Attitudes to recertification measured over time using a validated semantic differential scale.

OBJECTIVES: This study was designed to measure the acceptability of the Royal New Zealand College of GPs' Recertification programme to the GPs in the programme. DESIGN: Questionnaire study of a stratified random sample of members of the RNZCGP. METHOD: A semantic differential attitude scale was developed and validated. The scale was administered to 300 GPs before the Recertification programme began and repeated with 100 of these GPs 18 months later. After 3 years of the programme the questionnaire was administered to the original 300 GPs. RESULTS: Baseline data showed reasonable acceptance of the concept of recertification but by 18 months there was a significant deterioration in the way the programme was perceived and this did not change over 3 years. Many GPs were not convinced of the value of the programme.

Changes in CME uptake caused by reaccreditation.

AIM: To determine whether the requirements of the reaccreditation programme of the Royal New Zealand College of General Practitioners (RNZCGP) have changed the amount and type of continuing medical education (CME) done by the participating general practitioners. METHOD: A written questionnaire was sent to 200 randomly selected general practitioners doing the RNZCGP reaccreditation programme. RESULTS: The response rate was 82%. Although almost half the general practitioners had been motivated to spend more time on CME by the reaccreditation programme, for most this was a small increase. However, there was a trend towards selection of higher quality courses and towards increasing the time spent on educational activities more likely to result in changed behaviour. CONCLUSION: The RNZCGP reaccreditation programme is having beneficial effects on the CME activities of many of the participating general practitioners.

The validity of general practitioners' self assessment of knowledge: cross sectional study.

OBJECTIVE: To determine whether general practitioners can make accurate self assessments of their knowledge in specific areas. DESIGN: 67 general practitioners completed a self assessment of their level of knowledge over a variety of topics using a nine point semantic differential scale. An objective assessment of their knowledge was then made by administering true-false tests on two of the topics: thyroid disorders and non-insulin dependent diabetes. The study was repeated with another group of 60 general practitioners, using sexually transmitted diseases as the topic. SETTING: General practices in New Zealand. SUBJECTS: Random sample of 67 general practitioners in Auckland. MAIN OUTCOME MEASURE: Test scores for self assessment and for actual knowledge. RESULTS: Correlations between self assessments and test scores were poor for all three topics studied (r = 0.19 for thyroid disorders, 0.21 for non-insulin dependent diabetes, 0.19 for sexually transmitted diseases). CONCLUSIONS: As general practitioners cannot accurately assess their own level of knowledge on a given topic, professional development programmes that rely on the doctors' self perceptions to assess their needs are likely to be seriously flawed.

Older adults and healthy lifestyle issues: results of a community study.

AIM: To discover sources of information about, levels of understanding of, and degrees of commitment to a healthy lifestyle on the part of elderly people in the community as a preliminary to mounting health promotion and education initiatives. METHOD: In 1992 500 people aged 60 and over were surveyed anonymously using a 33 item questionnaire. This sought information on a wide range of health and lifestyle issues in older age. The material in this paper refers to only four of the questions asked, namely those relating to sources of, knowledge of, and interest in information on health and ageing. RESULTS: Doctors were perceived to be the most important sources of health information (89% of respondents rating them as "very" or "moderately" important). Relatives/friends and books/magazines were the next most important sources (56 and 55% respectively). High levels of misinformation about lifestyle issues were revealed. Whilst 85+% of respondents answered correctly that smoking was deleterious and strong social ties advantageous to good health in old age there was confusion about causes of osteoporosis, use of vitamins, likelihood of developing dementia and even the importance of exercise. This has implications for the content of health promotion programmes. Contrary to previously published research, we found no correlation between educational or socioeconomic status or gender, and knowledge about health issues and healthy lifestyles. CONCLUSION: Studies of this type clearly have the ability to provide a range of information which ought to be available to those responsible for the planning of health promotion and education initiatives for older adults.

