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A survey of knowledge and expressed attitudes on cervical cancer screening in a sample taken from a Dunedin general practice

Introduction

Cervical cancer is the fourth most common cancer in women, and with the advent of the Papanicolaou smear for the early detection of precancerous lesions it is now well established that it is possible with adequate treatment to prevent the development of invasive carcinoma of the cervix.  Carcinoma in situ of the cervix accounts for more than 45,000 new cases per year in the USA, presumably CIN1 and CIN2 lesions are more common and with the postulated transformation to invasive carcinoma of these pre-invasive lesions it is important to diagnose and treat early.

However what has not been well research is the attitudes, and knowledge, of women to the Papanicolaou smear test.  Several studies have shown that a significant number of women have not heard about the test, particularly lower socioeconomic classes, a group at high risk, and older women.  It has also been shown that women do not know what the test is for or, more frequently, believe its function is the detection and not prevention of cancer, this itself may cause women to be less likely to present for a test because of the risk in finding what is generally accepted in the community as a fatal disease.  Further studies have shown that features inherent in the test may deter women from having a test, particularly pain and embarrassment, also that not being able to find the time is also a major deterrent.

Working within the Preventive and Social Medicine Department of the University of Otago, and in conjunction with Dr I. St George a local general practitioner, six final year medical students interviewed a random sample of women aged 20-60 years in a pilot study.

The aim was to determine:

  1. The knowledge of cervical cancer and the cervical smear test.
  2. The acceptability of the cervical smear test and a general health examination, plus the acceptability of doctor initiated recall for these.
  3. The preference of who performed the smear, and where.
  4. The aspects of the cervical smear test that would put women off having the test.

We collected a large volume of data all of which is included with our results, plus we correlated the various answers but only those of statistical significance or those of major interest where there was no significance are included.  Unfortunately some of our sub groups were of such a small size to preclude statistical analysis.

Authors of Report

C Brebner, L Garrett, M Hadler, S Hardy, T Hou, L Middleton.

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Descriptive study of indwelling urethral catherizations and urinary infections

Abstract

To determine the incidence of urinary tract infection following indwelling urinary catherization at Dunedin Public Hospital, a prospective descriptive study was undertaken.

Of 82 patients studies, 3 (3.7%) developed urinary tract infections.  The average duration of catherization was 2.7 days with a maximum duration of 9 days.

Although our results obviously underestimated the infection rate, Dunedin Public Hospital appears to compare favourably with published data.

Authors of Report

MJ Chin, DM Dalziel, JC Fenwick, SD Gardiner, RM Hardie Boys.

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General practice nurses:  What do they do?

Introduction

The following is a project undertaken by 5 final year students at Otago University Medical School.  It is part of our community attachment model.

Our client was Dr Ian St George a general practitioner in Dunedin.  His concern was that he did not know enough about his patients post discharge from hospital.  He said his liaison was poor with district nurses and he wondered whether there could be a potential role for a practice nurse in his field.  On further questioning it was decided that doctors knew little about:

  1. The present role of Dunedin practice nurses
  2. The work of other community nurses.

Therefore we decided to carry out a pilot study on Dunedin practice nurses to discover what they do.

The fully subsidised practice nurse scheme bas been functioning now since the late 1960s and several definitions of their role have emanated from the Health Department.  This has been a necessity because, as the Health Department recognizes to its credit, there are marked differences between practices.  Consequently the work of the nurse in practice is adjusted to its needs.  However there was an element of criticism of the scheme because it is potentially open to abuse by the medical practitioner.  The purpose of our study was to produce a job definition by describing the job that is done rather than an unrealistic ideal definition from a more realistic bureaucratic angle.  We also decided to look at the relationship between doctors, practice nurses and community nurses.

The main angles of the questionnaires were to find out:

  1. What practice nurses think they are doing
  2. What they are doing
  3. What they think they ought to be doing
  4. What their general practitioners think they ought to be doing

Authors of Report

J Kirby, G Poole, D Porter, D Souter, A Wilson.

