Changes in hospitalisation rates in older people before and after moving to a retirement village

OBJECTIVES

An increasing proportion of older people live in Retirement Villages ('villages'). This population cites support for health-care issues as one reason for relocation to villages. Here, we examine whether relocation to villages is associated with a decline in hospitalisations.

METHODS

Retrospective, before-and-after observational study.

SETTING

Retirement villages, Auckland, New Zealand.

PARTICIPANTS

466 cognitively intact village residents (336 [72%] female); mean (SD) age at moving to village was 73.9 (7.7) years. Segmented linear regression analysis of an interrupted time-series design was used.

MAIN OUTCOME MEASURES

all hospitalisations for 18 months pre- and postrelocation to village.

SECONDARY OUTCOME

acute hospitalisations during the same time periods.

RESULTS

The average hospitalisation rate (per 100 person-years) was 44.9 (95% confidence interval [CI] = 36.3-55.6) 18-10 months before village relocation, 58.9 (95% CI = 48.3-72.0) 9-1 months before moving, 47.9 (95% CI = 38.8-59.1) 1-9 months after moving and 62.4 (95% CI = 51.2-76.0) 10-18 months after moving. Monthly average hospitalisation rate (per 100 person-years) increased before relocation to village by an average of 1.2 (95% CI = 0.01-1.57, p = .04) per month from 18 to 1 month before moving, and there was a change in the level of the monthly average hospitalisation rate immediately after relocation (mean difference [MD] = -18.4 per 100 person-years, 95% CI = -32.8 to -4.1, p = .02). The trend change after village relocation did not differ significantly from that before moving.

CONCLUSIONS

Although we cannot reliably claim causality, relocation to a retirement village is, for older people, associated with a significant but non-sustained reduction in hospitalisation.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Innovation in Aotearoa New Zealand's healthcare system-how to make it happen

To date innovation in Aotearoa New Zealand healthcare services has varied around the country. As we move into a health system restructure, it is important to reflect on what has worked to date and how we can take these elements into the new system. In this paper we describe the approach at Waitematā District Health Board (DHB) including the establishment of an Institute for Innovation and Improvement. We highlight what we view as the key elements of an innovation enabling environment and suggest measures of success.

Referral for publicly funded aged care services in Indigenous populations: An exploratory cohort study of ethnic variation in Aotearoa New Zealand

Objectives

As people age, they are more likely to require support to maintain activities of daily living. Referral for formal assessment of need (assessed using the ‘international Resident Assessment Instrument’ [interRAI]) is the first step to access publicly funded services in Aotearoa New Zealand (NZ). It is unclear whether ethnic access inequities present in other areas of the NZ health system occur in this referral process. This exploratory research aimed to explore ethnic variation in referrals for interRAI assessment, and associated factors.

Methods

A retrospective cohort study of all new referrals for aged care services for those 55‐plus, received in 2018 by Waitematā District Health Board (WDHB), was conducted. The primary outcome was referral outcome (assessment and no assessment). Secondary outcomes included time from referral to assessment, reason for referral, mortality and, in the assessed cohort, assessment outcome.

Results

New referrals (n = 3263) were ethnically representative of the general older adult population in WDHB. Māori were younger and more likely to be referred for higher‐level care needs than non‐Māori, non‐Pasifika (NMNP) (p = 0.03). There was no significant difference in referral outcome, time to assessment or mortality between ethnicities. NMNP were more likely to access lower‐level care services than Māori or Pasifika older adults (p = 0.002).

Conclusions

Ethnicity was not associated with aged care service assessment access once people were referred for publicly funded services, nor was it associated with time to assessment or mortality in this exploratory study. Māori had higher care needs than NMNP at the time of referral.

An interRAI derived frailty index predicts acute hospitalizations in older adults residing in retirement villages: A prospective cohort study

Objectives

The development of frailty tools from electronically recorded healthcare data allows frailty assessments to be routinely generated, potentially beneficial for individuals and healthcare providers. We wished to assess the predictive validity of a frailty index (FI) derived from interRAI Community Health Assessment (CHA) for outcomes in older adults residing in retirement villages (RVs), elsewhere called continuing care retirement communities.

Design

Prospective cohort study.

Setting and participants

34 RVs across two district health boards in Auckland, Aotearoa New Zealand (NZ). 577 participants, mean age 81 years; 419 (73%) female; 410 (71%) NZ European, 147 (25%) other European, 8 Asian (1%), 7 Māori (1%), 1 Pasifika (<1%), 4 other (<1%).

Methods

interRAI-CHA FI tool was used to stratify participants into fit (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) and severe (>0.36) frail groups at baseline (the latter two grouped due to low numbers of severely frail). Primary outcome was acute hospitalization; secondary outcomes included long-term care (LTC) entry and mortality. The relationship between frailty and outcomes were explored with multivariable Cox regression, estimating hazard ratios (HRs) and 95% confidence intervals (95%CIs).

Results

Over mean follow-up of 2.5 years, 33% (69/209) of fit, 58% (152/260) mildly frail and 79% (85/108) moderate-severely frail participants at baseline had at least one acute hospitalization. Compared to the fit group, significantly increased risk of acute hospitalization were identified in mildly frail (adjusted HR = 1.88, 95%CI = 1.41–2.51, p<0.001) and moderate-severely frail (adjusted HR = 3.52, 95%CI = 2.53–4.90, p<0.001) groups. Similar increased risk in moderate-severely frail participants was seen in LTC entry (adjusted HR = 5.60 95%CI = 2.47–12.72, p<0.001) and mortality (adjusted HR = 5.06, 95%CI = 1.71–15.02, p = 0.003).

Conclusions and implications

The FI derived from interRAI-CHA has robust predictive validity for acute hospitalization, LTC entry and mortality. This adds to the growing literature of use of interRAI tools in this way and may assist healthcare providers with rapid identification of frailty.

Factors associated with healthcare utilization and trajectories in retirement village residents

BACKGROUND

To study healthcare utilization and trajectories, and associated factors, in older adults in retirement villages (RVs), also known as continuing care retirement communities.

METHODS

Prospective cohort study of 578 cognitively intact residents from 34 RVs in Auckland, New Zealand (NZ).

MEASUREMENT

InterRAI-Community Health Assessment (includes core items that may trigger functional supplement (FS) completion in those with higher needs, and generates clinical assessment protocols (CAPs) in those with potential unmet needs).

OUTCOMES

time to acute hospitalization, long-term care (LTC), and death during average 2.5 years follow-up.

RESULTS

Three hundred seven (53%) residents had acute hospitalizations, 65 (11%) moved to LTC, and 51 (9%) died over a mean of 2.5 years. Factors associated with increased risk of acute hospitalization included CAP-falls (high risk) triggered, number of comorbidities, not having left RV in 2 weeks prior, moderate/severe hearing impairment, CAP-cardiorespiratory conditions triggered, acute hospitalization in year prior and age, with significant hazard ratios (HR) ranging between 1.03 and 2.90. Factors associated with reduced risk of hospitalization included other (non-NZ) European ethnicity (HR 0.73, 95% CI 0.55-0.98, p = 0.04), presence of on-site clinic (HR 0.62, 95% CI 0.45-0.85, p = 0.003), no influenza vaccination (HR 0.56, 95% CI 0.38-0.83, p = 0.004). Factors associated with LTC transition included FS triggered (HR 3.84, 95% CI 1.92-7.66, p < 0.001), CAP-instrumental activities of daily living (IADL) (HR 2.62, 95% CI 1.22-5.62, p = 0.01), CAP-social relationship triggered (HR 2.00, 95% CI 1.13-3.55, p = 0.02), and age (HR 1.13, 95% CI 1.07-1.18 p < 0.001). Factors associated with mortality included number of comorbidities (HR 3.75, 95% CI 1.54-9.10, p = 0.004 for 3-5 comorbidities), CAP-IADL triggered (HR 3.05, 95% CI 1.30-7.16, p = 0.01), and age (HR 1.11, 95% CI 1.05-1.18, p < 0.001).

