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Aortic arteriovenous malformations (AVMs) are rare vascular anomalies where the aorta communicates with adjacent venous structures, bypassing the capillary system. We report a case of a neonate born at 34 weeks gestation who presented at 3 weeks of life in respiratory distress. Echocardiography demonstrated severe pulmonary hypertension with right ventricular dilatation but an otherwise structurally normal heart. Clinical examination revealed a pulsatile abdominal mass with an audible bruit. Abdominal ultrasound was performed and it demonstrated a large cystic mass arising from the inferior vena cava (IVC) with both arterial and venous vascular flow within it. Further evaluation with magnetic resonance angiography (MRA) showed a massive arteriovenous malformation from both left and right iliac arteries, and lumbar arteries communicating with the IVC. A decision was made with interventional radiology to attempt coiling of the vascular lesion. Following this procedure his pulmonary hypertension worsened in severity, culminating in acute heart failure and multi-organ dysfunction. A subsequent interventional radiology procedure found that there was no blood flow to his bowel or abdominal viscera. Cardiac arrest followed with an unsuccessful attempt at resuscitation. This case describes a presentation of severe pulmonary hypertension initially considered to be secondary to either congenital heart disease or intrinsic pulmonary disease, but which was found to be as a result of a very rarely occurring massive aortic AVM.

BACKGROUND Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and cardiovascular events. In New Zealand (NZ), Māori (indigenous New Zealanders) and Pacific people experience higher rates of AF compared with non-Māori/non-Pacific people. AIM To describe a primary care population with AF in NZ. Stroke risk and medication adherence according to ethnicity are also detailed. METHODS Electronic medical records for adults (≥20 years, n = 135 840, including 19 918 Māori and 43 634 Pacific people) enrolled at 37 NZ general practices were analysed for AF diagnosis and associated medication prescription information. RESULTS The overall prevalence of non-valvular AF (NVAF) in this population was 1.3% (1769), and increased with age (4.4% in people ≥55 years). Māori aged ≥55 years were more likely to be diagnosed with NVAF (7.3%) than Pacific (4.0%) and non-Māori/non-Pacific people (4.1%, P < 0.001). Māori and Pacific NVAF patients were diagnosed with AF 10 years earlier than non-Māori/non-Pacific patients (median age of diagnosis: Māori = 60 years, Pacific = 61 years, non-Māori/non-Pacific = 71 years, P < 0.001). Overall, 67% of NVAF patients were at high risk for stroke (CHA2 DS2 -VASc ≥ 2) at the time of AF diagnosis. Almost half (48%) of Māori and Pacific NVAF patients aged

Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and cardiovascular events. In New Zealand (NZ), Māori (indigenous New Zealanders) and Pacific people experience higher rates of AF compared with non-Māori/non-Pacific people.To describe a primary care population with AF in NZ. Stroke risk and medication adherence according to ethnicity are also detailed.Electronic medical records for adults (≥20 years, n = 135 840, including 19 918 Māori and 43 634 Pacific people) enrolled at 37 NZ general practices were analysed for AF diagnosis and associated medication prescription information.The overall prevalence of non-valvular AF (NVAF) in this population was 1.3% (1769), and increased with age (4.4% in people ≥55 years). Māori aged ≥55 years were more likely to be diagnosed with NVAF (7.3%) than Pacific (4.0%) and non-Māori/non-Pacific people (4.1%, P0.001). Māori and Pacific NVAF patients were diagnosed with AF 10 years earlier than non-Māori/non-Pacific patients (median age of diagnosis: Māori = 60 years, Pacific = 61 years, non-Māori/non-Pacific = 71 years, P0.001). Overall, 67% of NVAF patients were at high risk for stroke (CHAAF screening and stroke thromboprophylaxis in Māori and Pacific people could start below the age of 65 years in NZ.

