The effect of naturally acquired rumen fluke infection on animal health and production in dairy and beef cattle in the UK.

The incidence of paramphistomosis, caused by the rumen fluke, Calicophoron daubneyi, has greatly increased within Europe in the last 15-20 years. However, the production impacts of this disease are poorly understood. This study firstly aimed to investigate the prevalence of rumen fluke in England and Northern Ireland (NI) by conducting an abattoir survey of dairy and beef cattle which also allowed the impact of rumen fluke on carcass weight, conformation and fat classification to be assessed. Secondly, an experiment aimed to assess the impact of C. daubneyi infection on diarrhea score, production loss and welfare in dairy heifers, while also evaluating the impacts of treating infected heifers with oxyclozanide. Rumen fluke prevalence was greater in NI than in England, with 53.8% (95% CI 51.9 - 55.9%) of the NI cattle carcases sampled being infected compared to 16.3% (95% CI 15.8 - 16.8%) and 17.9% (95% CI 17.4 - 18.4%) detected at the two abattoirs in England. However, there was no significant difference (P > 0.05) in the cold carcass weight between infected and non-infected cattle. Similarly, carcass conformation and fat classification were unaffected (P > 0.05) by the presence of rumen fluke. In the second experiment, daily live weight gain (DLWG), diarrhea score and welfare score were also unaffected (P > 0.05) by rumen fluke infection and by oxyclozanide treatment against rumen fluke. The farms in this experiment were managed to a high standard and animals had no intercurrent disease. Therefore, these findings suggest that on well-managed farms, production losses (growth rates) should not be compromised as a result of sub-clinical rumen fluke infection.

Risky drinking among community pharmacy customers in New Zealand and their attitudes towards pharmacist screening and brief interventions.

INTRODUCTION AND AIMS: To estimate the prevalence of risky drinking among customers in community pharmacies and to explore customer attitudes towards screening and brief intervention (SBI). DESIGN AND METHODS: Cross-sectional, anonymous survey, using random selection of community pharmacies in New Zealand to collect data using self-completion questionnaires and an opportunity to enter a prize draw. Participants were customers/patients attending the community pharmacy on a specific, randomly selected day (Monday to Friday) in one set week. Alcohol Use Disorder Identification Test (AUDIT)-C using a cut-off score of 5 was used to measure risky drinking. Attitudes towards pharmacists engaging in SBI for risky drinkers were measured. RESULTS: 2384 completed customer/patient questionnaires from 43 participating pharmacies. Almost 84% ever drank alcohol and using a score of 5 or more as a cut-off, 30% of the sample would be considered as risky drinkers. Attitudes were generally positive to pharmacists undertaking SBI. Logistic regression with AUDIT-C positive or negative as the dependent variable found those taking medicines for mental health and liver disease being more likely to score negative on the AUDIT-C, and smokers and those purchasing hangover cures were more likely than average to have a positive AUDIT-C screen. DISCUSSION AND CONCLUSIONS: This study indicates there is scope for community pharmacists to undertake SBI for risky drinking, and that customers find this to be acceptable. Targeted screening may well be useful, in particular for smokers. Further research is required to explore the effectiveness of SBI for risky drinkers in this setting.

The General Practitioner-Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy.

OBJECTIVES: There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for 'medication reviews' there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients. METHODS: A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed-up 3-monthly. The control group received usual care. The main outcome measures were Quality of Life (SF-36) and Medication Appropriateness Index. KEY FINDINGS: A total of 498 patients were enrolled in the study. The quality-of-life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study. CONCLUSION: Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.

General practitioner perceptions of clinical medication reviews undertaken by community pharmacists.

