How have services for diabetes, eye, hearing and foot health been integrated for adults? Protocol for a scoping review

INTRODUCTION

The global population is ageing, and by 2050, there will be almost 2.1 billion people over the age of 60 years. This ageing population means conditions such as diabetes are on the increase, as well as other conditions associated with ageing (and/or diabetes), including those that cause vision impairment, hearing impairment or foot problems. The aim of this scoping review is to identify the extent of the literature describing integration of services for adults of two or more of diabetes, eye, hearing or foot services.

METHODS AND ANALYSIS

The main database searches are of Medline and Embase, conducted by an information specialist, without language restrictions, for studies published from 1 January 2000 describing the integration of services for two or more of diabetes, eye, hearing and foot health in the private or public sector and at the primary or secondary level of care, primarily targeted to adults aged ≥40 years. A grey literature search will focus on websites of key organisations. Reference lists of all included articles will be reviewed to identify further studies. Screening and data extraction will be undertaken by two reviewers independently and any discrepancies will be resolved by discussion. We will use tables, maps and text to summarise the included studies and findings, including where studies were undertaken, which services tended to be integrated, in which sector and level of the health system, targeting which population groups and whether they were considered effective.

ETHICS AND DISSEMINATION

As our review will be based on published data, ethical approval will not be sought. This review is part of a project in Aotearoa New Zealand that aims to improve access to services for adults with diabetes or eye, hearing or foot conditions. The findings will be published in a peer-reviewed journal and presented at relevant conferences.

Symptoms and Engagement in Anti-social Behavior 10 Years After Mild Traumatic Brain Injury Within a Community Civilian Sample: A Prospective Cohort Study With Age-Sex Matched Control Group

OBJECTIVE

To determine if there are longer-term effects on symptoms, health status, mood, and behavior 10 years after a mild traumatic brain injury (mTBI).

DESIGN

Prospective cohort study.

SETTING

Community-based, civilian sample.

PARTICIPANTS

Adults aged ≥16 years at follow-up who experienced an mTBI 10 years ago, and an age and sex-matched non-injured control group.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

mTBI cases and controls were asked to complete self-report assessments of functioning (WHO Disability Assessment Schedule Version 2), symptoms (Rivermead Post-Concussion Symptom Questionnaire), health status (100-point scale), alcohol (Alcohol Use Disorders Identification Test) and substance use (Alcohol, Smoking and Substance Involvement Screening Test), and whether they had engaged in any anti-social behaviors over the past 12 months.

RESULTS

Data were analyzed for 368 participants (184 mTBI cases and 184 age-sex matched controls). Just over a third of mTBI cases (64, 34.8%) reported that they were still affected by their index mTBI 10 years later. After adjusting for education and ethnicity, the mTBI group had statistically higher overall symptom burden (F=22.32, P<.001, ηp2=0.07) compared with controls. This difference remained after excluding those who experienced a recurrent TBI. The mTBI group were more than 3 times as likely to have engaged in anti-social behavior during the previous 12 months (F=5.89, P=.02). There were no group differences in health status, functioning, or problematic alcohol or substance use 10 years post-injury.

CONCLUSIONS

This study provides evidence of potential longer-term associations between mTBI, post-concussion symptoms, and anti-social behavior which warrants further evaluation. Future research should also examine if longer-term effects may be preventable with access to early rehabilitation post-injury.

Randomised pragmatic waitlist trial with process evaluation investigating the effectiveness of peer support after brain injury: protocol

INTRODUCTION

Traumatic brain injury (TBI) is an important global health problem. Formal service provision fails to address the ongoing needs of people with TBI and their family in the context of a social and relational process of learning to live with and adapt to life after TBI. Our feasibility study reported peer support after TBI is acceptable to both mentors and mentees with reported benefits indicating a high potential for effectiveness and likelihood of improving outcomes for both mentees and their mentors.

OBJECTIVES

To (a) test the effectiveness of a peer support intervention for improving participation, health and well-being outcomes after TBI and (b) determine key process variables relating to intervention, context and implementation to underpin an evidence-based framework for ongoing service provision.

METHODS AND ANALYSIS

A randomised pragmatic waitlist trial with process evaluation. Mentee participants (n=46) will be included if they have moderate or severe TBI and are no more than 18 months post-injury. Mentor participants (n=18) will be people with TBI up to 6 years after injury, who were discharged from inpatient rehabilitation at least 1 year prior. The primary outcome will be mentee participation, measured using the Impact on Participation and Autonomy questionnaire after 22 weeks. Primary analysis of the continuous variables will be analysis of covariance with baseline measurement as a covariate and randomised treatment as the main explanatory predictor variable at 22 weeks. Process evaluation will include analysis of intervention-related data and qualitative data collected from mentors and service coordinators. Data synthesis will inform the development of a service framework for future implementation.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the New Zealand Health and Disability Ethics Committee (19/NTB/82) and Auckland University of Technology Ethics Committee (19/345). Dissemination of findings will be via traditional academic routes including publication in internationally recognised peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12619001002178.

