The Canterbury Initiative (CI) is a clinically-led way of working which focuses on addressing and resolving the challenges of health care in Canterbury by:
Clinical leadership is provided by experienced general practitioners and secondary care specialists.
Workgroups form the starting point for system change. It can be the first time primary and secondary care clinicians have met to discuss and identify issues in their area of care.
Goal of workgroups is to identify and implement system change to improve the patient journey.
Clinicians across community, primary and secondary care meet over several sessions.
When engaging in system change for the first time the workgroup starts with a blank whiteboard, and seeks to identify
These are clinically led workgroups, not managerial. Canterbury Initiative provides the framework, clinical leadership, facilitation and project management support, as well as support of clinical audit and analysis. As an output Canterbury Initiative provides clinical editors who work to develop pathways.
In addition to the toolbox Canterbury Initiative continues to manage a number of programmes that support patients .
Canterbury Initiative has been involved in developing many other programmes since 2008 which are now part of business as usual in the Canterbury Health System and managed by other groups.
Canterbury Initiative runs an education programme for three audience types: general practitioners, practice nurses and allied health providers.
These education sessions involve secondary care specialists presenting to their primary care colleagues about best practice in diagnosis, management, treatment and/or referral of patients in their area of expertise, with a focus on what the audience needs to know and put it into practice. Often the topic is driven by the work undertaken in the workgroups and development of pathways.
The Canterbury Initiative (CI) began as the Canterbury DHB Referral Project in August 2007, and has since evolved into a way of working that is achieving significant change in the way health is being delivered across Canterbury.
The Initiative was set up by Carolyn Gullery, Executive Director Planning, Funding and Decision Support at Canterbury DHB, and was led by Dr David Kerr, Dr Graham McGeoch and Bruce Penny. The small team, collaborated with Planning and Funding, and community, primary & secondary care clinicians, and this approach continues today.
Tracey Maisey, Executive Director Planning, Funding and Decision Support, Canterbury DHB
Canterbury Initiative supports documenting the outcomes and changes in practice following implementation of agreed changes in service delivery. Clinical audit and analysis is always a component of establishing new pathways and services and has frequently led to publication of results in peer reviewed journals:
Establishing a community infusion service in Canterbury, New Zealand: strategies and lessons, Lisa McGonigle, Brett Shand, Graham McGeoch, Journal of Primary Health Care, Published 20 May 2022.
Background and context: An increasing number of drugs and blood products need to be delivered by intravenous infusion. In the Canterbury region of New Zealand, these have historically been delivered at a hospital site; however, some infusions could be delivered in a community setting without compromising patient safety.
Assessment of problem: The Canterbury health system has a key strategic objective of delivering care close to patients’ homes. In 2018, Canterbury district health board (DHB) put out a tender for a community infusion service that would deliver blood products and other intravenous drugs with appropriate medical oversight.
Strategies for improvement: Following an interview and selection process, a fee-for-service contract was developed with a group of general practices with partial common ownership. It was nurse-led with medical oversight available. In July 2018, a Community Infusion Service (CIS) was started in two urban sites in Canterbury. It later expanded to two more sites, one urban and one rural.
Results: From July 2018 to May 2021, over 3000 infusions and blood transfusions were delivered by the CIS across seven infusion types (blood; immunoglobulin; infliximab; natalizumab; pamidronate; toculizumab; zoledronic acid). Both general practice and hospital services referred patients to the CIS. No major incidents were reported. Patients reported satisfaction with the service.
Lessons: Infusions and blood products can be delivered safely nearer to patients’ homes in primary care in a New Zealand setting. Medical input was rarely required; however, the transition was resource-intensive; it required both overall process and criteria negotiations, as well as individual patient discussions. In its initial stages, the CIS did not have adequate clinical governance and operational support, which affected the speed and scale of its development.
The Canterbury Initiative – implementation of integration - Graham McGeoch, Carolyn Gullery and Greg Hamilton, Journal of Primary Health Care, published 13 April 2022
A community-based initiative to improve transgender mental health in Canterbury, New Zealand Lisa McGonigle and Rebecca Nicholls, Journal of Primary Health Care, published 13 April 2022
Background and context: The transgender community experiences high levels of mental distress. In the Canterbury region of New Zealand, transgender care was fragmented and there were gaps in service provision.