Assessment for rest home subsidy: are the elderly getting a fair deal?

AIM: To describe the role of a geriatric service in assessing the needs of elderly people at home or in rest homes referred for a subsidy for rest home care, and to compare this assessment with the composite dependency scale (CDS), a Department of Social Welfare assessment instrument. METHODS: A 47 item questionnaire was completed by the geriatric service at the time of assessment of elderly people in the community or in rest homes. RESULTS: Of 280 assessments, 100 were from private homes, 180 from rest homes. Sixty-three per cent in rest homes were referred only because private funds were exhausted, 33% for a change in dependency category. These two groups plus those at home were used as a basis for comparison in subsequent analysis. Of those at home: 30% already had a rest home bed arranged; 77% remembered being consulted about rest home care, but only 38% were sure they wanted to go into such care. The proportion of those too independent or too sick for rest home care was: private homes 14%, rest home resident requiring subsidy 6%, rest home requiring change in category status 11%. Twenty three percent of those at home could continue there with or without additional support. No significant difference was found in dependency between those in rest homes only seeking funding, and those at home, but both of these groups were significantly less dependent than those seeking an increase in subsidy. There was only a moderate correlation (rs = 0.778) between the geriatric service assessment of dependency and the composite dependency score. CONCLUSIONS: Many elderly people do not feel properly consulted about rest home placement, and some could be supported at home for longer. It is likely that many who can afford rest home fees are entering too early and then asking for a subsidy when their funds are exhausted. By then it is almost impossible to insist on alternatives in the community. A policy of geriatric service assessment for all seeking entry into rest home care should ensure independent consultation and consideration of alternative strategies. More research is required to examine cost implications of unrestricted movement into rest homes.

Young disabled residents in old people's homes.

A survey of the status of residents in aged care facilities in the Auckland region conducted in 1988 indicated that almost 9% (645) of the 7516 people studied were under 65 years of age. Rates were markedly higher for people of Maori descent than for those of European descent in this age group. For nonMaori, the rate for men was higher than that for women, but for Maori the opposite was the case. The majority of these young residents (94%) were being cared for in commercial old people's homes. One half were cared for in just 29 of the 223 homes in the region. While most (59%) were admitted after the age of 50, 15% were admitted before they were 40 and must expect to liver their lives out in institutions primarily housing elderly residents. Almost half of those in old people's homes had been admitted from a psychiatric hospital. The authors are concerned that so many young people appear to be in old people's homes because of a lack of alternative accommodation which is more suited to their care.

Functional disability in residents of Auckland rest homes.

OBJECT: to measure the extent of disability in residents of Auckland rest homes and to document any differences between religious and welfare homes and commercial homes. METHODS: analysis of a 36 item questionnaire on 2087 residents in 32 religious and welfare homes and 3126 residents in 191 commercial homes (98.7% response rate). RESULTS: residents in commercial homes were significantly more disabled than those in religious and welfare homes: 24% compared with 12% were incontinent, 62% and 31% confused, and 78% and 49% respectively needed assistance with mobility and selfcare. Of special concern were 7% and 3% who were doubly incontinent, 7% and 2% confused to the point of disturbing other residents, and 4% and 2% who met the criteria for hospital care. CONCLUSIONS: a significant number of residents were disabled and required help in important aspects of simple self care. Informed advice, variety, and choice in type of care are mandatory before entering a rest home. Homes must employ trained staff who can identify and minimise problems so as to ensure optimal quality of life for residents.

Boom in rest homes in Auckland: implications for the future.

Available beds for frail elderly people in the rest home sector in Auckland increased from 44 to 67 per 1000 population over 65 years between 1981 and 1988. This expansion is partly explained by the financial incentives provided by various government subsidies including an open-ended number of rest home subsidies available subject only to an assessment by a geriatric team and a means and assets test. Four estimates of the number of beds required in the Auckland region for the year 2001 indicate that as few as 3414 beds or as many as 7450 beds will be required depending on the assumptions used. The best estimate suggests that approximately 5200 beds are required for the population 65 years and over in the year 2001, 800 fewer than the 6000 currently available. This estimate does not include an allowance for the provision of care for people less than 65 years of age, nor for a proportion of beds to remain vacant and nor for seasonal fluctuations in the demand for rest home beds. These projections have important policy implications for the future funding and provision of rest home care.

