Published: 1st November, 2024
Contents
New from bpacnz: Recovery at Work: Reframing the conversation
We are pleased to announce the launch of a major bpacnz programme on supporting clinicians to help patients navigate the ACC Recovery at Work process. This initiative promotes the benefits of returning people to their work after an injury, ensuring best outcomes for their overall health and wellbeing.
Workplace reintegration is an important milestone following injury, and unnecessary delays can adversely affect patient outcomes. However, evidence suggests that many injured patients are being signed off work for too long. The reasons for this are multifactorial, and addressing the barriers to returning to work involves a co-ordinated effort from the patient, the clinicians and other health providers involved in their care, their workplace and ACC.
In keeping with the principles of rational medicine use, if time off work is required following injury, “prescribe” it at an appropriate dose, frequency and duration. Just as prescribing too much medicine can lead to harm, prescribing too much time off work can detrimentally affect health, vocational and social outcomes, without providing any added benefit to recovery.
We have identified several key shifts in thinking that need to occur:
- The role of the clinician is to assess the physical and cognitive capabilities of the patient after an injury, and identify what functions they can perform, and at what intensity and duration: you are writing a “fit note”, rather than a “sick note”
- Applying these functional limitations to the context of the patient’s employment, and setting specific work tasks and hours is the responsibility of the employer and employee, with support from ACC if required: the clinician does not need to determine if there are suitable work tasks available
- There are three definitions of work certification:
- Fully unfit – the patient has a total inability to work because they are admitted to hospital/confined to bed, there is an infection risk due to the nature of their injury and their work environment, or they pose a specific health and safety risk that cannot be overcome with modifications to their tasks or workplace (e.g. require strong analgesia)
- Fit for selected work – the patient can engage in some level of work with amended duties and/or hours and modifications to their workplace
- Fully fit – the patient can perform their normal work duties and hours
- After an appropriate period of rest, most people should be classified as “Fit for selected work” as they recover– this is based on their functional capacity
- If a patient is classified as “Fit for selected work” and after discussion with their employer there are no suitable work tasks available, they still receive full support from ACC
- Patients do not need to be “Fully unfit” to be eligible for ACC compensation; those certified as “Fully unfit” can receive 80% of their pre-injury income and those certified as “Fit for selected work” can receive up to 100% of their income via a combination of work-related income topped up with ACC compensation (up to 80%)
For an overview of the “Recovery at Work” initiative, and to explore these points in more detail, we invite you to browse our comprehensive guide for primary care clinicians. Read about considerations when conducting an initial medical certification consultation, medical certificate definitions, as well as the ACC-mediated supports available if further assistance is required.
A B-QuiCK summary of key clinical points is available here.
We will be releasing further additions to this resource in the coming months, including CPD activities and a panel discussion. We acknowledge that there can sometimes be frustrations when working through the ACC Recovery at Work process with patients. This is an opportunity to explore all aspects of the framework and seek answers where clarification is needed. We encourage readers to send feedback so we can incorporate this in our development. Email: editor@bpac.org.nz
In case you missed it – Smoking cessation: supporting patients to break the cycle
Smoking rates are declining in New Zealand, but there are still certain groups who require extra support to become smokefree. The Ask, Brief advice, Cessation support framework is the recommended tool for primary care clinicians. Nicotine replacement therapy is usually the most appropriate smoking cessation medicine to trial first, and it is also suitable for patients who want to reduce the amount they smoke. A key factor is to ensure patients are using enough NRT; combination treatment is often the most effective approach.
For a comprehensive guide to supporting patients to quit smoking, read the full article here. A B-QuiCK summary and Clinical Audit are also available.
A national vaping cessation guideline supported by Te Whatu Ora, Health New Zealand, is now available. The guideline follows the Ask, Brief advice, Cessation support framework: the ABCs of vaping cessation and the ABCs of vaping to stop smoking.
MedSafetyWeek 2024: 4th – 10th November
The ninth annual #MedSafetyWeek is being held next week from the 4th – 10th of November. This campaign is supported by medicine regulators and stakeholders across the world, and aims to raise awareness of reporting suspected adverse medicine reactions. This year’s focus is on preventing adverse effects of medicines. Look out for the campaign on social media next week; we will be joining in, so follow, like and share!
