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A Patient Satisfaction Measure for Use in Assessing GP Intimate Partner Violence Training

Introduction

Intimate Partner Violence (IPV) is an important issue in New Zealand and it has major implications for society as a whole.  Research has found that victims of IPV usually present first to health professionals seeking treatment for the effects of physical violence, rather than to disclose the violence itself.  The web-based continuing medical education (CME) training programme is an intervention tool that has shown to be effective in increasing General Practitioners’ knowledge and skills in dealing with IPV.  The injury Prevention Unit (IPRU) in Otago plans to conduct a randomized controlled trial to assess the effectiveness of the CME training programme.  However there is currently no validated tool for the assessment of this intervention.

Aim

To develop a questionnaire to measure patient satisfaction, with a specific focus on addressing the issue of IPV, in the New Zealand General Practice setting.

Methods

We developed the questionnaire by (1) carrying out the literature review, (2) synthesizing a draft questionnaire based on literature, (3) conducted focus groups with appropriate participants, (4) applying in a general inductive approach to the results of the focus groups, and (5) refinement and adaptation of the questionnaire based on feedback from the IPRU.

Results

Universals themes were identified by the focus groups, including the importance of: a trusting relationship, accessibility, comprehensive knowledge, and; clear terminology.  The end result was a 31-item self administered questionnaire designed specifically for use in the New Zealand GP setting.

Conclusions

We have developed a patient satisfaction assessment tool with regards to IPV that is appropriate for the local GP setting.  The involvement of a wide range of local community contacts from vastly different background and the collaboration with local agencies were encouraging factors.  There were some limitations in the development of our questionnaire which we have identified and discussed.  There were also some interesting findings which challenge current views on IPV.  However, these were outside the scope of our study.  The construct validity and reliability of this instrument still requires further testing.

Authors of Report

Sarah Dunn, Rajini Reeva Jayaballa, Helen Lindsay, Claire Manning, Samantha Paul, Jack Tsai, Jonathon Wills

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Application of Best Practice Guidelines for the Secondary Prevention of Coronary Artery Disease at Dunedin Hospital

Introduction

Coronary artery disease is a leading cause of death in developed countries. Better application of currently available guidelines may offer savings of life and function. Best practice guidelines for the secondary prevention of coronary artery disease include drug therapy and lifestyle management.

Method

This study examines the application of best practice guidelines for the secondary prevention of Coronary Artery Disease in the Departments of General Medicine and Cardiology at Dunedin Public Hospital. Secondary outcome measures included differences between departments and which guidelines were applied more frequently to which patient groups. A  retrospective cross-sectional audit of 222 patient files (112 Cardiology, 110 General Medical records) with a coded diagnosis or comorbidity of Coronary Artery Disease (ICD-10 I25.1) revealed that of 6 globally applicable guidelines an average of 3.8 guidelines were implemented during admission.

Results

Cardiology patients received an average of 4.3 out of 6 interventions, while General Medicine patients were offered 3.4.  Pharmacological interventions were applied more consistently, lipid lowering therapy (87.8%), beta-blockers (81.1%) and antiplatelet therapy (93.2%) than lifestyle interventions (exercise, dietary advice  and smoking cessation 34%, 27% and 53% respectively). Female patients were more likely to be offered lifestyle advice than male patients.

Discussion

Best practice guidelines for the secondary prevention of CAD are not applied consistently or completely at Dunedin Public Hospital. Potential reasons for this discrepancy include a lack of dedicated staff and comprehensive care pathways on general medical wards, and a reluctance by medical staff to take every opportunity to optimise patient management. There are also potential issues of inadequte documentation.

Authors of Report

Dk Hana Baharudin, Parteshma Chand, Maneesha De Silva, Niva Jayaballa, Cynthuja Packianathan, Karen Phillips, Jalal Al Wabari, Ryan Walklin

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Experiences in Relation to Racial / Ethnic Equality at the Dunedin School of Medicine

Introduction

Medical schools are becoming increasingly ethnically diverse in New Zealand, and while overt racism is no longer tolerated, the more subtle form, conceptualised as ‘everyday racism’ may continue to exist. ‘Everyday racism’ can be broken down into categories of ‘marginalisation’, ‘problematisation’ and ‘containment’.