Assessment of problem: In 2019, a working group co-designed a model to coordinate and improve health care for the Canterbury transgender community. Their aim was to co-design and implement a comprehensive system for transgender health care that filled any existing gaps.
Results: A need was identified for support in the community for transgender patients with mild to moderate mental health needs who did not meet the threshold for referral to secondary care.
Strategies for improvement: Psychological packages of care were put in place in the community for transgender patients with mental health needs. In the first 9 months of the initiative, 85 patients received a package of care.
Lessons: This community-based model was well received by the community. Data analysis did not demonstrate a statistically significant reduction in depression and anxiety, but it did show a significant reduction in stress. Some further improvement opportunities existed, including shifting to a peer worker model and changing the evaluation tool.
Goodwin J, Shand B, Wiseman R, Brough N, McGeoch G, Hamilton G, Grundy K. Achievements and challenges during the development of an advance care planning program. Australas J Ageing. 2021 Apr 13. doi: 10.1111/ajag.12945.
A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.
Peter J Davidson, Graham McGeoch, Brett Shand Assessment of a clinical pathway for investigation of haematuria that reduces the need for cystoscopy: The New Zealand Medical Journal Published 18 December 2020
To evaluate prospectively a clinical pathway for investigation of haematuria that involves an initial screening using a urinary biomarker of bladder cancer (Cxbladder Triage™ (CxbT)) in combination with either a renal ultrasound or a computed tomography imaging. Only test-positive patients are referred for specialist assessment and flexible cystoscopy.
The clinical outcomes of 884 patients with haematuria who presented to their general practitioner were reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, specialist assessment and histology.
Forty-eight transitional cell carcinomas (TCC) and three small cell carcinomas were diagnosed in the study cohort. The clinical pathway missed a solitary, small, low-risk TCC. When combined, imaging and CxbT had a sensitivity of 98% and a negative predictive value of 99% to detect a bladder cancer. Follow-up for a median of 21 months showed no further new cases of bladder cancer had occurred in the patient cohort. Review of all new bladder cancers diagnosed in the 15 months following the study showed that none had been missed by haematuria assessment using the clinical pathway.
The combination of CxbT and imaging reliably identifies patients with haematuria who can be managed safely in primary care without the need for a secondary care referral and a flexible cystoscopy.
Lisa McGonigle , Graham McGeoch An initiative to improve equity, timeliness and access to District Health Board-funded physiotherapy in Canterbury, Christchurch, New Zealand Journal of Primary Health Care Published 16 December 2020
Background and context: General practice teams frequently request orthopaedic and musculoskeletal physiotherapy. In the Canterbury District Health Board (DHB) region, before November 2018, the criteria for DHB-funded physiotherapy were unclear. Wait times were many months. Care was provided on hospital sites. Limited data were available about the service.
Assessment of problem: A clinical project group including private and DHB hospital physiotherapists and general practitioners was established. Patients requiring orthopaedic and musculoskeletal physiotherapy who had certain criteria were seen by physiotherapists in contracted private clinics in the community instead of by physiotherapists in hospital departments. Patients received up to NZ$300 (excluding GST) of care. A claiming process was established that required the physiotherapy clinics to provide data on patient outcomes.
Results: In the first 12 months of the programme, 1229 requests were accepted. Patients waited an average of 11.1 days for their first appointment. There was an average Patient Specific Functional Scale increase of 3.7 after treatment.
Strategies for improvement: A change environment was critical for this community-based, geographically distributed model to succeed. It was supported by key clinicians and funders with sufficient authority to make changes as required. It required ongoing clinical oversight and operational support.
Lessons: DHB orthopaedic and musculoskeletal physiotherapy can be moved from hospital sites to a community-based, distributed service in a timely, effective and equitable fashion. There was a prompt time to treatment. Data collection was improved by tracking ‘before’ and ‘after’ measures.
