Primary Care Environment Research Articles

Oral cancer screening programmes

The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase and CANCERLIT. Randomised controlled trials (RCTs) of screening for oral cancer or potentially malignant disorders using visual examination, toluidine blue, fluorescence imaging or brush biopsy were included. There were no restrictions regarding language or date of publication. The original review identified 1,389 citations and this update identified an additional 330 studies. Validity assessment, data extraction and statistics evaluation were undertaken by six independent review authors. Only one 9-year cluster RCT was included (n = 13 clusters: 191,873 participants). No statistically significant differences in the age-standardised oral cancer mortality rates for the screened group (16.4/100,000 person-years) and the control group (20.7/100,000 person-years) were identified. A 43% reduction in mortality was reported between the intervention cohort (29.9/100,000 person-years) and the control arm (45.4/100,000) for high-risk individuals who used tobacco or alcohol or both, which was statistically significant. However, this study had a number of methodological weaknesses and the associated risk of bias was high. Although there is evidence that a visual examination as part of a population-based screening programme reduced the mortality rate of oral cancer in high-risk individuals, whilst producing a stage shift and improvement in survival rates across the population as a whole, the evidence is limited to one study and is associated with a high risk of bias. This was compounded by the fact that the effect of cluster randomisation was not accounted for in the analysis. Furthermore, no robust evidence was identified to support the use of other adjunctive technologies like toluidine blue, brush biopsy or fluorescence imaging within a primary care environment. Further RCTs are recommended to assess the efficacy, effectiveness and cost-effectiveness of a visual examination as part of a population based screening programme.

What should be our approach to knowledge translation in primary care?

Evaluations of delivered care have consistently demonstrated gaps between existing medical knowledge and current practice. Studies examining the quality of care across disciplines and jurisdictions have estimated that 30% to 45% of patients are not offered evidence-based best care, and 20% to 30% receive contraindicated and potentially harmful care [1,2]. Respiratory disease care gaps are equally alarming, with only 48% of recommended care delivered to patients with asthma exacerbations, and only 46% of routine recommended care delivered to patients with COPD [3]. Knowledge translation (KT) is a methodological approach developed specifically to address these care gaps. Because the most prevalent conditions are managed predominantly in primary care, there has been a great deal of interest in developing KT interventions targeting the primary care environment. A meta-analysis of randomized trials of guideline implementation interventions has demonstrated only modest effects on care across a wide range of disciplines, care settings, recommendation types and intervention types [4]. However, few of these studies employed behavioral theories to inform intervention design, and this lack of an appropriate theoretical underpinning may be partly responsible for their limited success [5]. A multi-step approach to KT intervention design might improve success. Knowledge implementers should start by investigating the theory-based factors that underlie existing clinical practice, in order to identify the theoretical constructs that should be targeted by an intervention. Once these factors are known, one can design interventions to enhance the processes supporting change in these specific constructs [6]. When targeting individual behaviour change, relevant theoretical categories include motivational theories (which explain how individuals wish, intend and ultimately decide to change behaviour), action theories (which explain how individuals move from intention to actual behaviour change), and stage theories (which describe an orderly progression through discrete stages toward behaviour change) [6]. Concepts of behavioural intention and self-efficacy are among the best predictors of subsequent health behaviour and are found in virtually all social cognitive models of health behaviour. Baseline factors influencing current behaviour can be identified directly through previous literature, or through direct measurement via interviews, questionnaires or group methods. An alternative approach is to analyze practice variation with respect to its determinants. With this technique, determinants identified predominantly in practices which adhere to or do not adhere to behaviour can be characterized as facilitators or barriers, respectively. Finally, researchers can analyze previously effective KT interventions to retrospectively ascertain which factors were likely influencing behaviour [7]. After having thus identified the relevant components of a behavior that should be targeted, an appropriate intervention can be developed based on approaches previously shown to be effective in other settings. General categories of interventions include educational interventions, which can be passive or interactive; audit-and-feedback; provision of “just-in-time” information, including reminders and clinical decision support systems; organizational changes such as role revisions or financial incentives; and patient-directed interventions such as pre-consultation questionnaires. Electronic tools are emerging as a modality to facilitate a wide range of these interventions and require further study.

