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Biomedical subjects

M Tilyard

Publications and source records attributed to M Tilyard.

15 recordsLinked to original sources
PubMed1998

Comparison of potency of inhaled beclomethasone and budesonide in New Zealand: retrospective study of computerised general practice records.

OBJECTIVE: To determine whether inhaled budesonide and beclomethasone are equipotent in the treatment of asthma in primary care. DESIGN: Retrospective study of computerised clinical records from 28 general practices in New Zealand. SUBJECTS: 5930 patients who received 16 725 prescriptions for inhaled budesonide or beclomethasone from 1 July 1994 to 30 June 1995. SETTING: General practices on the database of the Royal New Zealand College of General Practitioners Research Unit. Linked information from secondary care was available for a subset of the practices. MAIN OUTCOME MEASURE: Mean prescribed daily inhaled corticosteroid dose. RESULTS: The daily prescribed dose was higher for patients receiving inhaled budesonide (mean 979 microg) than beclomethasone (mean 635 microg), a difference of 344 microg (95% confidence interval 313 to 376 microg). This difference was consistent in all age bands and with different types of inhalation device. Evidence of systematic prescribing of higher doses of budesonide to patients with more severe asthma was not found. CONCLUSIONS: In primary care in New Zealand evidence suggests that budesonide is less potent than beclomethasone. Consideration of validated, established, and other possible markers of asthma severity did not support confounding by severity as a reason for the higher prescribed doses of budesonide. Pending further epidemiological evaluation, international asthma guidelines may need to be modified on the equivalence of inhaled corticosteroid doses. Furthermore, the comparative potency of newly developed inhaled steroids in clinical trials will need to be confirmed in appropriately designed epidemiological studies based in general practice.

Administration, Inhalation↗
PubMed1996

General practitioners' opinions of continence care training.

AIMS: To examine general practitioners' confidence in the diagnosis and management of urinary incontinence, to define their unmet continence training and educational needs, and to evaluate the current provision of continence care in general practice, including the role of practice nurses. METHODS: A pre-tested postal questionnaire was sent to 600 general practitioners throughout New Zealand to obtain information about their demography and training in incontinence management, their confidence in diagnosis and treatment, and their perceptions of met and unmet educational needs in continence care. They were also asked about current provision of continence promotion in their practice and their views on the role of practice nurses in caring for incontinent patients. Confidence data were recorded on five point scales and analysed using chi square tests. Cluster analysis was used to describe groups with different opinions on practice nurses' roles. RESULTS: The response rate from eligible contacts was 81.3%. Although most respondents provide continence care, only 2.6% offered special clinics for continence promotion. Fewer than half felt confident to diagnose the causes of incontinence. Confidence in managing incontinence in children was consistently lower than for other incontinence presentations. There was no difference by sex in confidence in caring for incontinent patients although female respondents were more likely to consider management of continence care part of a practice nurse's role (chi 2 = 47.5, p < 0.01) and to routinely ask well women about incontinence (chi 2 = 243.6, p < 0.01). Most respondents (71.9%) could not remember having had any formal training in the management of incontinence at either undergraduate or postgraduate level. Recall of postgraduate education was associated with greater levels of confidence in management of continence problems. There was general agreement that it was appropriate to include training in continence management in vocational and continuing medical education. CONCLUSION: A substantial proportion of general practitioners perceive a lack of adequate medical training in incontinence care at both undergraduate and postgraduate levels. There is a need for improved education for both general practitioners and practice nurses.

Adult↗
PubMed1996

Pravastatin and risk factor modification in patients with moderate primary hypercholesterolaemia.

AIM: To evaluate the efficacy and safety of pravastatin 20mg at night, versus placebo, in combination with dietary, smoking cessation, and other lifestyle advice in general practice. METHODS: This was a multicentre, randomised double blind placebo controlled trial carried out in thirty general practices in three New Zealand centres. Patients with moderate primary hypercholesterolaemia (5.2-6.7 mmol/L) and two or more risk factors for coronary heart disease were enrolled. After a minimum of 6 weeks lifestyle changes, 95 patients (aged 18-70 years) were randomised to active or placebo therapy. They continued to receive advice and encouragement in maintaining dietary, exercise or smoking cessation changes. RESULTS: Seventy eight patients, pravastatin (n = 39) and placebo (n = 39), completed the treatment phase of the study. After 6 weeks on 20 mg pravastatin, total cholesterol decreased by 18% (0.9 mmol/L, p < 0.0001), triglycerides decreased by 6% (0.1 mmol/L ns), LDL-cholesterol decreased by 23% (1.1 mmol/L, p < 0.0001), and HDL-cholesterol increased by 8% (0.1 mmol/L, ns). A similar effect was also observed after 26 weeks of therapy. These effects were also significant when compared with the placebo group. In 61% of patients treated with pravastatin there was a reduction in cholesterol to less than 5.2 mmol/L, and no real change in lipid levels in patients receiving placebo. No significant differences were observed between the active and placebo groups with regard to patient withdrawal, compliance, or adverse reactions. CONCLUSIONS: In general practice pravastatin is a well tolerated and safe drug that induces a favourable effect on lipid profile in patients with primary moderate hypercholesterolaemia and two or more other risk factors for coronary artery disease.

