Journal of the New Zealand Medical Association, 30-November-2007, Vol 120 No 1266
Proceedings of the Waikato Clinical School Research Seminar, Wednesday 12 September 2007
Brief interventions in primary health care: referral and intake assessment processes, Julia Davis. University of Waikato
The Brief Interventions Project was a large study evaluating brief mental health interventions (4-6 sessions) as provided by the Waikato Primary Health Organisation in 2006-2007. GPs referred nearly 1500 people in the Waikato region to Brief Interventions therapists in the space of a year. Analyses of GP referral rates found broad differences in referral rates between GPs, from no referrals to more than 40 patients referred. These differences could not be accounted for by practice locality (e.g. rural compared with urban GPs). Alternative explanations might include different strategies for managing patients’ mental health concerns, different utilization of mental health professionals by GPs, or varying levels of GP’s ‘psychological mindedness’ in the conceptualization and treatment of psychological distress. Intake assessment results suggest that those people referred by GPs were appropriate for referral to the Brief Interventions service. Finally, some demographic groups were under-represented in the group who were referred (such as males, and people identifying as Maori), although referral rates are reflective of the demographic profile of GP patients. Based on these results, issues for the continued provision of brief interventions and its evaluation were discussed.
Mental health outcomes for primary care patients enrolled in the Waikato PHO Brief Interventions Project. John Fitzgerald, Karma Galyer, Juanita Ryan, Lauren Gaffaney. The Psychology Centre, Hamilton
Accessing mental health care is challenging, particularly when difficulties are not severe enough for secondary care services. The Waikato PHO Brief Interventions Project aimed to increase access to care by funding up to six sessions of counselling for GP patients with mild to moderate psychological distress. This type of brief intervention in primary care has had positive outcomes internationally, but had not been investigated in New Zealand. Evaluation participants completed the Brief Symptom Inventory-18 (BSI-18 n=107, matched pairs = 85) and The General Health Questionniare-12 (GHQ-12 n=100, matched pairs = 81) at their first and last session. Patients’ scores were significantly improved at outcome, with 68% of the group showing reliable change on the BSI-18 and 64% on the GHQ-12. Therapists’ (n = 254) and patients’ (n=152) feedback concurred that the interventions improved psychological wellbeing. Qualitative examples of the benefits obtained included symptom reduction, skill development, and insight into the problem experienced. These results provide support for the value of a brief intervention service for mental health care in a New Zealand setting. Ongoing evaluation is required to check that benefits continue to be maintained, and to identify relevant areas for service development.
Factors affecting clinical decision-making in bronchiolitis. D Graham, K-C Hsiao, M Ferry-Parker, N Manikkam, Child Health, Waikato Hospital, Hamilton
Aim: To evaluate clinicians decision-making process in acute bronchiolitis, including relative impact of clinical status and pulse oximetry.
Methods: Multi-centre randomised controlled study on clinicians’ management preferences using hypothetical vignettes of an infant with acute bronchiolitis. Four possible vignettes were generated using two different clinical presentations combined with two different pulse oximetry readings, and randomly distributed, one per clinician. Clinicians indicated investigation and management preferences. Eligible clinicians included paediatric medicine nurses and doctors and emergency medicine nurses and doctors working in New Zealand public hospitals.
Results: From 299 vignettes, 63.6% of clinicians decided to either perform no investigation or only perform nasal virology. Investigations chosen included chest x-rays (33.4%), full blood counts (12.4%), electrolytes (12.0%) and blood cultures (8.4%). Therapy chosen included inhaled bronchodilators (15.4%), systemic corticosteroids (7.0%), and antibiotics (7.0%), and supplemental oxygen (53.9%).
Well infants were less likely than unwell infants to have un-necessary investigations (OR 2.47, CI 1.51-4.04), more likely to have ineffective therapies (OR 0.61, CI 0.38-0.98) and as likely to have necessary therapies (OR 1.41, CI 0.84-2.38). Infants with lower pulse oximetry values were more likely to have un-necessary investigations (OR 2.69, CI 01.65-4.40), more likely to have ineffective therapies (OR 7.98, CI 4.62-13.79) and as likely to have necessary therapies (OR 0.62, CI 0.36-1.04) as children with higher pulse oximetry values. Well children with lower pulse oximetry were more likely to have un-necessary investigations (OR 5.50, CI 2.29-13.21), more likely to have ineffective therapies (OR 24.38, CI 9.98-59.55) and less likely to have necessary therapies (OR 0.03, CI 0.00-0.09) than well children with higher pulse oximetry values. Unwell children with higher pulse oximetry were as likely to have un-necessary investigations (OR 1.83, CI .97-3.48), less likely to have ineffective therapies (OR 3.36, CI 1.64-6.91) and less likely to have necessary therapies (OR 9.32, CI 3.38-25.73) than unwell children with lower pulse oximetry values.