CONCLUSION

A large proportion of cognitively intact RV residents are admitted to hospital in mean 2.5 years of follow-up. Multiple factors were associated with acute hospitalization risk. On-site clinics were associated with reduced risk and should be considered in RV development.

Learning from a multidisciplinary randomized controlled intervention in retirement village residents

BACKGROUND

Retirement villages (RVs), also known as continuing care retirement communities, are an increasingly popular housing choice for older adults. The RV population has significant health needs, possibly representing a group with needs in between community-dwelling older adults and those in long-term residential care (LTC). Our previous work shows Gerontology Nurse Specialist (GNS)-facilitated multidisciplinary team (MDT) interventions may reduce hospitalizations from LTC. This study tested whether a similar intervention reduced hospitalizations in RV residents.

METHODS

Open-label randomized controlled trial in which 412 older residents of 33 RVs were randomized (1:1) to an MDT intervention or usual care.

SETTING

RVs across two District Health Boards in Auckland, New Zealand. Residents were eligible if considered high risk of health/functional decline (triggering ≥3 interRAI Clinical Assessment Protocols or needing special consideration identified by GNS).

INTERVENTION

GNS-facilitated MDT intervention, including geriatrician/nurse practitioner and clinical pharmacist, versus usual care. Primary outcome was time from randomization to first acute hospitalization. Secondary outcomes were rate of acute hospitalizations, LTC admission, and mortality. Twelve residents died before randomization; all others (n = 400: MDT intervention = 199; usual care = 201) were included in intention-to-treat analyses.

RESULTS

Mean (SD) age was 82.2 (6.9) years, 302 (75.5%) were women, and 378 (94.5%) were European. Over median 1.5 years follow-up, no difference was found in hazard of acute hospitalization between the MDT intervention (51.8%) and usual care (49.3%) groups (Hazard ratio [HR] = 1.01, 95% CI = 0.77-1.34). No difference was found in the incidence rate of acute hospitalizations between the MDT intervention (0.69 per person-year) and usual care (0.86 per person-year) groups (incidence rate ratio = 0.81, 95% CI = 0.59-1.10). Similar results were seen for the proportion of residents with LTC transition (HR = 1.18, 95% CI = 0.65-2.11) and mortality (HR = 0.70, 95% CI = 0.36-1.35).

CONCLUSION

Further studies are needed to assess the effects of other patient-centered interventions and outcomes with adequate primary care integration.

Research in the retirement village community-The problems of recruiting a representative cohort of residents in Auckland, New Zealand

OBJECTIVES

Retirement villages are semi-closed communities, access usually being gained via village managers. This paper explores issues recruiting a representative resident cohort, as background to a study of residents, to acquire sociodemographic, health and disability data and trial an intervention designed to improve outcomes.

METHODS

We planned approaching all Auckland/Waitematā District villages and, via managers, contacting residents ('letter-drop'; 'door-knocks'). In 'small' villages (n ≤ 60 units), we planned contacting all residents, randomly selecting in 'larger' villages. We excluded those with doubtful or absent legal capacity.

RESULTS

We approached managers of 53 of 65 villages. Thirty-four permitted recruitment. Some prohibited 'letter-drops' and/or 'door-knocks'. Hence, we recruited volunteers (23 villages) via meetings, posters, newsletters and word-of-mouth, that is representative sampling obtained from 11/34 villages. We recruited 578 residents (median age = 82 years; 420 = female; 217:361 sampled:volunteers), finding differences in baseline parameters of sampled vs. volunteers.

CONCLUSION

Due to organisational/managers' policy, and national legislation restrictions, our sample does not represent our intended population well. Researchers should investigate alternative data sources, for example electoral rolls and censuses.

An interRAI-derived frailty index is associated with prior hospitalisations in older adults residing in retirement villages

OBJECTIVES

To develop and validate a frailty index (FI) from interRAI-Community Health Assessments (CHA) on older adults in retirement villages (RVs).

METHODS

This is a cross-sectional analysis of a current RV research study. A FI was generated using the cumulative deficit model. Health-care utilisation measures were acute, and all, hospitalisations 12 months before baseline assessment. Associations between FI and hospitalisations were explored using multivariable logistic regression to estimate odds ratio (OR).

RESULTS

Of 577 included residents, mean (SD) age was 81 (7) and 419 (73%) were female. Mean (SD) FI was 0.16 (0.09); 260 (45%) were mildly frail, and 108 (19%) moderate-severely frail. In multivariate-adjusted analysis, odds of acute hospitalisation for mild (OR = 3.3, P < .001) and moderate-severely frail (OR = 6.4, P < .001) were significantly higher than fit residents. Higher odds were also observed for all hospitalisations.

CONCLUSION

A considerable proportion of RV residents were moderately-severely frail. FI was associated with acute and all hospitalisations.

Health profile of residents of retirement villages in Auckland, New Zealand: findings from a cross-sectional survey with health assessment

OBJECTIVES

Retirement villages (RV) have expanded rapidly, now housing perhaps one in eight people aged 75+ years in New Zealand. Health service initiatives might better support residents and offer cost advantages, but little is known of resident demographics, health status or needs. This study describes village residents-their demographics, socio-behavioural and health status-noting differences between participants who volunteered and those who were sampled.

DESIGN

Cross-sectional study of village residents. The cohort formed will also be used for a longitudinal study and a randomised controlled trial. Village managers (sometimes after consulting residents) decided if representative sampling could be undertaken in each village. Where sampling was not approved, volunteers were sought.

SETTING

33 RV were included from a total of 65 villages in Auckland, New Zealand.

PARTICIPANTS

Residents (n=578) were recruited either by sampling (n=217) or as volunteers (n=361) during 2016-2018. Each completed a survey and an International Resident Assessment Instrument (interRAI) health needs assessment with a gerontology nurse specialist.

RESULTS

Median age of residents was 82 years, 158 (27%) were men; 61% lived alone. Downsizing (77%), less stress (63%) and access to healthcare assistance (61%) were most common reasons for entry. During the 2 weeks prior to survey, 34% received home supports and 10% personal care. Hypertension, heart disease, arthritis and pain were reported by over 40%. Most common unmet needs related to managing cardiorespiratory symptoms (50%) and pain (48%). Volunteers and sampled residents differed significantly, mainly in socio-behavioural respects.

CONCLUSIONS

Common conditions including hypertension, arthritis and atrial fibrillation, are recorded in interRAI as text, and thus overlooked in interRAI reports. Levels of unmet need indicate opportunities to improve health services to better manage chronic conditions. Healthcare service providers and village operators could cooperate to design and test service initiatives that better meet residents' needs and offer cost benefits.

TRIAL REGISTRATION NUMBER

ACTRN12616000685415.

