationship, spousal occupation and the presence of children. The intensity of these impacts for our participants appeared to vary depending on the degree of marital support and frequency of on-call., Conclusion: After-hours on-call has a generally negative impact on paediatricians' spouses and families., (© 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Background: Strokes are a common cause of adult disability and mortality worldwide. Transient ischaemic attacks (TIA) are associated with a high risk of subsequent stroke, and rapid intervention has the potential to reduce stroke burden. This study will assess a novel electronic decision support (EDS) tool to allow general practitioners (GPs) to implement evidence-based care rapidly without full reliance on specialists., Methods/design: This is a cluster randomized controlled trial comparing TIA/stroke management of GPs with access to the EDS tool versus usual care. The intervention period is 12 months with a 3-month follow-up period for individual patients. Primary outcomes consist of stroke within 90 days of presenting event and adherence to the New Zealand national TIA guideline., Discussion: A positive study will provide strong evidence for widespread implementation of this tool in practice and has the potential to improve key outcomes for patients and reduce the burden of stroke., Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12611000792921.

Background: In 2005, the injury compensation legislation in New Zealand was reformed to extend coverage for medical injury removing both 'error' and 'severity' from eligibility criteria. This led to an increase in claiming and claims acceptance rate, thus enlarging the treatment injury claims database. This database provides an unusual 'no-fault' perspective of patient safety events., Methods: The authors analysed the first 4 years of primary care treatment injury claims data to identify the type, incidence, severity and cause of injury in primary care., Results: There were 6007 primary care treatment injury claims; 64% were accepted as treatment injuries. Most claims arose in general practice (62%), and most claimants were female (62%). Most claims were assessed as minor (83%), 12% major, 4% serious and 1% sentinel. Medication caused most injuries (38%) and most serious and sentinel injuries (60%). Dental treatment caused 16% of injuries; injections and vaccinations combined caused 10%; and venepuncture, cryotherapy and ear syringing combined caused 13.5% of injuries, mostly minor. 'Delay in diagnosis' caused few injuries overall (2%), but a disproportionate number of serious and sentinel injuries (16%) and deaths (50%). Spinal/ neck manipulation caused 2% of serious and sentinel injuries., Conclusions: New Zealand's no-fault treatment injury claims database provides information about primary care patient safety events from an unusual 'no-fault' perspective. This analysis reinforces previous research identifying medication as a high-risk primary care activity and further identifies other primary care activities (dental care, injections, venepuncture, cryotherapy and ear syringing) as carrying important risks for patient harm.

Context: Laboratory tests for inflammatory response, thyroid function and infectious diarrhoea were not being ordered as recommended by clinical guidelines., Objective: To measure changes in community laboratory-test ordering following marketing programmes promoting guidelines recommendations., Design: Controlled before-and-after study involving 2 years of national laboratory payment data before and after each intervention. Comparisons were with doctors ordering the same tests but not receiving interventions., Setting: New Zealand primary care., Participants: 3161, 3140 and 3335 general practitioners and 2424, 2443 and 2766 Comparison doctors ordering inflammatory response, thyroid function and acute diarrhoea tests from community laboratories, July 2003 to March 2009., Interventions: Three separate marketing programmes to general practitioners, each comprising written material advising of guidelines recommendations, individual laboratory-test use feedback and professional development opportunities., Main Outcome Measures: Number of tests, tests/doctor, patients having tests and tested patients/doctor/year before and after each intervention. Change in expenditure from before each intervention to after., Results: For Intervention doctors, erythrocyte sedimentation rate tests decreased 60.0% after the intervention; tests for C-reactive protein increased 63.1%; simultaneous erythrocyte sedimentation rate and C-reactive protein orders decreased 32.6%. Tests for free thyroxine and free triiodothyronine decreased 44.1% and 36.0%. The proportion of thyroid function tests where thyroid-stimulating hormone was the sole test ordered increased from 43.2% before the intervention to 65.2% afterwards (p<0.001; 95% CI 21.7% to 22.2%). Testing for faecal culture decreased 31.5%, giardia and cryptosporidium 31.5%, and ova and parasites 56.9%. Faecal culture as the sole initial test increased from 31.4% to 39.1% (p<0.001; 95% CI 7.2% to 8.2%). Testing by Comparison doctors changed in the same direction but with significantly less magnitude. The estimated reduction in expenditure for study tests was 23.5%., Conclusions: Clear information marketed to general practitioners improved the quality of laboratory test ordering for patients in New Zealand.