INTRODUCTION: Delivery of current health care services focuses on interdisciplinary teams and greater involvement of health care providers such as nurses and pharmacists. This requires a change in role perception and acceptance, usually with some resistance to changes. There are few studies investigating the perceptions of general practitioners (GPs) towards community pharmacists increasing their participation in roles such as clinical medication reviews. There is an expectation that these roles may be perceived as crossing a clinical boundary between the work of the GP and that of a pharmacist. METHODS: Thirty-eight GPs who participated in the General Practitioner-Pharmacists Collaboration (GPPC) study in New Zealand were interviewed at the study conclusion. The GPPC study investigated outcomes of a community pharmacist undertaking a clinical medication review in collaboration with a GP, and potential barriers. The GPs were exposed to one of 20 study pharmacists. The semi-structured interviews were recorded and transcribed verbatim then analysed using a general inductive thematic approach. FINDINGS: The GP balanced two themes, patient outcomes and resource utilisation, which determined the over-arching theme, value. This concept was a continuum, depending on the balance. Factors influencing the theme of patient outcomes included the clinical versus theoretical nature of the pharmacist recommendations. Factors influencing resource utilisation for general practice were primarily time and funding. CONCLUSION: GPs attributed different values to community pharmacists undertaking clinical medication reviews, but this value usually balanced the quality and usefulness of the pharmacist's recommendations with the efficiency of the system in terms of workload and funding.

Community pharmacist perceptions of clinical medication reviews.

INTRODUCTION: Changes in delivery of health care services has led to pressure for community pharmacists to extend their traditional role and become more involved with patient-focussed services such as medication reviews, in collaboration with general practitioners (GPs). This has not been generally implemented into routine practice, and many barriers have been suggested that inhibit community pharmacists extending their role. These have often focussed on physical or functional barriers. This study explores possible attitudinal factors that prevent increased participation of community pharmacists in medication reviews undertaken in collaboration with GPs. METHODS: Twenty community pharmacist participants who participated in the General Practitioner-Pharmacist Collaboration (GPPC) study were interviewed. The GPPC study investigated the outcomes of community pharmacists undertaking a clinical medication review in collaboration with GPs, and the potential barriers. Semi-structured interviews were analysed using a general inductive thematic approach. FINDINGS: Emerging themes were that community pharmacists perceived that they were not mandated to undertake this role, it was not a legitimate role, particularly from the business perceptive, and pharmacists were concerned that they lacked the skills and confidence to provide this level of input. CONCLUSION: While there is concern that community pharmacists' skills are underutilised, there are probable attitudinal barriers inhibiting pharmacists from increasing their role in clinical medication reviews. Perceived legitimacy of the service was a dominant theme, which appeared to be related to issues in the business model. Further investigation should consider the use of a clinical pharmacist working within a general practice independent of a community pharmacy.

Estimating problem drinking among community pharmacy customers: what did pharmacists think of the method?

OBJECTIVES: Community pharmacists have successfully been involved in brief interventions in many areas of health, and also provide services to substance misusers. There has been recent interest in community pharmacists providing screening and brief interventions (SBI) to problem drinkers. The aim of this study was to develop a method for measuring prevalence of risky drinking among community pharmacy customers and to explore acceptability of this method to participating pharmacists. METHODS: Forty-three pharmacies (from 80 randomly selected) in New Zealand agreed to participate in data collection. On a set, single, randomly allocated day during one week, pharmacies handed out questionnaires about alcohol consumption, and views on pharmacists providing SBI, to their customers. At the end of the data collection period semi-structured telephone interviews were carried out with participating pharmacists. KEY FINDINGS: Pharmacists were generally positive about the way the study was carried out, the support and materials they were provided with, and the ease of the data collection process. They reported few problems with customers and the majority of pharmacists would participate again. CONCLUSIONS: The method developed successfully collected data from customers and was acceptable to participating pharmacists. This method can be adapted to collecting data on prevalence of other behaviours or medical conditions and assessing customer views on services.

Four policies to end the sale of cigarettes and smoking tobacco in New Zealand by 2020.