Study protocol: older people in retirement villages. A survey and randomised trial of a multi-disciplinary invention designed to avoid adverse outcomes

Background

There is increasing interest among older people in moving into retirement villages (RVs), an attractive option for those seeking a supportive community as they age, while still maintaining independence. Currently in New Zealand there is limited knowledge of the medical, service supports, social status and needs of RV residents. The objective of this study is to explore RV facilities and services, the health and functional status of RV residents, prospectively study their healthcare trajectories and to implement a multidisciplinary team intervention to potentially decrease dependency and impact healthcare utilization.

Methods

All RVs located in two large district health boards in Auckland, New Zealand were eligible to participate. This three-year project comprised three phases: The survey phase provided a description of RVs, residents’ characteristics and health and functional status. RV managers completed a survey of size, facilities and recreational and healthcare services provided in the village. Residents were surveyed to establish reasons for entry to the village and underwent a Gerontology Nurse Specialist (GNS) assessment providing details of demographics, social engagement, health and functional status. The cohort study phase examines residents’ healthcare trajectories and adverse outcomes, over three years. The final phase is a randomised controlled trial of a multidisciplinary team intervention aimed to improve health outcomes for more vulnerable residents.

Residents who triggered potential unmet health needs during the assessment in the survey phase were randomised to intervention or usual care groups. Multidisciplinary team meetings included the resident and support person, a geriatrician or gerontology nurse practitioner, GNS, pharmacist and General Practitioner. The primary outcome of the randomised controlled trial will be first acute hospitalization. Secondary outcomes include all acute hospitalizations, long-term care admissions, and all-cause mortality.

Discussion

This paper describes the study protocol of this complex study. The study aims to inform policies and practices around health care services for residents in retirement villages. The results of this trial are expected early 2020 with publication subsequently.

Trial registration

Australia and New Zealand Clinical Trials Registry: ACTRN12616000685415. Registered 25.5.2016.

Universal Trial Number (UTN): U111–1173-6083.

The population prevalence of undetected abdominal aortic aneurysm in New Zealand Māori

BACKGROUND

The prevalence of abdominal aortic aneurysm (AAA) in Polynesian populations such as the New Zealand Māori has not been characterized. We measured this in a large population-based sample.

METHODS

A cross-sectional population-based prevalence study was conducted as part of an AAA screening pilot; 2467 Māori men aged 54 to 74 years and 1526 women aged 65 to 74 years registered with a primary care practice in Auckland (New Zealand) were invited to be screened by abdominal ultrasound between June 2016 and March 2018. Patients with pre-existing AAA disease and those with terminal conditions or circumstances that would make them unlikely to benefit from screening were excluded. The prevalence rate of AAA in Māori women was calculated with a cutoff definition of 27 mm as well as with the normal 30-mm definition (used in men). A log-binomial regression model estimated the prevalence rate at exactly 65 years for the purpose of comparison with screened populations in the United Kingdom.

RESULTS

The crude prevalence rate of undiagnosed AAA in Māori men aged 60 to 74 years was 3.6%. In women, it was 1.7% at the 30-mm threshold and 2.3% at 27 mm. The prevalence rate at exactly 65 years of age was calculated from the log-binomial regression model to be 2.7% (confidence interval [CI], 2.0%-3.8%) in men, 0.9% (CI, 0.4%-2.2%) in women at the 30-mm threshold, and 1.5% (CI, 0.7%-3.0%) in women at the 27-mm threshold. Among smokers, the crude prevalence rates were 7.5% (CI, 4.9%-11.5%) in men and 6.9% (CI, 4.1%-11.5%) in women (30 mm+).

CONCLUSIONS

The prevalence of undiagnosed AAA in New Zealand Māori men is considerably higher than in screened populations of equivalent age in the United Kingdom and Sweden. Prevalence rates in New Zealand Māori women are close to those of screened British men. New Zealand should consider implementing a population-based screening program for Māori men and conduct further research into the health impact of screening Māori women.

Feasibility and reliability of clinical coding surveillance for the routine monitoring of adverse drug events in New Zealand hospitals

AIM

To explore the feasibility and reliability of Clinical Coding Surveillance (CCS) for the routine monitoring of Adverse Drug Events (ADE) and describe the characteristics of harm identified through this approach in a large district health board (DHB).

METHOD

All hospital admissions at Waitemata DHB from 2015 to 2016 with an ADE-related ICD10-AM code of Y40-Y59, X40-X49 or T36-T50 were extracted from clinical coded data. The data was analysed using descriptive statistics, statistical process control and Pareto charts. Two clinicians assessed a random sample of 140 ADEs for their accuracy against what was clinically documented in medical records.

RESULTS

A total of 11,999 ADEs were identified in 244,992 admissions (4.9 ADEs per 100 admissions). ADEs were more prevalent in older adults and associated with longer average length of stays and medicines such as analgesics, antibiotics, anticoagulants and diuretics. Only 2,164 (18%) of ADEs were classified as originating within hospital. Of ADEs originating outside of the hospital, the main causes were poisoning by psychotropics, anti-epileptics and anti-parkinsonism agents and non-opioid analgesics. Clinicians agreed that 91% of ADE positive admissions were accurately classified as per clinical documentation.

CONCLUSION

CCS is a feasible and reliable approach for the routine monitoring of ADEs in hospitals.

Reducing emergency presentations from long-term care: A before-and-after study of a multidisciplinary team intervention

INTRODUCTION

The complexity of care required by many older people living in long-term care (LTC) facilities poses challenges that can lead to potentially avoidable referrals to a hospital emergency department (ED). The Aged Residential Care Intervention Project (ARCHIP) ran an implementation study to evaluate a multidisciplinary team (MDT) intervention supporting LTC facility staff to decrease potentially avoidable ED presentations by residents.

METHODS

ARCHIP (conducted in 21 facilities [1,296 beds] with previously noted high ED referral rates) comprised clinical coaching for LTC facility staff by a gerontology nurse specialist (GNS) and an MDT (facility senior nurse, resident's general practitioner, GNS, geriatrician, pharmacist) review of selected high-risk residents' care-plans. A before-after repeated measures analysis was conducted for 9 months before and 9 months after intervention commencement (a 29-month period because of staggered facility enrolment). Modelling was adjusted for time trend, seasonality, facility size, and cluster effect.

RESULTS

ED admission rate ratio post- versus pre-intervention was 0.75 (95% C.I. 0.63, 0.89, p-value = 0.0008), a 25% reduction in ED presentations post-intervention. A sensitivity model used a shorter, staggered time period centred on intervention start (9 months pre-intervention and 9 months post-intervention) for each facility, and a four-level categorical intervention variable testing intervention effect over time. The sensitivity test showed a 24% reduction in ED presentations in months 1-3 post-intervention (p-value = 0.07), a 34% reduction in months 4-6 (p-value = 0.01), and a 32% reduction in ED presentations in months 7-9 (p-value = 0.03). However, when the higher ED referral rates for 3 months immediately pre-intervention were modelled, the impact of the intervention on ED presentation rates reverted almost to previous levels.

KEY CONCLUSIONS

A GNS-led MDT outreach intervention, targeted at selected conditions, decreases avoidable ED admissions of high-risk residents from selected facilities.