When prescribing or dispensing a medicine, ensure patients understand how to take it to reduce the risk of adverse effects, and that they know what potential adverse effects may occur, including when to report a suspected adverse reaction to their prescriber or pharmacist.
Suspected adverse effects to medicines and vaccines can be reported to the Centre for Adverse Reactions Monitoring (CARM) or directly via your practice management software.
A patient information sheet about medicines and adverse effects is available from Healthify here.
Medicine supply news: contraceptives, ezetimibe, rivastigmine, levomepromazine
The following news relating to medicine supply, of particular interest to primary care, has recently been announced. These items are selected based on their relevance to primary care and where issues for patients are anticipated, e.g. no alternative medicine available or changing to the alternative presents issues. Information about medicine supply is available in the New Zealand Formulary at the top of the individual monograph for any affected medicine and summarised here.
IUD supply issue ongoing + new brands of oral contraceptives Medsafe approved
Copper IUDs. Stock of the two replacement copper IUDs, Cu 375 Standard and TCu 380 Plus Normal, that were recently listed is now limited due to high demand. Pharmac is asking that these products only be ordered as needed. Shipments are due to arrive mid-December; it is hoped that stock should last until then for the Cu 375 Standard, however, TCu 380 Plus Normal IUD may be briefly out of stock before the new shipment arrives.
Norethisterone-containing oral contraceptives. There is an ongoing supply issue affecting stock of norethisterone-containing oral contraceptives, i.e. Brevinor 1/28, Norimin and Noriday 28 (as reported in Bulletins 105 and 106).
The alternative brands of Brevinor 1/28: Alyacen 1/35 (funded since October, 2024) and Noriday 28: Norethindrone* Tablets USP (funded since September, 2024), have now been approved by Medsafe, and can be prescribed by any relevant practitioner. There is currently no alternative brand listed for Norimin. Supply of Brevinor 1/28 and Noriday 28 is expected to return to normal by the end of 2024.
* Norethisterone is known as norethindrone in the USA
Ezetimibe temporarily moved to monthly dispensing
Dispensing of ezetimibe (for hypercholesterolaemia) has been temporarily switched to monthly. Ezetimibe Viatris was listed as an alternative to Ezetimibe Sandoz from March, 2024, due to an ongoing supply issue, but stock of this brand (Viatris) is now low. Stat dispensing is expected to resume once new stock of Ezetimibe Sandoz arrives early next year.
Rivastigmine patches still in short supply
Supply issues affecting stock of Rivastigmine BNM patches (for dementia) remain ongoing (as reported in Bulletins 83 and 101). Rivastigmine Patch 4.6 mg/24 hours (BNM 5) is now out of stock; Novartis Exelon Patch 5 is available as an alternative (Section 29). This supply issue also affects Rivastigmine Patch 9.5 mg/24 hours (BNM 10), however, Pharmac advise that limited quantities of an alternative brand (Exelon Patch 10; Section 29) are available. Resupply for both patch strengths is expected in December, 2024.
Levomepromazine injections possible supply issue
Pharmac is warning of a potential supply issue affecting levomepromazine hydrochloride (previously known as methotrimeprazine) injection 25 mg/1 mL ampoules (Wockhardt), indicated for the management of nausea and vomiting and agitation or distress in palliative care/last days of life. There is no alternative injection product at this stage. Resupply is expected by mid-November, 2024.
For further information on the use of levomepromazine when managing symptoms in the last days of life, see: https://bpac.org.nz/2023/last-days-of-life/nausea.aspx and https://bpac.org.nz/2023/last-days-of-life/delirium.aspx
Proposal to widen access to denosumab for osteoporosis
Pharmac is seeking feedback on a proposal to widen access to denosumab (Prolia, 60 mg/mL, 1 mL pre-filled syringe) for patients with osteoporosis who meet Special Authority criteria. Consultation closes 5 pm Thursday, 14th November. An associated press release is available here.
It is proposed that from 1st March, 2025, access to denosumab (Prolia) will be widened to include patients with a contraindication to other funded bisphosphonates or who have experienced an inadequate response or intolerance to them. Full criteria can be found here.
Also included in the consultation is a proposal to widen access to denosumab (Xgeva, 70 mg/mL, 1.7 mL vial) from 1st February, 2025, for patients with hypercalcaemia of malignancy who also have severe renal impairment.