Estimating the economic costs of Indigenous health inequities in New Zealand: a retrospective cohort analysis

OBJECTIVES

Despite significant international interest in the economic impacts of health inequities, few studies have quantified the costs associated with unfair and preventable ethnic/racial health inequities. This Indigenous-led study is the first to investigate health inequities between Māori and non-Māori adults in New Zealand (NZ) and estimate the economic costs associated with these differences.

DESIGN

Retrospective cohort analysis. Quantitative epidemiological methods and 'cost-of-illness' (COI) methodology were employed, within a Kaupapa Māori theoretical framework.

SETTING

Data for 2003-2014 were obtained from national data collections held by NZ government agencies, including hospitalisations, mortality, outpatient and primary care consultations, laboratory and pharmaceutical usage and accident claims.

PARTICIPANTS

All adults in NZ aged 15 years and above who had engagement with the health system between 2003 and 2014 (deidentified).

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of 'potentially avoidable' hospitalisations and mortality as well as 'excess or underutilisation' of healthcare were calculated, as the difference between actual rates for Māori and the rate expected if Māori had the same rates as non-Māori. These differences were then quantified using COI methodology to estimate the financial cost of ethnic inequities.

RESULTS

In this conservative estimate, health inequities between Māori and non-Māori adults cost NZ$863.3 million per year. Direct costs of NZ$39.9 million per year included costs from ambulatory sensitive hospitalisations and outpatient care, with cost savings from underutilisation of primary care. Indirect costs of NZ$823.4 million per year came from years of life lost and lost wages.

CONCLUSIONS

Indigenous adult health inequities in NZ create significant direct and indirect costs. The 'cost of doing nothing' is predominantly borne by Indigenous communities and society. The net cost of adult health inequities to the government conceals substantial savings to the government from underutilisation of primary care and accident/injury care.

Feasibility and acceptability of a paeārahi (Indigenous Whānau Ora navigator) intervention for unintentional injury prevention for older Māori: non-randomised, non-comparator trial study protocol

Background

Māori (the Indigenous population of Aotearoa New Zealand) experience increased burden of unintentional injury and reduced access to publicly funded injury prevention and rehabilitation services, compared with non-Māori. Māori-led models of care have been shown to improve outcomes for Māori. Paeārahi navigate across sectors (including health, education, housing and employment) to advocate for the best possible outcomes for individuals and families. This study aims to (1) test the acceptability and feasibility and (2) undertake exploratory efficacy analysis of a paeārahi injury intervention for Māori older adults.

Methods

A prospective non-randomised, non-comparator study with preintervention and postintervention measurements of predefined outcomes. Eligible participants who consented to participate (Māori, 55+ years, community-dwelling and enrolled in one of three study general practices) will undergo a multivisit paeārahi intervention. The intervention includes home-hazard assessment, basic health screening, teaching of strength and balance exercises, education relating to injury prevention and access to injury-related, referral and connection to other health and social services) and participants can choose to have whānau (family) involved in the intervention.

Outcomes

The primary outcome of interest is participant, whānau and paeārahi acceptability of the intervention. Secondary outcomes include intervention feasibility, cost-effectiveness and exploratory efficacy (including preintervention and postintervention unintentional injury-related hospitalisation, primary care access and public injury-related claims).

Discussion

The findings of this intervention research will be used to inform injury care models for older Māori and process for Māori-led health intervention development more generally.

Trial registration number

ACTRN12621001691831p.

Neurocognitive correlates of probable posttraumatic stress disorder following traumatic brain injury

Introduction

Neurocognitive problems associated with posttraumatic stress disorder (PTSD) can interact with impairment resulting from traumatic brain injury (TBI).

Research question

We aimed to identify neurocognitive problems associated with probable PTSD following TBI in a civilian sample.

Material and methods

The study is part of the CENTER-TBI project (Collaborative European Neurotrauma Effectiveness Research) that aims to better characterize TBI. For this cross-sectional study, we included patients of all severities aged over 15, and a Glasgow Outcome Score Extended (GOSE) above 3. Participants were assessed at six months post-injury on the PTSD Checklist-5 (PCL-5), the Trail Making Test (TMT), the Rey Auditory Verbal Learning Test (RAVLT) and the Cambridge Neuropsychological Test Automated Battery (CANTAB). Primary analysis was a complete case analysis. Regression analyses were performed to investigate the association between the PCL-5 and cognition.