Conclusions: Infants with acute bronchiolitis are over investigated and often inappropriately treated. The decision making process is strongly and inappropriately influenced by pulse oximetry readings. Clinical practice should focus on the patient and clinical findings, rather than on pulse oximetry. It may be appropriate to review the risks, as well as the benefits, of pulse oximetry in routine paediatric practice.
The use of the general health questionnaire 12 in detecting mental health difficulties in primary care. TJ Halliday. Hamilton Psychological Service
The focus of this presentation is on the use of the GHQ-12 within two primary care practices in order to explore case selection, and referral decisions made by general practitioners. Results from the current study found that a number of clients presenting with mental health difficulties were identified by the GHQ-12, but not referred on by general practitioners. Of those that were recognized, few were referred on to specialist mental health providers. The discussion and recommendations focus on outlining a role for psychologists in enhancing screening and referral accuracy, enhancing appropriate access to specialist services where necessary, and identifying those individuals whose needs may be better met within the primary care environment.
A Phase I pharmacokinetic study of PR-104, a hypoxia-targeting agent, in patients with solid tumors. MB Jameson1, D Rischin2, M Pegram3, J Gutheil4, A Patterson5, W Denny5, W Wilson5; 1Waikato Hospital, Hamilton, New Zealand; 2Peter MacCallum Cancer Centre, Melbourne, Australia; 3University of California, Los Angeles, CA, USA; 4Proacta, Inc., San Diego, CA, USA; 5Auckland Cancer Society Research Centre, Auckland, New Zealand
Background: PR-104 is a novel pre-prodrug (precursor of a prodrug) designed to form a cytotoxic nitrogen mustard (alkylating agent) in hypoxic regions of tumors. Following IV administration, PR-104 is converted by systemic phosphatases to the alcohol intermediate PR-104A, which, under hypoxic conditions, is reduced to form the active DNA-crosslinking mustard species PR-104H. This phase I trial defines a Maximally Tolerated Dose (MTD) and pharmacokinetics (PK) for this schedule.
Methods: Patients (pts) with relapsed/recurrent solid tumors received PR-104 as a 1-hour IV infusion every 3 weeks with PK sampling on days 1-2 of cycle 1. Cohorts of ≥3 pts were treated starting at 135 mg/m2.
Results: 23 pts have been enrolled: median age 51 years (range 29-72); 13 (57%) male. Most pts had received prior radiation or chemotherapy and had metastatic disease. Six dose levels (135, 216, 354, 550, 770, and 1100 mg/m2) have been evaluated. Dose-limiting toxicity (DLT) was observed in one patient at 1100 mg/m2 (grade 3 fatigue) and this dose level was expanded to 6 pts. In the first 4 cohorts, 54 adverse events (AEs) were considered drug-related by the investigator including nausea (26% of all AEs), fatigue (19%), vomiting (11%) and anorexia (6%); remaining AEs each constituted < 3% of the total. Of 16 grade 3 AEs, 3 were considered drug-related by the investigator (anemia, dehydration and vomiting). Prophylactic anti-emetics largely prevented nausea and vomiting at higher doses, at which dose-related decreases in neutrophils and platelets were seen.
Conclusions: PR-104 has shown manageable toxicities similar to other cytotoxic agents, with no serious mucositis, diarrhea or alopecia. DLT is likely to be myelosuppression based on preclinical and current clinical data, with the MTD close to 1100 mg/m2. The preclinical PK target for the alcohol intermediate has been exceeded at higher doses and, while no objective responses have been documented, reductions in tumor volume have been seen at these doses.
Cmax and AUC for PR-104 and PR-104A:
Retention of patients in the "Get Checked" free annual diabetes review program in Waikato, New Zealand. G Joshy 1, RA Lawrenson1, D Simmons2. 1Waikato Clinical School, University of Auckland, Hamilton, Waikato, New Zealand; 2Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
Aim: To characterise the retention of patients in the "Get Checked" free annual diabetes review program in New Zealand.
Methods: Retrospective review of Waikato Primary Health registered patients who had at least one "Get Checked" review between 1st July 2000 and 30th Jun 2006. The time reviews were analysed using Kaplan-Meier survival curves. Predictors for the likelihood of a second review were identified using Cox's regression analysis.