Background Quality indicators are an important part of the primary care landscape, but focus strongly on point-in-time measurements, such as a patient's last blood pressure (BP) measurement. There is a larger space of possible measurements, including ones that more explicitly consider management over an interval of time. Objective To determine the predictive abilities of five different quality indicators related to poor BP control. Methods Data from two New Zealand general practices was analysed on five BP control indicators for patients with diagnosed hypertension: 1) last BP high (>150/90 mmHg); 2) last BP high or no BP measurement; 3) two or more consistently high BP measurements for _90 days; 4) a high BP then lapse of >120 days in BP measurement; and 5) antihypertensive medication possession ratio (MPR) of Results Positive predictive value (PPV) of indicators for the same indicator nine months later ranged from 27% (last BP high) to 64% (MPR). PPVs among the five measures with respect to the same time period ranged from 9% to 77% (median 33%). Conclusions Modest PPVs between indicators suggest the importance of considering multiple indicators to incentivise best management across diverse aspects of BP control.

Diabetes is a common disease affecting 9% of the adult population worldwide. People with impaired glucose tolerance ('prediabetes') are at high risk of progressing to type 2 diabetes.To understand prediabetes incidence rate, we analysed the electronic medical records (EMR) from 14 New Zealand general practices regarding patients aged ≥20 years and enrolled with the practices between 2009 and 2012. Prediabetes incidence rate was calculated by the number of patients with an initial HbA1c of 41-49 mmol/mol in 2011 among those who had not been diagnosed or treated for diabetes.28,192 adults were included in the analysis, 11% of this cohort had diabetes before 2011. 1,276 new cases of prediabetes were identified in 2011, giving a 5.0% incidence rate. The relative risk (RR) for prediabetes was increased for the Māori and Pacific groups versus non-Māori/non-Pacific people, with RR of 1.97 in the younger age groups (lt;50 years) and RR of 1.42 in the 50+ group. The RR for having uncontrolled HbA1c (highest HbA1c in 2011 ≥65 mmol/mol) among the whole adult population was also increased for the Māori and Pacific groups versus non-Māori/non-Pacific people (RR=3.35 among thoselt;50 years, RR=4.35 in the 50+ group).EMR analysis identified an alarming incidence rate of prediabetes, especially among Māori and Pacific groups, highlighting the need to better prevent and manage the condition.

Skin and subcutaneous tissue infections (SSTI) are common conditions that cause avoidable hospitalisation in New Zealand. As part of a program to improve the management of SSTI in primary care, electronic medical records (EMR) of four Auckland general practices were analysed to identify SSTI occurrences in the last three years.An ontology for SSTI risks, manifestation and treatment was created based on literature and guidelines. An SSTI identification algorithm was developed examining EMR data for skin swab tests, diagnoses (READ codes) and textual clinical notes.High occurrence and recurrence rates in those aged 20 or younger were found. Due to low usage of READ coding and laboratory tests, 65% of SSTI occurrences were identified by notes. However, 91% of all identified SSTI occurrences were appropriately treated with oral/topical antibiotics according to prescription records in the EMR. The F1 score of the analysis algorithm is 0.76 using manual review as gold standard.The SSTI identification algorithm shows a reasonable accuracy suggesting the feasibility of automatic detecting SSTI occurrences using clinical data that are routinely collected in healthcare delivery.

