Massey University, Auckland, Aotearoa, New Zealand.
La Trobe University, Bendigo, Australia.
Int J Equity Health. 2024 Oct 4;23(1):198. doi: 10.1186/s12939-024-02288-z.
Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes.
We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics.
Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree.
Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.
在新西兰的发病率和死亡率统计数据中，毛利人（Māori）的比例过高。其他健康需求较高的人群包括太平洋岛民（Pacific peoples）和生活贫困的人群。全科医生已经发展成七种初级保健模式：传统模式、公司模式、医疗保健之家模式、毛利模式、太平洋模式、信托/非政府组织模式（Trust/NGOs）和地区卫生局/初级保健组织模式（DHB/PHO）。我们描述了护士在这些护理模式、高健康需求人群和患者健康结果方面的工作。
我们对国家数据集和患者层面的实践数据进行了横断面研究（截至 2018 年 9 月 30 日）。选择了六个主要的结果衡量指标，因为它们可以通过初级保健来改善：（患者）用药过多（≥65 岁）、成年人糖尿病血糖控制检测、免疫接种（6 个月时）、（0-14 岁、45-64 岁）门诊敏感住院治疗和急诊就诊。分析调整了患者和实践特征。
信托/非政府组织、毛利和太平洋实践中的护士临床时间以及护士、护士从业者和全科医生的综合临床时间都大大高于其他模式。患者临床复杂性的增加与所有结果衡量指标的更多临床投入和更高分数有关。护士进行的预防性护理（宫颈癌筛查、心血管风险评估、抑郁筛查、血糖控制检测）率最高的是毛利、信托/非政府组织和太平洋实践。在护理模式中，护士进行抑郁筛查的比例相差八倍，宫颈癌筛查和血糖控制检测的比例相差五倍。在 PHO/DHB、太平洋、信托/非政府组织和毛利实践中，护士在下班后和为未注册患者提供的咨询量最高，从而改善了获得护理的机会。在实践记录中未归因于护士的工作意味着护士的工作被低估到未知程度。
将工作转移到传统、医疗保健之家和公司实践中的护士手中，可以为全科医生腾出更多的临床时间来处理其他工作。患者健康结果较差与较高的患者需求和较高的临床投入有关。可能是临床投入不足，无法满足患者需求的程度。需要更多的从业者临床时间，尤其是在有大量复杂患者的实践中。
