Diverticular Disease Management in Primary Care: How do Estimates from Community-Dispensed Antibiotics Inform Provision of Care
Broad, JB; Wu, Z; Ng, J; Arroll B; Connolly MJ; Jaung R, et al (2019)
PLOS ONE. 2019;14(7):e0219818.View abstract
BACKGROUND: The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed.
AIM: To estimate how often DDI is managed in primary care, using antibiotics dispensing data.
DESING AND SETTING: Hospitalisation records of New Zealand residents aged 30+ years during 2007–2016 were individually linked to databases of community-dispensed oral antibiotics.
METHOD: Patients with an index hospital admission 2007–2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007–2016 for these people with ten individually-matched non-DDI residents, taking the case’s index date. Multivariable negative binomial models were used to estimate rates of antibiotic use.
RESULTS: From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation.
CONCLUSION: DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.
Post-operative Mortality Rates for Neck of Femur Fracture at Waitemata DHB
Kirk, R J; Lawes, C M M; Farrington, W; Misur, P; Walker, M L; Kluger, M; Seow, M Y; Andrew, P (2019)
NZMJ. 22 Feb 2019; 132(1490)View abstract
Our study investigated patient death rates following surgery for hip fracture at Waitemata DHB between 2009 and 2016. We found that 23.8% of patients died within one year of surgery; however death rates have gradually reduced in recent years. We also found that decreased time from hospital presentation to surgery was linked to improved survival in patients with hip fracture.
AIM: Mortality rates of up to 38% at one year have been reported following surgery for neck of femur fractures. The aim of this review is to evaluate the post-operative mortality rates and trends over time for patients with fractured neck of femur at Waitemata District Health Board.
METHOD: A retrospective cohort study of all patients who received surgery following a neck of femur fracture at Waitemata District Health Board between 2009 and 2016. Inpatient data was retrieved from electronic hospital records and mortality rates from the Ministry of Health, New Zealand. Analyses included crude mortality rates and trends over time, and time-to-theatre from presentation with neck of femur fracture.
RESULTS: A total of 2,822 patients were included in the study; mean age 81.9 years, 70.4% female and 29.6% male. Overall post-operative crude rates for inpatient, 30-day and one-year mortality were 3.7%, 7.2% and 23.8% respectively. Adjusted analyses showed a statistically significant decrease in mortality rates between 2009 and 2016 at inpatient (p=0.001), 30 days (p=<0.001) and one year (p=<0.001) time periods. There was also a significant association between time-to-theatre and mortality at inpatient (p=0.002), 30 days (p=0.0001), and one year (p=0.0002) time periods.
CONCLUSION: Mortality rates following surgery for fractured NOF have significantly improved over recent years at Waitemata District Health Board. Reduced time-to-theatre is associated with decreased inpatient, 30-day and one-year mortality.
Feasibility and Reliability of Clinical Coding Surveillance for Routine Monitoring of Adverse Drug Events in NZ Hospitals
Ng, J; Andrew, P; Muir, P; Greene, M; Mohan, S; Knight, J; et al (2018)
NZMJ. 26 Oct 2018; 131(1484)View abstract
The routine measurement of adverse drug events (ADE) is important for monitoring and informing improvement, but current detection tools are manual and too resource intensive. Our research, for the first time, shows ADEs can be reliably and sustainably measured using clinical coding surveillance (CCS). Using CCS, almost 12,000 ADEs over two years were detected in hospitalised patients. Most ADEs originated from the community setting.
AIM: To explore the feasibility and reliability of Clinical Coding Surveillance (CCS) for the routine monitoring of Adverse Drug Events (ADE) and describe the characteristics of harm identified through this approach in a large district health board (DHB).
METHOD: All hospital admissions at Waitemata DHB from 2015 to 2016 with an ADE-related ICD10-AM code of Y40-Y59, X40-X49 or T36-T50 were extracted from clinical coded data. The data was analysed using descriptive statistics, statistical process control and Pareto charts. Two clinicians assessed a random sample of 140 ADEs for their accuracy against what was clinically documented in medical records.
RESULTS: A total of 11,999 ADEs were identified in 244,992 admissions (4.9 ADEs per 100 admissions). ADEs were more prevalent in older adults and associated with longer average length of stays and medicines such as analgesics, antibiotics, anticoagulants and diuretics. Only 2,164 (18%) of ADEs were classified as originating within hospital. Of ADEs originating outside of the hospital, the main causes were poisoning by psychotropics, anti-epileptics and anti-parkinsonism agents and non-opioid analgesics. Clinicians agreed that 91% of ADE positive admissions were accurately classified as per clinical documentation.