N.B. Osteoporosis is an approved indication for the Prolia brand of denosumab, and hypercalcaemia is an approved indication for the Xgeva brand.
For further information on bisphosphonates, see: https://bpac.org.nz/2019/bisphosphonates.aspx
NZF updates for November
Significant changes to the NZF in the November, 2024, release include:
You can read about all the changes in the November release here. Also read about significant changes to the NZF for Children (NZFC), here, including the addition of two new sections on pain control and a change to the dosing regimen for cefalexin.
HPV vaccination remains a priority
HPV vaccination with Gardasil 9 is recommended for all females and males ideally before the onset of sexual activity, and is funded for eligible people aged 9 – 26 years inclusive. School immunisation programmes and general practices generally offer HPV vaccination to students in Year Eight (around age 12 years). Coverage needs to be 75 – 80% to achieve herd immunity. Latest data show that vaccine coverage is well below target and rates are lower compared to last year.
Read more:
The HPV immunisation programme was introduced in 2008. The complete vaccination rate among the eligible population (including males) born in 2011 (latest birth cohort available; data up to June, 2024) was 43.8%; 65.4% of people had received one dose. Vaccination rates were highest among Asian peoples (complete: 47.1%; one dose: 70.5%), followed by Other (complete: 46.6%; one dose: 67.7%), Pacific peoples (complete: 39.7%; one dose: 62.4%) and Māori (complete: 37.2%; one dose: 57.9%). This is a reduction in vaccination rates compared to previous birth cohorts, e.g. HPV immunisation coverage of the 2009 birth cohort (data up to December, 2023) was 54% for complete coverage and 69.2% for one dose.
The low HPV vaccination rate in New Zealand was recently highlighted in a report published by the Head and Neck Foundation Aotearoa about HPV-related cancers. The report also raised the importance of HPV vaccination in reducing the incidence of most cervical cancers, anogenital and oropharyngeal cancers.
Is your patient population up to date with HPV vaccinations? This is a timely reminder to opportunistically check whether eligible patients are up to date with HPV vaccination and to offer vaccination where appropriate. Some children may have missed their scheduled vaccine during the last few years, due to the COVID-19 pandemic and lockdowns. A Clinical Audit is available on sexual health checks in younger males, which includes checking the HPV vaccination status of these patients.
For further information on HPV vaccination, see: https://bpac.org.nz/2019/hpv.aspx
Also opportunistically check whether eligible patients are up to date with cervical screening
The latest data from the National Cervical Screening Programme show an increase in cervical screening of almost 5% since HPV testing was introduced in September, 2023; the overall coverage rate was 67% in September, 2023, increasing to 71.6% in September, 2024 (the highest rate since 2018). HPV testing appears to have increased participation in cervical screening; however, the target is for 80% screening coverage for eligible females and so continued efforts are needed to increase uptake. A Clinical Audit is available for identifying patients who are not participating in regular cervical screening.
For further information on HPV primary screening, see: https://www.tewhatuora.govt.nz/health-services-and-programmes/ncsp-hpv-screening/understand-hpv-primary-screening/
A brief guide to HPV testing is also available from bpacnz, here.
Accelerated registration pathway for overseas doctors
The Medical Council of New Zealand has announced that an expedited registration pathway for international medical graduates will be available from today (1st November), following consultation on a proposal in June (as reported in Bulletin 102).
Overseas medical graduates who have completed postgraduate medical training in certain specialities in the United Kingdom, Ireland and Australia who have worked for at least two years in the past five years in a comparable health system are eligible to apply for fast-track registration. The relevant specialities include anaesthesia, dermatology, emergency medicine, general practice, internal medicine, anatomical pathology and psychiatry.
Further information, including how to apply, is available here.
The Medical Council has also recently published the 2024 Workforce Survey. Read the full report here. A media release about the report is also available here.
New version of the Immunisation Handbook released
The latest version of the Immunisation Handbook 2024 (Version 6) has been released. Key updates include a new chapter on mpox and vaccine brand changes (Varilrix and Act-HIB, replacing Varivax and Hiberix). Click here to view a summary of all the changes for this release.