AIM: To phase out sales of cigarettes and of smoking tobacco products in New Zealand by the year 2020. CURRENT SITUATION: 99% of tobacco is smoked as cigarettes. Cigarettes are highly addictive, lethal, and cannot be made safer. Since 1950 commercial cigarettes have prematurely killed over 160,000 New Zealanders. Despite causes-disease warnings on tobacco packaging (from 1987) and graphic warnings (2007), bans on tobacco advertising and promotions (1990), bans on indoor workplace smoking (1990, 2004), subsidies on medicinal nicotine (2000), and despite one-third of smokers annually making serious attempts to quit, 1 in 5 New Zealand adults smoke, 2 in 5 Maori adults smoke, and cigarette consumption per adult remains virtually unchanged since 2003. Four in 5 smokers regret they ever started. PROPOSED POLICIES: Four policies combined could make cigarette smoking less attractive and the use of nicotine-only products more attractive, with respect to relative price, availability and addictiveness. These mean increasing tax on all cigarettes equally; and a bill to strengthen the Smoke-free Environments (SFE) Act: to allot cigarette sales quotas and then gradually lower them; reduce the nicotine content of cigarettes gradually by a sinking lid or by nicotine tax; and permit the sale of satisfying non-combustible nicotine-only products for smokers. As supply reduces, prices rise, and nicotine satisfaction decreases, smokers will quit; and black market risk will be minimised. Commercial cigarettes will no longer be obtainable, and even if some smoke tobacco grown legally for their own use, or even if some is obtainable illegally, tobacco consumption will greatly reduce. CONCLUSION: The smoking of tobacco sold legally kills 5000 New Zealanders annually. The SFE Act can be amended to phase out legal sales within this decade. Intensive policy research is needed now as public interest increases. Support from the public and from legislators to promote a suitable amendment bill is now needed.

General practitioners' and pharmacists' perceptions of the role of community pharmacists in delivering clinical services.

BACKGROUND: Because community pharmacists are encouraged to provide clinical services, there is a need to determine the role perceptions of both community pharmacists and general practitioners (primary care physicians). Differing role perceptions are likely to result in barriers to pharmacists expanding their roles in health care. OBJECTIVES: The purpose of this study was to investigate whether community pharmacists' and general practitioner's perceptions of the role of community pharmacists may be a barrier to pharmacists increasing their role in medication management. Other potential barriers were also explored that could provide a framework for future research. METHODS: A postal survey to 900 and 1000 randomly selected community pharmacists and general practitioners, respectively, elicited the perceptions of these groups toward the role of community pharmacists. Likert scales were used to quantify the results. RESULTS: The results revealed a gap in perceptions regarding the role of the community pharmacist, with general acceptance of the technical roles but less acceptance of clinical roles by general practitioners. Barriers to increased involvement of community pharmacists in clinical services included a perceived lack of mandate, legitimacy, adequacy, and effectiveness by both groups. Also observed was a lack of readiness to change by community pharmacists. CONCLUSIONS: This study suggests that there are significant barriers to community pharmacists increasing clinical services, both from the community pharmacists themselves and from the general practitioners. Attention to change management in a complex environment will be necessary if community pharmacists are to change their role toward more clinical services.

Screening for alcohol misuse in elderly primary care patients: a systematic literature review.

BACKGROUND: Alcohol problems in the elderly are common and frequently undetected, and therefore a potential target for a screening program. METHOD: Using Medline, Psychinfo and reference lists from relevant publications, articles were identified testing pen-and-paper screens in the primary care population aged over 60 years. RESULTS: Using standard definitions of alcohol problems, conventional screens adapted for use in the elderly have performances similar to screens in the younger primary care population. However, it can be argued that special screens perform better for the elderly. CONCLUSIONS: The Alcohol Use Disorders Identification Test is a useful screen for detecting harmful and hazardous drinking in the elderly while the CAGE is valuable when screening for dependence. In the future, the Alcohol-Related Problems Survey, a computer-based screen, may prove to be superior if practical implementation problems can be overcome.

Problem gambling: patients affected by their own or another's gambling may approve of help from general practitioners.

AIMS: To identify the health effects, including depression, on problem gambling patients and family members, and their perception of their GP as a help provider for problem gambling. METHODS: 1580 patients from practices in Auckland, Taranaki, and Rotorua completed an anonymous questionnaire containing brief screens for problem gambling, effects on family of gambling, and depression. Patients were asked to assess their GP as a help provider for problem gambling. RESULTS: 7.5% of patients were positive for problem gambling, ranging from 3% of NZ European patients to 24% of Pacific patients; 18% of patients were affected by another's gambling. Less than one in four problem gambling patients, and one in three family positives, did not perceive their GP as a suitable help provider for problem gambling issues. Problem gambling patients were more likely than other patients to approve their GP as a help-provider. Patients affected by problem gambling were more depressed than other patients. No other disease indicators were found. Patients over 54 years are less likely than others to be problem gamblers. CONCLUSIONS: Problem gambling is associated with depression in patients. GPs are an important complementary resource for brief interventions for gambling problems, and for some possibly a more acceptable alternative than attending specialist problem gambling treatment providers.