INTRODUCTION: Maori are overrepresented in cardiovascular disease (CVD) mortality and morbidity statistics in New Zealand (NZ). AIM: To examine cardiovascular risk (CVR) assessment and management for Maori, utilising Caring Does Matter (CDM) initiative data. METHODS: Using 16 general practices? electronic medical records ? which include ethnicity data ? the rate of CVR screening, CVD medication treatment and adherence levels, and physiological measures for Maori patients at high CVR (=15% five-year risk of a cardiovascular event) were compared to findings for Pacific and non-Maori/non-Pacific patients. RESULTS: Records for 72 351 adults (10 358 Maori; 14%) showed that Maori patients have a poorer CVR assessment rate (46% at guideline-indicated age) than Pacific and non-Maori/non-Pacific groups; when assessed, a greater proportion of Maori patients (38%) were at high CVR. The proportion of high-CVR Maori patients being treated with oral antidiabetic medication (42%) was lower than for Pacific patients but higher than for non-Maori/non-Pacific patients. Lower rates of antihypertensive adherence were found for high-CVR Maori patients than for non-Maori/non-Pacific patients (although higher than for Pacific patients). The high-CVR Maori patients who adhered to CVD medications had lower blood pressure, total-to-HDL cholesterol ratio and HbA1c than non-adherers. DISCUSSION: The association between higher medication adherence and better control of risk factors suggests that adherence should be further promoted by clinicians. More active CVR assessment, treatment and support of medication adherence in Maori attending general practices is justified, given their high mortality rate from CVD in comparison to the overall NZ population. KEYWORDS: Antihypertensives; blood pressure; cardiovascular diseases; haemoglobin A, glycosylated; medication adherence

The Caring Does Matter (CDM) programme aimed to improve cardiovascular disease risk (CVR) management in Pacific people, targeting medication adherence problems. This paper presents cluster analysis of CDM data to model medication adherence and cardiovascular risk factors in high-CVR patients.Changes in cardiovascular medication adherence status and in physiological measures of high-CVR Pacific patients, as well as their baseline physiological measures, demographics and other risk factors are included in the analysis. Differences in resulting clusters are described to provide insight into the population.1786 Pacific patients were identified with high CVR (≥ 10%, 5 year event risk) at baseline and were still enrolled with the thirteen participating general practices at CDM end. Two of three models attempted produced significant clusters: a two-cluster model indicating patients who failed to improve adherence during the programme had higher prevalence of diabetes; and a three-cluster model where one cluster was characterised by higher but improving blood pressure, and another characterised by higher but improving HbA1c.Cluster analysis reveals statistically distinct patient groups, including differences in characteristics of patients less responsive to the programme intervention. This provides a basis for further efforts to understand the population and better tailor interventions.

Background: Prior studies suggest that only about twothirds of patients who present with an acute coronary syndrome (ACS) are maintained on a statin post-discharge. This could be due to sub-optimal initiation or poor longer-term adherence. The aim of this study was to identify the pattern of statin adherence following ACS from initial prescription to three years post-discharge. Methods: ANZACS-QI registry data for consecutive New Zealand residents hospitalised with ACS was anonymously linked to national datasets to derive a Statin Possession Ratio (SPR) to assess maintenance. Results: Of 1846 patients discharged alive 95% were prescribed a statin at discharge and 92% were dispensed a statin within 3 months, but only 75% had an adequate SPR 0.8 in the first year, and 67% in year 3. In year 3, 11% had no statin dispensed and another 21% had intermittent statin dispensing (SPR >0 to

To assess gender differences in cardiovascular disease risk (CVR) assessment and management for Pacific people in New Zealand.New Zealand guidelines indicate CVR assessment from age 35 years for Pacific men and from age 45 years for Pacific women. Using general practice electronic medical records from 16 practices in New Zealand, the rate of CVR screening, treatment patterns and physiological measures for high-CVR (≥15% five-year) patients were assessed for Pacific patients ≥20 years of age by gender.Records for 10 863 Pacific patients showed a higher proportion of indicated women screened for CVR (65 vs 56%), but a lower proportion of assessed women with high CVR (28% for Pacific women vs 40% for Pacific men). Many of these high-CVR patients had physiological measures well above desirable levels based on their most recent readings. In the high-CVR group, women had similar CVR levels to men, but higher systolic blood pressure and HbA1c level, and a higher proportion of women were treated with antihypertensive and oral antidiabetic medication. There were substantial levels of poor medication adherence, particularly for cholesterol-lowering medication. Women and men were equally likely to adhere to treatment. Those adhering to relevant medications had lower blood pressure, total-to-HDL cholesterol ratio and HbA1c than non-adherers.Pacific men were less likely than Pacific women to have their CVR assessed when indicated, more likely once assessed to have high CVR and equally likely to adhere to treatment. Medication adherence was associated with better control of risk factors and should be further promoted in this population.

