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Evaluating the use of risk scoring systems to detect low risk patients after acute upper gastrointestinal haemorrhage in New Zealand

Abstract

Acute upper gastrointestinal (GI) haemorrhage is defined as bleeding into the GI tract proximal to the Ligament of Treitz. Acute upper GI bleeding is a common presentation to emergency departments around the world, with an estimated incidence in the United Kingdom of 100-172/ 100,000 adults per year (1, 2). The severity of the bleeding varies markedly; from insignificant bleeds which patients may not even seek hospital care for, to fatal haemorrhages. Acute upper GI haemorrhage has an average mortality around 10-14% (3-5) in the international literature, New Zealand data suggests that the rate is similar at 11% (6). The mortality rate from this condition has been reported as stable over the last 30 years. Recent observational studies have shown that the profile of patients presenting with this condition is changing compared to previous studies, with patients more likely to be older and to have more concurrent co-morbidities (5, 7). As age and medical co-morbidities are strongly associated with adverse outcomes and death, this likely explains the stable mortality rate over the last 30 years in the face of improving interventions and management. The most common cause of acute upper GI haemorrhage in Western countries is Peptic Ulcer Disease (PUD), estimated to make up almost 50% of cases (2, 8) with H. Pylori infection and non-steroidal anti-inflammatory drug (NSAID) use the most common predisposing factors. Another significant cause of acute haemorrhage is bleeding from oesophageal varices. This has a higher incidence in patients with hepatic failure or cirrhosis, and bleeding from this source is often associated with a significantly higher mortality.

Authors of report

Chelsea Baines, Emily Fawcett, Terry Fesaitu, Matthew Johnston, Hin Leung, Peter McLeod, Heather Norton, Nathan O’Donnell, Jenny Park, Adibah Salleh, Wei Zhang

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Evaluation of a social worker within the Police Department for low level domestic violence

Abstract

Domestic violence (DV) is a huge issue in New Zealand and results in 200 callouts for police per day on average with ‘low-level’ violence recurrence contributing to the majority of these callouts. ‘Low level’ violence, such as psychological abuse and minor physical and verbal disputes, form a major part of the police family violence coordinator’s (FVC) work load but due to resource constraints, survivors are often inadequately supported. Typically DV escalates in both frequency and severity, making early intervention imperative as well as potentially cost-effective. DV intervention programmes are difficult to evaluate due to heterogeneity of both participants and outcomes and it is known that a qualitative approach is best suited to evaluate these interventions.

Methods

This qualitative study involves interviews with 14 key representatives from a variety of Dunedin based organisations who provide and coordinate services to both survivors and offenders of DV. A large variety of outcomes were explored using a semi-structured questionnaire.

Results

14 out of the 16 organisations suggested as appropriate by the FVC were interviewed. Main findings include: 1. Existent service gaps exist for males, both as victims and as offenders, and for minority groups, particularly for people of Pacific Island descent, and elderly people. 2. A need for greater cooperation between organisations and less departmental overlaps is required to reduce DV. 3. Social workers (SWs) were considered suited to this role by virtue of their specialist communication skills training and knowledge of available support organisations, which some stakeholders commented lead to more appropriate, succinct referrals and easier communication between services. Reservations about having a SW within the police included blurring of the police role, and professional isolation for the SW.

Discussion

SW intervention decreased the work load of the FVC and increased effective communication between organisations but it was unclear if this role was best filled by a SW. Other options suggested by stakeholders included administrative support, another police officer, a SW from another organisation working within the police, or another agency taking sole responsibility. Stakeholders were unanimous that the FVC requires assistance in order to adequate support and involve other agencies immediately after a low level DV incident.

Authors of Report

Lance Buckthought, Ashton Ellison, Clarence Kerrison, Thomas Kuperus, Catherine Liddle, Jong Hoon Park, Helen Slade, Hannah Walker, April Xu-Holland.

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Green Prescription (Grx): An analysis of referral rates within Otago and an evaluation of opinions of GRx and the value of education session provided by Sport Otago

Context

Physical inactivity is a significant risk factor for many chronic health conditions and is a leading cause of mortality, however 50% of NZ adults are not reaching the recommended physical activity guidelines. This being 30 min per day, of moderate intensity physical activity, five times a week. The Green Prescription (GRx) is a primary care approach to increase physical activity levels in NZ, and while it has shown to be effective it is not being used to its full potential.

Aims

Aim 1: To find out how referral rates to Green Prescription by General Practitioners / Practice Nurses correspond to education sessions provided by the Green Prescription Area Manager from Sport Otago. Aim 2: To find out General Practitioners'/Practice Nurses' ideas and attitudes towards Green Prescription. Aim 3: To find out General Practitioners'/Practice Nurses' thoughts on how effective the Green Prescription education and training is, and what strategies could be used to be improve referral rates.