Introduction: Patient safety is a major concern, both in hospitals and in primary care settings. The current focus internationally is on the prospect of improving patient safety through cultural transformation. There are no tools designed to assess and strengthen safety culture in New Zealand (NZ) general practices, but a United Kingdom (UK) group have developed a tool--the Manchester Patient Safety Framework (MaPSaF)--to assess safety culture in UK Primary Care Trusts. We aimed to modify the MaPSaF and test its acceptability and utility in the NZ primary care setting., Methods: We modified the MaPSaF to suit the NZ context and then used it in 12 Dunedin general practices at baseline and at three months. Participants were all practice personnel present in the practice on the day. Participants rated their practice individually on each of the nine MaPSaF dimensions of safety culture, then discussed the dimensions and their scores and chose a practice-wide consensus score for each dimension in turn. These discussions were recorded, transcribed and analysed to determine acceptability and utility of the modified framework in NZ practices., Findings: The framework process took about one hour. Most participants found the process acceptable and useful. The framework directed team discussion about patient safety issues and facilitated communication and prompted some practices to make changes. Some participants from smaller practices deemed the systems advocated in the framework superfluous., Conclusion: The framework can be adapted and used in NZ practices to stimulate learning about safety culture and to facilitate team communication.

Background: In work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that there was a need to try to understand how the meaning of patient safety and underlying concepts relate to the existing safety and quality frameworks commonly used in healthcare., Objectives: To unfold the concept of patient safety and how it relates to safety and quality frameworks commonly used in healthcare and to trace the evolution of the ICPS framework as a basis of the electronic capture of the component elements of patient safety., Conclusion: The ICPS conceptual framework for patient safety has its origins in existing frameworks and an international consultation process. Although its 10 classes and their semantic relationships may be used as a reference model for different disciplines, it must remain dynamic in the ever-changing world of healthcare. By expanding the ICPS by examining data from all available sources, and ensuring rigorous compliance with the latest principles of informatics, a deeper interdisciplinary approach will progressively be developed to address the complex, refractory problem of reducing healthcare-associated harm.

Introduction: By the time medical students graduate many wish to work part-time while accommodating other lifestyle interests., Aim: To review flexibility of medical registration requirements for provisional registrants in New Zealand, Australia, the United Kingdom, Ireland and Canada., Methods: Internet-based review of registration bodies of each country, and each state or province in Australia and Canada, supplemented by emails and phone calls seeking clarification of missing or obscure information., Results: Data from 20 regions were examined. Many similarities were found between study countries in their approaches to the registration of new doctors, although there are some regional differences. Most regions (65%) have a provisional registration period of one year. Extending this period was possible in 91% of regions. Part-time options were possible in 75% of regions. All regions required trainees to work in approved practice settings., Discussion: Only the UK provided comprehensive documentation of their requirements in an accessible format and clearly explaining the options for part-time work. Australia appeared to be more flexible than other countries with respect to part- and full-time work requirements. All countries need to examine their registration requirements to introduce more flexibility wherever possible, as a strategy for addressing workforce shortages.

Aims: To report the development of the first Rural Medical Immersion Programme (RMIP) of the University of Otago in New Zealand., Method: We review medical education trends and challenges for educating New Zealand's doctors and recruiting them to careers in rural practice. We describe key features of the RMIP developed in response to these challenges., Results: Medical education is evolving from discipline and hospital-based teaching to using more integrated, community-based teaching. The RMIP aims to immerse 5th-year medical students in an integrated, patient-centred, community-based, parallel learning environment where learners' experiences in primary, secondary, and tertiary settings are always based on patient care. Government funding for the RMIP pilot was granted in November 2006 and the first 6 students started in the programme in 2007. Experiences of the programme from 2007-2009 are reported., Conclusion: The RMIP remains true to the principles underpinning its establishment and has to date delivered successful medical education outcomes for the first 18 students of the 2007 and 2008 cohorts. We cannot yet assess its role in future recruitment to rural medical careers.