Chan D, Skidmore P, O'Brien L, Watson S, Gearry R. A feasibility study investigating the impact of a dietitian-led low in fermentable oligosaccharide, disaccharide, monosaccharide and polyols diet group education programme with irritable bowel syndrome. N Z Med J. 2020 Sep 25;133(1522):42-51.
Aims: To investigate the feasibility and effectiveness of dietitian-led education on using the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet in adults with irritable bowel syndrome (IBS) in Christchurch, New Zealand.
Methods: Patients with IBS (n=25) were referred by their general practitioner to attend a group education programme. The number recruited and subsequent attendance were used to evaluate feasibility. The Structured Assessment of Gastrointestinal Symptoms (SAGIS) questionnaire and Hospital Anxiety and Depression Scale (HADS) were compared at baseline and at follow-up. Semi-structured telephone interviews assessed the acceptability of the education programme.
Results: Of the 25 recruited participants, 17 attended the group education programme. The SAGIS score decreased significantly (p<0.05) between baseline (mean 1.844) and follow-up (mean 0.607). Similarly, there was non-significant trend of lower HADS anxiety and depression scores from baseline to follow-up. Symptomatic improvement was reported by 13 participants (76.5%), while two participants (11.8%) did not improve and two others (11.8%) had not implemented the diet. Overall, participants were positive and grateful for the improvement the diet had made to their symptoms.
Conclusions: A dietitian-led low FODMAP group education programme in Christchurch adults with IBS was found to be both feasible and effective.
Graham McGeoch, Brett Shand, Carolyn Gullery, Greg Hamilton, Matthew Reid. Hospital avoidance: An integrated community system to reduce acute hospital demand. In press Primary Health Care Research and Development (October 2019).
Background: Growth in emergency department attendance and acute medical admissions has been managed to very low rates for 18 years in Canterbury, New Zealand, using a combination of community and hospital avoidance strategies. This paper describes the specific strategies that supported management of acutely unwell patients in the community as part of a programme to integrate health services.
Intervention: Community-based acute care was established by a culture of close collaboration and trust between all sectors of the health system, with general practice closely involved in the design and management of the services, and support provided by hospital specialists, coordination and diagnostic units, and competent informatics. Introduction of the community-based services was aided by a clinical guidance website and an education programme for general practice teams and allied health professionals.
Outcomes: Attendance at emergency departments and acute medical admission rates have been held at low growth, and in some cases, shorter lengths of hospital stay. This trend was especially evident in elderly patients and those with ambulatory care sensitive or chronic disorders.
Conclusions: A system of community-based care and education has resulted in sustained gains for the Canterbury health system and freed-up hospital resources. This outcome has engendered a sense of empowerment for general practice teams and their patients.
Key words: acute demand; ambulatory care; emergency services, hospital; growth and development; home care services; primary health care
Aditya Raina, Michael Ardagh, Belinda Loring. What influences clinicians to choose wisely? New Zealand Medical Journal 2019, 134 (1502) 16-24. https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1502-20-september-2019/4015
Aim: To evaluate the effectiveness of awareness-raising by the Choosing Wisely campaign in a New Zealand public hospital to reduce routine pre-operative testing and to determine what can be done to bring about change in clinician behaviour.
Methods: Short, semi-structured, one-on-one interviews were conducted with 15 doctors of varying seniority from general surgery who were exposed to the campaign between August and October 2018. The interviews covered four general topics including background information, asking about awareness and effectiveness of Choosing Wisely campaign, exploring barriers to changing clinician behaviour around pre-operative testing and exploring potential interventions which may be useful to change behaviour. Data were analysed using Braun and Clarke thematic analysis methodology.
Results: Four themes and 17 sub-themes emerged from the interviews. The main themes included awareness of Choosing Wisely, thoughts around pre-operative testing, barriers for changing clinician behaviour and strategies for reducing unnecessary pre-operative testing.
Conclusions: The findings of this study suggest that a strategy that relies on revising guidelines and raising staff awareness alone is likely to be of limited effectiveness in reducing unnecessary pre-operative testing. In addition to increasing clinician awareness of evidence-based recommendations on unnecessary testing, other strategies may be needed to support behaviour change.