Results

Of the 1134 participants included in the complete case analysis, 13.5% screened positive for PTSD. Probable PTSD was significantly associated with higher TMT-(B-A) (OR ​= ​1.35, 95% CI: 1.14–1.60, p ​< ​.001) and lower RAVLT-delayed recall scores (OR ​= ​0.74, 95% CI: 0.61–0.91, p ​= ​.004) after controlling for age, sex, psychiatric history, baseline Glasgow Coma Scale and education.

Discussion and conclusion

Poorer performance on cognitive tests assessing task switching and, to a lesser extent, delayed verbal recall is associated with probable PTSD in civilians who have suffered TBI.

•

Six months after traumatic brain injury 13.5% of people screen positive for PTSD.

•

Task switching performance and verbal memory are related to probable PTSD.

•

PTSD severity is related to processing speed and task switching performance.

Impact and predictors of quality of life in adults diagnosed with a genetic muscle disorder: a nationwide population-based study

OBJECTIVES

To determine the impact of genetic muscle disorders and identify the sociodemographic, illness, and symptom factors influencing quality of life.

METHODS

Adults (aged 16-90 years) with a confirmed clinical or molecular diagnosis of a genetic muscle disorder identified as part of a nationwide prevalence study were invited to complete an assessment of the impact of their condition. Quality of life was measured using the World Health Organization Quality of Life questionnaire. Impact was measured via the prevalence of symptoms and comparisons of quality of life against New Zealand norms. Multivariate regression models were used to identify the most significant predictors of quality of life domains.

RESULTS

490/596 participants completed the assessment (82.2% consent rate). Quality of life was lower than the general population on physical (t = 9.37 p < 0.0001, d = 0.54) social (t = 2.27 p = 0.02, d = 0.13) and environmental domains (t = 2.28 p = 0.02, d = 0.13), although effect sizes were small. No difference was found on the psychological domain (t = - 1.17 p = 0.24, d = 0.07). Multivariate regression models (predicting 42%-64% of the variance) revealed personal factors (younger age, being in employment and in a relationship), symptoms (lower pain, fatigue, and sleep difficulties), physical health (no need for ventilation support, fewer activity limitations and no comorbidities), and psychosocial factors (lower depression, anxiety, behavioural dyscontrol and higher self-efficacy, satisfaction with health care and social support) contributed to improved quality of life.

CONCLUSIONS

A range of factors influence the quality of life in adults diagnosed with a genetic muscle disorder and some may serve as targets for multi-faceted intervention.

Economic analysis of the 'Take Charge' intervention for people following stroke: Results from a randomised trial

OBJECTIVE

To undertake an economic analysis of the Take Charge intervention as part of the Taking Charge after Stroke (TaCAS) study.

DESIGN

An open, parallel-group, randomised trial comparing active and control interventions with blinded outcome assessment.

SETTING

Community.

PARTICIPANTS

Adults (n = 400) discharged to community, non-institutional living following acute stroke.

INTERVENTIONS

The Take Charge intervention, a strengths based, self-directed rehabilitation intervention, in two doses (one or two sessions), and a control intervention (no Take Charge sessions).

MEASURES

The cost per quality-adjusted life year (QALY) saved for the period between randomisation (always post hospital discharge) and 12 months following acute stroke. QALYs were calculated from the EuroQol-5D-5L. Costs of stroke-related and non-health care were obtained by questionnaire, hospital records and the New Zealand Ministry of Health.

RESULTS

One-year post hospital discharge cost of care was mean (95% CI) $US4706 (3758-6014) for the Take Charge intervention group and $6118 (4350-8005) for control, mean (95% CI) difference $ -1412 (-3553 to +729). Health utility scores were mean (95% CI) 0.75 (0.73-0.77) for Take Charge and 0.71 (0.67-0.75) for control, mean (95% CI) difference 0.04 (0.0-0.08). Cost per QALY gained for the Take Charge intervention was $US -35,296 (=£ -25,524, € -30,019). Sensitivity analyses confirm Take Charge is cost-effective, even at a very low willingness-to-pay threshold. With a threshold of $US5000 per QALY, the probability that Take Charge is cost-effective is 99%.

CONCLUSION

Take Charge is cost-effective and probably cost saving.

Correction to: The Cost Effectiveness of Genetic Testing for CYP2C19 Variants to Guide Thienopyridine Treatment in Patients with Acute Coronary Syndromes

Unfortunately, the article's Supplementary File Link is not working and the ESM material.

