Zed Med in N. Zed

In the first 10 weeks I've been here I've diagnosed 3 cases of cancer. One woman in her 50's presented with an obvious breast lump, but the other two were elderly patients with colon problems. One gent, who was quite severely in denial, had the classic med school history of "constipation" with altered bowel habit and development of "pencil-thin" stools. The other woman had several episodes of vomiting, one with GI bleeding that sent her to A&E. When I saw her in the office a rectal exam was suspicious for a mass at the very tip of my finger, and colonoscopy confirmed that this week.

By themselves these are routine "bread & butter" cases for family practice, and they cause me, as cancer cases always do, to wonder if they could not have been found earlier. Very few patients here come in for a "well adult" visit- I spend at least 95% of my time in our office dealing with chronic and acute illnesses. But I did print off the "Men-Stay Healthy at Any Age" checklist from the AHRQ, and I've reviewed it with the local doctors here, to use it in the clinic but be consistent with New Zealand guidelines and practice. This was timely, as the New Zealand National Health Committee recently announced a national policy of NOT supporting prostate cancer screening.

This got me thinking about variations in practice. Now W. Edwards Deming, the great efficiency expert, noted that variation in process is a quality issue. Logically, if there is more than one way to do things, it either means that both methods are equally valid, or is an opportunity for study, to discover which method might be "best". (This assumes that you can define "best" in terms of measurable outcomes.)

So in this light, I thought it might be interesting to look at the New Zealand variations of the USPHS guidelines for preventive care. It’s a good opportunity to think about what the USPHS defines as "best", and the reasons for its conclusions. Or at least wonder what the evidence to date is- but that's a question I will come back to after I return home. These variations will provide excellent fodder for teachable moments for years to come- for both my students, and me!
FOR SOME REASON BLOGGER HAS PUT A BUNCH OF BLANK SPACE IN HERE, SO BE SURE TO SCROLL DOWN TO SEE THE TABLE! {I'M TOO TIRED TO DEBUG HTML TONITE- EMAIL ME IF YOU KNOW WHY IT DID THIS...THANKS.}

USPHS Guidelines	New Zealand Practice	Comments:
Cholesterol check every 5 years	Same	The number one killer in NZ is cardiovascular disease, and the population here is very aware of high cholesterol; including knowing the importance of HDL vs LDL levels
Blood Pressure check every  2 years	Same	In contrast, few patients know the numbers for an acceptable blood pressure, and its not a routine Vital Sign on office visits, so this guideline is often not met
Colorectal Cancer Tests: Begin regular screening at age 50	"your doctor will help you decide which  test is right for you"	Almost no patients are having colonoscopy or flex sig tests here unless they have a strong family history.  Interest in stool testing is very low, just as in the U.S.
Prostate Cancer Tests: "Talk to your doctor about the possible benefits and harms of prostate cancer screening if you are considering having a prostate-specific antigen (PSA) test or digital rectal examination (DRE)."	NZ Medical Council recommends against routine screening with any tests	Lots of PSA tests have been done on men in our practice, by past locums and the local physicians.  This is likely to become less common now that the NZMC has recommended against it.
Mammograms Have a mammogram every 1 to 2 years starting at age 40.	Curently mammograms are paid for between ages 50 to 64, yearly.	In near future, the lower limit will drop to 45 years old and the upper limit extend to 70. Its not yet in place..
Pap Smears Have a Pap smear every 1 to 3 years if you have been sexually active or are older than 21.	For screening, only once every 3rd year, ages 20-69.	The nurses are keen on Thin Prep which has been marketed to the practice and is available.  However it costs the patient an extra NZ$23 out of pocket, and I've been discouraging it for low risk patients.
Diabetes Screening  "Have a test to screen for diabetes if you have high blood pressure or high cholesterol."	Same plus must be older than 50.	I have to remember to screen at  younger ages  if obese or Maori or Pacific Islander descent.
Depression "If you've felt "down," sad, or hopeless, and have felt little interest or pleasure in doing things for 2 weeks straight, talk to your doctor about whether he or she can screen you for depression."	Same....,	although a Christchurch professor recently made headlines here when he warned against "overuse of antidepressants" for the "normal ups and downs of life"
Chlamydia and STDs: Women: Have a test for Chlamydia if you are 25 or younger and sexually active. Men: "Talk to your doctor to see whether you should be screened for sexually transmitted diseases, such as HIV."	Same	There seems to be little to no worry here about HIV, to the point of lack of worry about strict blood/body fluid exposure rules.  Patients do not seem very aware of HIV, and the rates in New Zealand are low, with only 160 some people diagnosed last year.
Osteoporosis Tests:  Women Only Have a bone density test at age 65 to screen for osteoporosis (thinning of the bones). If you are between the ages of 60 and 64 and weigh 154 lbs. or less, talk to your doctor about whether you should be tested.	Bone density screening is done based mostly on risk factors.	Alendronate can only be subsidized if patients meet strict criteria of having low DEXA values + a fracture.  Calcium and cyclical etidronate are subsidized without jumping through hoops.
Immunizations: "Stay up-to-date with your immunizations: Have a flu shot every year starting at age 50. Have a tetanus-diphtheria shot every 10 years. Have a pneumonia shot once at age 65. Talk to your doctor to see whether you need hepatitis B shots."	Flu shots are given every autumn (thats NOW, April, here).	We do not give routine or preventive pneumonia vaccine in either children or adults.  I'm not sure why our office doesn't do it, but it might be a funding issue, because they are not on the New Zealand routine immunization schedule.. The nurses just say its not available here. Its not in the Pharmac schedule. One of those things to ask about.