Davidson P, McGeoch G, Shand B. Inclusion of molecular markers of bladder cancer in a clinical pathway for investigation of haematuria reduces the need for cystoscopy. New Zealand Medical Journal 2019;132 (1497):55-64. https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2019/vol-132-no-1497-21-june-2019/7915
Aim: To examine prospectively the impact of adding a urinary biomarker of bladder cancer (Cxbladder TriageTM, CxbT) to a clinical pathway for investigating haematuria.
Methods: The clinical outcome of 571 patients with haematuria who presented to their general practitioner was reviewed. Outcome measurements included the findings of laboratory tests, imaging, cystoscopies, histology and specialist assessments. The data were used to model a theoretical clinical pathway that involved initial screening using CxbT in combination with imaging, and only test positive patients being referred for specialist assessment and cystoscopy.
Results: All patients underwent cystoscopy and 44 transitional cell carcinomas were diagnosed in the study cohort, with two low-risk cancers missed by CxbT, one of which was also not detected by imaging. When combined, imaging and CxbT had a sensitivity of 97.7% and negative predictive value of 99.8%.
Conclusions: In our series, all significant bladder cancers were diagnosed by imaging and CxbT before cystoscopy was undertaken. The high negative predictive value of this clinical pathway would allow approximately one-third of patients with haematuria to be managed without cystoscopy.
Epton M, Limber C, Gullery C, McGeoch G, Shand B, Laing R, Brokenshire S, Meads A, Nicholson-Hitt R. Reducing hospital admissions for COPD – perspectives following the Christchurch Earthquake. BMJ Open Respiratory Research. 2018;5:e000286. https://doi.org/10.1136/bmjresp-2018-000286
The devastating 2011 earthquake in Christchurch destroyed or badly damaged healthcare infrastructure, including Christchurch Hospital. This forced change in management of exacerbations of chronic obstructive pulmonary disease (COPD), which until that point had frequently led to admission to hospital and focused attention on providing safe community options for care. This paper describes the process of understanding factors contributing to high admission frequency with exacerbations of COPD and also describes a process of change, predominantly to healthcare delivery systems and philosophies, and the subsequent outcomes. What became clear in understanding admissions with COPD to Christchurch Hospital was that the behaviour of the patient, in the context of exacerbations, and the subsequent response of the system to the patient, led to admission being the default option, in spite of low severity of the exacerbation itself. By altering systems' responses to exacerbations, with a linked care process between ambulances, community care and hospitals, we were able to safely reduce admissions for COPD, with a sustained overall reduction in bed-day occupancy for COPD of ~48%. We would encourage these discussions and changes to occur without the stimulus of an earthquake in your healthcare environment!
Keywords: access to information; ambulances; copd exacerbations; earthquakes; general practice; hospitalisation; patient care; safety
Holland K, McGeoch G, Gullery C. A multifaceted intervention to improve primary care radiology referral quality and value in Canterbury. New Zealand Medical Journal 2017;130 (1454):55-64. https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1454-28-april-2017/7228
Aims: This article describes a seven-year multifaceted intervention leading to sustained improvement in primary care radiology referral quality and value in Canterbury, New Zealand, and discusses the transferability to other health systems.
Methods: Access criteria were developed with input from general practitioners and hospital-based specialists, and embedded in locally developed clinical pathways. A referral management service was created to streamline referral processes. Systems were developed to enable electronic referral and triage, and to provide visibility of prior imaging. A team of general practitioners was formed to continually review referrals relative to agreed criteria and to provide advice to referrers. Referring general practitioners were provided data and education about their referral patterns relative to their peers. A clinical audit programme was introduced to ensure quality and safety of care.
Results: The service achieved sustained improvements in referral quality (referral acceptance rates increased from 78% to 88%, urgent referrals reduced from 59% to 22%) and value (plain film volumes reduced by 40%).
Conclusions: Sustained improvement to primary care radiology referral quality and value is achievable at scale using a multifaceted intervention. The transferability of this outcome is likely to be connected to supporting factors present in the Canterbury health system.