Aims

To discover whether ‘everyday racism’ exists at the Dunedin School of Medicine and to explore students’ experiences of it, identifying the main sources and issues regarding the complaints process therefore enabling us to examine possible improvements to the overall situation.

Methods

A survey was conducted of all 4th (N=75), 5th (N=73) and 6th (N=54) year students at the Dunedin School of Medicine. Both quantitative and qualitative items were included in the survey.

Results

Of a total study population of 202, we had an overall response rate of 64% (n=130). Students from minority groups were more likely to experience ‘everyday racism’ in the forms of ‘marginalisation’, ‘problematisation’ and ‘containment’ than those of the majority (p-values<0.05). Students were more likely to encounter these behaviours from teaching staff (34%) and peers (33%), whilst other staff (18%) and patients (15%) were minor contributors. There was no significant difference in students’ responses, ethnicity-wise, regarding the question “how much of an issue do you think racial/ethnic inequality is at Medical School?” (p=0.391). The qualitative analysis identified that of the 19 students who said they experienced a racially based incident they considered reporting only 3 complained, and none had a satisfactory outcome. The main reason given for not reporting incidents was fear of adverse consequences. Other issues commented on by students were pertaining to existence of stereotyping as well as opinions that other issues such as language and/or cultural barriers, gender inequalities and ‘reverse racism’, were more important than racism.

Conclusions

‘Minority’ medical students at Dunedin School of Medicine are more likely to experience ‘everyday racism’ than those of NZ European descent, mainly from teaching staff and peers. However they are not more likely to view this issue as a problem. Recommendations include increasing awareness of the Ethical Behaviour Policy amongst staff and students, formal inclusion of cultural competence teaching within the medical curriculum, and improving the complaints process for students to report incidents.

Authors of Report

Aya Amer, Simon Collins, Asima Dervishi, Matt Hale, Brian Hsu, Osasehi Ikhu-Omoregbe

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Legal Party Pill Use Amongst Otago Tertiary Students

Aims

To investigate the prevalence of party pill use and use of concurrent alcohol and party pills amongst Dunedin tertiary students; to determine whether there is differing use between male and females; to examine the prevalence of adverse effects associated with party pills use and student attitudes towards party pills.

Design

Cross sectional study of tertiary students on and around the University of Otago campus.

Methods

499 tertiary students were approached to answer a questionnaire by way of convenience sampling method. Students who were enrolled in University of Otago, Otago Polytechnic or Otago College of Education were eligible to participate.  Each participant completed an interviewer led questionnaire and those who refused to take part in the study were recorded as declined to answer. The questionnaire consisted of 19 questions that were answered by party pills users and 9 questions which were answered by non-users. The survey was conducted at 4 different locations around the campus including, the student medical centre, lecture theatres, student common areas and sporting arenas.

Result

490 completed the questionnaire, a response rate of 98.2%. The sampled population consisted of 55% females with median age of 20. The prevalence of tertiary students that ever used party pills was 38.4% (n=188); 24% (n=120) were current users while 14% (n=68) were past users. There was significant difference of party pills use between males and females, 43% and 34% respectively (p-value < 0.048). The median age of first use was 20 in both genders. 84% of the ever users always or sometimes co-ingest alcohol with party pills and 44% of the ever users always or sometimes exceed the recommended dose.  The most common side effect that students experienced after taking party pills was insomnia which occurred in 80% of the current users. This was followed by nausea and palpitation which was 40% and 38% respectively. Side effects were more common and severe in those who exceed the recommended dose; 80% of the students experience insomnia after having overdose of party pills. 23.4% of the ever users reported having psychosocial side effects after taking the party pills which include damage to property, regrettable sexual experience, criminal activities, harm to self or others. Although there were a significant number of students experiencing harmful effects from the party pills, only 6 students (3.2%) had ever sought medical attention. Of those who ever used party pills, there was high rates of other illicit drug use; 62% of ever users used marijuana in the past 12 months. When questioning about the likelihood of future use, the past users and non-users reported strong tendency of not using the party pills in the future in contrast to the current users who indicated a relatively stronger likelihood of future use.