The trade-off between equity and efficiency in population health gain: Making it real

Two fundamental goals of health systems are to maximise overall population health gain (referred to as efficiency) and to minimise unfair health inequalities (equity). Often there is a trade-off in maximising efficiency vis a vis equity and the relative weight given to one goal over the other is acknowledged to be essentially a value judgement. Health systems necessarily make those value judgements but in making them would benefit from relevant and accurate opportunity cost information. Unfortunately the development of practical tools to measure equity-efficiency trade-offs has lagged theoretical advances in this area. We address this gap by presenting a practical technique to reveal opportunity costs of equity (and efficiency) gains in decentralised population-based health systems, applying stochastic data envelopment analysis to ethnic-specific life expectancy (LE) changes for 20 New Zealand (NZ) District Health Boards for the inter-census period 2006-2013, thereby deriving a notional health frontier from 10,000 Monte Carlo simulations. Four different ways to increase health equity emerge. These show that a trade-off between equity and efficiency does not always exist. In particular, improving both productive efficiency and allocative efficiency (up to its maximum) can also yield gains in equity through reductions in LE inequalities. However, in NZ's case, the opportunity cost (in sacrificed European life-years) of achieving gains in equity beyond the point of maximum productive and allocative efficiency is relatively high, even for quite small reductions in the LE gap between Māori and European populations. This high opportunity cost may explain why, despite governments' strong rhetorical commitment to equity, NZ's health gains have not strayed far from the path of maximising allocative efficiency. Nevertheless, this opportunity cost could be reduced significantly by measures which shift the health frontier outward, highlighting the importance of technical and organisational innovation as potential drivers of greater equity in health outcomes.

Pathways to ambulatory sensitive hospitalisations for Māori in the Auckland and Waitemata regions

AIM

Ambulatory Sensitive Hospitalisations (ASH) are a group of conditions potentially preventable through interventions delivered in the primary health care setting. ASH rates are consistently higher for Māori compared with non-Māori. This study aimed to establish Māori experience of factors driving the use of hospital services for ASH conditions, including barriers to accessing primary care.

METHOD

A telephone questionnaire exploring pathways to ASH was administered to Māori (n=150) admitted to Auckland and Waitemata District Health Board (DHB) hospitals with an ASH condition between January 1st-June 30th 2015.

RESULTS

A cohort of 1,013 participants were identified; 842 (83.1%) were unable to be contacted. Of the 171 people contactable, 150 agreed to participate, giving an overall response rate of 14.8% and response rate of contactable patients of 87.7%. Results demonstrated high rates of self-reported enrolment, utilisation and preference for primary care. Many participants demonstrated appropriate health seeking behaviour and accurate recall of diagnoses. While financial barriers to accessing primary care were reported, non-financial barriers including lack of after-hours provision (12.6% adults, 37.7% children), appointment availability (7.4% adults, 17.0% children) and lack of transport (13.7% adults, 20.8% children) also featured in participant responses.

CONCLUSIONS

Interventions to reduce Māori ASH include: timely access to primary care through electronic communications, increased appointment availability, extended opening hours, low cost after-hours care and consistent best management of ASH conditions in general practice through clinical pathways. Facilitated enrolment of ASH patients with no general practitioner could also reduce ASH. Research into transport barriers and enablers for Māori accessing primary care is required to support future interventions.

Is ‘Clicky Hip’ a Risk Factor in Developmental Dysplasia of the Hip?

Background: The role of the ‘clicky hip’ symptom as a prognostic predictor of developmental dysplasia of hip (DDH) is controversial. We aim to study the role of isolated hip clicks as a prognostic predictor of DDH. Material and methods: 235 babits with persisting or referred with clicky hip beyond six weeks of age were prospectively followed up to note the incidence of DDH. Of these 176 babies were referred for a hip click without additional risk factors. Results: 7 out of 176 cases (4 - IIa, 2 - IIb, 1 - IIc) had initial abnormal ultrasound examination based on Graf classification. However, all babies with isolated hip clicks eventually had normal hips on clinical and radiographic examination. Discussion: While screening of babies with clicky hips does help in diagnosing the odd case of DDH this is not consistently reproducible. Modifying the targeted ultrasound screening by including clicky hip as a risk factor will not reduce the incidence of missed cases. Isolated clicks in the hip joint beyond six weeks age are rarely a predictor of DDH. However when in doubt such cases should be referred to be reviewed by an orthopaedic surgeon or a radiologist experienced in hip ultrasound.

Do polypills lead to neglect of lifestyle risk factors? Findings from an individual participant data meta-analysis among 3140 patients at high risk of cardiovascular disease

AIM

The aim of this study was to investigate whether polypill-based care for the prevention of cardiovascular disease (CVD) is associated with a change in lifestyle risk factors when compared with usual care, among patients with CVD or high calculated cardiovascular risk.

METHODS

We conducted an individual participant data meta-analysis of three trials including patients from Australia, England, India, Ireland, the Netherlands and New Zealand that compared a strategy using a polypill containing aspirin, statin and antihypertensive therapy with usual care in patients with a prior CVD event or who were at high risk of their first event. Analyses investigated any differential effect on anthropometric measures and self-reported lifestyle behaviours.

RESULTS

Among 3140 patients (75% male, mean age 62 years and 76% with a prior CVD event) there was no difference in lifestyle risk factors in those randomised to polypill-based care compared with usual care over a median of 15 months, either across all participants combined, or in a range of subgroups. Furthermore, narrow confidence intervals (CIs) excluded any major effect; for example differences between the groups in body mass index was -0.1 (95% CI -0.2 to 0.1) kg/m(2), in weekly duration of moderate intensity physical activity was -2 (-26 to 23) minutes and the proportion of smokers was 16% vs 17% (RR 0.98, 0.84 to 1.15) at the end of trial.

DISCUSSION

This analysis allays concern that polypill-based care may lead to neglect of lifestyle risk factors, at least among high-risk patients. Maximally effective preventive approaches should address lifestyle factors alongside pharmaceutical interventions, as recommended by major international guidelines.

Ethnicity and risk of lower limb amputation in people with Type 2 diabetes: a prospective cohort study

AIM

Lower limb amputation is a serious complication of diabetic foot disease and there are unexplained ethnic variations in incidence. This study investigates the risk of amputation among different ethnic groups after adjusting for demographic, socio-economic status and clinical variables.

METHODS

We used primary care data from a large national multi-ethnic cohort of patients with Type 2 diabetes in New Zealand and linked hospital records. The primary outcome was time from initial data collection to first lower limb amputation. Demographic variables included age of onset and duration since diabetes diagnosis, gender, ethnicity and socio-economic status. Clinical variables included smoking status, height and weight, blood pressure, HbA1c , total cholesterol/HDL ratio and albuminuria. Cox proportional hazards models were used.

RESULTS

There were 892 lower limb amputations recorded among 62 002 patients (2.11 amputations per 1000 person-years), followed for a median of 7.14 years (422 357 person-years). After adjusting for demographic and socio-economic variables and compared with Europeans, Māori had the highest risk [hazard ratio (HR) 1.84 (95%CI:1.54-2.19)], whereas East Asians [HR 0.18, (0.08-0.44)] and South Asians [HR 0.39 (0.22-0.67)] had the lowest risk. Adjusting for available clinical variables reduced the differences but they remained substantial [HR 1.61 (1.35-1.93), 0.23 (0.10-0.56) and 0.48 (0.27-0.83), respectively].

CONCLUSIONS

Ethnic groups had significantly different risk of lower limb amputation, even after adjusting for demographic and some major clinical risk factors. Barriers to care should be addressed and intensive prevention strategies known to reduce the incidence of lower limb amputations could be prioritized to those at greatest risk.

