August 2021 Clinical Snippets

Summary

Dr Dave Maplesden and Dr Jo Scott-Jones discuss “snippets” of information that are important for general practice in New Zealand. 

This month Acc consent, the end of life choice act, a new statin, acute coronary syndrome in women 

A video version of this podcast is available on the Pinnacle Practices website here https://www.pinnaclepractices.co.nz/resources/clinical-zoom-meeting-snippets-august-2021/ 

Shownotes

Clinical Snippets – August 2021

1.  ACC Consent

You no longer need to record and maintain a patient’s signature when you lodge a claim with ACC. Instead, you can record their consent in their clinical record. 

To confirm consent, you need to read these statements to your patient (or an authorised representative), and note their response: 

• Do you declare that you have provided true and correct information and you’ll tell ACC if your situation changes?
• Do you authorise me as your (name of health profession: GP, physiotherapist, etc) to lodge your claim with ACC?
• Do you authorise your records to be collected or disclosed to ACC to help determine cover for your claim, determine what you’ll be entitled to, or for research purposes (such as injury prevention, or assessment, and rehabilitation)?

2.  Childhood Eczema Resources

BPAC has recently published an update on managing childhood eczema.  Information includes:

• The funded brand of emulsifying ointment is now sodium lauryl sulphate-free which means it can be used as a leave-on emollient as well as a soap substitute.  Following a skin infection, discard the current tub of emollient and replace with a new tub.

• Use the lowest potency topical corticosteroid needed to control the patient’s symptoms; avoid the term “use sparingly” and encourage appropriate use.  For children with frequent flares, eg. two flares per month, “weekend treatment” with topical corticosteroids may reduce the frequency of flares and overall corticosteroid use.

• A short (10-15 minute) warm bath twice daily with moisturising after can improve symptoms.  Research does not support bleach baths, bath additives or water softeners for eczema symptoms.

• Treatment adherence can be improved by prescribing simple regimens and ensuring patients and caregivers know how to follow them.  Some helpful resources include:

• Instructional videos on the use of moisturisers, bathing and topical corticosteroids:
  • Printable information sheets for parents including general and patient specific eczema management and managing infected eczema (does still emphasise bleach baths)

• There is increased access to pimecrolimus and tacrolimus cream (via SA) for treatment of eyelid and facial eczema when steroids are ineffective or contraindicated.   

3.  End of Life Choice Act

Just a reminder this legislation comes into force on 7 November 2021.  The LearnOnLine education module about the Act takes around 20 minutes to complete and gives a clear review of a medical practitioner’s responsibilities, eligibility criteria, assessment of capacity etc. 

The Ministry of Health is hosting a forum for the health workforce who may be involved in delivering parts of the assisted dying service on 29 and 30 September 2021.  Registration details are available here. 

4.  Alternatives to in-person consults

A great and practical set of resources on many aspects of tele-consultations has been developed by PHOs and is available here.  The resource includes a Doxy.me toolkit, PMS specific set-up instructions as well as generic ‘how to’ guides, and various practical tips for getting the most out of a consultation.  Some practical tips I appreciated were:

• Use of screen sharing to show the patient relevant information eg anatomical diagrams during a consultation
• Use of standardised patient information leaflets which are emailed to the patient immediately following the consultation and might cover issues such as red flags for headache, shortness of breath, abdo pain etc. 

Further information for providers and patients is available on the Health Navigator website including a tip sheet for patients preparing for a video consult.   The Telehealth Leadership Group has offered in a useful one-pager some initial guidance to health providers as they rapidly adapt to Telehealth and additional resources are being developed by the group. 

5.  Rosuvastatin

• PHARMAC has announced that from 1 December, 2021, rosuvastatin will be funded with Special Authority Approval as a treatment for people with an increased risk of cardiovascular complications associated with high lipid levels.

• Māori and Pacific patients are specifically listed in the Special Authority criteria and can access funded treatment as first line if they are “considered to be at high risk of cardiovascular disease”.  Patients can also access funded treatment if they have a calculated five-year CVD risk of ≥15% and high lipid levels, despite treatment with atorvastatin and/or simvastatin. Any relevant practitioner can apply for the Special Authority funding.

• Rosuvastatin is considered the most potent statin available and is associated with a comparable safety profile to other medicines in this class with no greater risk of myopathy or serious renal injury when dosed appropriately.   Rosuvastatin tablet strengths are 5, 10, 20 and 40mg (5mg approximately equivalent potency to 40mg simvastatin).  For recent upodated information on prescribing statins, including dose equivalency, see: https://bpac.org.nz/2021/statins.aspx

6.  Acute coronary syndrome in women

A systematic review and meta-analysis of sex differences in symptom presentation in acute coronary syndrome published by the American Heart Association last year included the following conclusions:

• Symptoms experienced by men and women with confirmed acute coronary syndromes show substantial overlap.
• Yet some sex differences in symptoms exist as women have higher odds of experiencing pain between the shoulder blades, nausea or vomiting and shortness of breath, and lower odds of experiencing chest pain or diaphoresis.
• These differences and similarities between women and men with confirmed acute coronary syndromes in symptoms experienced have been established in literature for more than a decade.

What Are the Clinical Implications?

• Symptoms of acute coronary syndromes should no longer be labelled as “typical” or “atypical” for women and/or men.
• Attention for sex differences in symptoms of acute coronary syndromes should be proportional to the large overlap in symptoms of acute coronary syndromes between women and men.

The NZ Heart Foundation is currently running a TV ad campaign emphasising how women with ACS may present in a different manner to men.  I have recently seen two cases where women with marked nausea and shoulder ache were (falsely in hindsight) reassured they weren’t having a heart attack when they queried the diagnosis.