Optimising pharmacological maintenance treatment for COPD in primary care

Chronic obstructive pulmonary disease (COPD) is a multi-faceted disease that is a major cause of morbidity and mortality worldwide, and is a significant burden in terms of healthcare resource utilisation and cost. Despite the availability of national and international guidelines, and effective, well-tolerated pharmacological treatments, COPD remains substantially under-diagnosed and under-treated within primary care. As COPD is both preventable and treatable there is an urgent need to raise the awareness and profile of the disease among primary care physicians and patients. Increasing evidence suggests that initiation of long-acting bronchodilator treatment at an early stage can significantly improve the patient's long-term health and quality of life (QoL). Recent large-scale trials in COPD have confirmed the longterm benefits of maintenance treatment with long-acting bronchodilators. A wide range of benefits have been shown in selected patient groups including improved lung function and QoL, reduced exacerbations and, in some studies, delayed disease progression and improved survival. In this review, we consider recent developments in our understanding of COPD, including current and emerging pharmacological treatment options, and identify steps for optimising early diagnosis and pharmacological treatment of COPD within the primary care environment.

“I Fired My Last Doctor for Not Taking Me Seriously”: Collaborating With a Difficult Medical Patient in a Multidisciplinary Primary Care Facility

We present the case of a multidisciplinary primary care assessment of a 32-year-old woman with multiple medical and psychological complaints. Following the collaborative care model, this assessment was conducted by a team consisting of a clinical health psychologist, Dr. J. L. Skillings, and a family physician, Dr. W. J. Murdoch. We describe the primary care environment in which this referral was made including the methods that were utilized to insure a successful professional collaboration. We report the results and recommendations from a comprehensive biopsychosocial assessment; we place emphasis on the psychological diagnosis and pain symptoms. We also describe the feedback session in which the assessment results were provided to the patient and her spouse by both physician and psychologist. Multiperspective commentary about the assessment is offered by the patient and her husband as well as the physician and psychologist assessors.

Can we make sense of multidisciplinary co‐operation in primary care by considering routines and rules?

Although it is widely acknowledged that the complex health problems of chronically ill and elderly persons require care provision across organisational and professional boundaries, achieving widespread multidisciplinary co-operation in primary care has proven problematic. We developed an explanation for this on the basis of the concepts of routines (patterns of behaviour) and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. We used data about primary care providers situated in the Dutch region of Limburg, a region that, despite high numbers of chronically and elderly persons, has traditionally few healthcare centres and where multidisciplinary co-operation is limited. A qualitative study design was used, in which interviews and documents were the main data sources. Semi-structured interviews were conducted with providers from six primary care professions in the Dutch region of Limburg; relevant documents included co-operation agreements, annual reports and internal memos. To analyse the evidence, several data matrices were developed and all data were structured according to the main concepts under study, i.e. routines and rules. Although more research is needed, our study suggests that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their solo care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current, rather limited shape of multidisciplinary co-operation to expand. Further research should attempt to validate this explanation by utilising a larger research population and systematically operationalising the rules existing in the legal and--more importantly--organisational environment of primary care.

Bringing psychotherapy to primary care: Innovations and challenges.

[Clin Psychol Sci Prac 17: 191–214, 2010] The segregation of mental health treatment and primary medical care in our health care system is increasingly recognized as anachronistic, as a majority of patients with psychosocial problems are turning to primary care providers. Accordingly, the development and dissemination of evidence-based psychotherapeutic interventions compatible with the constraints of primary care is becoming increasingly urgent. This article discusses the importance of finding feasible ways to bring psychotherapy to primary care, examines interventions either specifically adapted for primary care or consistent with its constraints, assesses the compatibility of these interventions with the primary care environment, considers barriers inhibiting the widespread integration of such interventions into primary care, and discusses future directions.