A profile of the 7500 people in aged-care institutions in Auckland.

A study was carried out in 1988 to describe the residents and patients of aged-care institutions in Auckland against which future measures, including planned changes in licensing and funding, could be made. Information was collected for each patient in every hospital (public and private) and each resident in all old people's homes in the Auckland region between January and June 1988. Of the 7516 people surveyed (99.4% response rate), 70% were residents in old people's homes, 25% were patients in private hospitals and 6% were cared for in the public hospital sector. Of the people surveyed, 71% were women. The average age of women, 82 years, was 6.5 years older than that of men. Three-quarters of all women and 44% of men in care were widowed. Women had a higher rate of admission to institutions than did men with almost one in two women and one in four men in the age group 85 years and over being in long term care. Rates of institutionalisation for Maoris and Pacific Islanders were the same as for Europeans. The majority of elderly people received regular contact and concern from family members. This study has demonstrated that Auckland has a higher proportion of the elderly population (7.6% of the population 65 years and over) in long term care compared with other areas of New Zealand.

Dependency levels of people in aged care institutions in Auckland.

Between January and June 1988, a survey of 7516 people in aged care facilities in the Auckland region (99.4% response rate) was undertaken to ascertain the extent and provision of care for elderly people requiring ongoing care in order to make comparisons with other centres in New Zealand. Information was gathered about their ability to perform various activities of daily living by staff members who completed a structured precoded and pretested questionnaire for each resident or patient. Overall levels of dependency were also assessed as part of the questionnaire: 13% were assessed as requiring long stay hospital care, 48% had moderate or appreciable dependency, and the remainder had some dependency (23%) or none at all (16%). Almost one quarter (23%) of the 5213 residents in old people's homes were rated as apparently independent. Of people in religious and welfare residential homes, 38% were rated as independent whereas in commercial rest homes 12% of people were classified in this way. This high level of apparent independence in religious and welfare homes is the main aspect in which the Auckland long term care scene is distinct from other regions in the country.

The prognosis of acute post infectious glomerulonephritis in adults: a long-term prospective study.

The contributions of pre-selected predictions of outcome for survival and renal function following acute post infectious glomerulonephritis were tested in a group of 41 adults, followed up for a mean of 13 years 5 months (range: 2 weeks to 15 years 2 months), using a proportional hazards model. The best predictor of outcome was the severity of the renal lesion, as judged by histology obtained at renal biopsy. The extent of functional deterioration during the acute phase and the aetiology were also related to outcome, though less significantly. Other variables including sex, age, race and the presence or absence of hypertension during the acute phase did not appear in this model to have an important bearing on prognosis, whether the latter was determined by patient and renal survival or by the extent of renal functional deterioration in survivors.

What has happened to programmes in quality assurance by physicians in large teaching hospitals in Australia and New Zealand?

Hospital Quality Assurance (QA) programmes by divisions and departments of medicine have developed since the late 1970s. The Continuing Education Unit of the Royal Australasian College of Physicians played a facilitatory role in this development, especially in the first five to six years. A survey of 38 major teaching hospitals in Australia and New Zealand early in 1989 revealed that of the 35 responding all had introduced a formal QA programme in internal medicine between 1976 and 1988. The 'Austin Hospital Method' of review seminars was the most popular format when QA programmes were introduced and 26 hospitals still maintain such a format - at least as a component of their programmes. Most programmes have been subject to modification to suit local needs. There have been no serious problems in maintaining confidentiality of information derived from QA exercises. Despite a formidable array of constraining forces, the majority of continuing QA programmes appeared to be stable. Seventeen hospitals reported that the organising group was recognised as an official committee of their hospital's administration. Although eight programmes have been discontinued in the last four years, nearly as many new ones have been introduced.