McGeoch G. Letter in response to letter by Bagshaw P, Hudson B. Unmet health-care need. Journal of Primary Health Care 2018;10:178-180. https://doi.org/10.1071/HC18009
We share Bagshaw and Hudson’s concerns that access to affordable general practice may hide unmet health need. Unmet health need can occur for several reasons around accessibility, availability, or acceptability of services. Our survey described in the journal used a novel method to measure unmet need for referred services in patients attending their general practice. Our survey was not intended to measure total population need and did not include patients who do not attend a general practice. In contrast, the paper of Bagshaw et al. was based mainly on the findings of a postal survey in a sample of the total population that measured unmet need for secondary care. Direct comparison of the rate of unmet health need measured by our survey and that of Bagshaw et al. is therefore not valid, nor is the conclusion that our method under estimated what we were seeking to measure. Our study was carried out mainly in response to concern that active referral management might be hiding unmet health need in the community and to inform service planning.
We also agree with Bagshaw and Hudson that it is important to choose a survey method that will provide accurate answers to study questions but do not believe a single, simple method can answer such a complex question as measuring unmet need. A strength of our survey method was that the joint discussion of the health need between patient and general practitioner minimised any tendency for patients to not recognise their needs or over estimate their needs and to include things that either could not be fixed or did not need intervention. Another strength of our survey method was the use of electronic referral to collect survey data, a system used routinely by nearly all general practices, backed up by support from a liaison person who worked with the practices to ensure successful completion of the survey. This approach led to active participation by general practices in Canterbury and successful data collection of over 2000 patients in a relatively short period of time. In contrast, the general practitioner arm of the Bagshaw et al. survey had a low participation rate of general practices and limited patient data, leading the authors to conclude that such a survey method was not worthwhile. We believe the practicality of the methodology is important and consider the method we used in our survey, with emphasis on conversation and agreement between a patient and their general practitioner, provides an efficient and balanced method for measuring unmet need for referred services in a primary care setting. It does not address the issue of unmet health need in those not attending general practice.
Our experience leads us to believe that general practice involvement can enhance the value and integrity of data about unmet health need but should be combined with other methods to collect data on patients who rarely attend general practice. Perhaps we need to work together with Bagshaw et al. to combine a population survey approach with some general practitioner and independent medical verification of a proportion of the study population. New Zealand needs to develop a method that observes trends in access to public health care over many years.
McGeoch, G, Holland K, Kerdemelidis M, Elliot N, Fink C, Dixon A, Shand B, Gullery C. Unmet need for referred services as measured by general practice. Journal of Primary Health Care. 2017 https://doi.org/10.1071/HC17044
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 Māori. 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.
Keywords: general practitioners; health research; health services; equity; doctor–patient relationships
Epton MJ, Kelly PT, Shand BI, Powell S, Jones J, McGeoch G, Hlavac MC. Development and outcomes of a primary care-based sleep assessment service in Canterbury New Zealand. npj Primary Care Respiratory Medicine. 2017;27:26. https://doi.org/10.1038/s41533-017-0030-1
Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for 'at risk' patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not 'at risk' waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist.
Keywords: sleep assessment; general practice; quality control; cooperative behaviour
Comment: Sleep disorders; More assessments, shorter waits with community sleep service: A community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region's largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital's sleep unit.
Dixon B, Gray J, Annandale M, Elliot N, Shand B, Lynne A. A multifaceted programme to reduce the rate of tongue-tie release surgery in newborn infants: Observational study. International Journal of Paediatric Otolaryngology. 2018;113:156-163 https://doi.org/10.1016/j.ijporl.2018.07.045
Objectives: A programme was introduced in Canterbury, New Zealand to evaluate the diagnosis and treatment of frenulum releases in newborn infants with suspected tongue-tie (ankyloglossia). The primary goals were to support breastfeeding and ensure that unnecessary surgery was avoided.
Methods: Local healthcare professionals reached consensus on a pathway for improving management of infants with tongue-tie and breast-feeding difficulties. This embedded an expert breast-feeding review and assessment of lingual function using a validated method, the Bristol Tongue-tie Assessment Tool (BTAT). Infants with breastfeeding problems related to tongue-tie had a frenotomy at a hospital outpatient clinic. An education programme was developed to support introduction of the new clinical pathway and included seminars and online information for healthcare professionals and the general public.