Evaluation of a New Zealand program to improve transition of care for older high risk adults

Transition interventions aim to improve care and reduce hospital readmissions but evaluations of these interventions have reported inconsistent results. We report on the evaluation of an intervention implemented in Auckland, New Zealand. Participants were people over the age of 65 who had an acute medical admission and were at high risk of readmission. The intervention included an improved discharge process and nurse telephone follow-up soon after discharge. Outcomes were 28 day readmission rates and emergency attendances. The study is observational, using both interrupted times series and regression discontinuity designs. 5239 patients were treated over a one year period. There was no change in readmission rates or ED attendances or secondary outcomes. Not all patients received all components of the intervention. This transition intervention was not successful. Possible reasons for this and implications are discussed. Although non-experimental methods were used, we believe the results are robust.

Successful melanoma triage by a virtual lesion clinic (teledermatoscopy)

BACKGROUND

A Virtual Lesion Clinic (VLC) using teledermatoscopy was established to improve efficiency of the melanoma referral pathway.

OBJECTIVES

To assess diagnostic accuracy and to compare wait-times and costs of VLC and conventional clinics.

METHODS

Patients with suspected melanoma referred from primary care into a publicly funded health system attended local skin imaging centres, rather than hospital outpatient clinics. A teledermatologist assessed each lesion choosing specialist assessment/excision, General Practitioner (GP) follow-up, to re-image in 3 months, or self-monitoring/no concern.

RESULTS

613 skin lesions in 310 patients were evaluated over 12 months. Median time between receipt of referral and attendance at the VLC was 9 days compared to 26.5 days for standard outpatient assessment. Sixty-six percent (404/613) of lesions were considered benign, and 12% (73/613) were suspicious for melanoma. Of 129 lesions excised, 98 were skin cancers including 48 histologically confirmed melanomas with one spitzoid tumour of unknown malignant potential (STUMP), i.e. one melanoma per 1.59 suspected lesions biopsied and one melanoma in every 12.8 referred to the service. There were 49 non-melanoma skin cancers (NMSC). Teledermatoscopic diagnosis of melanomas was found to have a positive predictive value (PPV) of 63%. Compared to the conventional clinic, cost reductions from running the VLC for 1 year were in excess of NZ$364,000 (or NZ$1174/patient seen).

CONCLUSIONS

The VLC offered an efficient, accurate and cost effective way of processing suspected melanoma referrals to the public health system.

The Health Quality and Safety Commission: making good health care better

New Zealand has one of the best value health care systems in the world, but as a proportion of GDP our spending on health care has increased every year since 1999. Further, there are issues of quality and safety in our system we must address, including rates of adverse events. The Health Quality and Safety Commission was formed in 2010 as a crown agent to influence, encourage, guide and support improvement in health care practice in New Zealand. The New Zealand Triple Aim has been defined as: improved quality, safety and experience of care; improved health and equity for all populations; and best value for public health system resources. The Commission is pursuing the Triple Aim via two fundamental objectives: doing the right thing by providing care supported by the best evidence available, focused on what matters to each individual patient, and doing the right thing right, first time, by making sure health care is safe and of the highest quality possible. Improvement efforts must be supported by robust but economical measurements. New Zealand has a strong culture of quality, so the Commission's role is to work with our colleagues to make good health care better.

Effect of fixed dose combination treatment on adherence and risk factor control among patients at high risk of cardiovascular disease: randomised controlled trial in primary care

OBJECTIVE

To evaluate whether provision of fixed dose combination treatment improves adherence and risk factor control compared with usual care of patients at high risk of cardiovascular disease in primary care.

DESIGN

Open label randomised control trial: IMPACT (IMProving Adherence using Combination Therapy).

SETTING

54 general practices in the Auckland and Waikato regions of New Zealand, July 2010 to August 2013.

PARTICIPANTS

513 adults (including 257 indigenous Māori) at high risk of cardiovascular disease (established cardiovascular disease or five year risk ≥ 15%) who were recommended for treatment with antiplatelet, statin, and two or more blood pressure lowering drugs. 497 (97%) completed 12 months' follow-up.

INTERVENTIONS

Participants were randomised to continued usual care or to fixed dose combination treatment (with two versions available: aspirin 75 mg, simvastatin 40 mg, and lisinopril 10 mg with either atenolol 50 mg or hydrochlorothiazide 12.5 mg). All drugs in both treatment arms were prescribed by their usual general practitioners and dispensed by local community pharmacists.

MAIN OUTCOME MEASURES

Primary outcomes were self reported adherence to recommended drugs (antiplatelet, statin, and two or more blood pressure lowering agents) and mean change in blood pressure and low density lipoprotein cholesterol at 12 months.

RESULTS

Adherence to all four recommended drugs was greater among fixed dose combination than usual care participants at 12 months (81% v 46%; relative risk 1.75, 95% confidence interval 1.52 to 2.03, P<0.001; number needed to treat 2.9, 95% confidence interval 2.3 to 3.7). Adherence for each drug type at 12 months was high in both groups but especially in the fixed dose combination group: for antiplatelet treatment it was 93% fixed dose combination v 83% usual care (P<0.001), for statin 94% v 89% (P=0.06), for combination blood pressure lowering 89% v 59% (P<0.001), and for any blood pressure lowering 96% v 91% (P=0.02). Self reported adherence was highly concordant with dispensing data (dispensing of all four recommended drugs 79% fixed dose combination v 47% usual care, relative risk 1.67, 95% confidence interval 1.44 to 1.93, P<0.001). There was no statistically significant improvement in risk factor control between the fixed dose combination and usual care groups over 12 months: the difference in systolic blood pressure was -2.2 mm Hg (-4.5 v -2.3, 95% confidence interval -5.6 to 1.2, P=0.21), in diastolic blood pressure -1.2 mm Hg (-2.1 v -0.9, -3.2 to 0.8, P=0.22) and in low density lipoprotein cholesterol -0.05 mmol/L (-0.20 v -0.15, -0.17 to 0.08, P=0.46). The number of participants with cardiovascular events or serious adverse events was similar in both treatment groups (fixed dose combination 16 v usual care 18 (P=0.73), 99 v 93 (P=0.56), respectively). Fixed dose combination treatment was discontinued in 94 participants (37%). The most commonly reported reason for discontinuation was a side effect (54/75, 72%). Overall, 89% (227/256) of fixed dose combination participants' general practitioners completed a post-trial survey, and the fixed dose combination strategy was rated as satisfactory or very satisfactory for starting treatment (206/227, 91%), blood pressure control (180/220, 82%), cholesterol control (170/218, 78%), tolerability (181/223, 81%), and prescribing according to local guidelines (185/219, 84%). When participants were asked at 12 months how easy they found taking their prescribed drugs, most responded very easy or easy (224/246, 91% fixed dose combination v 212/246, 86% usual care, P=0.09). At 12 months the change in other lipid fractions, difference in EuroQol-5D, and difference in barriers to adherence did not differ significantly between the treatment groups.

CONCLUSIONS

Among this well treated primary care population, fixed dose combination treatment improved adherence to the combination of all recommended drugs but improvements in clinical risk factors were small and did not reach statistical significance. Acceptability was high for both general practitioners and patients, although the discontinuation rate was high.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12606000067572.

General practice ethnicity data: evaluation of a tool

INTRODUCTION

There is evidence that the collection of ethnicity data in New Zealand primary care is variable and that data recording in practices does not always align with the procedures outlined in the Ethnicity Data Protocols for the Health and Disability Sector. In 2010, The Ministry of Health funded the development of a tool to audit the collection of ethnicity data in primary care. The aim of this study was to pilot the Ethnicity Data Audit Tool (EAT) in general practice. The goal was to evaluate the tool and identify recommendations for its improvement.