Does familiarity breed respect? Physician attitudes toward nurse practitioners in a medically underserved state

An evolving primary care environment underscores the importance of physician and nurse practitioner (NP) interactions. We analyze how physician characteristics and close working relationships (presence of NPs in practice) influence physicians' attitudes toward NPs. Bivariate analyses of 2007-2008 Mississippi Physician Workforce Study survey data (response rate 23.3%) identified Mississippi physician characteristics associated with having NPs in practices and discrete NP-attitudinal items. Generalized physician attitudes toward NPs were modeled using multivariate regression. Generalists, physicians in public sector employment and physicians in larger practices are more likely to work in practices that also include NPs. Physicians working with NPs are somewhat younger than those who do not. Regression analysis indicates that male physicians had less-positive attitudes toward NPs, while physicians who practice alongside NPs and who have been in practice longer have the most positive generalized attitudes toward NPs. Physicians who work in the same practice with NPs have more positive attitudes toward them. However, regardless of work arrangements, MS physicians are reluctant for NPs to practice independently. Physicians with early collaborative training with NPs may have more positive attitudes, but even such exposure will not necessarily lead physicians to support NPs' independent practice.

Educational Interventions for Implementation of Arthritis Clinical Practice Guidelines in Primary Care: Effects on Health Professional Behavior

The dissemination and adoption of clinical practice guidelines (CPG) has been suggested as one method for improving arthritis care delivery. This article provides a review and synthesis of studies evaluating the influence of educational programs designed to implement CPG for osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care. A systematic literature search was conducted to identify relevant educational interventions that reported behavioral outcomes that ensured actual knowledge utilization in primary care. A standardized approach was used to assess the quality of the individual studies and a modified version of the Philadelphia Panel methodology allowed for grading of studies based on strength of design, clinical relevance, and statistical significance. The search identified 485 articles; 7 studies were selected for review. In OA, peer facilitated workshops with nurse case-management support for patients decreased the number of referrals to orthopedics by 23%, and educational outreach by trained physicians improved prescribing of analgesics. Interprofessional peer facilitated workshops were successful in increasing referrals to rehabilitation services for people with OA and RA. There was sparse literature on educational programs for the implementation of arthritis CPG in the primary care environment. Future studies are needed to evaluate which specific organizational, provider, patient, and system level factors influence the uptake of arthritis CPG in primary care.

Getting it all done. Organizational factors linked with comprehensive primary care

Comprehensiveness, a defining feature of primary care (PC) is associated with patient satisfaction and improved health status. This paper evaluates comprehensive services in fee-for-service (FFS), Health Service Organizations (HSOs), Family Health Networks (FHNs) and Community Health Centres (CHCs) payment models in Ontario. To assess how organizational models of PC differ in the delivery of comprehensive services and which organizational factors predict comprehensive PC delivery. Cross-sectional mixed-method study with nested qualitative case studies. PC practices in Ontario. One hundred and thirty-seven PC practices (35 FFS, 32 HSO, 35 FHN and 35 CHC) and 358 providers. Surveys based on the Primary Care Assessment Tool and qualitative interviews. Comprehensiveness scores were calculated from practice report of clinical services offered in women's health, psychosocial counselling, procedural and diagnostic services. Confounding variables were calculated from provider and patient surveys. Performance at a model level was compared using analysis of variance. Multiple regressions then established factors independently associated with comprehensiveness. CHCs offered significantly more comprehensive services (74%) than other models (61%-63%; P < 0.005). Thirty-five per cent of the variance in comprehensiveness was explained by a regression model that included the number of family physicians working at the practice, presence of other allied health providers, rurality and length of practice operation. Practice size and diversity of providers seemed to partially explain the better performance of CHCs. Practice setting and, probably, practice maturity are significant drivers in the provision of comprehensive PC services. These factors warrant further examination in other PC environments.

