Unmet need for referred services as measured by general practice.

INTRODUCTION Unmet needs are a key indicator of the success of a health system. Clinicians and funders in Christchurch, Canterbury, New Zealand were concerned that unmet health need was hidden. AIM The aim of this survey was to estimate the proportion of patients attending general practice who were unable to access clinically indicated referred services. METHODS The survey used a novel method to estimate unserviced health needs. General practitioners (GPs, n = 54) asked their patients (n = 2135) during a consultation about any health needs requiring a referred service. If both agreed that a service was potentially beneficial and not available, this was documented on an e-referral system for review. The outcomes of actual referrals were also reviewed. RESULTS The patient group was broadly representative of the Canterbury population, but over-sampled female and middle-aged people and under-sampled Maori. Data adjusted to regional demographics showed that 3.6% of patients had a GP-confirmed unserviced health need. Elective orthopaedic surgery, general surgery and mental health were areas of greatest need. Unserviced health needs were significantly (P ≤ 0.05) associated with greater deprivation, middle-age, and receiving high health-use subsidies. DISCUSSION To our knowledge, this is the first survey of GP and patient agreement on unserviced referred health needs. Measuring unserviced health needs in this way is directly relevant to service planning because the gaps identified reflect clinically indicated services that patients want and need. The survey method is an improvement on declined referral rates as a measure of need. Key factors in the method were using a patient-initiated GP consultation and an e-referral system to collect data.

The primary prevention of rheumatic fever.

Rheumatic fever (RF), caused by untreated group A streptococcal (GAS) pharyngitis, is a major cause of morbidity and mortality throughout much of the less developed world and disadvantaged populations (Indigenous and other) in the developed world. Through systematic literature searches, our group has identified potential risk factors for RF and possible interventions for its prevention. The causes can be divided into biological factors, socio-economic, and lifestyle factors and health-care systems and services. Currently, the most promising medical areas look to be improving access to health care and introducing community and school-based sore throat interventions (which aim to diagnose and treat GAS pharyngitis). We could find no convincing support for skin sepsis causing RF. Overall evidence suggests that measures that aim to alleviate poverty and crowding may also reduce the incidence of RF. In comparatively rich countries such as New Zealand and Australia, urgent measures based on available evidence should be undertaken to reduce the very striking health disparity seen with RF and its sequela, rheumatic heart disease in our at-risk populations.

Guidelines for sore throat management in New Zealand.

AIMS: Untreated group A streptococcal (GAS) sore throats can cause acute rheumatic fever (ARF), with permanent cardiac damage in 30%. An algorithm and guideline for appropriate screening and management of sore throats in the New Zealand setting was crafted to guide appropriate treatment in high risk rheumatic fever areas and reduce antibiotic use in low risk areas. METHODS: Three American sore throat guidelines were used as a framework, and searches were made of databases including Medline, Old Medline, Cochrane, DARE, Central, NHS EED, WHOLIS, (www.clinicalevidence.com), and (www.pubmed.gov). No European guidelines were available. RESULTS: A guideline for GAS pharyngitis was created, including an algorithm which stratifies patients according to their risk of ARF. Revised Centor criteria to determine the likelihood of GAS pharyngitis were used. Patients at medium or high risk for GAS pharyngitis should have throat swabs taken if possible. Recommended treatment tables are given. CONCLUSIONS: Patients presenting with sore throats need to have their risk of developing rheumatic fever assessed, and then the risk of GAS pharyngitis determined. Appropriate antibiotic therapy is instigated on the basis of proven or likely GAS pharyngitis. Ten days of oral penicillin V is the first-line treatment. Other household members are at high risk of infection. Unnecessary antibiotic use is a guiding principle in low risk patients.

Meta-analysis of trials of streptococcal throat treatment programs to prevent rheumatic fever.

BACKGROUND: Rheumatic fever (RF) is the commonest cause of pediatric heart disease globally. Penicillin for streptococcal pharyngitis prevents RF. Inequitable access to health care persists. PURPOSE: To investigate RF prevention by treating streptococcal pharyngitis in school- and/or community-based programs. DATA SOURCES: Medline, Old Medline, the Cochrane Library, DARE, Central, NHS, EED, NICE, NRMC, Clinical Evidence, CDC website, PubMed, and reference lists of retrieved articles. Known researchers in the field were contacted where possible. METHODS: Randomized, controlled trials or trials of before/after design examining treatment of sore throats in schools or communities with RF as an outcome where data were able to be pooled for analysis. Two authors examined titles, abstracts, selected articles, and extracted data. Disagreements were resolved by consensus. QUANTITATIVE ANALYSIS TOOL: Review Manager version 4.2 to assess pooled relative risks and 95% confidence intervals. DATA SYNTHESIS: Six studies (of 677 screened) which met the criteria and could be pooled were included. Meta-analysis of these trials for RF control produced a relative risk of 0.41 (95% CI: 0.23-0.70). There was statistical heterogeneity (I = 70.5%). Hence a random effects analysis was conducted. LIMITATIONS: Many studies were poor quality. Title and available abstracts of non-English studies were checked. There may be publication bias. This is the best available evidence in an area with imperfect information. DISCUSSION: It is expected acute RF cases would diminish by about 60% using a school or community clinic to treat streptococcal pharyngitis. This should be considered in high-risk populations.