Conclusion

The results of the study demonstrated that lifetime prevalence of party pill use is relatively high amongst tertiary student (38% 95% CI 34-43) as was expected from past studies of this age group.  A significant number of students experience adverse health effects but only a small proportion seeks medical attention.  Furthermore our study shows that current users are likely to continue using in the future despite knowledge of potential health risks.  All this suggests a need for readily available health information on safe party pill use as well as details on possible adverse effects.  Our study showed increase rate and severity of adverse effects when the recommended dose is exceeded.  Given that the median age of first use is 18 years it is arguable that health information be available for younger age groups enabling them to make an informed decision regarding party pills use before they first encounter them. Further studies are warranted to look at party pill use amongst high school students.

Authors of Report

Shaun Zhai, Rachael McConnell, Sean Cullen, Phil Shirley *Alvin Ling, Kush Patel, Paul Phillips

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Pandemic Influenza: GP Preparedness

Background

Within the past hundred years there have been three episodes of pandemic influenza that reached the shores of New Zealand. H5N1 type avian flu infection has spread among poultry, starting in Vietnam to many other countries since the end of 2003. Cases of H5N1 infections to humans are increasing with more than 200 confirmed cases worldwide. At present, person-to-person transmission of H5N1 has not been demonstrated. However, its spontaneous tendency to mutate is very much a real threat to humans. Based on the 1918 pandemic model, New Zealand Ministry of Health has predicted, that up to more than 1.3 million people in New Zealand would be infected causing more than 33,000 deaths over an eight week period.

Objective

Due to the severity of the prediction made by the Ministry of Health, it is imperative that general practitioners in New Zealand must be well prepared for this imminent threat. The aim of this study was to assess the preparedness of Otago and Southland GPs in terms of risk perception, resources, knowledge, and infectious control and to identify demographic characteristics which might influence preparedness.

Results and Conclusion

Overall, GPs in Otago and Southland areas were generally under prepared for a pandemic influenza. This could partly be due to the fact that GPs perceive the risk of an avian influenza to be low. In our study, only demographic factors had a significant influence on preparedness of GPs. These included, Cornerstone Accreditation status and gender of the general practioners.  Cornerstone accredited GPs were more prepared for a pandemic and female GPs had a higher risk perception. In summary, a larger and more systematic study needs to be carried out in New Zealand to further determine the preparedness of GPs, so that recommendations and action plans could be put forward to better prepare for an avian influenza.

Authors of Report

Chen Lau, Chris Ford, Linda Moore, Michele Monteath, Peter Cox, Tina Chen, Ashvini N Kahawatta

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Parental Understanding of the Recent Amendments to Section 59 of the Crimes Act: A Pilot Study

Introduction

The Recent amendments to Section 59 of the Crimes Act were ushered into legislation on May 16 2007 alongside an unprecedented level of public debate. This legislative change was largely in response to New Zealand’s poor domestic violence record and it is hoped that by following several other nations in legislating against the use of force for the purpose of correction that the amount of domestic violence will be reduced. Yet with these changes one must ask; do those people who these changes effect most actually understand the new legislation and the implications it has for them as Parents?

Aims

To evaluate parental understanding of the recent changes to Section 59 of the Crimes Act.

Methods

A survey was developed and distributed to Parents of children between the ages of 2-5 who attended one of 24 Early Childhood Learning Centres (ECLC) within Dunedin. The answers given by respondents were collated and analysed.

Results

Showed parents believe their level of understanding about the recent changes is inadequate, this belief was confirmed by comparing their answers in a number of situations, with our legal advisors answers. Demographic data suggested that those respondents of lower educational level, in single parenting roles, with more children had the lowest level of understanding. This data also suggested we over sampled university educated individuals and as such results obtained are likely to over estimate the level of understanding in the general population. Interestingly our results also demonstrate that where respondents made mistakes in their answers the majority were where they would believe lawful acts to be unlawful. Our results also highlight parents’ desire for greater clarification and information regarding the recent changes.