METHODS

Eight general practices in the Waitemata District Health Board region participated in the EAT pilot. Feedback about the pilot process was gathered by questionnaires and interviews, to gain an understanding of practices' experiences in using the tool. Questionnaire and interview data were analysed using a simple analytical framework and a general inductive method.

FINDINGS

General practice receptionists, practice managers and general practitioners participated in the pilot. Participants found the pilot process challenging but enlightening. The majority felt that the EAT was a useful quality improvement tool for handling patient ethnicity data. Larger practices were the most positive about the tool.

CONCLUSION

The findings suggest that, with minor improvements to the toolkit, the EAT has the potential to lead to significant improvements in the quality of ethnicity data collection and recording in New Zealand general practices. Other system-level factors also need to be addressed.

General practice ethnicity data: evaluation of a tool

INTRODUCTION: There is evidence that the collection of ethnicity data in New Zealand primary care is variable and that data recording in practices does not always align with the procedures outlined in the Ethnicity Data Protocols for the Health and Disability Sector. In 2010, The Ministry of Health funded the development of a tool to audit the collection of ethnicity data in primary care. The aim of this study was to pilot the Ethnicity Data Audit Tool (EAT) in general practice. The goal was to evaluate the tool and identify recommendations for its improvement. METHODS: Eight general practices in the Waitemata District Health Board region participated in the EAT pilot. Feedback about the pilot process was gathered by questionnaires and interviews, to gain an understanding of practices’ experiences in using the tool. Questionnaire and interview data were analysed using a simple analytical framework and a general inductive method. FINDINGS: General practice receptionists, practice managers and general practitioners participated in the pilot. Participants found the pilot process challenging but enlightening. The majority felt that the EAT was a useful quality improvement tool for handling patient ethnicity data. Larger practices were the most positive about the tool. CONCLUSION: The findings suggest that, with minor improvements to the toolkit, the EAT has the potential to lead to significant improvements in the quality of ethnicity data collection and recording in New Zealand general practices. Other system-level factors also need to be addressed. KEYWORDS: Data collection; ethnicity; general practice; primary health care

The effect of Māori ethnicity misclassification on cervical screening coverage

AIM

There is a large difference in the cervical screening coverage rate between Māori and European women in New Zealand. This paper examines the extent to which this difference is due to misclassification of ethnicity.

METHODS

Data from Waitemata District Health Board's two Primary Health Organisations (PHOs) was used to identify the population of Waitemata domiciled women aged 25-69 years eligible for cervical screening. Their cervical screening status was obtained from the National Cervical Screening Programme register (NCPS-R). Data from Auckland and Waitemata DHBs was used to determine the women's ethnicity in the National Health Index (NHI). Women who had withdrawn from the NCSP-R, women who were deceased and women for whom an NHI ethnicity code could not be obtained were excluded from the analysis. Ethnicity codes from the three sources (PHO registers, NCSP-R and NHI) were compared to identify women classified as non-Māori in the NCSP-R but Maori in either of the other two data sources. The effect on Maori cervical screening coverage rates of not counting these women was assessed.

RESULTS

Within the study population there was a total of 6718 women identified as Māori on the NCSP of whom 5242 had been screened within the last 3 years and 1476 who had not. In addition to these, there were 2075 women identified as Māori in either the PHO or NHI databases but not in the NCSP-R who had been screened within the preceding 3 years, and a further 2094 who had not been screened. There were also 797 women identified as Maori in the NHI or PHO datasets who were not on the NCSP-R (and therefore were not screened). If all screened women classified as Māori from any source were counted, Waitemata DHB's Māori screening coverage rate would rise from 49.3% to 68.8% (or to 61.0% and 63.2% respective if just PHO and NHI Māori were counted).

CONCLUSION

Misclassification of ethnicity could explain (in absolute terms) up to 19.5% of the 35.0% difference in cervical screening coverage rate between Māori and non-Māori , non-Pacific, non-Asian coverage in Waitemata District. Misclassification is likely to have similar effects on coverage estimates throughout New Zealand. Without improving the accuracy of ethnicity data in the NCSP-R it will be impossible for the country to achieve the target coverage rate of 80% among Māori.

New Zealand Diabetes Cohort Study cardiovascular risk score for people with Type 2 diabetes: validation in the PREDICT cohort

INTRODUCTION

New Zealand (NZ) guidelines recommend treating people for cardiovascular disease (CVD) risk on the basis of five-year absolute risk using a NZ adaptation of the Framingham risk equation. A diabetes-specific Diabetes Cohort Study (DCS) CVD predictive risk model has been developed and validated using NZ Get Checked data.

AIM

To revalidate the DCS model with an independent cohort of people routinely assessed using PREDICT, a web-based CVD risk assessment and management programme.

METHODS

People with Type 2 diabetes without pre-existing CVD were identified amongst people who had a PREDICT risk assessment between 2002 and 2005. From this group we identified those with sufficient data to allow estimation of CVD risk with the DCS models. We compared the DCS models with the NZ Framingham risk equation in terms of discrimination, calibration, and reclassification implications.

RESULTS

Of 3044 people in our study cohort, 1829 people had complete data and therefore had CVD risks calculated. Of this group, 12.8% (235) had a cardiovascular event during the five-year follow-up. The DCS models had better discrimination than the currently used equation, with C-statistics being 0.68 for the two DCS models and 0.65 for the NZ Framingham model.

DISCUSSION

The DCS models were superior to the NZ Framingham equation at discriminating people with diabetes who will have a cardiovascular event. The adoption of a DCS model would lead to a small increase in the number of people with diabetes who are treated with medication, but potentially more CVD events would be avoided.

Improving the productivity of elective surgery through a new 'package of care'

In response to a need to improve the productivity and throughput of elective surgical services, one district health board (DHB) in New Zealand has introduced a 'package of care' (POC) in which incentive-based, risk-sharing contracts were developed collaboratively between DHB managers, surgeons and anaesthetists. The POC includes throughput targets and facilitates consistent surgical teams and the cohorting of patients. Whilst many staff are very supportive of the POC, some are of the view that it conflicts with the ideals and principles of working in a public health system, and creates inequities amongst the hospital staff. Analysis indicates that, after controlling for age, casemix and complexity the POC has resulted in shorter theatre times, shorter lengths of stay and lower average inpatient event costs compared with standard care at the public hospital. An unintended consequence could be that the POC may encourage throughput of less complex cases at the expense of more complex cases. The average complexity and range of cases performed publicly should be carefully monitored to ensure this does not occur.

Increasing productivity, reducing cost and improving quality in elective surgery in New Zealand: the Waitemata District Health Board joint arthroplasty pilot

BACKGROUND

In 2010, Waitemata District Health Board piloted a new model of care for total hip and knee arthroplasties. The pilot was incentive based and clinically led. The participating surgeons and anaesthetists were responsible for increasing surgical throughput. The pilot aimed to increase productivity, reduce cost and increase quality for patients.

AIM

To compare costs and outcomes for elective hip and knee arthroplasties carried out at the pilot site (Waitakere Hospital) compared with the main District Health Board hospital site (North Shore Hospital (NSH)).

METHODS

A retrospective matched cohort study of hip and knee replacements discharged between 1 July 2010 and 31 March 2011, comparing costs and outcomes at the pilot site compared with the NSH site. Only non-complex procedures were included, and routinely collected data were used.

RESULTS

One hundred and seventy-seven hip replacements (77 NSH, 100 pilot) and 158 knee replacements (88 NSH, 70 pilot) were analysed. Total inpatient event costs were 12% and 17% lower for hip and knee replacements, respectively, at the pilot site compared with NSH. Significant reduction in operation length (39% hip, 36% knee) and length of stay (38% hip, 39% knee) were found in the pilot groups compared with NSH.