Influencing patients' oral hygiene behaviour

A patient-randomised controlled trial (RCT) and a cluster RCT of the same intervention were conducted independently of each other. The evidence-based intervention (a powered toothbrush and behavioural advice on timing, method and duration of toothbrushing) was framed to target oral hygiene self-efficacy (Social Cognitive Theory) and action plans (Implementation Intention Theory) to influence oral hygiene behaviour and therefore clinical outcomes. The content and the delivery of the intervention were standardised as a series of steps-altogether taking approximately 5 min. The control groups received routine care, even if that included oral hygiene advice. The primary outcome measures were behavioural (timing, duration and method of toothbrushing) matching the advice given in the intervention. Secondary outcomes were cognitive measures of self-efficacy and planning, and clinical measures of plaque and gingival bleeding. The study included 87 dental practices and 778 patients (patient RCT, 37 dentists and 300 patients; cluster RCT, 50 dentists and 478 patients). Controlled for baseline differences, pooled results showed that trial participants who experienced the intervention had better behavioural (timing, duration, method), cognitive (confidence, planning), and clinical (plaque, gingival bleeding) outcomes. Clinical outcomes were only significantly better in the cluster RCT, however. A simple, theory-based intervention delivered within the constraints of a primary care environment was more effective than routine care in influencing patients' oral hygiene cognitions, behaviour and health. As clinical outcomes were significantly better only in the cluster RCT, the impact of trial design on results needs to be further explored.

The Adequacy of Chronic Pain Management Prior to Presenting at a Tertiary Care Pain Center: The Role of Patient Socio-Demographic Characteristics

The Pain Management Index (PMI) is used to assess pain medication adequacy in black and white chronic pain patients (18-50 years) at referral to tertiary pain care. Using WHO guidelines for pain treatment, PMI was calculated from pain severity and drug analgesic potency. From 183 patients recruited, 128 provided treatment information for analyses (53% white, 60% female). Most (51.6%) had adequate PMI. Blacks were prescribed fewer pain medications (P = .03); fewer women had adequate medication strength (P = .04). In hierarchical regression, PMI was predicted at entry by female gender, lower MPI, higher affective MPQ, and a gender X age interaction. Younger men experienced better pain management, reducing toward the PMI level of women by age 50. In the final block, black race, being married, affective pain, and gender X age were associated with higher PMI, female gender and being employed were associated with lower PMI. Women, particularly younger women, were at higher risk for inadequate pain management in a primary care environment. These results support variability in chronic pain care and the need for research focusing on whether these disparities persist with specialized pain care. Most people with pain receive initial care in a primary care setting. This study examining the adequacy of pain management prior to specialty pain care showed blacks and women had less adequate pain care at referral. These results suggest the need for interventions and education in the primary care arena to improve pain care.

The Causal Role of Fatigue in the Stress-Perceived Health Relationship: A MetroNet Study

We conducted a cross-sectional survey of 4 primary care MetroNet centers in metropolitan Detroit. Our objective was to describe the causal role of fatigue in the relationship among stress, stress resiliency, and perceived health in primary care. Fatigue is a public health problem that has been linked to stress and poor health. The causal role of fatigue between stress and perceived health is unknown. Four hundred surveys were distributed to adult patients in 4 primary care centers in metropolitan Detroit between 2006 and 2007. Internal consistency reliabilities and principal factor analyses were calculated for the key psychological scales. Perceived health is the primary outcome. Path models were used to study the relationship among stress, fatigue, and perceived health. We also modeled the impact of select stress resiliency factors including sleep, recovery, and social support. Of the 400 distributed surveys, 315 (78.7%) had a response rate of 70% or more and were included in the analysis. Respondents were predominantly middle aged (median age, 43 years); female (58.7%); and African American (52.0%). The majority worked full time (56.5%); did not have a college degree (77.7%); and were not married (55.2%). Fatigue was reported by 59% of respondents, 42.7% of which was unexplained. The path model supported the causal role of fatigue between stress and perceived health. The positive effects of sleep, recovery, and social support on fatigue, stress, and perceived health were validated. Fatigue was common in this metropolitan primary care environment and completely mediated the relationship between stress and poor perceived health. Therefore, stress, when significant enough to cause fatigue, may lead to poor health.