Inhaler devices and the elderly.

This study compared the relative ease of use of the metered dose inhaler, the FO2 Inhalator and the Diskhaler by elderly subjects in a randomised cross over trial using placebo inhalants. Thirty-one nonasthmatic volunteers (average age 79.6 years) who lived independently in two residential homes for the elderly were recruited. One failed to complete the study. Subjects were taught to use the three inhaler devices in a randomly assigned sequence with a two week period elapsing between each training session. The Diskhaler device took longest to learn (16.5 minutes) and the Inhalator was significantly easier to learn to use than the other two (x2 = 40.3, p = 0.001). The Inhalator was preferred by 64%, metered dose inhaler by 25% and Diskhaler by 11% (p = 0.03). Problems in the use of each are described. The study found that the Inhalator was simple to use and was reliably self administered by older people. The metered dose inhaler was simple to use only for a minority who could accurately coordinate actuation and inhalation. The Diskhaler had no advantages in this age group.

Behavioural science at the Auckland Medical School: introduction and evaluation of a revised programme.

This paper provides an overview of developments in the Auckland Medical School behavioural science programme. From 1984 to 1987, an entirely new five year course was phased in, its design based on a survey of 165 clinical teachers. This course has eight topic streams oriented towards producing a behaviourally knowledgeable and skilled clinician. Evaluation of the course shows good acceptance by students. Recent and planned modifications to the course are described.

Cognitive impairment and its relationship to gait rehabilitation in the elderly.

In a prospective study of 116 elderly people admitted to a geriatric rehabilitation ward, mini-mental state score on admission was used to classify nonaphasic subjects into three groups: cognitively normal (24-30), mildly impaired (17-23) and severely impaired (less than 17). Forty-three percent of the subjects were normal, 34% had mild and 23% had severe cognitive impairment. Using walking speed as the index of gait rehabilitation, subjects with normal cognition had significantly greater gait improvement than those with cognitive impairment. Age and urinary incontinence did not contribute to predicting gait improvement in regression modelling. Cognitive impairment also predicted discharge placement to long term hospital care and to a higher level of care than the subject received prior to admission. Thus cognitive impairment on admission to a geriatric rehabilitation ward predicts poor rehabilitation outcome with respect to gait and discharge residence.

A prospective trial of serial gait speed as a measure of rehabilitation in the elderly.

Walking speed was measured on admission and then weekly during treatment of 125 subjects admitted to a geriatric rehabilitation ward. Walking speed was strongly related to the ability to stand up from a chair without help. Placement decisions at discharge were made without knowledge of gait speed data so that they could be used as a standard against which to compare walking speed as a valid and practical measure of mobility. It was found that a discharge walking speed of 0.15 m/s best separated immobile subjects who required long-term hospital care from those sufficiently mobile to be discharged home alone or to a rest home (54% versus 0% below cut-off, respectively). Relative walking speed (speed/height) was no better at predicting placement or mortality than walking speed. Uncorrected walking speed therefore remains the preferred clinical measure of velocity. A serial record showing improvement in walking speed proved useful in predicting eventual independent mobility of poorly mobile subjects. Thus walking speed is an objective yet inexpensive method of monitoring gait rehabilitation.

Quality assurance and patient care evaluation in the undergraduate curriculum.

To design a teaching and learning experience for medical students which would induce attitudes which would favourably influence their future involvement in patient care evaluation and quality assurance activities during their professional lives. A three hour seminar involving a minimal amount of didactic input and featuring role plays and analysis of reports of cases from real life in which the quality of care given had been unacceptable. An enjoyable seminar with some indication that the students had appreciated the objectives and--at least temporarily--become more positive in their attitudes towards Peer Review.