Adolescent↗
PubMed1996

Trends in antihypertensive prescribing.

AIM: To identify trends in the prescribing of antihypertensive medications and measure the changes in government and patient expenditure resulting from any identified change. METHODS: The computerised records of 16 069 patients from six Otago practices from 1991-3 were examined. Those patients prescribed any antihypertensive medication in all 3 years were selected for investigation. The antihypertensives prescribed were assigned to one of seven classes. The cohort was then divided into two groups; those remaining on the same class of medication for the three years and those changing medication class at any stage. Reasons for any change were identified. The direct costs of the prescribing decisions taken were evaluated. RESULTS: 914 patients were prescribed antihypertensive in all 3 years. Of these 579 (63.3%) remained on the same class of medication, while 335 (36.7%) changed class. A clinical reason was identified for medication change class. A clinical reason was identified for medication change in 98% of cases available for examination. There was no significant shift in expenditure for those remaining on the same medication, while costs for those remaining on the same medication, while costs increased by 20.6% for those changing. CONCLUSION: For this cohort increased expenditure on antihypertensive was driven by those changing medication. Although these changes were prompted by clinical reasons, better health outcomes for patients cannot be assumed due to lack of objective indicators.

Adult↗
PubMed1995

Delivery of hepatitis B immunisations in a selection of computerised general practices.

AIM: To assess the value of computerised general practices in providing information concerning the delivery of hepatitis B immunisation. METHODS: Hepatitis B immunisation data from August 1990 to June 1991 were collected from 27 general practices participating in a sentinel network. RESULTS: The study identified significant limitations in the use of data from computerised general practices for estimating hepatitis B immunisation coverage. While an accurate coverage figure could not be estimated, the results did suggest that hepatitis B coverage for three doses was at least 59.5% and that its use was very similar to the triple vaccine and measles/MMR for the third dose. Hepatitis B immunisation delivery outside the desirable time periods was common at 44%, suggesting a fairly disrupted immunisation schedule for many children. CONCLUSIONS: The relatively infrequent delivery of hepatitis B vaccine at the same time as other vaccinations may reflect provider concern about administering multiple injections at the same visit. Further improvement in the collection of data by computerised practices is necessary before the full value of this data source can be realised. Improvements in reminder/recall systems would improve the efficiency with which hepatitis B immunisation is delivered.

Child, Preschool↗
PubMed1995

Antibiotic use in upper respiratory tract infections in New Zealand.

Upper respiratory tract infections (URTIs) are a common reason for presentation to general practitioners. The current study used computerised consultation records of 100,222 patients from 17 general practices in New Zealand for the 12-month period 1 July 1991-30 June 1992. URTIs were noted in 8.9% of all consultations: 44.1% of cases were children aged less than 10 years. Females presented more frequently than males for all ages above five years. Fifteen different antibiotics were prescribed for URTIs, but in 22.5% of cases no antibiotic was prescribed. There was no statistically significant difference in the likelihood of a successful outcome with or without antibiotic therapy (chi 2 = 0.76, P > 0.05). The treatment failure profile of some antibiotics highlights the need for more prescriber education, especially as the range of medications available for general practitioner prescribing increases.

Adolescent↗
PubMed1994

The recognition and management of melanoma and other skin lesions by general practitioners in New Zealand.