Oral Cancer Screening: What Have We Learnt and What is There Still to Achieve?

Oral cancer is an important global healthcare problem. In the UK, the incidence is increasing and late-stage presentation is common. Determining the feasibility of a national screening program for oral cancer is therefore an important step in the prevention of the disease. Evidence exists to suggest that an oral examination of high-risk individuals may be a cost-effective screening strategy. However, questions remain over which primary care environment would be the most suitable and the criteria for a positive screen and referral. Further research is needed in the form of clinical trials or demonstration studies in primary care. The impact on secondary care, the role of auxiliaries and training needs also need to be determined. In addition, the assessment of adjunctive aids and evaluation of potential biomarkers are considered important.

A Nurse-Facilitated Depression Screening Program in an Army Primary Care Clinic

Depression, sometimes with suicidal manifestations, is a medical condition commonly seen in primary care clinics. Routine screening for depression and suicidal ideation is recommended of all adult patients in the primary care setting because it offers depressed patients a greater chance of recovery and response to treatment, yet such screening often is overlooked or omitted. The purpose of this study was to develop, to implement, and to test the efficacy of a systematic depression screening process to increase the identification of depression in family members of active duty soldiers older than 18 years at a military family practice clinic located on an Army infantry post in the Pacific. The Iowa Model of Evidence-Based Practice to Promote Quality Care was used to develop a practice guideline incorporating a decision algorithm for nurses to screen for depression. A pilot project to institute this change in practice was conducted, and outcomes were measured. Before implementation, approximately 100 patients were diagnosed with depression in each of the 3 months preceding the practice change. Approximately 130 patients a month were assigned a 311.0 Code 3 months after the practice change, and 140 patients per month received screenings and were assigned the correct International Classification of Diseases, Ninth Revision Code 311.0 at 1 year. The improved screening and coding for depression and suicidality added approximately 3 minutes to the patient screening process. The education of staff in the process of screening for depression and correct coding coupled with monitoring and staff feedback improved compliance with the identification and the documentation of patients with depression. Nurses were more likely than primary care providers to agree strongly that screening for depression enhances quality of care. Data gathered during this project support the integration of military and civilian nurse-facilitated screening for depression in the military primary care setting. The decision algorithm should be adapted and tested in other primary care environments.

The Scope of Pharmacological and Clinical Effects of Modern Antihistamines, With a Special Focus on Rupatadine: Section 4. Management of Allergies in the Primary Care Environment

The Scope of Pharmacological and Clinical Effects of Modern Antihistamines, With a Special Focus on Rupatadine: Section 4. Management of Allergies in the Primary Care Environment

Warfarin Sensitivity Genotyping: A Review of the Literature and Summary of Patient Experience