Aim: To describe the variety and range of work that New Zealand rural hospitals perform, and to examine the factors that might influence either of these, including: the characteristics of the doctors who work in rural hospitals; the facilities available; and environmental factors (such as geographical isolation and the size of the catchment population)., Method: Structured postal questionnaire., Results: There are about 44 rural hospitals in New Zealand, depending on definition. Catchment populations range from 750 to 45,000. They are staffed by either Medical Officers of Special Scale (MOSSes) or General Practitioners (GPs). They have varying levels of resources such as laboratory services and radiology services available on-site. They care for a wide range of patients and manage health conditions covering many different vocational areas of practice., Conclusion: Rural hospitals should be defined and recognised as a distinct entity to assist the development of appropriate vocational training pathways for their staff. They play an important and unique role in New Zealand's healthcare system which is currently unrecognised.

Aim: To measure trends in the cardiovascular preventive medication prescribing in New Zealand primary care during 2000-2003., Methods: Demographic, risk factor, and prescribing data from the Dunedin Royal New Zealand College of General Practitioners Research Unit database were analysed. The data set consisted of men aged at least 45 years and women at least 55 years, who consulted a doctor in 2000-2003 in a practice that supplied electronic clinical notes (total number varied by year from 24,292 to 30,842)., Results: Cardiovascular risk (as calculated by the Framingham-based [Anderson] risk equation) could only be estimated for one-third of the study population due to missing risk factor information. In 2000, prescription of both blood pressure- and cholesterol-lowering medications occurred in 28% of people with established vascular disease and 14-16% of people without vascular disease but with a 5-year cardiovascular risk over 5%. From 2000 to 2003, the treatment of all patient groups with a 5-year cardiovascular risk of >10% (vascular history or not) increased by about 4% per year. Those in the 5-10% cardiovascular risk bracket increased treatment by about 3% per year., Conclusions: Cardiovascular medicine treatment gaps in primary care reduced between 2000 and 2003 but a significant gap persisted. There is only modest evidence that treatment rates are targeted to estimated cardiovascular risk. Data on the prescription of these medications by cardiovascular risk needs to be collected, analysed, and disseminated on an ongoing basis to enable close monitoring of strategies to improve cardiovascular risk assessment and management.

Aim: To determine risk factors monitored in primary care that were significantly associated with diabetes complications requiring hospitalization., Methods: We examined clinical and demographic data for 1080 Type 1 and 11,283 Type 2 New Zealand diabetes patients attending a free primary care diabetes examination between 2000 and 2002. Hospital admissions data for the 2 years following the index examination were linked for each patient using a unique National Health Index code. Logistic regression was used to determine odds ratios for the likelihood of developing diabetic complications adjusted for each variable., Results: In the Type 1 cohort, 222 patients (20.6%) were hospitalized for diabetes complications and 1948 patients (17.3%) in the Type 2 cohort. In both cohorts, patients admitted with diabetes complications had significantly higher mean glycosylated haemoglobin (HbA1c) (p<0.001) and triglyceride levels (p<0.001), urine albumin:creatinine ratios (p<0.001) and duration of diabetes (p<0.01 Type 1: p<0.001 Type 2) than patients not admitted. In Type 2 patients, age, obesity, HbA1c, urine albumin:creatinine ratios, HDL levels and treatment with insulin or oral medication were all associated with increased odds of admission., Conclusions: Although it is well known that HbA1c is a significant predictor of diabetes complications, this study shows that urine albumin:creatinine ratio, body mass index, triglycerides and high density lipoproteins are also independent predictors of hospitalization for diabetes complications. Attention to all these factors in the primary care setting is indicated if the burden of diabetes complications to hospital services is to be minimized.