Results: Frenotomy intervention rate reduced markedly from 11.3% in 2015 to 3.5% by mid-2017. Feeding methods were not different before or after surgery between infants who received a frenotomy and those who did not. Initially, the BTAT threshold for frenotomy was set at ≤5, however the final clinical pathway combined a breastfeeding assessment and a BTAT threshold of ≤4. The education programs assisted with the changes in practice, while increased use of the clinician guidance and public health information websites confirmed growing awareness of tongue-tie and community breastfeeding support.
Conclusions: Establishing consistent multidisciplinary assessment of tongue-tie in infants with feeding difficulties led to a marked reduction in frenotomy intervention rate. 23% of the frenotomy group in the 2016 audit showed a significant improvement in the ability to breastfeed, but overall there was no difference in the feeding pattern of infants who either received or were declined a frenotomy. The development of a supportive education programme and availability of online information about tongue-tie for health professionals and consumers contributed to successful uptake of the new clinical pathway.
Keywords: ankyloglossia; breastfeeding; frenulum function and anatomy; health information; unnecessary procedures
Short J, Sharp B, Elliot N, McEwing R, McGeoch G, Shand B, Holland K. Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding? Australian and New Zealand Journal of Obstetrics and Gynaecology https://doi.org/10.1111/ajo.12490
This observational case series in 65 premenopausal women with abnormal uterine bleeding evaluated whether transvaginal ultrasound followed by saline infusion sonohysterography (SIS) prevented unnecessary hysteroscopy. Although SIS indicated that hysteroscopy was unnecessary in eight women, this benefit was offset by the invasive nature of the scan, the number of endometrial abnormalities falsely detected by SIS and the cost of the additional investigation.
Keywords: hysteroscopy; premenopausal period; saline infusion sonohysterography; transvaginal ultrasonography; uterine bleeding
Stravens M, Langdana F, Short J, Johnson K, Simcock B, Shand B, McGeoch G, Sykes P Management of postmenopausal bleeding by general practitioners in a community setting: an observational study. New Zealand Medical Journal 2016;129 (1434). https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1434-6-may-2016/6883
Aim: To evaluate the safety and effectiveness of a clinical pathway for investigation of postmenopausal bleeding (PMB), managed primarily by general practitioners. Women with an endometrial thickness (ET) ≥5mm on transvaginal ultrasound (TVUS) require either a pipelle biopsy in primary care or referral for specialist care.
Method: Data on 241 women with PMB were reviewed retrospectively over a 5-year follow-up period. Twenty-five women were excluded as they did not satisfy PMB clinical pathway criteria.
Results: TVUS showed 121 women had an ET <5mm, 83 an ET ≥5mm, and 12 an endometrial polyp. In the women with ET ≥5mm, 38 had a pipelle biopsy performed in primary care, 36 were referred directly to secondary care, and 9 declined further investigations. Only 17 pipelle biopsies provided sufficient tissue, with the remaining 21 women referred to secondary care. Seven cases of endometrial cancer were identified, 4 by pipelle biopsy and 3 by hysteroscopy. Of the study cohort, 68% were managed solely by their general practitioner to the point of diagnosis, while 81% with an ET ≥5mm required management in secondary care at some stage. No further cases of endometrial cancer were identified in reviews of patient medical records and cancer registries.
Conclusion: Community-based investigation of PMB is an alternative model of care with no evidence of additional risks to the patient. Targeted education of general practitioners on pipelle biopsies is essential to maximise the effectiveness of the pathway.
Keywords: post-menopausal bleeding, general practitioner, pipelle, transvaginal ultrasound
McGeoch G, Sycamore M, Shand B, Simcock J. A regional programme to improve skin cancer management. Journal of Primary Health Care 2015;7:339-344. https://doi.org/10.1071/HC15339
Background and context: In 2008, public specialist and general practice services in Canterbury were unable to manage demand for skin cancer treatment. Local clinicians decided the solution was to develop a see-and-treat skin excision clinic staffed by plastic surgeons and general practitioners (GPs), and the introduction of subsidised excisions in general practice. This paper describes the collaboration between clinicians, managers and funders and the results and quality management measures of these initiatives.