Alcohol assessment: the practice, knowledge, and attitudes of staff working in the general medical wards of a large metropolitan hospital.

AIMS: To measure the prevalence of routine alcohol assessment; to assess its clinical utility in the general medical wards of a large urban hospital; and to assess medical and nursing staff knowledge with regard to standard drink measures and recommended drinking limits as well as their attitudes towards alcohol assessment. METHODS: The prevalence of alcohol assessment and the clinical utility of the resulting information was determined via a retrospective file review (n=109). The knowledge and attitudes of medical and nursing staff were measured via questionnaire (n=106). RESULTS: The file review data indicated 78% (+/-7.25) of patients admitted to the general medical wards were queried with regard to their alcohol consumption. However, the clinical utility of the recorded information was generally poor and the accuracy questionable. Only 12% of questionnaire respondents were able to accurately identify the standard drink equivalents for beer, wine, and spirits and only 8% were able to accurately identify the recommended drinking limits (per drinking occasion and per week) for both males and females. Attitudes towards alcohol assessment were positive. CONCLUSIONS: Patient alcohol consumption is frequently assessed, but the clinical utility of the resulting information is limited. The use of a structured alcohol screen and the provision of appropriate staff training are recommended.

Rural New Zealand health professionals' perceived barriers to greater use of the internet for learning.

INTRODUCTION: The purpose of this research was to investigate rural North Island (New Zealand) health professionals' attitudes and perceived barriers to using the internet for ongoing professional learning. METHODS: A cross-sectional postal survey of all rural North Island GPs, practice nurses and pharmacists was conducted in mid-2003. The questionnaire contained both quantitative and qualitative questions. The transcripts from two open questions requiring written answers were analysed for emergent themes, which are reported here. The first open question asked: 'Do you have any comments on the questionnaire, learning, computers or the Internet?' The second open question asked those who had taken a distance-learning course using the internet to list positive and negative aspects of their course, and suggest improvements. RESULTS: Out of 735 rural North Island health professionals surveyed, 430 returned useable questionnaires (a response rate of 59%). Of these, 137 answered the question asking for comments on learning, computers and the internet. Twenty-eight individuals who had completed a distance-learning course using the internet, provided written responses to the second question. Multiple barriers to greater use of the internet were identified. They included lack of access to computers, poor availability of broadband (fast) internet access, lack of IT skills/knowledge, lack of time, concerns about IT costs and database security, difficulty finding quality information, lack of time, energy or motivation to learn new skills, competing priorities (eg family), and a preference for learning modalities which include more social interaction. Individuals also stated that rural health professionals needed to engage the technology, because it provided rapid, flexible access from home or work to a significant health information resource, and would save money and travelling time to urban-based education. CONCLUSIONS: In mid-2003, there were multiple barriers to rural North Island health professionals making greater use of the internet for learning. Now that access to broadband internet is available in all rural towns in New Zealand, there is a clear need to address the other identified barriers, especially the self-reported lack of IT skills, which are preventing many in the rural health workforce from gaining maximum advantage from both computers and the internet.

A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organization collaborative study.

OBJECTIVE: This study examines the impact of marketing strategies on the dissemination of a brief alcohol intervention program to general practitioners (GPs). The marketing strategy was tested to determine the most effective way to promote awareness about and consideration of a brief alcohol intervention program. The study also examines the impact of training and support strategies to promote the program's implementation in routine primary care. METHOD: A pragmatic trial was carried out in Australia, Belgium (Flanders), Denmark, England, New Zealand and Spain (Catalonia) in which GPs were randomly allocated into one of three marketing conditions (direct mail, telemarketing and academic detailing [personal visits]). The GPs who requested a brief intervention program and agreed to use it were stratified by previous marketing condition and randomly allocated into one of three implementation strategy groups: written guidance, outreach training and outreach training plus ongoing telephone support. RESULTS: Acceptance of the brief intervention program was more effective with use of telemarketing (65%) and academic detailing (67%) than with direct mail (32%) for promoting awareness about and consideration of a brief alcohol intervention program. The median proportion of patients screened was higher for trained GPs (6%) and supported GPs (9%) than for control GPs (1%), who received only written guidance on how to conduct brief intervention. Similarly, the median rate for giving advice to at-risk patients was higher for trained GPs (3%) and supported GPs (3%) than for control GPs (0%). CONCLUSIONS: The adoption of more direct approaches for disseminating evidence-based intervention programs to GPs is a necessary first step for changing practice behavior. However, outreach training was required to promote actual use of a new procedure in routine practice.