Aim: To measure changes in the health status of 840 Type 1 and 9998 Type 2 diabetes patients who had completed three free annual diabetes reviews by December 2005., Method: We evaluated changes in clinical measures and differences in proportions of patients achieving guideline targets between the first and third reviews. Logistic regression analysis examined variables associated with an absolute decrease in HbA1c level of at least 1% from the first to the third review., Results: The proportion of patients achieving guideline targets for glycaemic control fell from 17.1% to 12.2% for Type 1 diabetes (p=0.004) and from 56.1% to 50.2% for Type 2 diabetes (p<0.001). There were significant improvements in mean albumin:creatinine ratio, total cholesterol, and high density lipoprotein levels in both diabetes cohorts and mean blood pressure and triglyceride levels in Type 2 patients. Adjusted odds of improved glycaemic control were higher for Type 2 diabetics treated with oral medication only (OR=4.27 (95%CI: 3.45-5.14)), insulin only (OR=7.10 [95%CI: 5.58-9.04]), and insulin and oral therapy (OR=10.05 [95%CI: 7.72-13.09])., Conclusion: The introduction of a structured and systematic general practice review process aimed at improving diabetes care and patient outcomes resulted in significant improvements in mean blood pressure, cholesterol levels, and albumin:creatinine ratio. There was, however, no overall improvement in glycaemic control

Aim: To examine characteristics of general practice consultations in a New Zealand primary care population of patients who died by suicide., Methods: Case control study design, with data linkage between the RNZCGP Research Unit Database, the National Mortality Database and the Hospital Separation Diagnosis Database (hospital discharges) from 1996 to 2001. The cases were suicides who had attended a general practice contributing data to the Research Unit database. Each case was matched by gender and age to three randomly selected patients from the Research Unit database., Results: There were 221 cases of suicide identified, of which 60% had a general practice consultation in the 6 months prior to death. The significant exposure variables, corrected OR (95% CI) in the multivariate analysis were: any previous hospital admission (between January 1996 and date of death) for a psychiatric condition, 23.75 (9.01 to 62.63); any notation in the general practice record of depression, suicidal ideation or self-harm, 14.97 (4.61 to 48.65); previous hospital admission with self-harm, 8.39 (1.73 to 40.65); and general practice prescription of sedatives, 4.34 (1.69 to 11.10)., Conclusions: In general, general practice patients who commit suicide have higher rates of depression, suicidal ideation, previous self harm, and sedative prescription than average.

Aim: To characterise doctors' responses to complaints., Method: Survey of a systematic sample of New Zealand doctors, and indepth interviews with 12 doctors who recently received complaints., Results: 714 written survey responses and 12 indepth interviews revealed changes consistent with positive and negative defensive medicine as well as changes in the direction of "good practice". Positive defensive medicine changes were increased investigation and referral rates, active identification of potential problem patients, over-documentation and consenting, and altered approaches to time and workload. Negative defensive medicine changes involved withdrawal from the doctor-patient relationship and particular fields of practice. Good practice changes included reflective practice, greater sensitivity to societal and professional expectations, and initiating systemic change., Conclusions: The complaints process in New Zealand has the potential to improve healthcare delivery at a systemic level and to reinforce appropriate standards of professional behaviour, but it may cause individual doctors to practice defensively. Unless an appropriate educational process is allied to the complaints process, defensive medicine may compromise patient care and constrain potential improvements in healthcare delivery overall.