CONCLUSION

Implementation of an innovative new model in a public hospital setting has produced significant increases in productivity and reduced overall costs. This model could potentially be used in other public healthcare settings for non-complex elective surgery.

New Zealand Diabetes Cohort Study cardiovascular risk score for people with Type 2 diabetes: validation in the PREDICT cohort

INTRODUCTION: New Zealand (NZ) guidelines recommend treating people for cardiovascular disease (CVD) risk on the basis of five-year absolute risk using a NZ adaptation of the Framingham risk equation. A diabetes-specific Diabetes Cohort Study (DCS) CVD predictive risk model has been developed and validated using NZ Get Checked data. AIM: To revalidate the DCS model with an independent cohort of people routinely assessed using PREDICT, a web-based CVD risk assessment and management programme. METHODS: People with Type 2 diabetes without pre-existing CVD were identified amongst people who had a PREDICT risk assessment between 2002 and 2005. From this group we identified those with sufficient data to allow estimation of CVD risk with the DCS models. We compared the DCS models with the NZ Framingham risk equation in terms of discrimination, calibration, and reclassification implications. RESULTS: Of 3044 people in our study cohort, 1829 people had complete data and therefore had CVD risks calculated. Of this group, 12.8% (235) had a cardiovascular event during the five-year follow-up. The DCS models had better discrimination than the currently used equation, with C-statistics being 0.68 for the two DCS models and 0.65 for the NZ Framingham model. DISCUSSION: The DCS models were superior to the NZ Framingham equation at discriminating people with diabetes who will have a cardiovascular event. The adoption of a DCS model would lead to a small increase in the number of people with diabetes who are treated with medication, but potentially more CVD events would be avoided. KEYWORDS: Cardiovascular disease; diabetes; prevention; risk assessment; reliability and validity

Trends in incidence and mortality from abdominal aortic aneurysm in New Zealand

BACKGROUND

This study examined trends in abdominal aortic aneurysm (AAA) incidence and mortality in New Zealand (NZ) and compared these with mortality rates from England and Wales.

METHODS

Cause-specific death data were obtained from the NZ Ministry of Health, UK Office for National Statistics and National Archives (for England and Wales). The NZ National Minimum Data Set provided hospital discharge data from July 1994 to June 2009.

RESULTS

In 2005-2007 the age-standardized AAA mortality rate for men was 33·3 per cent less in NZ than in England and Wales (5·21 versus 7·81 per 100 000), whereas for women it was 9·8 per cent less (2·12 versus 2·35 per 100 000). Standardized mortality rates in NZ fell by 53·0 per cent for men and 34·1 per cent for women from 1991 to 2007. Between 1991-1992 and 2005-2007 the probability of a 65-year-old dying from an AAA fell by 28·2 per cent (from 1·872 to 1·344 per cent) in men, and by 6·3 per cent (from 0·837 to 0·784 per cent) in women. New AAA admission and hospital death rates in NZ peaked in 1999 for men, and in 2001 for women, and have since declined sharply. Hospital mortality ratios have also fallen, except for women with a ruptured aneurysm.

CONCLUSION

The burden of AAA disease has been falling since at least 1991 in NZ, and since 1995 in England and Wales. Although survival appears to be improving, most of the reduction is due to lower disease incidence.

A theory-based video messaging mobile phone intervention for smoking cessation: randomized controlled trial

Background

Advances in technology allowed the development of a novel smoking cessation program delivered by video messages sent to mobile phones. This social cognitive theory-based intervention (called “STUB IT”) used observational learning via short video diary messages from role models going through the quitting process to teach behavioral change techniques.

Objective

The objective of our study was to assess the effectiveness of a multimedia mobile phone intervention for smoking cessation.

Methods

A randomized controlled trial was conducted with 6-month follow-up. Participants had to be 16 years of age or over, be current daily smokers, be ready to quit, and have a video message-capable phone. Recruitment targeted younger adults predominantly through radio and online advertising. Registration and data collection were completed online, prompted by text messages. The intervention group received an automated package of video and text messages over 6 months that was tailored to self-selected quit date, role model, and timing of messages. Extra messages were available on demand to beat cravings and address lapses. The control group also set a quit date and received a general health video message sent to their phone every 2 weeks.

Results

The target sample size was not achieved due to difficulty recruiting young adult quitters. Of the 226 randomized participants, 47% (107/226) were female and 24% (54/226) were Maori (indigenous population of New Zealand). Their mean age was 27 years (SD 8.7), and there was a high level of nicotine addiction. Continuous abstinence at 6 months was 26.4% (29/110) in the intervention group and 27.6% (32/116) in the control group (P = .8). Feedback from participants indicated that the support provided by the video role models was important and appreciated.

Conclusions

This study was not able to demonstrate a statistically significant effect of the complex video messaging mobile phone intervention compared with simple general health video messages via mobile phone. However, there was sufficient positive feedback about the ease of use of this novel intervention, and the support obtained by observing the role model video messages, to warrant further investigation.

Trial registration

Australian New Zealand Clinical Trials Registry Number: ACTRN12606000476538; http://www.anzctr.org.au/trial_view.aspx?ID=81688 (Archived by WebCite at http://www.webcitation.org/5umMU4sZi)

Derivation and validation of a new cardiovascular risk score for people with type 2 diabetes: the new zealand diabetes cohort study

OBJECTIVE

To derive a 5-year cardiovascular disease (CVD) risk equation from usual-care data that is appropriate for people with type 2 diabetes from a wide range of ethnic groups, variable glycemic control, and high rates of albuminuria in New Zealand.

RESEARCH DESIGN AND METHODS

This prospective open-cohort study used primary-care data from 36,127 people with type 2 diabetes without previous CVD to derive a CVD equation using Cox proportional hazards regression models. Data from 12,626 people from a geographically different area were used for validation. Outcome measure was time to first fatal or nonfatal cardiovascular event, derived from national hospitalization and mortality records. Risk factors were age at diagnosis, diabetes duration, sex, systolic blood pressure, smoking status, total cholesterol-to-HDL ratio, ethnicity, glycated hemoglobin (A1C), and urine albumin-to-creatinine ratio.

RESULTS

Baseline median age was 59 years, 51% were women, 55% were of non-European ethnicity, and 33% had micro- or macroalbuminuria. Median follow-up was 3.9 years (141,169 person-years), including 10,030 individuals followed for at least 5 years. At total of 6,479 first cardiovascular events occurred during follow-up. The 5-year observed risk was 20.8% (95% CI 20.3-21.3). Risk increased with each 1% A1C (adjusted hazard ratio 1.06 [95% CI 1.05-1.08]), when macroalbuminuria was present (2.04 [1.89-2.21]), and in Indo-Asians (1.29 [1.14-1.46]) and Maori (1.23 [1.14-1.32]) compared with Europeans. The derived risk equations performed well on the validation cohort compared with other risk equations.

CONCLUSIONS

Renal function, ethnicity, and glycemic control contribute significantly to cardiovascular risk prediction. Population-appropriate risk equations can be derived from routinely collected data.

Performance of Framingham cardiovascular risk scores by ethnic groups in New Zealand: PREDICT CVD-10

AIM

To compare the calibration performance of the original Framingham Heart Study risk prediction score for cardiovascular disease and an adjusted version of the Framingham score used in current New Zealand cardiovascular risk management guidelines for high and low risk ethnic groups.