Measuring stroke and transient ischemic attack burden in New Zealand: Protocol for the fifth Auckland Regional Community Stroke Study (ARCOS V)

Aim: The goal of this paper is to provide a protocol for conducting a fifth population-based Auckland Regional Community Stroke study (ARCOS V) in New Zealand. Methods and Discussion: In this study, for the first time globally, (1) stroke and TIA burden will be determined using the currently used clinical and tissue-based definition of stroke, in addition to the WHO clinical classifications of stroke used in all previous ARCOS studies, as well as more advanced criteria recently suggested for an "ideal" population-based stroke incidence and outcomes study; and (2) age, sex, and ethnic-specific trends in stroke incidence and outcomes will be determined over the last four decades, including changes in the incidence of acute cerebrovascular events over the last decade. Furthermore, information at four time points over a 40-year period will allow the assessment of effects of recent changes such as implementation of the FAST campaign, ambulance pre-notification, and endovascular treatment. This will enable more accurate projections for health service planning and delivery. Conclusion: The methods of this study will provide a foundation for future similar population-based studies in other countries and populations.

Status epilepticus in Auckland, New Zealand: Incidence, etiology, and outcomes

OBJECTIVE

To determine the incidence, etiology, and outcome of status epilepticus (SE) in Auckland, New Zealand, using the latest International League Against Epilepsy (ILAE) SE semiological classification.

METHODS

We prospectively identified patients presenting to the public or major private hospitals in Auckland (population = 1.61 million) between April 6, 2015 and April 5, 2016 with a seizure lasting 10 minutes or longer, with retrospective review to confirm completeness of data capture. Information was recorded in the EpiNet database.

RESULTS

A total of 477 episodes of SE occurred in 367 patients. Fifty-one percent of patients were aged <15 years. SE with prominent motor symptoms comprised 81% of episodes (387/477). Eighty-four episodes (18%) were nonconvulsive SE. Four hundred fifty episodes occurred in 345 patients who were resident in Auckland. The age-adjusted incidence of 10-minute SE episodes and patients was 29.25 (95% confidence interval [CI] = 27.34-31.27) and 22.22 (95% CI = 20.57-23.99)/100 000/year, respectively. SE lasted 30 minutes or longer in 250 (56%) episodes; age-adjusted incidence was 15.95 (95% CI = 14.56-17.45) SE episodes/100 000/year and 12.92 (95% CI = 11.67-14.27) patients/100 000/year. Age-adjusted incidence (10-minute SE) was 25.54 (95% CI = 23.06-28.24) patients/100 000/year for males and 19.07 (95% CI = 16.91-21.46) patients/100 000/year for females. The age-adjusted incidence of 10-minute SE was higher in Māori (29.31 [95% CI = 23.52-37.14]/100 000/year) and Pacific Islanders (26.55 [95% CI = 22.05-31.99]/100 000/year) than in patients of European (19.13 [95% CI = 17.09-21.37]/100 000/year) or Asian/other descent (17.76 [95% CI = 14.73-21.38]/100 000/year). Seventeen of 367 patients in the study died within 30 days of the episode of SE; 30-day mortality was 4.6%.

SIGNIFICANCE

In this population-based study, incidence and mortality of SE in Auckland lie in the lower range when compared to North America and Europe. For pragmatic reasons, we only included convulsive SE if episodes lasted 10 minutes or longer, although the 2015 ILAE SE classification was otherwise practical and easy to use.

A Nationwide, Population-Based Prevalence Study of Genetic Muscle Disorders

BACKGROUND

Previous epidemiological studies of genetic muscle disorders have relied on medical records to identify cases and may be at risk of selection biases or have focused on selective population groups.

OBJECTIVES

This study aimed to determine age-standardised prevalence of genetic muscle disorders through a nationwide, epidemiological study across the lifespan using the capture-recapture method.

METHODS

Adults and children with a confirmed clinical or molecular diagnosis of a genetic muscle disorder, resident in New Zealand on April 1, 2015 were identified using multiple overlapping sources. Genetic muscle disorders included the muscular dystrophies, congenital myopathies, ion channel myopathies, GNE myopathy, and Pompe disease. Prevalence per 100,000 persons by age, sex, disorder, ethnicity and geographical region with 95% CIs was calculated using Poisson distribution. Direct standardisation was applied to age-standardise prevalence to the world population. Completeness of case ascertainment was determined using capture-recapture modelling.

RESULTS

Age standardised minimal point prevalence of all genetic muscle disorders was 22.3 per 100,000 (95% CI 19.5-25.6). Prevalence in Europeans of 24.4 per 100,000, (95% CI 21.1-28.3) was twice that observed in NZ's other 3 main ethnic groups; Māori (12.6 per 100,000, 95% CI 7.8-20.5), Pasifika (11.0 per 100,000, 95% CI 5.4-23.3), and Asian (9.13 per 100,000, 95% CI 5.0-17.8). Crude prevalence of myotonic dystrophy was 3 times higher in Europeans (10.5 per 100,000, 9.4-11.8) than Māori and Pasifika (2.5 per 100,000, 95% CI 1.5-4.2 and 0.7 per 100,000, 95% CI 0.1-2.7 respectively). There were considerable regional variations in prevalence, although there was no significant association with social deprivation. The final capture-recapture model, with the least deviance, estimated the study ascertained 99.2% of diagnosed cases.