Reminder: Mpox vaccination
A vaccine for mpox is available for eligible people (see below) at registered clinics. The vaccine was granted provisional approval by Medsafe in September, 2024. Two doses of the vaccine are required for full protection, administered at least 28 days apart (can be up to two years after the first dose).
Mpox pre-exposure vaccination is recommended for those at high risk of exposure to the mpox virus including:
- People whose occupation might put them at increased risk of mpox, e.g. some laboratory or healthcare workers, sex workers
- Gay, bisexual and other men who have sex with men, transgender and non-binary people with a recent sexually transmitted disease diagnosis, who have multiple sexual partners or have sex at a commercial venue or event where mpox transmission could occur
- Sexual partners of anyone at risk of mpox infection
- People recommended by a clinician to be vaccinated in the event of an mpox outbreak
- Close physical contacts of people infected with mpox, e.g. sexual partners, members of the same household
For close contacts of people infected, the vaccine is most effective if administered within four days of exposure, but it can be administered up to 14 days after.
The mpox vaccine is not approved for use in anyone aged under 18 years, however, it is highly recommended for those who meet the above eligibility criteria. In this situation, the vaccine needs to be prescribed, and the patient’s consent recorded in their notes.
For further information, see: https://www.tewhatuora.govt.nz/for-health-professionals/clinical-guidance/immunisation-handbook/14-mpox
Upcoming Goodfellow Unit webinars
The Goodfellow Unit, University of Auckland, is hosting several free access webinars in the coming months. These webinars are intended to provide topical and relevant health information for primary care clinicians. Continuing professional development (CPD) points are also available. Webinars are often recorded and available to watch at a later date. Upcoming webinars include:
- Optimising hormone therapy: the role of transdermal oestrogen gel, and the broader role of female hormones, presented by Dr Samantha Newman. The webinar will be held on Tuesday, 12th November from 7.30 pm. Click here to register.
- Tacrolimus use in moderate to severe eczema, presented by Dr George Moncrieff. The webinar will be held on Tuesday, 19th November from 7.30 pm. Click here to register.
- Enhancing patient outcomes: self-management support and atrial fibrillation, a Te Whatu Ora; Te Tiri Whakāro: Sharing Knowledge session on improving patient outcomes in long-term conditions, presented by Dr Janine Bycroft, Dr Frances King and Dr Alan Davis. The webinar will be held on Tuesday, 26th November from 7.30 pm. Click here to register.
- First presentation inflammatory arthritis, optimising patient outcomes, presented by Dr Rebecca Grainger. The webinar will be held on Tuesday, 3rd December from 7.30 pm. Click here to register.
- “Today I noticed”, an invitation to pause, observe and then record some of the tiny moments of daily life that often slip by unnoticed, presented by Willow Older and Deborah Huber. The webinar will be held on Tuesday, 10th December from 7.30 pm. Click here to register.
Podcast of the Week: Fertility management in primary care
Subfertility and infertility are becoming more common over time, and often the first point of contact for people experiencing difficulty with conception is with their general practice. Older age at conception, PCOS and endometriosis are the most predominant causes of subfertility and infertility in females. An increasing cause in males is testosterone misuse.
A recent episode of The Good GP, an Australian podcast series, discusses fertility management advice that primary care clinicians can discuss with patients. Some of the treatments discussed are not routinely recommended or available in New Zealand, or are only offered in a specialist fertility clinic. However, the podcast still provides practical advice for primary care clinicians to apply to patients in New Zealand.
Brief pre-conception care advice
- Begin with a review of aspects of health (for both partners) that may have an impact on fertility and pregnancy, e.g. smoking cessation, alcohol and drug use, weight, diet, long-term conditions, medicines, environmental exposures and psychosocial issues
- Discuss what normal fertility is, including realistic expectations of time to achieve pregnancy, fertile phase of the menstrual cycle
- Check immunity status, including rubella and varicella
- Ensure that cervical screening is up to date and consider if a STI check is required (for both partners)
- Discussion about recommended nutritional requirements during pre-conception, including folic acid (a supplement should be prescribed), iodine, vitamin D and iron (a multivitamin may be considered; ensure components are at recommended levels, and particularly that vitamin A does not exceed 10,000 IU/day [3,000 micrograms])
- What to do and where to attend if pregnancy is suspected
- When to seek further advice and referral if pregnancy is not achieved; this advice is dependent on the female’s age and other clinical considerations from their history
For further information on pre-conception care, including a suggested format of a pre-conception consultation, see: https://bpac.org.nz/bpj/2011/april/preconception.aspx N.B. Some of the information in this article is no longer current, e.g. folic acid fortification of flour is now in place in New Zealand.