CONCLUSION: CCS is a feasible and reliable approach for the routine monitoring of ADEs in hospitals.
Improving Quality of Clinical Coding of Post-Partum Haemorrhage: the Process and its Effects on Reported Incidence Rates in a NZ Hospital Maternity Service
Galgali, G; Fong, K; Bissell, K; Armstrong, D; Humphrey, G; (2018)
NZMJ. 27 Jul 2018; 131(1479):64-71.View abstract
AIM: The Waitemata District Health Board (DHB) aimed to investigate and improve the accuracy of its reporting of post-partum haemorrhage (PPH), to understand its true incidence.
METHOD: The quality improvement project included multidisciplinary collaboration between maternity clinicians and clinical coders, substantive redesign of the Waitemata DHB's birth documentation form, systematic auditing and follow-up of clinical documentation by a dedicated quality midwife, linking of maternity clinicians to a key designated senior coder and ongoing PPH incidence monitoring and staff education.
RESULTS: The coded rate of PPH has risen dramatically and is now in line with expected Australasian incidence levels. A corresponding increase in the value of cost-weighted discharges (estimated at $544,000 for the 2015/16 financial year) was realised as a result of the more accurate reported incidence.
CONCLUSION: This case illustrates the value of coding to a clinical service and the importance of clinical leadership and engagement in achieving successful and sustainable service redesign initiatives. It provides an example of how to evaluate and update coding and a process for changing the way clinicians and coders work that could benefit other services in Waitemata DHB as well as in other New Zealand district health boards.
Effectiveness of Text Message Based, Diabetes Self Management Support Programme (SMS4BG): Two Arm, Parallel Randomised Controlled Trial
Dobson, R; Whittaker, R; Jiang, Y; Maddison, R; Shepherd, M; McNamara, C; Cutfield, R; Khanolkar, M; Murphy, R; (2018)
BMJ May 2018; 361:k1959. DOI:10.1136/bmj.k1959.View abstract
OBJECTIVE: To determine the effectiveness of a theoretically based and individually tailored, text message based, diabetes self management support intervention (SMS4BG) in adults with poorly controlled diabetes.
DESIGN: Nine month, two arm, parallel randomised controlled trial.
SETTING: Primary and secondary healthcare services in New Zealand.
PARTICIPANTS: 366 participants aged 16 years and over with poorly controlled type 1 or type 2 diabetes (HbA1c ≥65 mmol/mol or 8%) randomised between June 2015 and November 2016 (n=183 intervention, n=183 control).
INTERVENTIONS: The intervention group received a tailored package of text messages for up to nine months in addition to usual care. Text messages provided information, support, motivation, and reminders related to diabetes self management and lifestyle behaviours. The control group received usual care. Messages were delivered by a specifically designed automated content management system.
MAIN OUTCOME MEASURES: Primary outcome measure was change in glycaemic control (HbA1c) from baseline to nine months. Secondary outcomes included change in HbA1c at three and six months, and self efficacy, diabetes self care behaviours, diabetes distress, perceptions and beliefs about diabetes, health related quality of life, perceived support for diabetes management, and intervention engagement and satisfaction at nine months. Regression models adjusted for baseline outcome, health district category, diabetes type, and ethnicity.
RESULTS: The reduction in HbA1c at nine months was significantly greater in the intervention group (mean −8.85 mmol/mol (standard deviation 14.84)) than in the control group (−3.96 mmol/mol (17.02); adjusted mean difference −4.23 (95% confidence interval −7.30 to −1.15), P=0.007). Of 21 secondary outcomes, only four showed statistically significant improvements in favour of the intervention group at nine months. Significant improvements were seen for foot care behaviour (adjusted mean difference 0.85 (95% confidence interval 0.40 to 1.29), P<0.001), overall diabetes support (0.26 (0.03 to 0.50), P=0.03), health status on the EQ-5D visual analogue scale (4.38 (0.44 to 8.33), P=0.03), and perceptions of illness identity (−0.54 (−1.04 to −0.03), P=0.04). High levels of satisfaction with SMS4BG were found, with 161 (95%) of 169 participants reporting it to be useful, and 164 (97%) willing to recommend the programme to other people with diabetes.