CONCLUSIONS

Ethnic and regional differences in the prevalence of genetic muscle disorders need to be considered in service delivery planning, evaluation, and decision making.

Estimating the economic costs of ethnic health inequities: protocol for a prevalence-based cost-of-illness study in New Zealand (2003-2014)

INTRODUCTION

There is significant international interest in the economic impacts of persistent inequities in morbidity and mortality. However, very few studies have quantified the costs associated with unfair and preventable ethnic/racial inequities in health. The proposed study will investigate inequities in health between the indigenous Māori and non-Māori adult population in New Zealand (15 years and older) and estimate the economic costs associated with these differences.

METHODS AND ANALYSIS

The study will use national collections data that is held by government agencies in New Zealand including hospitalisations, mortality, outpatient consultations, laboratory and pharmaceutical claims, and accident compensation claims. Epidemiological methods will be used to calculate prevalences for Māori and non-Māori, by age-group, gender and socioeconomic deprivation (New Zealand Deprivation Index) where possible. Rates of 'potentially avoidable' hospitalisations and mortality as well as 'excess or under' utilisation of healthcare will be calculated as the difference between the actual rate and that expected if Māori were to have the same rates as non-Māori. A prevalence-based cost-of-illness approach will be used to estimate health inequities and the costs associated with treatment, as well as other financial and non-financial costs (such as years of life lost) over the person's lifetime.

ETHICS AND DISSEMINATION

This analysis has been approved by the University of Auckland Human Participants Research Committee (Ref: 018621). Dissemination of findings will occur via published peer-reviewed articles, presentations to academic, policy and community-based stakeholder groups and via social media.

Meta-analysis and cost effective analysis of portal-superior mesenteric vein resection during pancreatoduodenectomy: Impact on margin status and survival

INTRODUCTION

The benefit of portal-superior mesenteric vein resection (PSMVR) with pancreatoduodenectomy (PD) remains controversial. This study assesses the impact of PSMVR on resection margin status and survival.

METHOD

An electronic search was performed to identify relevant articles. Pooled odds ratios were calculated for outcomes using the fixed or random-effects models for meta-analysis. A decision analytical model was developed for estimating cost effectiveness.

RESULTS

Sixteen studies with 4145 patients who underwent pancreatoduodenectomy were included: 1207 patients had PSMVR and 2938 patients had no PSMVR. The R1 resection rate and post-operative mortality was significantly higher in PSMVR group (OR1.59[1.35, 1.86] p=<0.0001, and OR1.72 [1.02,2.92] p = 0.04 respectively). The overall survival at 5-years was worse in the PSMVR group (HR0.20 [0.07,0.55] P = 0.020). Tumour size (p = 0.030) and perineural invasion (P = 0.009) were higher in the PSMVR group. Not performing PSMVR yielded cost savings of $1617 per additional month alive without reduction in overall outcome.

CONCLUSION

On the basis of retrospective data this study shows that PD with PSMVR is associated with a higher R1 rate, lower 5-year survival and is not cost-effective. It appears that PD with PSMVR can only be justified if R0 resection can be achieved. The continuing challenge is accurate selection of these patients.

Incidence of Transient Ischemic Attack in Auckland, New Zealand, in 2011 to 2012

BACKGROUND AND PURPOSE

There have been few recent population-based studies reporting the incidence (first ever) and attack rates (incident and recurrent) of transient ischemic attack (TIA).

METHODS

The fourth Auckland Regional Community Stroke study (ARCOS IV) used multiple overlapping case ascertainment methods to identify all hospitalized and nonhospitalized cases of TIA that occurred in people ≥16 years of age usually resident in Auckland (population ≥16 years of age is 1.12 million), during the 12 months from March 1, 2011. All first-ever and recurrent new TIAs (any new TIA 28 days after the index event) during the study period were recorded.

RESULTS

There were 785 people with TIA (402 [51.2%] women, mean [SD] age 71.5 [13.8] years); 614 (78%) of European origin, 84 (11%) Māori/Pacific, and 75 (10%) Asian/Other. The annual incidence of TIA was 40 (95% confidence interval, 36-43), and attack rate was 63 (95% confidence interval, 59-68), per 100 000 people, age standardized to the World Health Organization world population. Approximately two thirds of people were known to be hypertensive or were being treated with blood pressure-lowering agents, half were taking antiplatelet agents and just under half were taking lipid-lowering therapy before the index TIA. Two hundred ten (27%) people were known to have atrial fibrillation at the time of the TIA, of whom only 61 (29%) were taking anticoagulant therapy, suggesting a failure to identify or treat atrial fibrillation.