Methods

To address the first aim, an analysis of the Sport Otago GRx database allowed investigation of the correlation between referral numbers and education sessions. For Aims 2 and 3 surveys were sent to all potential referrers in the Otago region. This gained information from referrers about their attitudes toward green prescription, as well as their current referral habits. In total 388 surveys were posted to 46 practices in the Otago Region, 128 surveys were returned (33% response rate).

Results

Data from the Sport Otago database shows that overall referral rates are low with a background referral number of 1-1.2 patients every month from the average practice. Education sessions have a small impact with 1.61 referrals made in the 30 days following an education session. The survey showed that the majority of referrers (69%) believe GRx is beneficial to their patients. Referrers most commonly see patients' daily/weekly that would benefit from GRx but they only refer patients' monthly/3-monthly. The most common reasons for not referring patients to GRx were 'patients not interested', 'forget to refer' and 'not enough time in consultations'. To increase referral rates to GRx referrers believe more time for the consultation is needed, along with increased public awareness. Most referrers (79%) believe they do refer more following an education session, this is not what results from Aim 1 indicate. However, most referrers attend education sessions, find them useful and think they should happen once per year.

Conclusions

While the majority of referrers believe their patients gain benefit from GRx, referrals to GRx are low. Having more time in consultations and increasing public awareness of GRx are areas that should be addressed to increase referral rates. Practice Nurses remain an under-utilised resource in the GRx referral process and ways to increase their referral rates need to be considered.

Authors of report

Ivy Chen, Bronwyn Hanger, Sarah McConnell, Ruzaimah Mohammad, Emma Murgatroyd, Mike O'Grady and Lisa Stevenson.

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Impact of the ABC approach to smoking cessation in a hospital setting

Background

In New Zealand smoking remains a leading cause of morbidity and mortality, killing up to 5,000 New Zealanders per year. In 2009, the New Zealand Ministry of Health introduced a new health target with 95% of all hospitalised smokers to be provided advice and support to quit smoking by July 2012. The ABC intervention for smoking cessation was introduced nation-wide in 2009 as a tool to aid health professionals in achieving this health target.

Aims

Amongst smokers admitted to five designated wards in Dunedin Public Hospital, we aim to;

  1. Assess the impact of brief advice regarding smoking behaviour on patients following their inpatient stay.
  2. To investigate if receiving the ABC advice by hospital staff prompted changes in smoking behaviour and what other factors may have prompted changes in five wards/departments of Dunedin Public Hospital.
  3. To identify if further support for smoking cessation is sought by patients after their hospital stay.
  4. To investigate how patients feel about receiving ABC and quit advice.

Methods

Participants were selected from patients admitted to Dunedin Public Hospital between the 1st of December 2011 and the 31st of January 2012. The participating wards were 4C (surgical), 5B (neurosurgical, neurology, ENT), 7A (respiratory), 7C (cardiology), and Day Surgery Unit. Patients were included in the study if they had identified themselves as smokers at the time of admission, and consented to a follow-up by phone at a later date. Patients were excluded if they declined or were not asked to participate in the study by hospital staff. Telephone interviews were conducted with consenting participants approximately five months post-discharge. Information collected included demographic data, smoking background, whether or not they received all components of the ABC intervention, changes in smoking behaviour, and perceptions of the ABC approach. Both qualitative and quantitative analyses were undertaken. The study was conducted with approval from the Lower South Regional Ethics Committee, and in consultation with the Associate Dean of Māori of the Dunedin School of Medicine.

Results

31 participants were included in our final analysis (71% response rate). 30 participants (97%) recalled being given advice to quit smoking, but only 19 (61%) were offered cessation support. Our study reports a successful quit smoking rate of 10% and an overall quit attempt rate post-discharge of 39%. Participants were generally receptive to the ABC approach delivered by hospital staff, however a key concern identified among the respondents was a lack of cessation support, both during and after hospital stay.

Conclusion

The ABC approach was generally well received within the study population, and may have led to tangible changes in smoking behaviour following discharge from hospital. However, further improvement to this intervention is needed as a lack of cessation support from hospital staff was identified as a key concern.

Authors of report

Alexandra Grant, Matthew Hamilton, Megan Haywood, Zeyin Li, Andrew Maw, Nicki Pointing, Matthew Restieaux, Sam Taylor, Wan Noormastura Wan Deraman, Kimberley Wee.

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Risk perception, anxiety and beliefs about colonoscopy surveillance in patients with a family history of colorectal cancer

Abstract

Colorectal cancer is a common cause of morbidity and mortality. This burden may be reduced through surveillance measures and adoption of healthy life style behaviours. Patient anxiety, risk perception and beliefs about surveillance may contribute to variation in uptake of these factors.

