A comparative analysis of cardiovascular disease risk profiles of five Pacific ethnic groups assessed in New Zealand primary care practice: PREDICT CVD-13.

BACKGROUND: Data on the cardiovascular disease risk profiles of Pacific peoples in New Zealand is usually aggregated and treated as a single entity. Little is known about the comparability or otherwise of cardiovascular disease (CVD) risk between different Pacific groups. AIM: To compare CVD risk profiles for the main Pacific ethnic groups assessed in New Zealand primary care practice to determine if it is reasonable to aggregate these data, or if significant differences exist. METHODS: A web-based clinical decision support system for CVD risk assessment and management (PREDICT) has been implemented in primary care practices in nine PHOs throughout Auckland and Northland since 2002, covering approximately 65% of the population of these regions. Between 2002 and January 2009, baseline CVD risk assessments were carried out on 11,642 patients aged 35-74 years identifying with one or more Pacific ethnic groups (4933 Samoans, 1724 Tongans, 1366 Cook Island Maori, 880 Niueans, 1341 Fijians and 1398 people identified as Other Pacific or Pacific Not Further Defined). Fijians were subsequently excluded from the analyses because of a probable misclassification error that appears to combine Fijian Indians with ethnic Fijians. Prevalences of smoking, diabetes and prior history of CVD, as well as mean total cholesterol/HDL ratio, systolic and diastolic blood pressures, and Framingham 5-year CVD risk were calculated for each Pacific group. Age-adjusted risk ratios and mean differences stratified by gender were calculated using Samoans as the reference group. RESULTS: Cook Island women were almost 60% more likely to smoke than Samoan women. While Tongan men had the highest proportion of smoking (29%) among Pacific men, Tongan women had the lowest smoking proportion (10%) among Pacific women. Tongan women and Niuean men and women had a higher burden of diabetes than other Pacific ethnic groups, which were 20-30% higher than their Samoan counterparts. Niuean men and women had lower blood pressure levels than all other Pacific groups while Tongan men and women had the highest total cholesterol to HDL ratios. Tongan men and women had higher absolute 5-year CVD risk scores, as estimated by the Framingham equation, than their Samoan counterparts (Age-adjusted mean differences 0.71% [95% CI 0.36% to 1.06%] for Tongan men and 0.52% [95% CI 0.17% to 0.86%] for Tongan women) although these risk differences were only about 10% higher in relative terms. CONCLUSION: The validity of the analyses depend on the assumption that the selection of participants for CVD risk assessment in primary care is similar between Pacific groups. The ethnic-specific CVD risk profiles presented do not represent estimates of population prevalence. Almost all previous Pacific data has been aggregated with Pacific peoples treated as a single entity because of small sample sizes. We have analysed data from the largest study to date measuring CVD risk factors in Pacific peoples living in New Zealand. Our findings suggest that aggregating Pacific population data appears to be reasonable in terms of assessing absolute CVD risk, however there are differences for specific CVD risk factors between Pacific ethnic groups that may be important for targeting community level interventions.

When should I do rural general practice? A qualitative study of job/life satisfaction of male rural GPs of differing ages in New Zealand.

AIMS: There is a shortage of rural general practitioners in New Zealand (NZ), and many are approaching retirement. This qualitative study was undertaken to investigate the perceived advantages and disadvantages of rural general practice at various stages of family life of male NZ-trained GPs. METHODS: Semi-structured interviews were conducted with 12 male NZ-trained rural GPs from the Waikato and Northland regions during December 2006. Major themes relating to rural general practice as a career were identified and analysed with respect to the family life cycle: no children yet, pre-school children, high school children, or 'empty nest'. RESULTS: Trends in the frequency of themes, and changes in the sentiments within each theme across different stages of family life were noted. CONCLUSION: Based on the frequency of themes and sentiments, a conceptual picture of the influences of stages of a male rural GP's family life on the GP are discussed.

Troponin testing for chest pain in primary healthcare: a survey of its use by general practitioners in New Zealand.

AIM: Serum troponin is now the preferred biochemical marker for myocardial infarction. The aim of this study was to investigate general practitioner (GP) knowledge and use of serum troponin testing in primary healthcare. METHODS: We sent a postal survey about troponin testing to all GPs in the Wellington region (n=299) of New Zealand. RESULTS: Of the 299 surveys sent, 216 replies were received (72%). 54% (n=115) of participants were male and 58% (n=113) in full time practice. 92% were using troponin tests (58% monthly). ECG (79%) and serum troponin (78%) were the tests most commonly used to triage patients with chest pain. GPs had excellent knowledge of false negative scenarios (84% correctly identified false negative if test undertaken within 6 hours) and less knowledge of false positive scenarios (39% answered 'Don't know'). CONCLUSIONS: The majority of GPs use serum troponin tests, and have sufficient knowledge of the test for use in a primary care setting. Most GPs use the tests appropriately, although a small proportion of doctors may defer rapid admission to hospital while waiting for the test result (7%) or manage the patient within general practice (5%) in those patients who have chest pain considered 'possibly' due to myocardial infarction.

Troponin testing for chest pain in primary healthcare: a New Zealand audit.

AIM: Serum troponin is a widely used biomarker for the diagnosis of myocardial infarction (MI). The aim of this audit was to document the actual clinical circumstances when serum troponin tests are used to assess chest pain in primary healthcare. METHODS: We undertook an audit of general practitioner (GP) serum troponin requests made to community laboratories in the Wellington region over a 5-week period in 2004. RESULTS: 433 tests were ordered by 201 GPs and 10 tests were positive. We faxed 396 questionnaires to identifiable GPs requesting the tests and received 292 replies (74%). The time between initial onset of symptoms and troponin testing was biphasically distributed with peaks at 7-12 hours and 3.5 days. An ECG was performed in less than 50% of the cases. The GP's estimate of the likelihood of their patient's symptoms being due to MI was strongly influenced by both positive and negative test results. Patients were referred acutely to hospital on less than 5% of occasions. CONCLUSIONS: GPs used troponin testing mostly for late presentations some days after chest pain, to 'rule-out' MI. When used acutely, referral for admission occasionally awaited the troponin test result.