The consequences of sepsis extend well beyond the acute illness which required admission to the critical care unit. It is well established that that there is increased late mortality following a hospital admission for sepsis. The cause for this increased late mortality has been disputed, multiple observational studies have aimed to examine whether this risk is associated with pre-existing poor health, or if there is an underlying pathobiological mechanism occurring with sepsis that increases late mortality independent of baseline health.

Analysis of practice electronic medical records (EMRs) demonstrated widespread antihypertensive medication adherence problems in a Pacific-led general practice serving a predominantly Pacific (majority Samoan) caseload in suburban New Zealand. Adherence was quantified in terms of medication possession ratio (MPR, percent of days covered by medication supply) from the practice's prescribing data. We studied the effectiveness of general practice staff follow-up guided by EMR data to improve medication adherence.A framework for identification of suboptimal long-term condition management from routinely-collected EMR data, the ChronoMedIt (Chronological Medical Audit) tool, was applied to data of two Pacific-led general practices to identify patients with low MPR. One practice undertook intervention, the other provided usual care. A cohort was based on MPR80% for antihypertensive medication in a baseline 6-month period. At the intervention practice a team was established to provide reminders and motivation for these patients and discuss their specific needs for assistance to improve adherence for 12 months. MPR and systolic blood pressure (SBP) was collected at baseline and for last six months of intervention based on practice EMRs; national claims data provided assessment of MPR based on dispensing. Nursing notes were analysed, and patient and provider focus groups were conducted.Of the 252 intervention patients with MPR80% initially, MPR improved 12.0% (p=0.0002) and systolic blood pressure was 3.5mmHg lower (p=0.07) as compared to the control cohort. MPR from national claims data improved by 11.5% (p=0.0001) as compared to the control. Patients welcomed the approach as caring and useful. Providers felt the approach worthy of wider deployment but that it required dedicated staffing.Systematic follow-up of patients with demonstrated poor medication possession appears effective in the context of a Pacific-led general practice serving a largely Pacific caseload. It was possible to exploit the EMR database to identify patients with low antihypertensive medication possession and to raise their level of medication possession significantly. The measured effect on systolic BP was only marginally significant, leaving open the question of the precise value of the intervention in terms of morbidity and mortality. The intervention was found to be feasible and was met with good acceptance from the intervention patients, who appreciated the concern reflected in the follow-up effort. The intervention practice is continuing use of ChronoMedIt to guide long-term condition management with extension to cholesterol and blood sugar.

Poor adherence to long-term prescription medication is a frequent problem that undermines pharmacological control of important risk factors such as hypertension. A medication possession ratio (MPR) can be calculated from Practice Management System (PMS) data to provide a convenient indicator of adherence. We investigate how well prior MPR predicts later MPR, taking MPRlt;80% as indicative of 'non-adherence,' to assess the potential value of MPR calculation on PMS data for targeting adherence promotion activities by general practices. We examine PMS data for two New Zealand metropolitan general practices, one with a predominantly Pacific caseload, across 2008 and 2009. We find prevalence of non-adherence in 2009 to be 51.63% (95% confidence interval [CI] 47.9-55.3) for patients at the Pacific practice and 28.09% (95% CI 25.0-31.1) at the other practice for patients who are demonstrably active with the practice in 2009. The positive predictive value (PPV) of 2008 non-adherence for 2009 non-adherence is 71.80% (95% CI, 66.5-77.1) and negative predictive value (NPV) 61.52% (95% CI 56.9-66.1) for the Pacific practice; PPV is 61.38% (95% CI 54.6-68.2) and NPV is 82.19% (95% CI 79.2-85.2) for the other practice. The results indicate good potential for decision support tools to target adherence promotion.