Objective: To compare the care and health status of different ethnic groups attending general practices with diabetes., Method: We analysed information about 13,281 patients with any type of diabetes, collected by 242 general practices in the first visit of the Southlink Independent Practitioner Association's Get Checked program. These patients constituted about 60% of patients with diabetes in the South Island of New Zealand., Results: 13,196 (99.4%) patients had Type 1 or Type 2 diabetes. Of these, 11,911 (90.3%) were Europeans, and 759 (5.8%) were Maori or Pacific Islanders (mostly of Samoan, Tongan, Niuean, or Cook Islands origin). There was no difference between ethnic groups in total cholesterol, proportions on oral therapy or statins, or having a foot check. Maori and Pacific Islanders had poorer glycaemic control (HbA1c > 8.0 for 41.5% of Maori or Pacific Islanders versus 23.8% of New Zealand Europeans; 95% confidence interval for the difference [CI]: 14.0, 21.1), and were less likely to have retinopathy screening (71.9% versus 77.9%; CI: -9.2, -2.6). In patients with Type 2 diabetes (and compared with Europeans) Maori and Pacific Islanders were younger, had higher mean body mass indices (males 33.9 versus 29.5; CI: 3.9, 5.0 and females - 34.6 versus 30.7; CI: 3.2, 4.6) and diastolic blood pressures 82.4 mmHg versus 78.7 mmHg (CI: 2.9, 4.5), and were more likely to smoke (27.5% versus 10.9%; CI: 13.3, 19.9). Overall, Maori and Pacific Islanders were more likely to be at high risk for microvascular complications (9.0% versus 4.4%; CI: 2.5, 6.6)., Conclusions: In this study, Maori and Pacific Island patients had a demographic profile suggesting greater health vulnerability (especially for those with Type 2 diabetes) yet similar routine diabetes care (especially for those with Type 1 diabetes). Ethnic inequalities were noted in seven of nine health status measures., Implications: The Get Checked program aims to increase the health of all patients with diabetes but whether it accentuates or diminishes ethnic disparities is not yet known.

Objective: To describe errors Canadian family physicians found in their practices and reported to study investigators. To compare errors reported by Canadian family physicians with those reported by physicians in five other countries., Design: Analytical study of reports of errors. The Linnaeus Collaboration was formed to study medical errors in primary care. General practitioners in six countries, including a new Canadian family practice research network (Nortren), anonymously reported errors in their practices between June and December 2001. An evolving taxonomy was used to describe the types of errors reported., Setting: Practices in Canada, Australia, England, the Netherlands, New Zealand, and the United States., Participants: Family physicians in the six countries., Main Outcome Measures: Types of errors reported. Differences in errors reported in different countries., Results: In Canada, 15 family doctors reported 95 errors. In the other five countries, 64 doctors reported 413 errors. Although the absence of a denominator made it impossible to calculate rates of errors, Canadian doctors and doctors from the other countries reported similar proportions of errors arising from health system dysfunction and gaps in knowledge or skills. All countries reported similar proportions of laboratory and prescribing errors. Canadian doctors reported harm to patients from 39.3% of errors; other countries reported harm from 29.3% of errors. Canadian physicians considered errors "very serious" in 5.8% of instances; other countries thought them very serious in 7.1% of instances. Hospital admissions and death were among the consequences of errors reported in other countries, but these consequences were not reported in Canada., Conclusion: Serious errors occur in family practice and affect patients in similar ways in Canada and other countries. Validated studies that analyze errors and record error rates are needed to better understand ways of improving patient safety in family practice.

Aim: To report tactics for avoiding and remedying medical errors observed by general practitioners in New Zealand and five other countries., Methods: The Primary Care International Study of Medical Errors collected 66 reports of medical errors in New Zealand and 363 reports from general practitioners in Australia, Canada, England, the Netherlands, and the United States. Strategies for avoiding and overcoming errors were grouped by themes, for New Zealand and the five other countries combined., Results: In all New Zealand reports and 336 (92.6%) reports from other countries, doctors offered at least one error prevention idea. The largest category of suggestions was 'more diligence' (New Zealand: 69.7% of reports, other countries: 55.3%). Other strategies were: 'provide care differently' (New Zealand 22.7%, other countries 36.4%); 'improve communication' (19.7% and 17.8% of reports); 'education' (7.8% and 11.0% of reports); and 'more resources' (12.1% and 14.0% of reports)., Conclusions: In general practitioners' medical errors reports, a culture of individual blame is more evident than recognised need for systems design. A minority of reports contained specific, pragmatic suggestions for changing healthcare systems to protect patients' safety. Error reporting systems may be a practical way to generate innovative solutions to potentially harmful problems facing general practice patients.