CONCLUSIONS

This study describes the burden of TIA in an era of aggressive primary and secondary vascular risk factor management. Education programs for medical practitioners and patients around the identification and management of atrial fibrillation are required.

The Global Burden of Cancer 2013

IMPORTANCE

Cancer is among the leading causes of death worldwide. Current estimates of cancer burden in individual countries and regions are necessary to inform local cancer control strategies.

OBJECTIVE

To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 28 cancers in 188 countries by sex from 1990 to 2013.

EVIDENCE REVIEW

The general methodology of the Global Burden of Disease (GBD) 2013 study was used. Cancer registries were the source for cancer incidence data as well as mortality incidence (MI) ratios. Sources for cause of death data include vital registration system data, verbal autopsy studies, and other sources. The MI ratios were used to transform incidence data to mortality estimates and cause of death estimates to incidence estimates. Cancer prevalence was estimated using MI ratios as surrogates for survival data; YLDs were calculated by multiplying prevalence estimates with disability weights, which were derived from population-based surveys; YLLs were computed by multiplying the number of estimated cancer deaths at each age with a reference life expectancy; and DALYs were calculated as the sum of YLDs and YLLs.

FINDINGS

In 2013 there were 14.9 million incident cancer cases, 8.2 million deaths, and 196.3 million DALYs. Prostate cancer was the leading cause for cancer incidence (1.4 million) for men and breast cancer for women (1.8 million). Tracheal, bronchus, and lung (TBL) cancer was the leading cause for cancer death in men and women, with 1.6 million deaths. For men, TBL cancer was the leading cause of DALYs (24.9 million). For women, breast cancer was the leading cause of DALYs (13.1 million). Age-standardized incidence rates (ASIRs) per 100 000 and age-standardized death rates (ASDRs) per 100 000 for both sexes in 2013 were higher in developing vs developed countries for stomach cancer (ASIR, 17 vs 14; ASDR, 15 vs 11), liver cancer (ASIR, 15 vs 7; ASDR, 16 vs 7), esophageal cancer (ASIR, 9 vs 4; ASDR, 9 vs 4), cervical cancer (ASIR, 8 vs 5; ASDR, 4 vs 2), lip and oral cavity cancer (ASIR, 7 vs 6; ASDR, 2 vs 2), and nasopharyngeal cancer (ASIR, 1.5 vs 0.4; ASDR, 1.2 vs 0.3). Between 1990 and 2013, ASIRs for all cancers combined (except nonmelanoma skin cancer and Kaposi sarcoma) increased by more than 10% in 113 countries and decreased by more than 10% in 12 of 188 countries.

CONCLUSIONS AND RELEVANCE

Cancer poses a major threat to public health worldwide, and incidence rates have increased in most countries since 1990. The trend is a particular threat to developing nations with health systems that are ill-equipped to deal with complex and expensive cancer treatments. The annual update on the Global Burden of Cancer will provide all stakeholders with timely estimates to guide policy efforts in cancer prevention, screening, treatment, and palliation.

Use of the EpiNet database for observational study of status epilepticus in Auckland, New Zealand

The EpiNet project has been established to facilitate investigator-initiated clinical research in epilepsy, to undertake epidemiological studies, and to simultaneously improve the care of patients who have records created within the EpiNet database. The EpiNet database has recently been adapted to collect detailed information regarding status epilepticus. An incidence study is now underway in Auckland, New Zealand in which the incidence of status epilepticus in the greater Auckland area (population: 1.5 million) will be calculated. The form that has been developed for this study can be used in the future to collect information for randomized controlled trials in status epilepticus. This article is part of a Special Issue entitled "Status Epilepticus".

Burden of Traumatic Brain Injury in New Zealand: Incidence, Prevalence and Disability-Adjusted Life Years

Objective: The study aimed to estimate the incidence, prevalence and disability-adjusted life years (DALY) for traumatic brain injury (TBI) in New Zealand (NZ) in 2010. Methods: A multi-state life table model was constructed using inputs from the Brain Injury Outcomes New Zealand in the Community study for the first-ever incidence of TBI in a lifetime and its severity distribution, from the NZ Ministry of Health's Mortality Collection for the data on TBI mortality and from Statistics of NZ for the population data. The modeled estimate of prevalence was combined with the disability weights for TBI (by stage and severity level) from the Global Burden of Disease 2010 study to obtain estimates of health loss (DALYs) for TBI. Results: Approximately, 11,300 first-ever incident TBIs occurred in NZ during 2010, with 527,000 New Zealanders estimated to have ever experienced a TBI (prevalent cases). The estimated 20,300 DALYs attributable to TBI accounted for 27% of total injury-related health loss and 2.4% of DALYs from all causes. Of the total DALYs attributable to TBI, 71% resulted from fatal injuries. However, non-fatal outcomes accounted for a substantial share of the burden (29%) with mild TBI making the greater contribution of non-fatal outcomes (56%). Conclusions: The burden of TBI in NZ is substantial, and mild TBI contributes to a major part of non-fatal outcomes.