Conclusion

Our study has demonstrated a significant lack of understanding regarding the recent amendments to Section 59 of the Crimes Act. We recommend further studies into the extent and specific nature of this deficit. Development of educational programs, which address what the new legislation means for parents in simple terms, alternative methods of correcting a child’s undesirable behaviour and those supports available to parents, is also recommended. The distribution of these programs should be through those services involved in with supporting families.

Authors of Report

Brecon Wademan, Rebekah Bennett, Rosalie Fergusson, Brent Sew Hoy, Fadhel Al-Herz, William Chang, Zia Loo, Ajay Sud

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The Safety of Liver Biopsy and Prediction of Severity of Liver Fibrosis by Simple Non-Invasive Methods: A Retrospective Study of Liver Biopsies at Dunedin Public Hospital, New Zealand 2001-2006

Abstract 1 - Aims

  1. To determine whether percutaneous liver biopsies could safely be done in a hospital outpatient setting by analysing the type and rate of complications.
  2. The type and time of analgesia administration.
  3. The effect of pre-operative pethidine on the administration of post-operative analgesia.

Methods

A retrospective audit was carried out on all percutaneous liver biopsies from Dunedin Public Hospital (DPH), New Zealand during 2001-2006. The parameters collected were sex, age at biopsy, indication for biopsy, administration of pre-operative pethidine, post-operative complications and the type and time of analgesia administration. Rates of complications were collated and statistical analyses were used to determine if any significant association existed between complication rates and pre-biopsy pethidine use.

Results

There were 534 liver biopsies, of which 465 were eligible for inclusion in this study. The most common indication for biopsy was Hepatitis C (38.1%), abnormal liver function test (17.2%), methotrexate therapy (12.5%), Hepatitis B (4.3%) and others (28%) which included; malignancy, haemochromatosis, post-liver transplant, NASH and primary biliary cirrhosis. The complication rate was 33.8%. The most common complication requiring analgesia was pain (31.8%). Non-opiate and opiate (codeine, pethidine, morphine, fentanyl) analgesia were given to 8.6% and 23.2% of patients, respectively. Of the patients in this study, 20.4% required analgesia in the first 2 hours, 3.7% between 2-4 hours and 7.1% > 4 hours post-procedure. Other minor complications included nausea/vomiting (1.1%), hypotension (0.9%), vasovagal episode (n=1) and non-liver tissue sample (n=1). There was only 1 major complication and this was a pneumothorax. Females (39%) had a higher complication rate than males (29%). There was no significant difference in the complication rate with or without pre-operative pethidine. However, those who were given pre-operative pethidine received less opiate-based analgesia post-operatively.

Conclusion

At DPH, the rate of minor complications following biopsies is comparable with previous studies, while the rate for major complications is lower. Pain was the most common complication and the need for analgesia 2 hours post procedure was low. Therefore, percutaneous liver biopsies could be considered for performing in an outpatient setting. A randomised control trial would be beneficial in determining whether pre-operative pethidine is beneficial in the type of post-operative analgesia required.

Astract 2 - Aims

  1. To evaluate the diagnostic accuracy of two simple non-invasive parameters (platelet count and abdominal ultrasound) in predicting the severity of liver fibrosis compared to histology obtained from liver biopsy in patients at a large New Zealand teaching hospital. Also, to determine whether it is possible to identify subgroups of patients in whom a liver biopsy could either have been avoided or should be strongly encouraged.

Methods

A retrospective audit was carried out on all percutaneous liver biopsies from Dunedin Public Hospital (DPH) during 2001-2006.  Platelet counts and the ultrasound parameters of liver size, liver shape, liver texture, spleen size, portal vein diameter and presence of ascites were collected. The parameters were statistically analysed individually as well as the combination of platelet count with spleen diameter for their ability to predict cirrhosis (stage 4 fibrosis), significant fibrosis (stages 3-4 fibrosis) and stages 2-4 fibrosis when compared to histological grading from liver biopsy.