The antithrombotic benefits of warfarin are countered by a narrow therapeutic index that contributes to excessive bleeding or cerebrovascular clotting and stroke in some patients. This article reviews the current literature describing warfarin sensitivity genotyping and compares the results of that review to the findings of our study in 189 patients at Mayo Clinic conducted between June 2001 and April 2003. For the review of the literature, we identified relevant peer-reviewed articles by searching the Web of Knowledge using key word warfarin-related adverse event. For the 189 Mayo Clinic patients initiating warfarin therapy to achieve a target international normalized ratio (INR) in the range of 2.0 to 3.5, we analyzed the CYP2C9 (cytochrome P450 2C9) and VKORC1 (vitamin K epoxide reductase complex, subunit 1) genetic loci to study the relationship among the initial warfarin dose, steady-state dose, time to achieve steady-state dose, variations in INR, and allelic variance. Results were compared with those previously reported in the literature for 637 patients. The relationships between allelic variants and warfarin sensitivity found in our study of Mayo Clinic patients are fundamentally the same as in those reported by others. The Mayo Clinic population is predominantly white and shows considerable allelic variability in CYP2C9 and VKORC1. Certain of these alleles are associated with increased sensitivity to warfarin. Polymorphisms in CYP2C9 and VKORC1 have a considerable effect on warfarin dose in white people. A correlation between steady-state warfarin dose and allelic variants of CYP2C9 and VKORC1 has been demonstrated by many previous reports and is reconfirmed in this report. The allelic variants found to most affect warfarin sensitivity are CYP2C9*1*1-VKORC1BB (less warfarin sensitivity than typical); CYP2C9*1*1-VKORC1AA (considerable variance in INR throughout initiation); CYP2C9*1*2-VKORC1AB (more sensitivity to warfarin than typical); CYP2C9*1*3-VKORC1AB (much more sensitivity to warfarin than typical); CYP2C9*1*2-VKORC1AB (much more sensitivity to warfarin than typical); CYP2C9*1*3-VKORC1AA (much more sensitivity to warfarin than typical); and CYP2C9*2*2-VKORC1AB (much more sensitivity to warfarin than typical). Although we were unable to show an association between allelic variants and initial warfarin dose or dose escalation, an association was seen between allelic variant and steady-state warfarin dose. White people show considerable variance in CYP2C9 allele types, whereas people of Asian or African descent infrequently carry CYP2C9 allelic variants. The VKORC1AA allele associated with high warfarin sensitivity predominates in those of Asian descent, whereas white people and those of African descent show diversity, carrying either the VKORC1BB, an allele associated with low warfarin sensitivity, or VKORC1AB or VKORC1AA, alleles associated with moderate and high warfarin sensitivity, respectively.

Community diabetes consultants: the case for additional training

On behalf of all diabetes consultants working in the community—whether employed through primary care or hospital trusts—we are writing in response to the letter in the March issue which suggested that additional training for community consultants was unnecessary.1 We agree that diabetes is the same condition whether it is managed in the hospital or community setting—or in specialist or primary care—but would like to point out a few of the challenges for consultants leading services for people who do not attend traditional ‘secondary care’, and where additional training is helpful to consultants who are considering working in this environment. Strong leadership skills are needed to develop diabetes services in the rapidly changing environment of primary care (e.g. getting to grips with General Medical Services, Quality and Outcomes Framework and Practice Based Commissioning). ‘Our health, Our care, Our say’ encourages most diabetes manage-ment to be undertaken in local community settings or primary care. Clinics in the hospital setting are increasingly focusing on patients with highly complex or subspecialty diabetes needs. The community diabetologist has an important role in leading services for people who do not meet the criteria for such hospital clinics but who have more complex needs than those the GP can manage. The development of high quality services that have ‘economies of scale’ to cope with large numbers of patients (particularly in patient education, group consultations etc) will be essential. Community diabetol-ogists are increasingly working alongside public health specialists, epidemiologists and statisticians on issues such as prevention and increas-ing the ascertainment of diabetes, whilst acquiring knowledge of techniques such as social marketing! Clinically, community consultants are more likely to see patients who are not seen in a hospital clinic—e.g. those who are housebound, living in a nursing home, travellers, and psychiatric patients who all have particular diabetes needs. Community consultants need to develop new ways of working due to the fact that they also see patients who do not attend hospital clinics because the system there does not work for them. Although many hospital-based diabetes care teams have always been involved with the education of GPs and practice nurses, the community consultant's role includes not just delivering training but also ensuring it is embedded into the local diabetes management framework (e.g. Local Enhanced Services) which they have developed. The consultant may be working in environments very different from those of hospital clinics (e.g. commu-nity centres, GP surgeries, mosques, even supermarkets!) with different computer systems and organisation of care. Multidisciplinary team working is as important as it is in secondary care, but there are different levels and disciplines in the community (e.g. local pharmacists, nursing home staff, district nurses, and case managers). Community consultants are an important link between primary and specialist care. Experienced commu-nity diabetes consultants can see diabetes issues from both primary and specialist care perspectives and, with appropriate skills, can facilitate integrated care and partnership in the challenging NHS in which we are all working. Gillian Hawthorne Community Diabetes Consultants committee, Waqar Malik Community Diabetes Consultants committee, Felix Burden Community Diabetes Consultants committee, Chris Walton Community Diabetes Consultants committee, Jill Hill Community Diabetes Consultants committee