Few rural general practitioners use the Internet frequently in regard to patient care.

AIMS: To benchmark North Island rural general practitioner (GP) access to computers and the Internet, both at work and home, and assess whether rural GPs are using the Internet in regard to patient care. METHODS: Cross-sectional postal survey of all North Island rural GPs in mid-2003. RESULTS: 175 of 289 GPs (60.6%) returned useable questionnaires. Most (89.0%) reported computer availability at work when consulting, but even more had access to a computer at home (97.1%, p<0.01). Access to the Internet was also lower at work (68.6%) than at home (98.8%, p<0.01). Fewer GPs (p<0.05) reported ever using the Internet at work in regard to patients (56.5%) than at home (71.9%). Less than 10% of all GPs used the Internet three or more times a week at work (6.9%) or home (8.6%) in regard to patients. Of those with Internet access at work, 27.0% had broadband (fast Internet) access. Predictors of having (versus not having) work Internet access were computer availability in consultations (p=0.04). CONCLUSIONS: Few North Island rural GPs use the Internet frequently in regard to patient care, despite increasing access to computers and the Internet, both at work and home.

Experiences and preferences of general practitioners regarding continuing medical education: a qualitative study.

AIM: To explore the experiences and preferences of general practitioners (GPs) regarding their continuing medical education (CME). METHODS: Qualitative study using semi-structured interviews of twenty four GPs from Auckland and North Island rural areas assessing GPs' experiences and preferences. RESULTS: The need for CME was emphasised. Primary themes identified were: the value of personal interaction; the perception that CME that did not involve personal interaction was adjunctive; an opportunistic rather than needs-based approach to learning; a preference for succinct, evidenced-based, GP-focused content; and lack of time as a major barrier to obtaining optimal CME. CONCLUSIONS: Interactive formats are generally preferred, but identification of which elements of interactive formats facilitate learning is not established. Most GPs do not direct their CME according to the adult learning model. The challenge for CME providers is to provide avenues to facilitate needs identification and self-directed learning.

General practitioners' perceptions of continuing medical education's role in changing behaviour.

CONTEXT: The effectiveness of moving to compulsory, prescriptive continuing medical education (CME) for New Zealand general practitioners (GPs) is questioned. Motivational interviewing theory suggests that a series of interventions gradually increase awareness of the need to change until change is finally actioned. This study aimed to explore GPs' views on their need for CME, experiences regarding its provision and perceptions on the effect of CME in changing their clinical behaviour. METHOD: Qualitative study using semi-structured interviews of 24 GPs from Auckland and North Island rural areas assessing their CME experiences and preferences. FINDINGS: All participants acknowledged that CME is a life-long process essential for GPs. Changing behaviour is generally seen as an incremental, evolutionary process with reinforcement of knowledge from different sources. Single events were perceived to effect change rarely. These were often high-impact, either punitive or incentive-based. GPs have a myriad of CME sources including reading, the internet, specialist letters, conversations with colleagues, quality assurance feedback, as well as traditional meetings. Credit-based quota requirements received mixed opinions but mostly were perceived negatively, discouraging needs-based approaches to learning. GPs' greatest barrier to obtaining CME is time. DISCUSSION: GPs perform poorly in assessing their specific learning needs. Their behaviour change is likely to be incremental. Therefore multi-faceted interventions and reinforcement from different sources are likely to be most effective in changing clinical practice. Understanding this is important for CME providers, GP Colleges and funders. Narrow, credit-based approaches to CME may discourage time-strapped GPs obtaining motivation to change from exposure to a wide variety of CME sources.