CONCLUSION: A tailored, text message based, self management support programme resulted in modest improvements in glycaemic control in adults with poorly controlled diabetes. Although the clinical significance of these results is unclear, the findings support further investigation into the use of SMS4BG and other text message based support for this patient population.
Visiting Fellow on Patient Engagement - After-Visit Report & Plan
De Bronkart, D; (2018)View abstract
The Revera i3 visting fellowship on patient engagement was a jointly sponsored opportunity to raise Revera's profile and commitment to "digital health to unleash the potential for all New Zealanders", in partnership with high-profile allies from Waitemata EDHB and the HINZ technical society.
OPPORTUNITY, PURPOSE & ACTIVITIES
New Zealand is uniquely positioned to benefit from, and participate in developing, the potential value of combining e-health innovations with patient engagement. The country’s evolving demographics, expanding infrastructure and widely dispersed population combine to set the stage for relevant innovations.
Aptly, this fellowship was a partnership between private sector infrastructure / innovation (Revera), government (Waitemata DHB and i3), and technical workforce (HINZ). Revera’s infrastructure is enhanced by it’s cloud platform for integration of data from diverse sources. Waitemata DHB is at the forefront of Digital Health and patient engagement in NZ, and HINZ is New Zealand’s meeting place for digital health, providing a neutral and constructive environment for information sharing. Never in my travels have I encountered such a relevant partnership.
Evaluating Fundamentals of Care: The Development of a Unit Level Quality Measurement and Improvement Programme
Parr, J; Bell, J; Koziol-McLain, J; (2018)
Journal of Clinical Nursing (JCN). DOI: 10.111/jocn.14250. 2018;00:1-13. Feb 2018.View abstract
AIMS/OBJECTIVES: The project aimed to develop a unit level quality measurement and improvement programme using evidence based fundamentals of care.
BACKGROUND: Feedback from patients, families, whānau, staff, and audit data in 2014 indicated variability in the delivery of fundamental aspects of care such as monitoring, nutrition, pain management and environmental cleanliness at a New Zealand District Health Board.
DESIGN: A general inductive approach was used to explore the fundamentals of care and design a measurement and improvement programme, the Patient and Whānau Centred Care Standards (PWCCS), focused on fundamental care.
METHODS: Five phases were used to explore the evidence, and design and test a measurement and improvement framework. Results Nine identified fundamental elements of care were used to define expected standards of care and develop and test a measurement and improvement framework. Four six-monthly peer reviews have been undertaken since June 2015. Charge Nurse Managers used results to identify quality improvements. Significant improvement was demonstrated overall, in six of the 27 units, in seven of the nine standards and three of the four measures. In all, 89% (n=24) of units improved their overall result.
CONCLUSION: The PWCCS measurement and improvement framework makes visible nursing fundamentals of care in line with continuous quality improvement to increase quality of care.
RELEVANCE TO CLINICAL PRACTICE: Delivering fundamentals of care is described by nurses as getting ?back to basics'. Patient and family feedback supports the centrality of fundamentals of care to their hospital experience. Implementing a unit-level fundamentals of care quality measurement and improvement programme clarifies expected standards of care, highlights the contribution of fundamentals of care to quality and provides a mechanism for ongoing improvements.
Co-designing an mHealth Tool in the New Zealand Māori Community with a "Kaupapa Māori" Approach
Te Morenga, L; Pekepo, C; Corrigan, C; Matoe, L; Mules, R; Goodwin, D; Dymus, J; Tunks, M; Grey, J; Humphrey, G; Jull, A; Whittaker, R; Verbiest, M; Firestone, R; Ni Mhurchu, C; (2018)
AlterNative: An International Journal of Indigenous Peoples Jan 2018. DOI:10.1177/1177180117753169. Epub Jan 2018View abstract
Obesity rates in Aotearoa/New Zealand continue to rise, and there is an urgent need for effective interventions. However, interventions designed for the general population tend to be less effective for Māori communities and may contribute to increased health inequities. We describe the integration of co-design and kaupapa Māori research approaches to design a mobile-phone delivered (mHealth) healthy lifestyle app that supports the health aspirations of Māori communities. The co-design approach empowered our communities to take an active role in the research. They described a holistic vision of health centred on family well-being and maintaining connections to people and place. Our resultant prototype app, OL@-OR@, includes content that would not have been readily envisaged by academic researchers used to adapting international research on behaviour change techniques to develop health interventions. We argue that this research approach should be considered best practice for developing health interventions targeting Māori communities in future.
Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial
Hatcher, S; Whittaker, R; Patton, M; Sylvester, W; Ralph, N; Kercher, K; Sharon, C; (2018)
JMIR Mental Health 2018; 5(1):e5. DOI: 10.2196/mental.8510. PMID: 29362207.View abstract
BACKGROUND: The evidence for the effectiveness of Web-based therapies comes mainly from nonclinical populations, with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. Adherence to Web-based therapies is often poor. One way to increase this is to create a new health service role of a coach to guide people through the therapy.
OBJECTIVE: This study aimed to test in people referred to secondary care with depression if a Web-based therapy (The Journal) supported by a coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about Web-based resources after 12 weeks.
METHODS: We conducted a randomized controlled trial with two parallel arms and a process evaluation that included structured qualitative interviews analyzed using thematic analysis. The coach had a background in occupational therapy. Participants were recruited face-to-face at community mental health centers.
RESULTS: We recruited 63 people into the trial (intervention 35, control 28). There were no statistically significant differences in the change from baseline in Patient Health Questionnaire-9 (PHQ-9) scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group, t41=1.05, P=.30; mean difference=2.3, 95% CI −2.1 to 6.7). People who were offered The Journal attended on average about one less outpatient appointment compared with usual care, although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group, t45=−0.80, P=.43; mean difference=1.3, 95% CI −4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 (SD=1.9; range=0-6) and the number of contacts with the coach was a mean of 8.1 (SD=4.4; range=0-17). The qualitative interviews highlighted the problem of engaging clinicians in research and their resistance to recruitment: technical difficulties with The Journal, which prevented people logging in easily; difficulty accessing The Journal as it was not available on mobile devices; participants finding some lessons difficult; and participants saying they were too busy to complete the sessions.
CONCLUSIONS: The study demonstrated that it is feasible to use a coach in this setting, that people found it helpful, and that it did not conflict with other care that participants were receiving. Future trials need to engage clinicians at an early stage to articulate where Web-based therapies fit into existing clinical pathways; Web-based therapies should be available on mobile devices, and logging in should be easy. The role of the coach should be explored in larger trials.
Stakeholder Views Do Matter: A Conceptual Framework for Medication Safety Measurement
Ng, J; Scahill, S; Harrison, J; (2017)
Journal of Pharmaceutical Health Services Research Sep 2017; DOI; 10.1111/jphs.12203View abstract
Many patients are harmed by medications intended to help them. Significant efforts have been directed toward the improvement of medication safety. Policymakers, clinicians, researchers and consumers are interested in knowing the progress of medication safety but it is unclear whether it is safer than before.
Part of the challenge has been the achievement of a common understanding of what medication safety means to multi-stakeholders, and then developing a measurement framework. Existing approaches to measurement have been narrow and piecemeal, failing to encompass diverse stakeholder beliefs and preferences.
A multi-stakeholder derived conceptual framework for medication safety measurement was required. The interview method was used to elicit and explore stakeholder views in-depth. Stakeholders were selected by purposive sampling on the basis of their job role or expertise in the area of medication safety in the New Zealand public hospital setting. Snowball sampling was also used and data collection was continued until data saturation which occurred after interviewing 30 people.
Transcripts were thematically analysed and interpreted with the aid of NVivo and mind maps using a general inductive approach. The developed multi-stakeholder derived conceptual framework for medication safety measurement consists of seven key dimensions meaningful to multi-stakeholders in the New Zealand public hospital setting. These are:
1) Outcome goals of medication safety;
2) Financial costs and effectiveness;
3) Medications available for and their use;
4) Safety culture;
5) Technical components of the medication use system;
6) Factors affecting medication use by patients; and
7) Staff competency.
The contribution to knowledge has been the development of a multi-stakeholder derived conceptual framework for medication safety measurement. As a consequence of this research, the measurement of medication safety should change from one which has been narrow and fragmented, to one which is multi-dimensional and holistic.
The developed framework incorporates diverse multi-stakeholder views and preferences increasing its relevance in the local context and is important for engagement and buy-in. It draws together all meaningful dimensions and facets providing a necessary and robust single theoretical frame to measure medication safety. Understanding stakeholders’ priorities and beliefs for medication safety can also be used to facilitate improvement programmes.