Background: The structure of family practice residency programs remains essentially unchanged from the model first proposed more than 35 years ago. Advances in medical technology and knowledge combined with increasing restrictions on resident work hours and decreasing medical student interest invite reconsideration of how family physicians are trained., Methods: We resurveyed 442 third-year family practice residents who had participated in a prior study in 2000 to determine whether their opinions about the length and content of residency had changed and whether they would still choose to be a physician and a family physician., Results: Thirty-seven percent of responding third-year residents favored extending family practice residency to 4 years. Compared as groups, there was relatively little change in opinion between first- and third-year residents. However, residents' individual responses about the settings and content areas for which they would be willing to consider extending training varied considerably between years 1 and 3. Personal characteristics did not seem to influence residents' opinions about length and content of training. Reasons for favoring a 4-year program and barriers to change were similar to those reported previously. Residents' commitment to medicine and family medicine was still strong and was not associated with their opinions about length of training., Conclusion: Although most surveyed residents favored a 3-year residency program, a substantial minority still supported extending training to 4 years, and the majority would still choose to enter family medicine programs if they were extended. Given a lack of consensus about specific content areas, family medicine should consider a period of experimentation to determine how to best prepare future family physicians.

Background: There is general consensus that the size of the US physician workforce now exceeds the health care needs of the American public. There is a greater proportion of specialists than primary care physicians, a specialty mix different from that of most other developed countries., Methods: The Colorado Board of Medical Examiners sent a one-page questionnaire to all physicians licensed to practice in the state. It contained the question: "How many hours in the last week did you provide primary care services, defined as either preventive care, routine physical exams, or treatment of common ailments?" The responses of physicians who reported non-primary-care medical specialties were analyzed with respect to their personal and practice characteristics., Results: Just under half (46.5%) of the 2745 specialist respondents reported having provided primary care services. As a group, however, 27.9% of specialist physicians' direct patient care time was devoted to primary care activities. The amount of primary care services being provided was greater among those not board-certified in their specialties, osteopathic physicians, and specialists spending less time in direct patient care., Conclusion: Additional evaluation is needed with a more comprehensive definition of primary care than used in this article, which includes important but difficult-to-measure elements, such as the integration of services, a sustained partnership with patients, and practice in the context of family and community. To the extent possible, this definition should not rely on physician self-definition of which examinations are routine and which ailments are common. However, the contribution of specialists should be considered in future primary care needs assessments, and specialists who experience low demand for their particular specialties may be especially inclined to provide primary care services.

Background: Medical care ecology has previously been investigated for adults, but no similar exploration has been made specifically for children., Objective: To describe proportions of children receiving care in 6 types of health care setting on a monthly basis and to identify characteristics associated with receipt of care in these settings., Methods: Nationally representative data from the 1996 Medical Expenditure Panel Survey were used to estimate the number of children per 1000 per month who received care at least once in each type of setting. Multivariate analyses assessed associations between receiving care in various settings and children's sociodemographic factors (age, sex, ethnicity, poverty, parent's education, urban or rural residence, insurance status, and whether or not the child had a usual source of care)., Results: Of 1000 children aged 0 to 17 years, on average each month 167 visited a physician's office, 82 a dentist's office, 13 an emergency department, and 8 a hospital-based outpatient clinic. Three were hospitalized and 2 received professional health care in their home. Younger age was associated with increased proportions of children receiving care in all health care settings except dentists' clinics. Poverty, lack of health insurance, black race, and Hispanic ethnicity were associated with decreased receipt of care in physicians' and dentists' offices. Only age (<2 years and 13-17 years) and poverty status were associated with hospitalization (P <.05 for each). Rural residence was not associated with any significant variation in proportions of children receiving care in any setting. Having a usual source of care was associated with increased receipt of care in all settings except hospitals., Conclusions: The ecology of children's medical care is similar to that of adults in the United States in that a substantial proportion of children receive health care each month, mostly in community-based, outpatient settings. In all settings except emergency departments, receipt of care varies significantly by children's age, race, ethnicity, income, health insurance status, and whether they have a usual source of care.

Background and Objectives: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States., Methods: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis., Results: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988-1997 to 4.8 per year in the 4 years following passage of the BBA., Conclusions: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.

