Determining immunisation coverage rates in primary health care practices: a simple goal but a complex task

PURPOSE: To explore the quality of data recording by practices and identify issues to be considered and addressed before such data can be used as a continuous measure of immunisation delivery. METHODS: One hundred and twenty-four randomly selected general practices visited to measure immunisation coverage using the various practice management systems (PMS) in use. To capture all target children it was necessary to build two queries: one generated a list of all children aged between 6 weeks and 2 years who had been to the practice, regardless of enrollment status; the other asked dates and nature of all immunisations given. Each different PMS required a unique query to extract the necessary information. RESULTS: Variability encountered included different types and versions of PMS and operating systems; variable degree of staff technical competence with their PMS; proportion of enrolled children ranging from nearly 0 to 100%; lack of consistency of the nature and location of data entry and coding; and unreliability of dates relating to some vaccination events. RECOMMENDATIONS: To improve recording of immunisation coverage we recommend a standard early age of registration and enrollment; standard definitions of the denominator and of immunisation delay; greater uniformity of PMS; improved staff training; intrinsic data quality checks; integration of PMS with changes in the immunisation schedule; incentives and interval electronic checks to improve data quality.     

Fall prevention in residential care: a cluster, randomized, controlled trial

OBJECTIVES: To establish the effectiveness of a fall-prevention program in reducing falls and injurious falls in older residential care residents. DESIGN: Cluster, randomized, controlled trial. SETTING: Fourteen randomly selected residential care homes in Auckland, New Zealand. PARTICIPANTS: All older residents (n=628, 95% participation rate). INTERVENTION: Residential care staff, using existing resources, implemented systematic individualized fall-risk management for all residents using a fall-risk assessment tool, high-risk logo, and strategies to address identified risks. MEASUREMENTS: Number of residents sustaining a fall, falls, and injurious-falls incidence rates. RESULTS: During 12 months of follow-up, 103 (43%) residents in the control group and 173 (56%) residents in the intervention group fell (P<.018). There was a significantly higher incidence rate of falls in intervention homes than in control homes (incident rate ratio=1.34, 95% confidence interval=1.06-1.72) during the intervention period after adjusting for dependency level (type of home), baseline fall rate, and clustering. There was no difference in the injurious fall incidence rate or incidence of serious injuries. CONCLUSION: This fall-prevention intervention did not reduce falls or injury from falls. Low-intensity intervention may be worse than usual care.     

A randomized trial to reduce the prevalence of depression and self-harm behavior in older primary care patients

PURPOSE

We wanted to determine whether an educational intervention targeting general practitioners reduces the 2-year prevalence of depression and self-harm behavior among their older patients.

METHODS

Our study was a cluster randomized controlled trial conducted between July 2005 and June 2008. We recruited 373 Australian general practitioners and 21,762 of their patients aged 60 years or older. The intervention consisted of a practice audit with personalized automated audit feedback, printed educational material, and 6 monthly educational newsletters delivered over a period of 2 years. Control physicians completed a practice audit but did not receive individualized feedback. They also received 6 monthly newsletters describing the progress of the study, but they were not offered access to the educational material about screening, diagnosis and management of depression, and suicide behavior in later life. The primary outcome was a composite measure of clinically significant depression (Patient Health Questionnaire score ≥10) or self-harm behavior (suicide thoughts or attempt during the previous 12 months). Information about the outcomes of interest was collected at the baseline assessment and again after 12 and 24 months. We used logistic regression models to estimate the effect of the intervention in a complete case analysis and intention-to-treat analysis by imputed chain equations (primary analysis).

RESULTS

Older adults treated by general practitioners assigned to the intervention experienced a 10% (95% CI, 3%–17%) reduction in the odds of depression or self-harm behavior during follow-up compared with older adults treated by control physicians. Post hoc analyses showed that the relative effect of the intervention on depression was not significant (OR = 0.93; 95% CI, 0.83–1.03), but its impact on self-harm behavior over 24 months was (OR = 0.80; 95% CI, 0.68–0.94). The beneficial effect of the intervention was primarily due to the relative reduction of self-harm behavior among older adults who did not report symptoms at baseline. The intervention had no obvious effect in reducing the 24-month prevalence of depression or self-harm behavior in older adults who had symptoms at baseline.

CONCLUSIONS

Practice audit and targeted education of general practitioners reduced the 2-year prevalence of depression and self-harm behavior by 10% compared with control physicians. The intervention had no effect on recovery from depression or self-harm behavior, but it prevented the onset of new cases of self-harm behavior during follow-up. Replication of these results is required before we can confidently recommend the roll-out of such a program into normal clinical practice.     

Dietary protein intake may reduce hospitalisation due to infection in Māori of advanced age: LiLACS NZ

Objective: To investigate factors related to hospital admission for infection, specifically examining nutrient intakes of Māori in advanced age (80+ years). Method: Face‐to‐face interviews with 200 Māori (85 men) to obtain demographic, social and health information. Diagnoses were validated against medical records. Detailed nutritional assessment using the 24‐hour multiple‐pass recall method was collected on two separate days. FOODfiles was used to analyse nutrient intake. National Health Index (NHI) numbers were matched to hospitalisations over a two‐year period (12 months prior and 12 months following dietary assessment). Selected International Classification of Disease (ICD) codes were used to identify admissions related to infection. Results: A total of 18% of participants were hospitalised due to infection, most commonly lower respiratory tract infection. Controlling for age, gender, NZ deprivation index, diabetes, CVD and chronic lung disease, a lower energy‐adjusted protein intake was independently associated with hospitalisation due to infection: OR (95%CI) 1.14 (1.00–1.29), p=0.046. Conclusions: Protein intake may have a protective effect on the nutrition‐related morbidity of older Māori. Improving dietary protein intake is a simple strategy for dietary modification aiming to decrease the risk of infections that lead to hospitalisation and other morbidities.     

Evaluation of a New Zealand program to improve transition of care for older high risk adults

Transition interventions aim to improve care and reduce hospital readmissions but evaluations of these interventions have reported inconsistent results. We report on the evaluation of an intervention implemented in Auckland, New Zealand. Participants were people over the age of 65 who had an acute medical admission and were at high risk of readmission. The intervention included an improved discharge process and nurse telephone follow‐up soon after discharge. Outcomes were 28 day readmission rates and emergency attendances. The study is observational, using both interrupted times series and regression discontinuity designs. 5239 patients were treated over a one year period. There was no change in readmission rates or ED attendances or secondary outcomes. Not all patients received all components of the intervention. This transition intervention was not successful. Possible reasons for this and implications are discussed. Although non‐experimental methods were used, we believe the results are robust.