Public health nurses perception of clinical leadership in Ireland: narrative descriptions

The aim of the study was to identify how clinical leadership skills are perceived by Public Health Nurses in the course of their everyday work and the effectiveness and consequences of such skills in primary care delivery. Public health nurses deliver primary care to children and adults as part of small teams or in individual situations. Leadership skills are needed to fulfil their many roles. Rigorous analysis of narrative interviews with public health nurses working in primary care environments in Ireland was undertaken. Narrative information was obtained by having conversations with 20 public health nurses relating to their perceptions on what clinical leadership meant to them and how their leadership skills influenced effective primary care delivery. Analysis of conversations identified the tensions existing between the various roles and responsibilities of the public health nurse and other primary care workers. This tension was perceived by the nurses as being the main barrier to effective primary care delivery from their perspective. Clinical leadership is viewed narrowly by public health nurses as management skills rather than leadership skills were mainly identified. Education for the role was identified as a critical success factor. RELEVANCE TO NURSE MANAGERS: Public health nurses are well placed to shape and influence health service culture through effective clinical leadership.

An Image Based Auto-Focusing Algorithm forDigital Fundus Photography

In fundus photography, the task of fine focusing the image is demanding and lack of focus is quite often the cause of suboptimal photographs. The introduction of digital cameras has provided an opportunity to automate the task of focusing. We have developed a software algorithm capable of identifying best focus. The auto-focus (AF) method is based on an algorithm we developed to assess the sharpness of an image. The AF algorithm was tested in the prototype of a semi-automated nonmydriatic fundus camera designed to screen in the primary care environment for major eye diseases. A series of images was acquired in volunteers while focusing the camera on the fundus. The image with the best focus was determined by the AF algorithm and compared to the assessment of two masked readers. A set of fundus images was obtained in 26 eyes of 20 normal subjects and 42 eyes of 28 glaucoma patients. The 95% limits of agreement between the readers and the AF algorithm were -2.56 to 2.93 and -3.7 to 3.84 diopter and the bias was 0.09 and 0.71 diopter, for the two readers respectively. On average, the readers agreed with the AF algorithm on the best correction within less than 3/4 diopter. The intraobserver repeatability was 0.94 and 1.87 diopter, for the two readers respectively, indicating that the limit of agreement with the AF algorithm was determined predominantly by the repeatability of each reader. An auto-focus algorithm for digital fundus photography can identify the best focus reliably and objectively. It may improve the quality of fundus images by easing the task of the photographer.

General Practice in urban and rural New Zealand: Results of the 2007 RNZCGP membership survey

The provision of primary health care is an integral part of both a country's health system, and of the overall social and economic development of its communities. An adequate general practice and primary health care workforce is a prerequisite to the provision of good primary health care. Countries with stronger primary health care services have better health and much lower health costs. This paper reports the results of the RNZCGP's 2007 annual membership survey and discusses workforce development in urban and rural New Zealand (NZ). In 2007, the RNZCGP sent a survey form to all its financial members as part of the annual subscriptions mail-out to gather data about College members' current working patterns and help construct a longitudinal view of work preferences and hours worked per week. The response rate was 59% (1995 members/participants: 1098 males (55%) and 897 females). More female GPs (86%) worked in urban centres than male GPs (83%). NZ European GPs were overrepresented (67%) in the South Island when compared to their representation within the total population. Numbers of international medical graduates (IMGs) had increased in urban centres since 2005. All regions experienced a decrease in self-employed GPs. Rural GPs spend more hours per week in general practice than urban GPs. The GP workforce is an integral part of the NZ primary health care workforce, and is currently facing many challenges. Stakeholders need to ensure that NZ remains an attractive primary health care environment in order to retain NZ-trained GPs and attract IMGs.