METHODS

Since 2002 cardiovascular risk assessments have been undertaken as part of routine clinical care in many New Zealand primary care practices using PREDICT, a web-based decision support programme for assessing and managing cardiovascular risk. Individual risk profiles from PREDICT were electronically and anonymously linked to national hospital admissions and death registrations in January 2008. Calibration performance was investigated by comparing the observed 5-year cardiovascular event rates (deaths and hospitalisations) with predicted rates from the Framingham and New Zealand adjusted Framingham scores. Calibration was examined in a combined 'high risk' ethnic group (Maori, Pacific and Indian) and a European 'low risk' ethnic group. There was insufficient person-time follow-up for separate analyses in each ethnic group. The analyses were restricted to PREDICT participants aged 30-74 years with no history of previous cardiovascular disease.

RESULTS

Of the 59,344 participants followed for a mean of 2.11 years (125,064 person years of follow-up), 1,374 first cardiovascular events occurred. Among the 35,240 European participants, 759 cardiovascular events occurred during follow-up, giving a mean observed 5-year cumulative incidence of 4.5%. There were 582 events among the 21,026 Maori, Pacific and Indian participants, corresponding to a mean 5-year cumulative incidence rate of 7.4%. For Europeans, the original Framingham score overestimated 5-year risk by 0.7-3.2% at risk levels below 15% and by about 5% at higher risk levels. In contrast, for Maori, Pacific, and Indian patients combined, the Framingham score underestimated 5-year cardiovascular risk by 1.1-2.2% in participants who scored below 15% 5-year predicted risk (the recommended threshold for drug treatment in New Zealand), and overestimated by 2.4-4.1% the risk in those who scored above the 15% threshold. For both high risk and low risk ethnic groups, the New Zealand adjusted score systematically overestimated the observed 5-year event rate ranging from 0.6-5.3% at predicted risk levels below 15% to 5.4-9.3% at higher risk levels.

CONCLUSION

The original Framingham Heart Study risk prediction score overestimates risk for the New Zealand European population but underestimates risk for the combined high risk ethnic populations. However the adjusted Framingham score used in New Zealand clinical guidelines overcompensates for this underestimate, resulting in a score that overestimates risk among the European, Maori, Pacific and Indian ethnic populations at all predicted risk levels. When sufficient person years of follow-up are available in the PREDICT cohort, new cardiovascular risk prediction scores should be developed for each of the ethnic groups to allow for more accurate risk prediction and targeting of treatment.

An association between ethnicity and cardiovascular outcomes for people with Type 2 diabetes in New Zealand

AIMS

To investigate the association between ethnicity and risk of first cardiovascular (CV) event for people with Type 2 diabetes in New Zealand.

METHODS

A prospective cohort study using routinely collected data from a national primary health care diabetes annual review programme linked to national hospital admission and mortality data. Ethnicity was recorded as European, Maori, Pacific, Indo-Asian, East-Asian or Other. A Cox proportional hazards model was used to investigate factors associated with first CV event. Data was collected from 48,444 patients with Type 2 diabetes, with first data collected between 1 January 2000 and 20 December 2005, no previous cardiovascular event at entry and with complete measurements. Risk factors included ethnicity, gender, socio-economic status, body mass index, smoking, age at diagnosis, duration of diabetes, systolic blood pressure, serum lipids, glycated haemoglobin and urine albumin : creatinine ratio. The main outcome measures were time to first fatal or non-fatal CV event.

RESULTS

Median follow-up was 2.4 years. Using combined European and Other ethnicities as a reference, hazard ratios for first CV event were 1.30 for Maori (95% confidence interval 1.19-1.41), 1.04 for Pacific (0.95-1.13), 1.06 for Indo-Asian (0.91-1.24) and 0.73 for East-Asian (0.62-0.85) after controlling for all other risk factors.

CONCLUSIONS

Ethnicity was independently associated with time to first CV event in people with Type 2 diabetes. Maori were at 30% higher risk of first CV event and East-Asian 27% lower risk compared with European/Other, with no significant difference in risk for Pacific and Indo-Asian peoples.

The accuracy of ethnicity data in primary care and its impact on cardiovascular risk assessment and management--PREDICT CVD-8

BACKGROUND

Accurate ethnicity data are a prerequisite for evidence-based cardiovascular risk assessment and management according to national guidelines.

AIMS

(i) To investigate the accuracy of ethnicity data in primary care medical records by comparing them with self-identified ethnicity. (ii) To determine the clinical impact of ethnicity misclassification on cardiovascular risk assessment and management.

METHODS

A random sample of 870 patients from 18 general practices (who had ethnicity collected from their medical record as part of cardiovascular risk assessment using PREDICT, a web-based decision support tool) were sent a postal questionnaire asking their self-identified ethnicity using the 2001 Census ethnicity question.

RESULTS

Data were available for 665 people (77% response rate) who completed the postal questionnaire. Ethnicity in the primary care record and self-identified ethnicity from the questionnaire were identical for 68% of respondents at Statistics New Zealand Level 2 coding. Data concordance varied from 9.8% for the non-New Zealand European ethnic group to 90.9% for New Zealand European. The primary care record agreed with self-identified ethnicity for 64.9% of Maori respondents. Fortunately, when the same ethnicity data were categorised using the Statistics New Zealand ethnic group prioritisation rules and applied within PREDICT, which adds a risk weighting for Maori, Pacific, and Indian subcontinent peoples, the impact of misclassification was small. The main reason was that about half of misclassifications occurred between ethnic groups classified in the same high cardiovascular risk category. For about 6% of Maori, Pacific, and Indian subcontinent people in our study this misclassification could potentially have delayed risk assessment and resulted in under-treatment. In contrast, about 1.5% of those with other ethnicities may have undergone a premature risk assessment and been over-treated.

CONCLUSION

The clinical impact of ethnicity misclassification on cardiovascular risk assessment and management in primary care is modest because much of the misclassification does not alter cardiovascular risk classification. Nevertheless, efforts to improve the accuracy of ethnicity classification in primary care need to continue in order to support the sector's ability to monitor health service utilisation, outcomes, and performance related indicators.

Cardiovascular risk management of different ethnic groups with type 2 diabetes in primary care in New Zealand

AIMS

To examine cardiovascular preventive and renal protective treatment for different ethnic groups with diabetes in primary care.

METHODS

The study population included patients with type 2 diabetes attending an annual review in New Zealand primary care during 2004. Primary care data were linked to hospital admission data to identify previous cardiovascular disease (CVD). For those without previous CVD, 5-year cardiovascular risk was calculated. Proportions on, and predictors of appropriate treatment according to guidelines were investigated.

RESULTS

Data were available on 29,179 patients. Maori and Pacific participants had high rates of obesity, poor glycaemic control and albuminuria. Two thirds of all participants with previous CVD (68% of Maori and 70% of Pacific) and 44% with high CVD risk received appropriate CVD treatment; 73% of Maori, 62% of Pacific and 65% of European patients with albuminuria received ACE-inhibitors. Those with high CVD risk were more likely, and those that were young were less likely, to receive anti-hypertensive and lipid-lowering treatment after controlling for other factors.

CONCLUSION

Maori and Pacific people were receiving similar high rates of appropriate CVD and renal preventive drug therapy to Europeans, but their prevalence of smoking, obesity, raised HbA1c and albuminuria were substantially higher. Non-drug components of preventive care also need to be addressed to reduce major ethnic disparities in diabetes-related morbidity and mortality in New Zealand.