Traumatic brain injury within Pacific people of New Zealand

AIMS

Previous research has suggested there are ethnic disparities in the incidence of traumatic brain injury (TBI). This study aimed to: identify the incidence of TBI for Pacific people; describe the injury profile in this population; and determine if there were disparities in healthcare service use.

METHODS

All TBI cases that occurred within a 1-year period in the Hamilton and Waikato regions of New Zealand were identified using multiple case ascertainment methods as part of a population-based incidence study. Demographic and injury data from people who self-identified as a Pacific person (N=76) were extracted and compared to New Zealand (NZ) Europeans (N=794). Differences in injury severity, mechanism of injury and acute healthcare service use were explored between the two ethnic groups.

RESULTS

The total crude incidence of TBI in Pacific people was 1242 cases per 100,000 person-years, significantly higher than NZ Europeans (842 per 100,000). Peaks in incidence for Pacific people and NZ Europeans were observed between 0-4 and 15-24 years of age, with males at greater risk of injury than females. There were no statistically significant differences in TBI severity, mechanism of injury and acute healthcare use between the two groups.

CONCLUSION

Pacific people are at a significantly higher risk of experiencing a TBI than NZ Europeans and targeted prevention efforts are needed.

Cost of traumatic brain injury in New Zealand: evidence from a population-based study

OBJECTIVE

We aimed to estimate from a societal perspective the 1-year and lifetime direct and indirect costs of traumatic brain injury (TBI) for New Zealand (NZ) in 2010 projected to 2020.

METHODS

An incidence-based cost of illness model was developed using data from the Brain Injury Outcomes New Zealand in the Community Study. Details of TBI-related resource use during the first 12 months after injury were obtained for 725 cases using resource utilization information from participant surveys and medical records. Total costs are presented in US dollars year 2010 value.

RESULTS

In 2010, 11,301 first-ever TBI cases were estimated to have occurred in NZ; total first-year cost of all new TBI cases was estimated to be US $47.9 million with total prevalence costs of US $101.4 million. The average cost per new TBI case during the first 12 months and over a lifetime was US $5,922 (95% confidence interval [CI] $4,777-$7,858), varying from US $4,636 (95% CI $3,756-$5,561) for mild cases to US $36,648 (95% CI $16,348-$65,350) for moderate/severe cases. Because of the unexpectedly large number of mild TBI cases (95% of all TBI cases), the total cost of treating these cases is nearly 3 times that of moderate/severe. The total lifetime cost of all TBI survivors in 2010 was US $146.5 million and is expected to increase to US $177.1 million in 2020.

CONCLUSION

The results suggest that there is an urgent need to develop effective interventions to prevent both mild and moderate/severe TBI.

Potential gains and costs from increasing access to thrombolysis for acute ischemic stroke patients in New Zealand hospitals

BACKGROUND AND AIM

Treatment of ischemic stroke patients with tissue-type plasminogen activator (tPA) is known to be effective and cost-effective, yet the percentage of patients treated with thrombolysis in hospitals remains low. The purpose of this study is to examine whether providing thrombolysis in New Zealand hospitals is currently cost-effective and to estimate the amount that might be spent on campaigns aimed at increasing thrombolysis receipt rates.

METHODS

A decision-analytic model was developed and populated using health services data from the literature and the Auckland Regional Community Stroke Outcome Study. The cost-utilities of providing thrombolysis over one-year and patient lifetime were estimated. Using a threshold of NZ$20 000 (US$15 337) per quality-adjusted life year, the analysis identified the maximum amount that might be spent on campaigns aiming to increase rates of receipt of thrombolysis above their current levels. Monte Carlo simulations and probabilistic sensitivity analysis explored the robustness of the findings.

RESULTS

Providing thrombolysis was cost-effective, especially when long-term costs and effects were considered (NZ$6641 or US$5093 per quality-adjusted life year). The results suggest that better management within hospitals would be more effective in increasing thrombolysis receipt rates (up to 17%) than campaigns aiming at higher awareness of stroke symptoms in the community. The amount that might be spent on a national campaign to increase rate of receipt of thrombolysis from its current level (3% of eligible patients) depended upon the effectiveness of the campaign, ranging from under NZ$6 million for New Zealand for an increase in rate to 30% to over $9 million for an increase in rate to 50%.