Objective: To describe and classify process errors and preventable adverse events that occur from medical care in outpatient primary care settings., Study Design: Systematic review and synthesis of the medical literature., Data Sources: We searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care and limited the search to English-language publications. Published bibliographies and Web sites from patient safety and primary care organizations were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed and from seminal papers in the field., Outcomes Measured: Process errors and preventable adverse events., Results: Four original research studies directly studied and described medical errors and adverse events in primary care, and 3 other studies peripherally addressed primary care medical errors. A variety of quantitative and qualitative methods were used in the studies. Extraction of results from the studies led to a classification of 3 main categories of preventable adverse events: diagnosis, treatment, and preventive services. Process errors were classified into 4 categories: clinician, communication, administration, and blunt end., Conclusions: Original research on medical errors in the primary care setting consists of a limited number of small studies that offer a rich description of medical errors and preventable adverse events primarily from the physician's viewpoint. We describe a classification derived from these studies that is based on the actual practice of primary care and provides a starting point for future epidemiologic and interventional research. Missing are studies that have patient, consumer, or other health care provider input.

Objectives: To develop an international taxonomy describing errors reported by general practitioners in Australia and five other countries., Design and Setting: GPs in Australia, Canada, the Netherlands, New Zealand, the United Kingdom and the United States reported errors in an observational pilot study. Anonymous reports were electronically transferred to a central database. Data were analysed by Australian and international investigators., Participants: Non-randomly selected GPs: 23 in Australia, and between 8 and 20 in the other participating countries., Main Outcome Measures: Error categories, and consequences., Results: In Australia, 17 doctors reported 134 errors, compared with 301 reports by 63 doctors in the other five countries. The final taxonomy was a five-level system encompassing 171 error types. The first-level classification was "process errors" and "knowledge and skills errors". The proportion of errors in each of these primary groups was similar in Australia (79% process; 21% knowledge and skills) and the other countries (80% process; 20% knowledge and skills). Patient harm was reported in 32% of reports from Australia and 30% from other countries. Participants considered the harm "very serious" in 9% of Australian reports and 3% of other countries' reports., Conclusions: This pilot study indicates that errors are likely to affect primary care patients in similar ways in countries with similar primary healthcare systems. Further comparative studies are required to improve our understanding of general practice error differences between Australia and other countries.

Background: Title VII predoctoral and departmental grants for departments of family medicine are intended to increase the number of family and primary care physicians in the United States and increase the number of practices in rural and underserved communities. This study assessed the relationships of Title VII funding with physicians' choices of practice specialty and location., Methods: Non-federal direct patient care physicians who graduated from US medical schools from 1981-1993 were identified in the 2000 American Medical Association Masterfile. A grant history file was used to annotate Masterfile records with Title VII funding data for the physicians' 4-year medical school enrollment. Characteristics of the county in which they practice were taken from the Area Resource File. Title VII funding variables were then related to practice specialty and location., Results: Predoctoral training and departmental development funding were strongly related to attainment of each of the Title VII program objectives evaluated., Conclusions: Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues.

Background: Family practice residency programs are based largely on a model implemented more than 30 years ago. Substantial changes in medical practice, technology, and knowledge necessitate reassessment of how family physicians are prepared for practice., Methods: We simultaneously surveyed samples of family practice residency directors, first-year residents, and family physicians due for their first board recertification examination to determine, using both quantitative and qualitative methods, their opinions about the length and content of family practice residencies in the United States., Results: Twenty-seven percent of residency directors, 32% of residents, and 28% of family physicians favored extending family practice residency to 4 years; very few favored 2- or 5-year programs. There was dispersion of opinions about possible changes within each group and among the three groups. Most in all three groups would be willing to extend residency for more training in office-based procedures and sports medicine, but many were unwilling to extend residency for more training in surgery or hospital-based care. Residents expressed more willingness than program directors or family physicians to change training. Barriers to change included disagreement about the need to change; program financing and opportunity costs, such as loss of income and delay in debt repayment; and potential negative impact on student recruitment., Conclusion: Most respondents support the current 3-year model of training. There is considerable interest in changing both the length and content of family practice training. Lack of consensus suggests that a period of elective experimentation might be needed to assure family physicians are prepared to meet the needs and expectations of their patients.