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Mammography in Otago:  Its present role and future possibilities

Abstract

The present project looks at the use of mammography in Dunedin over the past year and considers the possibilities of a future screening programme for the Otago and Southland area.

Section I reviews the literature on the risk factors in breast cancer and considers the role of mammography both in diagnosis and screening.  Mammography is shown to have a role in the symptomatic women where there is a diagnostic problem (e.g. pain, general lumpiness or difficult with lump localisation).  Mammography has also been shown to be useful in screening giving a significant reduction in mortality in women over 50 years.  Difficulties in identifying a high risk group are discussed.

Section II looks at mammography in Dunedin Hospital over its first year (May ’84-May’85).  This time was primarily a learning period for the Radiology Department.  A total of 318 mammograms were performed on 311 patients.  The majority of them (63%) were under 50 years and came from the Dunedin area.  Most referrals over this first year were from surgeons and were for breast lumps; only 9% were for screening.  Mammograms suspicious of malignancy were reported in 8% and of these 50% turned out to have breast cancer.  A small sample of patients, General Practitioners and Surgeons were asked about their attitudes to mammography.  All the patients and 80% of the doctors supported a screening programme for the area.  The cost of mammography including materials and staff salaries (but excluding the capital costs of the machine) was calculated to be $14-22/person depending on the time taken, number of films, etc.

Section III considers the possibilities of a screening programme for Otago and Southland.  Four population groups are considered for an annual screening programme:  all women over 40 years, all over 50 years, those over 40 years with specific risk factors, and those over 50 years with specific risk factors.  For each of these, the population involved and the expected number of cancers detected is given.  The costs of a screening programme for each group is calculated on a figure of $16/mammogram.  The screening programme for Otago and Southland is estimated to cost from $34,000/year (high risk group, 9 cancers detected) to $616,000/year (all women over 40 years, 61 cancers detected).  The estimated cost/cancer cured varies from $11,3000 (high risk group) to $34,200 (all over 40 years).  Besides these costs for mammography, additional expenditure on increased support services (e.g. surgery referrals, FNA and biopsies) are discussed.  These are likely to increase the real costs of a screening programme from $16 to $27/person.  These costs compare favourably with overseas estimates for breast cancer screening and the cost per life saved is significantly less than for cervical cancer screening.

The possibility of a pilot scheme for the Otago/Southland areas is discussed.  At present the limiting factor for such a scheme is the unavailability of radiologists.  This would have been to resolved before further progress could be made towards generalised screening.

Authors of Report

G Mills, M Strettell, P Stoddart, P Waite.

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Patient expectations of and satisfaction with hospital inpatient and community care

Introduction

Fact 1: Since 1978/79 commissioned beds have fallen by 148 or 25% at Dunedin/Wakari for surgical, medical and paediatric services.

Fact 2: Average hospital stay has decreased from 9.2 days in 78/79 to 7.7 in 1984/85 – a 16.3% reduction.

Fact 3: Total day patient attendances have more than trebled in the last 7 years.

Fact 4: Average theatre waiting lists have nearly doubled since 1978.

Fact 5: Hospital patient population has changed.  In 1978 24.4% of patients were category 3 in the CSF classification system.  By April of 1985 this had increased to 45.5%.

More patients are waiting longer to get into hospital.  When they do finally get in the doors their average length of stay is shorter and they are cared for by nurses whose patient workload is much greater than it was 8-9 years ago.  The question arises as to whether these changes have produced a corresponding change in patients expectations of or their satisfaction with hospital services.

The general public has been long aware of their rights as consumers of goods and services.  However, it has taken a considerable time for consumerism to extent to health services.  For many years it was felt by everyone that the organisation and assessment of health care services was the sole province of the health care professionals.  These attitudes are now changing both on the part of the consumer and provider.  Public expectations of health services are growing and matters concerning health care are increasingly becoming the subject of public debate and controversy.  Awareness of these changes has promoted many “consumer studies” in the last 20 years in countries such as Canada, Australia, and United Kingdom and New Zealand looking at every aspect of the provision of health care.