Pay for performance incentives are becoming increasingly popular, but are typically based on only a single point-in-time measurement as an indicator of chronic condition management.To determine the association between three time-interval based indicators of suboptimal blood pressure (BP) control and two point-in-time indicators from the UK Quality and Outcomes Framework (QOF): BP5 (the percentage of patients with hypertension in whom the last BP in the previous nine months wasor = 150/90) and DM12 (the percentage of patients with diabetes in whom the last BP in the previous 15 months wasor = 145/85).We extracted classification data and BP measurements from four New Zealand general practices with 4260 to 6130 enrolled patients. Data were analysed for three indicators with respect to a nine-month evaluation period for patients with hypertension and a 15-month period for patients with diabetes: (1) two or more consistently high BP measurements spaced overor = 90 days, (2) a high BP measurement followed by a lapse of120 days in BP measurement and (3) no BP measurement for180 days.For the four practices, 65-81% of the patients satisfied BP5 and 59-68% of patients satisfied DM12. Of the hypertension patients satisfying BP5, 31% (95% CI: 28-33%) failed at least one of the three interval based indicators; 42% (95% CI: 39-46%) of the diabetes patients satisfying DM12 failed at least one of the three interval based indicators.Considering only a point-in-time controlled BP measurement provides an incomplete view of the quality of BP management in patients with hypertension or diabetes over a period of time.

Assessment for compensation of occupational injury forms is commonplace for occupational medicine specialists and less frequently for other health-care providers. There is no specific training to understand the legal system that forms the basis of any compensation system. This paper sets out a process for judging medical scientific evidence in cases of suspected occupational injury or disease. The process is confusing for medical and legal professionals because of the lack of a common understanding. Understanding the concepts of balance of probabilities and scientific probability is essential for clarity of approach. There is an inevitable conclusion that cause of occupational injury or disease in each case will rest on a sequential consideration of general and specific cause.

To assess use of Electronic Medical Records (EMRs) to identify patient cases for potential quality improvement in use of blood pressure-lowering medications in general practice.One metropolitan general practice in Auckland with a high proportion of Pacific patients.Patients registered as regular patients with the practice; classified within the previous 5 years as having hypertension; with at least one prescription for antihypertensive medication in the year prior to the evaluation period of 9 May to 8 November 2007.Iterative discussion of quality improvement opportunities and review of EMRs with a panel of practice clinicians to identify agreed quality indicators based on EMR data. This resulted in a set of eight evidence-based criteria for patients classified with hypertension, implemented as database queries, which identify cases for potential quality improvement. The panel conducted blind assessment of antihypertensive therapy on a sample of 20 cases matching at least one criterion and 20 cases that met no criterion; the case classifications based on the database queries were then revealed for direct comment and consideration by the panel.Of 517 eligible patients, 209 (40.4%) met one or more of the eight criteria. Of these 209, 110 (21.3%) met only criteria related to persistence of medication possession and/or blood pressure recording. After assessment of the 40-patient sample by the practice GPs, the eight criteria taken as a whole had a Positive Predictive Value of 70% (95% CI 46-88%) and Negative Predictive Value of 70% for clinician assessment of suboptimal therapy and/or process.EMRs can provide moderately reliable identification of patients with suboptimal management of blood pressure in general practice. It should be noted, however, that the complexity of required query formulation is substantial with current tools. Identification of patients with poor persistence of antihypertensive therapy is the most promising outcome for follow-up investigation. The study needs to be replicated in a range of different practice settings.