Results: 10,919 patients were reviewed at least once during this five year period. There were 69% Europeans, 18% Maori, 3% Pacific Islanders, and 4% Asian. 87% had Type 2 diabetes and 8% had Type 1 diabetes. Only 57% of the estimated 10,604 diabetes patients utilised the free check in 2005/06. One and a half years after initial review, 35% were yet to return for a second review (Figure 1). But those who were retained attended subsequent reviews more regularly. Those who attended a second review returned much earlier for the third review, 75% within 1.5 years after second review. Maori and Asians took a significantly longer time to return for a second review (median 1.4 years) compared with Europeans (1.1 years, p<0.0001). Younger patients aged <40 years returned for a second review much later (1.8 years) compared with 65+ year olds (1.1 years, p<0.0001). No significant gender difference was found. Younger patients aged <40 years (vs age 65+), those of Maori or Asian origin (vs Europeans) and those with Type 1 diabetes (vs Type 2) were less likely to return for a second review.
Conclusions: In spite of this program being of benefit and free to patients, a significant proportion of patients did not return for a second review within 1.5 years after initial review. The loss of those with Type-1 diabetes and younger patients may reflect their greater contact with specialist rather than GP services. Excess drop out among ethnic minorities need further investigation and intervention.
Figure 1. Kaplan-Meier Survival Curves for the Time to Reviews (from the Previous Review, Conditional that Patients Attended the Previous Review).
Table 1. Survival Analysis of Time to Second Review (from Initial Review)
Preschool development and cognitive ability at 8 years in very low birth weight infants. NA Keene, D Bourchier, S McGregor. Child Development Centre, Waikato Hospital, Hamilton
Very Low Birth Weight (VLBW) infants are at increased risk for development problems due to being born so early and so small. Infants born weighing less than 1250g, and discharged from Waikato Hospital New Born Unit, are routinely followed up at the Child Development Centre, at 1 & 2 years (age corrected for prematurity) and at age 4. The aims of this study were to: (1) assess the cognitive outcome of these children at 8 years of age, and (2) determine the potential value of the preschool developmental assessments in predicting school-age outcomes.
Thirty five infants born in 1998, weighing less than 1250g, were identified for the study. Twenty three children participated, 52% were male. The mean age was 100.65 months (8yr 4mths) and the mean birth weight was 878.04gms (range 580g – 1112g). The Wechsler Intelligence Scale for children, Fourth Edition (WISC IV) was used to assess cognitive ability.
Full Scale Cognitive scores (WISC IV, mean 100, SD 15) were 1 Standard Deviation below the mean (mean FSIQ 84.30, SD 18.17, median 90, range 50-109). A Repeated Measures ANOVA found that scores at 4 years were not significantly different than scores at 8 years.
Overall, our hypotheses were supported, with VLBW infants achieving substantially lower cognitive scores compared to normative data on the WISC IV. Results suggest that the 4 year assessment is more predictive of 8 year cognitive outcome than earlier assessments. Further results and clinical significance will be discussed.
Diagnosing mental illness in general practice. Steven Lillis, Graham Mellsop. Waikato Clinical School, University of Auckland
A qualitative study was undertaken in the Waikato to understand the use of diagnostic schema by general practitioners when making a diagnosis of mental illness. The results suggested that formal classifications were seldom used and that disease management imperitives were strong drivers of diagnostic process. A subsequent nationwide survey of general practitioners found that the most common reasons for not using diagnostic schema was lack of familiarity and experience with them, perceived ridgidity and high complexity. The most important roles of the diagnostic process are assistance with pharmacological choices and communication with other health workers. It is imperitive for classification systems to successfully integrate with practice management systems.
Mindfulness-Based Stress Reduction (MBSR) training: challenges and achievements for people with chronic health problems. P Thomas1, J Shennan2, W Tuck2, J Bell 3, H Conaglen4.1The Psychology Centre, 2Health Waikato, 3Private Practice, 4Research Consultant
The evidence indicates that mindfulness-based stress reduction training, or MBSR, is effective in alleviating suffering and improving coping related to many chronic illnesses. We believe this is the first New Zealand/Aotearoa pilot study of MBSR training for people with chronic health problems; for example, chronic pain, diabetes, a history of strokes, hypertension, and cancer. Between October 2005 and December 2006, forty-two participants (randomly allocated to treatment and waitlist conditions) attended and completed one of four eight-week MBSR training groups. The impact of MBSR training on their physical and psychological health was monitored, and followed up six months later. Research challenges included recruitment and conservation of a sample big enough to be statistically significant, and consequent problems for the study design. The significant achievements reported by two group members with considerable health difficulties will be discussed, and possibilities for future research will be noted.
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