Results

A total of 589 liver biopsies were performed over the 6-year study period of which 252 were classified as having a chronic hepatitis with histological grading and fibrosis staging. 239 of these had data on recent platelet counts and were included in the study. Of these participants, 108 (43%) had an ultrasound scan close to the time of liver biopsy. Only 5% of participants had cirrhosis. No fibrosis was present in 7% of participants. In predicting cirrhosis, platelet count below 140 x109/ L has an excellent specificity (95%) and negative predictive value (97%), while spleen size  >12cm has an excellent negative predictive value (99%). The platelet and spleen size combined does not significantly improve specificity or negative predictive values compared to assessing platelet count alone. Liver texture abnormalities was the only parameter that gave reasonable sensitivity (74%) when testing for significant fibrosis (Stages 3-4) but it had a high false positive rate (20 true positives, 40 false positives). Low platelet count and irregular liver shape had high likelihood ratio (LR) positive figures that were both statistically significant. Therefore a positive result in either of these two tests increases a patient’s post-test odds of having significant fibrosis. Only abnormal liver texture had an adequate sensitivity of 69% when attempting to predict fibrosis stages 2-4.  No test had an acceptable negative predictive value to effectively rule out stage 2-4 fibrosis.

Conclusion

No test is able to definitively rule in cirrhosis. Platelet count is a useful test in ruling out cirrhosis. Ultrasound markers show similar negative predictive values to low platelet count but platelet count is a cheap, simple test. Low platelet count or irregular liver shape significantly increases the post-test probability of significant fibrosis. Neither low platelet count nor abnormal ultrasound findings were beneficial in ruling out significant fibrosis. This study was consistent with research by Iacobellis et al. (2005) who found platelet counts to be a useful parameter which was not significantly improved by the addition of ultrasound. Platelet counts and an ultrasound scan should be performed on all potential liver biopsy patients to aide counselling patients about their pre-biopsy odds of hepatic fibrosis and whether they should proceed to biopsy. Non-invasive tests cannot at this stage replace liver biopsy to predict exact stages of fibrosis. Prospective studies are warranted to look into non-invasive parameters with more complete data sets.

Authors of Report

Ivor Cammack, Lara Colbourne, Michael Hamilton, Rowena Howard, George Karageorge, Victor Kong, Ben La Hood, Kate Van Harselaar

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To Stike or Not to Strike? That is the Question

Opinions of Dunedin Hospital Doctors

Introduction

A doctors’ strike is an action that is both disruptive to patients and medical professionals alike.  It is an issue that is highly debated, with many differing opinions and clashes of beliefs.  There have been multiple reasons documented as to why doctors go on strike, but personal attitudes of medical professional’s over this issue have never been assessed.

Methods

We interviewed 46 randomly selected doctors and final year medical students about their opinions regarding doctors’ strikes.  Interviews were analysed qualitatively for the presence of common themes.

Results

The interviews resulted in a variety of views being expressed.  The majority of doctors interviewed felt that doctors did have the right to strike, however many acknowledged that this is not an easy decision to make and that patient suffering must be minimised.  Most doctors felt that patients suffer the most during strike action.  Experiences reported during the last junior doctors strike were conflicting and generally doctors found it to be a difficult time regardless of whether they were on strike or not.

Conclusions

There was a wide range of opinions expressed during the interviews which was consistent with our literature-based research findings.  The main issues frequently agreed upon were the reasons as to why doctors go on strike; these revolved around increased pay, improved working conditions and contractual disputes.  We found that the majority of our participants felt that doctors should have the right to strike.  Most expressed the idea that despite wanting to strike for their own personal reasons, it was difficult as many felt their patients were the ones who would suffer in the short term.

Authors of Report

Tony Chang, Ming Han Lim, Natasha Lingard, Leigh Martin, Simon Tsao, Sylvia Wu, Cassandra Wys, Joel Yap

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