Aims

In patients undergoing surveillance colonoscopy for an elevated risk of colorectal cancer due to family history we aim to determine the:

  1. Patient perceived versus actual lifetime risk of developing colorectal cancer
  2. Perceived risks and benefits of colonoscopy surveillance
  3. Perceived causes of colorectal cancer and self-reported change in life style risk factors
  4. The interaction of anxiety, risk perception, and risk conferred by family history on the above

Methods

Participants were randomly selected from a database of patients undergoing surveillance colonoscopy at Dunedin Public Hospital. Participants were eligible for inclusion if they underwent at least one surveillance colonoscopy due to family history of colorectal cancer between 1996 and March 2012, and were ineligible if aged 75 or over, had a personal history colorectal cancer or inflammatory bowel disease. A visual aid was mailed to all potential participants, and a phone interview was conducted. Clinical details were collected from hospital databases. Information collected included demographics, family history and history of surveillance colonoscopies, perception of life time risk of colorectal cancer, perception of risks and benefits of colonoscopy, and self-reported behavioural change. General anxiety was assessed using the GAD-7 scale. All participants gave oral consent and this study was conducted with the approval of the Lower South Regional Ethics Committee.

Results

In all, 148 participants were included (69% response rate). We found that participants had inaccurate perceptions of their life time risk of colorectal cancer, with the majority over estimating their risk. Overall, participants had realistic views about the risks and benefits of surveillance colonoscopy, and attributed high value to this service. There was preponderance towards thinking that colorectal cancer was caused mostly by genetics in this population, but also a high degree of self-reported change in life style risk factors due to thoughts about colorectal cancer. There was no association between anxiety, risk perception and risk due to family history, but higher degrees of worry about cancer due to family history was associated with both anxiety and risk perception. Those with higher levels of anxiety appeared to be more likely to adopt healthy life style behaviours.

Conclusions

Patients undergoing colonoscopy surveillance for a family history of colorectal cancer over-estimate their risk of colorectal cancer, but have realistic views of the risks and benefits of colonoscopy surveillance. These results may have implications for the development of national screening programme. Self-reported behavioural change due to concern about colorectal cancer was common and clinicians should recognise and support these efforts.

Authors of report

Andrew Crowley, Rhys John, Jonathan Kok, Ho-Nam Lee, Hasif Mustafa, Kia Miang Sii, Rebecca Smith, Sung-Eun Son, Gregory Tarr, Lauren Weaver.

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Sexual experiences and difficulties among young adults

Introduction

Sexual difficulties have been identified as a common issue in a wide variety of sexual health surveys. However there is limited data on the sexual difficulties, and associated sexual behaviours in the New Zealand University population.

Aims and study design

The aims of our study were to both determine/define the sexual behaviours, including contraceptive use, Sexually Transmitted Infection exposure, and the effects of alcohol in a random sample of the university population; and also elicit the prevalence of sexual difficulties, determine how significant a problem they are in a university population, and how access and acceptance of help can be improved for addressing sexual difficulties from the students' point of view. We conducted an online survey of 500 male and 500 female students randomly selected from the University of Otago during July 2012 and they were sent an email invitation to complete an online survey.

Results

345 students responded to the survey and were included in the analysis. In our sample population, 79.8% of participants were sexually active. Of these 62% of males and 79% of females experienced sexual difficulties, with females more likely to report the difficulty as a significant problem. 14.4% had previously had a Sexually Transmitted Infection (STI). Female participants were more likely to have unwanted sexual contact under the influence of alcohol (22.7%), compared to male respondents (17.5%). There was a greater than 60% awareness for the Emergency Contraceptive Pill (ECP), Oral Contraceptive Pill (OCP), diaphragm and condoms, with condoms the most commonly used contraceptive method. Of those using condoms, over 50% experienced a lack of enjoyment or delay in achieving climax. The majority of study participants (68.3%) would seek help for a sexual problem, with the greatest reported barrier to seeking help being embarrassment (42%). The internet was the most commonly used source of information (60.9%).

Conclusions

Sexual difficulties are a common self-reported problem in our sample of the university population. Condom use is widespread, but there are significant sexual difficulties associated with condom use, requiring further programmes for education and awareness of their benefits for both contraception and STI protection. The internet is a widely available and already readily utilised source for information about sexual difficulties. Health Professionals can enhance the awareness and education around sexual behaviour and difficulties by recommending useful internet resources to their patients.

Authors of report

Dennis Chan, Joon Chin, Sarah Ibrahim, Michael Kang, Jonathon Keast, Rick Kumar, Genevieve Law, Helen Martyn, Anna McInnes, Morrison Wu.

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