Listen to the podcast here (25 minutes)
Paper of the Week: “Your results will be available online…”
The introduction of patient portals that allow online access to health records and test results (e.g. Manage My Health) has increased ownership of personal health information. This access, however, can also present problems when communicating test results. For example, some people may not have the digital skills required to operate a patient portal or the health literacy to interpret test results in the format they are presented (e.g. understanding medical terminology, reference ranges, clinical relevance). For the clinician, an online system of delivering results can save time, but it may increase workload in other ways, e.g. acknowledging normal results before they are released, patients seeking more information or further investigations based on perceived concerns with their results. There are also scenarios where it is not appropriate for a patient to self-check their results without clinical support.
A systematic review published in the British Journal of General Practice evaluated and appraised the available evidence on blood test result communication in primary care. Both patient and clinician opinions varied on how and when patients should access test results and the methods for communicating those results. Generally, online portals and text message notification of normal results were acceptable for most patients, whereas notification in person or via phone call was preferred for abnormal or sensitive results, or when the results need to be actioned, e.g. follow-up testing, dose adjustment. The practical takeaways from this study are limited but it prompts an important discussion about clinician (and patient) responsibilities around notification of test results.
Reflection questions
- What is your practice policy when notifying patients about normal results? Do you regularly ask how your patients prefer to receive their test results?
- Have you received any feedback from patients regarding the availability of their test results or the useability of patient portals? If so, has the feedback been positive or negative?
- What methods do you use to communicate abnormal test results to patients? Does the method differ between expected and unexpected abnormal results?
- How does your practice manage notification of test results when the clinician who arranged the test(s) is not available? Do you perform “hand-overs” before a clinician leaves on a planned absence to alert whoever is taking responsibility to possible abnormal test results? If so, do you discuss preferred notification methods?
Study summary
Patient viewpoints:
- Most found online access and text notification involving normal test results acceptable
- Online notifications via patient portals often contain limited information outside the numerical results. Some patients wanted more of an explanation (e.g. “what happens next?”), especially if the results were abnormal. This could increase the clinician’s workload (if they are directly contacted by the patient), or patients choosing other sources of health information, e.g. friends and family, the internet.
- Opinions varied regarding online access to sensitive results, although this could be considered acceptable if there were delays in discussing results with a clinician
- Early communication of test results was preferred, particularly in those with higher health literacy. Setting expectations regarding likely turnaround times for test results may help to avoid anxiety and frustration associated with longer wait times.
Clinician viewpoints:
- Passive communication such as text notifications and email were acceptable for normal test results. Interactive communication (i.e. in person or over the phone notification) was preferred when test results required actioning, e.g. arranging follow-up testing, dose adjustments.
- There were mixed opinions on the automatic release of normal test results; it was acceptable to some, while others were worried about increased patient anxiety and clinician workload
- Clinician opinions on the benefits of providing links to further information with test results were also variable. Some clinicians questioned the usefulness of it given the availability of information online, however, this must be balanced against the patient’s ability to locate and interpret that information.
- Receiving test results at different times and having to communicate these individually to the patient instead of all at once increased clinician workload. Waiting until all test results have been received (if appropriate) before notifying the patient could address this concern.
Conclusions:
- The use of online portals and text messages are not sufficient alone to communicate test results and their implications; multiple communication methods are often required, and their suitability depends on both medical clinic policies and the needs of the individual patient
- Primary care practices should have established protocols and policies for communicating test results and patients should be made aware of them when tests are ordered
- A discussion regarding a patient’s preferred communication method may be beneficial to improve patient-centred care and the clinician-patient relationship
Nankervis H, Huntley A, Whiting P, et al. Communicating blood test results in primary care: a mixed methods systematic review. Br J Gen Pract 2024;:BJGP.2024.0338. doi:10.3399/BJGP.2024.0338.
For further reading, see:
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