Assessment of problem: There is an increasing incidence of skin cancer. GPs in Canterbury were unable to meet increasing demand for skin cancer treatment because some lacked confidence and competence in skin cancer management. There was no public funding for primary care management of skin cancer, driving patients to fully funded secondary care services. Secondary care services were at capacity, with no coordinated programme across primary and secondary care.
Results: The programme has resulted in a greater number of skin cancers being treated by the public health system, a reduction in waiting times for treatment, and fewer minor skin lesions being referred to secondary care. Quality measures have been achieved and are improving steadily. Development of the programme has improved working relationships between primary and secondary care clinicians.
Strategies for improvement: The strategy was to facilitate the working relationship between primary and secondary care and increase the capacity for skin lesion excisions in both sectors.
Lessons: Skin cancer management can be improved by a coordinated approach between primary and secondary care.
Keywords: continuing medical education; general practice; minor surgical procedures; referral and consultation; skin neoplasms
Epton MJ, Stanton JD, McGeoch GRB, Shand BI, Swanney MP. The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery. npj Primary Care Respiratory Medicine 25, 15003. doi.org/10.1038/npjpcrm.2015.3; published online 5 March 2015.
In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.
Keywords: spirometry; pulmonary disease; chronic pulmonary; general practice; quality control; cooperative behaviour
McGeoch G, Anderson I, Gibson J, Gullery C, Kerr D, Shand B Consensus pathways: Evidence into practice. New Zealand Medical Journal 2015;128 (1408):86-96. http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1408/6418
HealthPathways is a website that provides general practice teams with guidance on clinical assessment and management of medical conditions, relevant to local services and resources. The website evolved in 2008 as part of changes towards an integrated healthcare system in the Canterbury region of New Zealand. The website differs from other clinical guidance websites as the clinical pathways are formulated by local healthcare professionals, health managers, and technical writers. This process is facilitated by a proactive group called the Canterbury Initiative. The website now contains over 570 clinical pathways, with access increasing seven-fold since 2009 (visits/mth; 1053 in 2009 vs. 7729 in 2014). HealthPathways has contributed to the delivery of more care in the community (e.g. primary care spirometry; 1443 measurements in 2014 representing one-quarter of the total number). Introduction of the website has been associated with an improvement in referral quality, more equitable referral triage, and more transparent management of demand for secondary care. Because the website provides relevant localised clinical information required during a patient consultation in an easy-to-use standardised format, it has overcome many of the barriers encountered by other online clinical guidance systems. The website has also acted as a change management tool by disseminating information required for successful integration of health services.
Keywords: general practice; clinical guidance; referral and consultation; internet; decision support
Comment: Kenealy TW, Sheridan NF, Connolly MJ. HealthPathways website: making the right thing the easy thing to do. New Zealand Medical Journal 2015;128 (1408):6-9.
McGeoch G, Shand B. HealthPathways: some clarification. Letter in New Zealand Medical Journal 2015;128 (1412).
We wish to respond to several points raised by Kenealy, Sheridan and Connolly in their thoughtful and encouraging editorial on HealthPathways in the 30 January 2015 issue of the Journal. The statement that the “patient voice is not obvious in the HealthPathways process” is a fair comment, although it needs some clarification.
HealthPathways evolved after a period of intense consumer consultation in Health Services Planning and fulfilled many of the desires to see more transparent and available information for both clinicians and patients. We have presented and discussed HealthPathways with many consumer groups in Canterbury and their usual response is amazement that information on health services was not already available to general practice. The development of the clinical pathways can lead to robust debate and whether this would be stifled or be inappropriate with consumers in the room is a point that needs to be considered. While HealthPathways is written primarily for general practice teams, the main consideration when developing the clinical pathways is the impact on the patient of any proposed change in healthcare delivery. As pointed out in our papers, this safeguarding of the patient is backed up by biannual review of the pathways and regular clinical audit of those in which nonadherence may result in serious adverse events.