This study was commissioned by Dr McKendrick, Superintendent of Dunedin Public Hospital and Dr Emery, Director of Community Services.  It was carried out over a total of 32 half days by 6 final year medical students as a necessary part of their degree course.

The specific aims, therefore, were twofold:

  1. to assess
    • patients’ expectations of hospital care
    • and - the level of satisfaction with present in hospital care
  2. to assess
    • patient’s satisfaction with present community services
    • and - their feelings towards replacement of long hospital stays with shorter admissions followed by community services support.

We chose to investigate these questions through a patient opinion survey.

Authors of Report

B Nyoni, N Scott, P Van Dyk, E White, M Williams, P Wytenburg.

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Review of patients from other regions treated in Dunedin Hospitals

Introduction

Population-based funding for hospital boards was formally introduced on 1 April 1983.  The purpose of the funding formula was not solely to determine a fairer distribution of hospital board funds, but also to better equate boards with their future entitlement to resources.  As central government confronted the problem of the health Vote in the present economic climate the population model provided a workable formal by which to apportion its financial resources.

This formula must be considered to be a dynamic entity.  Its conception has encouraged hospital boards to assess their own management and also has resulted in a flurry of research which has greatly improved the quality of data input into the formula.  With these improvements, and over time, a greater understanding of the formula has arisen.  Pundits argue that it is time to modify the formula, at all times remembering the national equity of care, at an acceptable standard, is the ultimate goal.

The following project was conducted by sixth year medical students at the Otago Medical School as part of their Community Management Module.  It confronts the problems of Otago Hospital Board, and particularly Dunedin Public Hospital, which serves not only as a national teaching hospital and centre of care or patients within the Board area, but also is the primary referral centre for boards “South of the Waitaki River”.

Actual spending by OHB for the 1983 calendar year exceeded the funding model allowance by some $8.7 x 106 , i.e. 13.3%.

This trend to overspdending was also repeated in most boards south of the Waitaki (see Table 1.1).  Although the problems experienced by the latter boards can in part be explained by the sensitivity of the formula to population changes, especially in the smaller boards, this is not solely the case with Otago.

Although the formula is considered to be a population based model it is obviously adjusted to account for the individual variations within each area…

Authors of Report

R Massey, S Patchett, C Thomas, A Tonks, M Wardill, C Wong.

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Some health aspects of welders:  A pilot descriptive study in the Dunedin and Balclutha Regions

Forward

This study was carried out for our client, occupational health nurse Catherine Logan of the Otago Area Health Board under the supervision of Associate Professor Bill Glass of the Department of Preventive and Social Medicine.

The study was part of our final year medical training in which we engaged in a health care evaluation project.  A practical assessment of an identified problem in the delivery of health care in Dunedin.  The study could not have been carried out without the goodwill and assistance of the 86 welders and the managers of the firms in which they worked.  We are most grateful for their co-operation.

We would also like to thank, public health nurse Raelene Thompson of the Clutha Region of the Otago Area Health Board; Mr David Jones of the Respiratory Laboratory, Dunedin Hospital; Mr Peter Herbison, biostatistician in the Department of Preventive and Social Medicine and finally and most gratefully Celia Chisholm who typed the report.

The cover design was by Dunedin artist Lindsey Crooks who is currently working on commission to prepare 12 paintings celebrating working life for Associate Professor Bill Glass.

Authors of Report

M Bennet, M Coventry-Griffiths, P Burt, L Davies, D Cooper, R Griffiths, A Hunter.

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The impact of coronary artery bypass graft surgery on quality of life

There are 750 coronary artery bypass grafts (CABG) performed in New Zealand each year.

Although it has been shown to increase 5 year survival time in patients with Left Main Stem Disease and 3 vessel disease, for other subsets of disease it hasn’t been shown to, and indeed the natural history of the disease is changing so past data is questionable.