CONCLUSION

While thrombolysis is a cost-effective treatment in New Zealand, resources should be devoted to campaigns, both within hospitals and in the community, to increase coverage.

Reducing recurrent stroke: methodology of the motivational interviewing in stroke (MIST) randomized clinical trial

RATIONALE

Recurrent stroke is prevalent in both developed and developing countries, contributing significantly to disability and death. Recurrent stroke rates can be reduced by adequate risk factor management. However, adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor, leading to a large number of preventable recurrent strokes. Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke.

AIMS AND/OR HYPOTHESIS

The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke.

DESIGN

Recruitment of 430 first-ever stroke participants will occur in the Auckland and Waikato regions. Randomization will be to intervention or usual care groups. Participants randomized to intervention will receive four motivational interviews and five follow-up assessments over 12 months. Nonintervention participants will be assessed at the same time points.

STUDY OUTCOMES

Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke. Secondary outcomes include self-reported adherence and barriers to prescribed medications, new cardiovascular events (including stroke), changes in quality of life, and mood.

DISCUSSION

The results of the motivational interviewing in stroke trial will add to our understanding of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant.

The cost effectiveness of genetic testing for CYP2C19 variants to guide thienopyridine treatment in patients with acute coronary syndromes: a New Zealand evaluation

BACKGROUND

A recent clinical trial has demonstrated that patients with acute coronary syndromes (ACS) and the reduced function allele CYP2C19*2 (*2 allele), who are treated with thienopyridines, have an increased risk of adverse cardiac events with clopidogrel, but not with prasugrel. The frequency of the *2 allele varies by ethnicity and the Maoris, Asians and Pacific Islanders of New Zealand have a relatively high incidence.

OBJECTIVE

Our objective was to evaluate, from a New Zealand health system perspective, the cost effectiveness of treating all ACS patients with generic clopidogrel compared with prasugrel, and also compared with the genetically guided strategy that *2 allele carriers receive prasugrel and non-carriers receive clopidogrel.

METHODS

A decision-tree model consisting of five health states (myocardial infarction, stroke, bleeding, stent thrombosis and cardiovascular death) was developed. Clinical outcome data (two TRITON-TIMI 38 genetic sub-studies) comparing clopidogrel and prasugrel for both *2 allele carriers and non-carriers were combined with the prevalence of the heterozygosity for the *2 allele in New Zealand Europeans (15%), Maoris (24%), Asians (29%) and Pacific Islanders (45%) to determine the predicted adverse event rate for the New Zealand population. National hospital diagnosis-related group (DRG) discharge codes were used to determine alternative adverse event rates, along with the costs of hospitalizations during the 15 months after patients presented with an ACS. The primary outcome measure was the incremental cost per QALY (calculated using literature-reported weights). Monte Carlo simulations and alternative scenario analysis based on both clinical trial and national hospital incidence were used. Additional analysis considered the overall TRITON-TIMI 38 rates. Costs (in New Zealand dollars [$NZ], year 2009 values) and benefits were discounted at 3% per annum.

RESULTS

Actual hospital-based adverse event rates were higher than those reported in the TRITON-TIMI 38 randomized controlled trial and the genetic sub-studies, especially for myocardial infarction and cardiovascular death, and for Maoris and Pacific Islanders. For both sources of adverse event rates, treating the population with prasugrel was associated with worse outcomes (QALYs) than clopidogrel. However, prasugrel became cost effective ($NZ31 751/QALY) when the overall TRITON-TIMI 38 rates were used. A genetic test to guide the selected use of prasugrel was cost effective ($NZ8702/QALY versus $NZ24 617/QALY) for hospital and clinical trial incidence, respectively. Based on the hospital rates, the genetically guided strategy was especially cost effective for Maoris ($NZ7312/QALY) and Pacific Islanders ($NZ7041/QALY). These results were robust to the sensitivity analysis, except the genetically guided strategy under the 15-month clinical trial event rate scenario ($NZ168 748/QALY) did not remain cost effective under a $NZ50 000 threshold.

CONCLUSIONS

Use of a genetic test to guide thienopyridine treatment in patients with ACS is a potentially cost-effective treatment strategy, especially for Maoris and Pacific Islanders. This treatment strategy also has the potential to reduce ethnic health disparities that exist in New Zealand. However, the results comparing clopidogrel and prasugrel are sensitive to whether the genetic sub-studies or the overall TRITON-TIMI 38 rates are used. While the national hospital event rates may be more appropriate for the New Zealand population, many assumptions are required when they are used to adjust the genetic sub-studies rates.