The apparent lack of discussion on the ‘patient voice’ in our two papers may reflect the fact that patients do not have access to the website and in many cases may not even be aware their general practitioner is using the website during a consultation. A survey of patients on their perceptions of HealthPathways as suggested in the editorial would therefore not provide relevant or meaningful data. However it is comforting to know that previous studies have shown patients generally have a positive attitude towards clinicians’ use of computers during a consultation, with reservations mainly concerning depersonalisation and loss of efficiency of the doctor patient relationship.
The editorial interpreted our comments on HealthPathways increasing the length of consultations as a negative. However, we are unsure whether this is a positive or a negative as longer consultations may be a consequence of the time required to obtain the relevant clinical information, but result in more thorough and focused examination of the patient.
The importance of patients having access to accurate healthcare information led to the introduction, in 2011, immediately after the Christchurch earthquakes, of a parallel website called HealthInfo. This open access site contains easy to read information on common medical conditions and the details of locally available healthcare services. We are currently planning a survey of patients on their use and opinions of HealthInfo that may go some way to answering the questions raised by Kenealy and coauthors.
The concern raised in the editorial that ‘medical dominance poses an obstacle to interprofessional cooperation” and that “best care is provided by teams” is acknowledged. While the “team approach” used to develop the clinical pathways undoubtedly has been successful, unpublished data from our online survey showed that acceptance and use of HealthPathways by allied health professionals has not been as great as that of general practice teams. This finding confirms the viewpoint of the editorial that a greater degree of linkage of health, social and community services is necessary for further successful implementation of the website. With this aim in mind, nurses and allied health professionals have recently become more involved in the development of the pathways. Incorporating the input of these groups into the pathways has been hard work but has led to greater depth of the pathways and increased use of allied health services by general practice. For example, the falls prevention programme was led by allied health and is showing very good results since its dissemination on HealthPathways.
We agree with the viewpoint of the editorial on the importance of continued integration of health into social determinants of health and hope HealthPathways can assist to reflect and implement this. In this regard, we have already included information on diverse topics such as home heating and land contamination as well as links to social services and public health. The ability of HealthPathways to provide links with a diverse range of healthcare organisations and community groups represents a major challenge for the future, but would go a long way to establishing the website as “the right thing to do” for both patients and general practice teams. We also acknowledge the difficulties of assessing unmet need raised by Kenealy and coauthors. Unmet need is a much discussed and neglected issue and we are concerned that access criteria can leave need unmeasured. For this reason we are currently exploring opportunities to measure unmet need in both referred and unreferred groups of patients.
Lastly, we agree with the editorial that more evaluation of HealthPathways is required to support our conclusions. We consider that the enthusiasm that was apparent in our perspective paper was a reflection of the impact of the website in Canterbury and its scale of dissemination in New Zealand and Australia, but that this enthusiasm needs to be supported by evidence of effectiveness and lack of unexpected negative consequences, not just increased use of the website.
McGeoch G, McGeoch P, Shand B Is HealthPathways effective? An online survey of hospital clinicians, general practitioners and practice nurses. New Zealand Medical Journal 2015;128 (1408):36-46. http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1408/6413
Aim: An online survey was used to determine the perceptions of healthcare professionals in Canterbury on HealthPathways, a website that provides clinical and referral information for general practice teams, relevant to locally available health services and resources.
Methods: The survey questionnaire included questions on the effectiveness and ease-of-use of the website, computer literacy and use of online clinical guidance systems. Differences in the responses between work groups were analysed using the Mann-Whitney test.
Results: 249/480 (52%) of general practitioners, 72/156 (46%) of practice nurses, and 43/66 (65%) of hospital clinicians completed the questionnaire. Approximately 90-95% of general practice teams considered the website was easy to use and had contributed to both an increase and improvement of care in the community, with about 50% stating that it had improved their relationships with patients and hospital clinicians. Minor concerns included the website's increasing size and prescriptive nature and that it increased the duration of a patient consultation. Approximately 60% of hospital clinicians reported improvements in referral quality and triage and working relationships with general practices since the introduction of HealthPathways.
Conclusion: HealthPathways has achieved a high level of acceptance in both primary and secondary care, and has therefore acted as a valuable change management tool increasing healthcare integration in Canterbury.
Keywords: Online survey, clinical guidance, primary health care, secondary care, referral and consultation, New Zealand
Page last updated: 23 May 2022
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