AIM: To assess current levels of knowledge and management practices with respect to melanoma and other skin cancers, in a representative sample of New Zealand general practitioners. METHODS: A self-administered questionnaire was sent to a random sample of 900 general practitioners. The questionnaire included 12 cases with coloured photographs of skin lesions and a brief presenting history. Responders were asked to assess probable diagnosis, need for biopsy and management of the lesion. Other attitudinal and relevant background information was also gathered. The questionnaire was sent to a comparison sample of 35 dermatologists. RESULTS: The overall response rate was 66% among the general practitioners and 68% among the dermatologists. The sample responding was representative of the larger population of doctors practising in New Zealand. Correct decisions whether or not to biopsy lesions (mean score of 10.1 out of 12) were significantly higher than the number of correct diagnoses (mean 8.4). Correct identification and recognition of the need to biopsy melanomas was high. Diagnostic skills and recognition of the need for biopsy were somewhat lower among general practitioners aged 50 years and over than among younger doctors. Doctors who had experience of a patient with melanoma had higher diagnostic skills and made more correct biopsy decisions. The general practitioners' scores for correct biopsy decisions were similar to those of the dermatologists sampled, although their diagnostic skills were somewhat lower, particularly with respect to nonmelanoma skin cancers. CONCLUSION: The findings indicate a high level of expertise in terms of diagnosis of skin lesions and identification of need to biopsy suspicious lesions among general practitioners in this country.

Clinical Competence↗
PubMed1993

The economics of smoking: an overview of the international and New Zealand literature.

The majority of work to date on the costs of smoking has focused on the enumeration of direct medical care costs. Published estimates of excess medical care expenditure attributable to smoking range from $US54 to $US1058 per smoker per year (1990 prices). Most of these studies used a cross-sectional approach to costing, however consensus increasingly favours the 'life cycle' approach to estimating the costs of cigarette smoking. The life cycle approach to costing consists of tracking all expenditures associated with smoking over the individual's lifetime. The purpose of taking this approach is to separate out the opposite impacts on medical care expenditures of higher utilisation and higher mortality. Thus, in a cross-sectional costing approach, smokers always appear to incur higher medical care costs. Using the 'life cycle' methodology, however, some of the higher medical care costs of smokers are offset by their shorter life expectancy. The policy question is whether smoking is associated with higher healthcare expenditures over the lifetime. The conclusion from studies that have adopted the 'life cycle' approach have been inconsistent. One of the earliest studies, based on Swiss data, concluded that the lifetime medical care costs for a cohort of nonsmokers was equivalent to the costs of providing care for a society of smokers. This conclusion was based on the finding that nonsmokers lived longer than smokers and used medical services more heavily during the last years of their lives.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMed1992

The costs of smoking revisited.

AIMS: a previous study of the cost of smoking to the New Zealand health services estimated that the excess hospital resource use generated by smoking amounted to $81 million in 1986 dollars. The present study refined and updated the figures for hospital resource use, and extended the costing exercise to include aspects of primary health care. METHODS: excess hospital costs attributable to smoking were estimated from the 1987 national hospital discharge data (both public and private hospitals), and figures obtained from the Otago resource utilisation system (RUS). The costs of excess prescription medicines use and general practitioner consultations were estimated from existing data sources. RESULTS: the excess hospital costs attributable to smoking totalled $128.3 million. A further $37.8 million was consumed in excess prescription medicines use, plus $19.3 million in general practitioner consultations. The total cost to the health services of cigarette smoking was therefore conservatively estimated at $185.4 million (in 1989 dollars). CONCLUSIONS: previous estimates substantially underestimate the external costs imposed by smoking. The figure of $185.4 million contrasts with the $7.5 million of sponsorship support which the tobacco industry is estimated to provide for New Zealand sports. Politicians who intend to repeal Part 2 of the Smokefree Environments Act (1990) should consider these external costs imposed on society by cigarette smoking.

Adult↗
PubMed1990

Low-dose calcitriol versus calcium in established postmenopausal osteoporosis.

An ongoing randomized clinical trial of 3 years duration is being undertaken to evaluate the recurrent fracture rate and safety profile associated with low-dose calcitriol versus calcium supplementation in women with at least 3 years postmenopausal osteoporosis who are under the age of 80 years. A total of 856 patients were submitted for possible inclusion in the study by 123 primary care physicians, and 636 met all entry requirements. Each patient was randomly allocated to receive either 0.25 micrograms of calcitriol twice daily or calcium supplementation of 1,000 mg/d. If significant hypercalcemia developed (greater than 2.6 mmol/L) or a deterioration in renal function was observed, the dose of trial medication was to be halved or stopped if laboratory values did not return to normal. Patients were given no specific instructions regarding dietary calcium intake. To date, 528 patient-years experience with calcitriol and 527 patient-years experience with calcium the calcium supplementation have been accumulated. Thus far, low-dose calcitriol has not been observed to cause hypercalcemia, deterioration in renal function, or nephrocalcinosis. At 1 year, a loss in total anterior height (P less than .05) has been detected in the calcium-treated group compared with the calcitriol-treated group. Thus, calcitriol appears to preserve spinal height. Long-term follow-up of all patients for 2 or 3 years will be continued.

Aged↗