Because the operation may not help increase a patient’s survival time, and because it carries a significant mortality risk it is necessary that the operation should improve the quality of life (QOL).  It is equally important for the surgeon to know that it is.

To evaluate the impact of the CABG upon someone’s (QOL) we had first to assess what goods or states of being are indicative of QOL.

Thus, in about 2/52 we had to reach the conclusion on an issue that philosophers of ethics spend their lives contemplating! (But then they didn’t have to do a health care evaluation project).

Our survey was based upon the ideas written in an essay by an American philosopher Carl Cohen and the survey of the Coronary Artery Surgery Study.  We will now describe them.

As a man who he is and he will tell you what he has done, what he is doing, and what he hopes to do.  We all have our plans and our ideals and what seems of paramount importance in our lives in that we aspire to fulfill our plans and live up to our ideals.  Even if the plans are unfilled or the ideals unrealistic we need them because they give our lives coherence and meaning.  Each of us has many life plans whether it be achievements in sport, cherishing our family life, passing exams or being able to go to the pub.  And for each of us QOL represents the presence of these goods or qualities that promote fulfillment of those plans.

Some qualities seem universal, for example, strength and stamina seem needed for a marathon runner, the person who wants to work or the homemaker raising a family.

Other qualities are individual and indeed peculiar.  Thus our survey wanted to discover whether the CABG brought about the necessary changes in that particular person to allow him to aspire to his individual life plans.  For example Joe Bloggs after a CABG may well be able to run 5 minutes on a treadmill without any ST depression and he may well be back at work and he may well have only 5 pills to take/day instead of 6.

But does he care one way or the other? If he doesn’t one cannot infer any improvement in QOL.

QOL not only requires positive qualities present but also negative qualities absent.

Thus pain, hospitalizations and an excess of medication are important bearings on QOL because of an interference with one’s life plan.  Pain, surely is a universal nasty.  But again because life plans are individual these negative qualities have different importance to different individuals.  For example SOB may well be a positive quality for a slothful ne’re do well who more than anything else needs an excuse to fulfill his life plan of indolence.

Now, not only do we need to do things according to our plans we need to believe ourselves that we are Joe Bloggs after his CABG may well seem to have achieved his life plan of back to work, playing sport, etc., but what if he is a glum, brooding pessimist no matter how much he achieves or how well others think he’s doing?  Has his QOL really been changed by his CABG?  Thus what we wanted to know not just how Joe Blogg was doing but how he thought he was doing.  We wanted to assess changes in self perceptions.

A description of the method we used will now be described.

Next we will present the results of the individual sections with comment upon the results and indeed the (many) faults in the question.

Finally, such a survey on changes in QOL should be put into perspective against a background of costs, mortality and one or two other considerations.  This will  be done as part of the discussion at the end.

Authors of Report

PJ Bannister, MR Barnett, SJ Bentall, PD Guy, MJ Mills.

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Utilisation of accident and emergency services in Otago

Abstract

Five final year medical students interviewed all patients attending the Dunedin Public Hospital Accident and Emergency Department (A&E) over a one week period.  For each patient a questionnaire was completed at the time of presentation.  Demographic data were obtained, and compared to studies of other casualty departments in New Zealand.

Dunedin’s A%E Department has a high and indeed increasing level of utilization.  Among the patients seen there was an over-representation of the young, the single, and males.  People of lower socio-economic status tended to present more frequently and with less appropriate problems that those of higher socio-economic status.  The most common presenting problems were traumatic injuries especially burns and lacerations.  Only a small proportion of patients were delivered to the department by emergency services. 

The results also indicated that the majority of presentations could have been managed in a general practice, with a perceived unavailability of general practitioners for after-hours and minor trauma work accounting for many of these.

Anecdotal reports of a disproportionate representation of certain suburban areas were not substantiated.

Authors of Report

AC Buchanan, M Harty, S Jordan, R McGrath, I McLean.

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