The ‘four principle’ view of medical ethics has a strong international pedigree. Despite wide acceptance, there is controversy about the meaning and use of the principles in clinical practice as a checklist for moral behaviour. Recent attempts by medical regulatory authorities to use the four principles to judge medical practitioner behaviour have not met with success in clarifying how these principles can be incorporated into a legal framework. This may reflect the philosophical debate about the relationship between law and morals. In this paper, legal decisions from two cases in which general practitioners have been charged with professional shortcomings are discussed. Difficulties with the application of the four principles (autonomy, beneficence, nonmaleficence and justice) to judge medical practitioner behaviour are highlighted. The four principles are relevant to medical practitioner behaviour, but if applied as justifications for disciplinary decisions without explanation, perverse results may ensue. Solutions are suggested to minimise ambiguities in the application of the four principles: adjudicators should acknowledge the difference between professional and common morality and the statutory requirement to give decisions with reasons.

INTRODUCTION: There are shortages in community-based general practice placements for medical students. Innovative ways to teach the skills required in general practice are needed. AIM: To assess the effectiveness of ‘simulated’ general practice clinics using actors, compared with standard community-based general practice attachments in medical undergraduate education. METHODS: Randomised controlled trial involving medical students. Outcome measures included self-reported knowledge, clinical confidence, communication skills, and attitudes within general practice assessed at baseline and after one week. Intervention students participated in 24 simulated consultations with actor-patients over four days. Control students spent four days working with community-based general practitioners and real patients. RESULTS: Of 138 eligible medical students in the first clinical year, 128 (93%) participated and 106/128 (82%) completed the study. Those participating in simulated clinics improved in confidence in history-taking (p=0.03), communication skills (p=0.04), and ability to detect depression (p

The 'four principle' view of medical ethics has a strong international pedigree. Despite wide acceptance, there is controversy about the meaning and use of the principles in clinical practice as a checklist for moral behaviour. Recent attempts by medical regulatory authorities to use the four principles to judge medical practitioner behaviour have not met with success in clarifying how these principles can be incorporated into a legal framework. This may reflect the philosophical debate about the relationship between law and morals. In this paper, legal decisions from two cases in which general practitioners have been charged with professional shortcomings are discussed. Difficulties with the application of the four principles (autonomy, beneficence, nonmaleficence and justice) to judge medical practitioner behaviour are highlighted. The four principles are relevant to medical practitioner behaviour, but if applied as justifications for disciplinary decisions without explanation, perverse results may ensue. Solutions are suggested to minimise ambiguities in the application of the four principles: adjudicators should acknowledge the difference between professional and common morality and the statutory requirement to give decisions with reasons.

AIM: To explore influences on adherence to taking long-term medications among Samoan patients in an Auckland general practice. METHODS: Twenty Samoan participants from an Auckland general practice were identified and interviewed about their views on adherence or non-adherence to taking blood pressure–lowering medications. One-to-one semi-structured interviews using open-ended questions were undertaken in Samoan and English, recorded, transcribed and translated into English. Transcriptions were examined by two researchers to identify themes. FINDINGS: Patients with ‘high’ and ‘lower’ rates of adherence to taking usual medication were identified using medication possession ratio cut-offs from medical records of timely prescribing. Ten participants with ‘high’ and 10 with ‘lower’ rates of adherence were interviewed, including 11 women and nine men. Themes identified for those with lower adherence included ‘lack of transport’, ‘family commitments’, ‘forgetfulness’, ‘church activities’, ‘feeling well’ and ‘priorities’. Themes identified for those with high rates of adherence included ‘prioritising health’, ‘previous event’, ‘time management’, ‘supportive family members’ and ‘relationship with GP (language and trust)’. A theme common to both was ‘coping with the stress of multiple comorbidities’. CONCLUSION: Reasons for adherence and non-adherence to taking blood pressure–lowering medications among the Samoan patients interviewed were multifactorial and encompass personal, social, cultural and environmental factors. Interdisciplinary teams to support treatment decisions (including Pacific health professionals or community health workers), systematic identification of those with low rates of adherence, phone or text follow-up, use of church or family networks, provision of transport where needed and better tools and resources may help address this problem. KEYWORDS: Medication adherence; New Zealand; Pacific Islands; ethnic groups; qualitative research; antihypertensive agents