Do snacks of exercise lower blood pressure? A randomised crossover trial.

AIM: To assess whether four 10-minute 'snacks' of exercise per day are as effective at lowering blood pressure as 40 minutes of continuous moderate exercise, when compared with no exercise. METHOD: Single blind randomised crossover trial of three 'exercise' regimes in general practice. PARTICIPANTS: 35 hypertensive adults without complications. INTERVENTIONS: Regimes included 4x10-minute episodes of brisk walking per day, 40 minutes continuous brisk walking per day, and no brisk walking. Each regime lasted 4 days with 10 days of no exercise in between. OUTCOMES: Change of systolic and diastolic blood pressure. RESULTS: Mean age 53 years and mean baseline blood pressure 166/103 mmHg. Systolic blood pressure changed by: -7.5 mmHg (95%CI: -8.9, -6.0) with 40-minutes regime; -7.3 mmHg (95%CI: -8.7, -5.8) with 4x10-minutes regime; and +1.0 mmHg (95%CI: -0.4, 2.5) with 'no brisk walking' regime (p<0.001). Diastolic blood pressure reduced by -4.0 mmHg (95%CI: -5.0, -3.0) with 40 minutes regime; -5.4 mmHg (95%CI: -6.4, -4.4) with 4x10 minutes regime; and -0.2 mmHg (95%CI: -1.2, 0.8) with 'no brisk walking' regime (p<0.001). CONCLUSION: Four 10-minute snacks of brisk walking were as effective as 40 minutes of continuous brisk walking per day at reducing blood pressure. This has implications for public health messages and advice to patients with hypertension.

Cost-effectiveness of physical activity counselling in general practice.

AIM: To assess the cost-effectiveness of the 'Green Prescription' physical activity counselling programme in general practice. METHOD: Prospective cost-effectiveness study undertaken as part of a cluster randomised controlled trial with 12-month follow-up of 878 'less-active' patients aged 40-79 years in 42 general practices in the Waikato. The intervention was verbal advice and a written exercise prescription given by general practitioners, with telephone exercise specialist follow-up compared with usual care. Main outcome measures included cost per total and leisure-time physical activity gain from health-funders' and societal perspectives. RESULTS: Significant increases in physical activity were found in the randomised controlled trial. Programme-cost per patient was NZ170 dollars from a funder's perspective. The monthly cost-effectiveness ratio for total energy expenditure achieved was 11 dollars per kcal/kg/day. The incremental cost of converting one additional 'sedentary' adult to an 'active' state over a twelve-month period was NZ1,756 dollars in programme costs. CONCLUSION: Verbal and written physical activity advice given in general practice with telephone follow-up is an inexpensive way of increasing activity for sedentary people, and has the potential to have significant economic impact through reduction in cardiovascular and other morbidity and mortality.

Lifestyle screening: development of an acceptable multi-item general practice tool.

AIMS: To develop a short screening tool for lifestyle and mental-health risk factors that adults can self-administer, and to determine acceptability and feasibility of use of this tool in primary care settings. METHODS: The multi-item tool was designed to screen patients in rural and urban New Zealand general practices for smoking, alcohol and drug misuse, problem gambling, depression, anxiety, abuse, anger, sedentary lifestyle, and weight issues. Patients were offered help for identified risk factors. Fifty consecutive adult patients per practice (n=2,543) were recruited to participate from 20 randomly-selected urban general practitioners; 20 general practice nurses and 11 rural general practitioners. RESULTS: Patients came from diverse ethnic, geographical, and socioeconomic backgrounds. The sample prevalence of positive responses identified ranged from 2.8% (gambling) to 42.7% (depression). The number of patients requesting immediate assistance with these responses (0.5 to 13.5%) did not overwhelm clinicians. The tool was well accepted by patients, with few objections to specific questions (0.1-0.8%). Most practitioners stated they will use the screening tool once available. CONCLUSIONS: Screening for lifestyle and mental health risk factors is becoming increasingly important in primary health care. This screening tool was acceptable to patients and was not considered overly burdensome by practitioners.

New Zealand Rural General Practitioners 1999 Survey--Part 2: gender issues.

AIMS: To compare and contrast the demographic and working characteristics of female and male rural general practitioners (GPs) in New Zealand, and to highlight issues specific to female rural GPs. METHODS: Anonymous postal questionnaires were sent to 559 rural GPs in November 1999. RESULTS: Completed questionnaires were returned by 417 rural GPs (75%). Of the 338 rural GPs who fulfilled the inclusion criteria, 93 (28%) were female. Eighty percent of female rural GPs were younger than 45 years of age compared with 53% of male rural GPs (p < 0.01). Women were less likely to be in full-time practice (45% vs 90%) or own their own practice (63% vs 83%) (p < 0.01). Concerns about locum scarcities, overwork, excessive on-call, bureaucratic demands, and GP shortages were equally important to both genders--while issues of security, accreditation, and combining work and family were mentioned by female GPs. CONCLUSIONS: Most of the quantitative gender differences could be explained by the female rural GPs being younger (80% in their child-bearing years). Recognising and addressing the specific difficulties faced by part-time female rural GPs, such as by providing more flexible work options, would create a more favourable environment, likely to retain and recruit more women.