Emergency department crowding is not being caused by increased inappropriate presentations.

Contrary to the prevailing wisdom, there may be little or no room to move with respect to reducing emergency department (ED) utilisation, as ED utilisation in Aotearoa New Zealand is low by world standards and is not driven by patients presenting inappropriately with minor conditions. We should continue the excellent work done in the primary care sector to maintain our low ED presentation rate and support primary and urgent care providers to provide alternatives to the ED for people with minor conditions. However, to reduce the system pressure and harms caused by ED crowding due to access block for admitted patients, we also need to adequately resource our hospital-based inpatient teams and EDs so that the (appropriate) acute care workload can be managed safely.

Variation in gout care in Aotearoa New Zealand: a national analysis of quality markers.

AIM: To examine whether there was variation in markers for the quality of gout care using national linked data for the entire Aotearoa New Zealand population. METHOD: Data drawn for the New Zealand Atlas of Healthcare Variation was used to examine regularity of allopurinol dispensing, laboratory testing for serum urate, and acute hospitalisation for gout. Standardised rates by age, gender, ethnicity and District Health Board (DHB) of domicile were calculated. RESULTS: For New Zealanders aged 20-79 years with gout, 57% were dispensed allopurinol in 2010/11. Of these, 69% were receiving allopurinol regularly, and only 34% of people dispensed allopurinol had serum urate testing in a 6-month period. The annual hospitalisation rate was 1% of people with gout. Maori and Pacific people with gout were less likely to be on regular allopurinol treatment, despite having more than twice the chance of being hospitalised with acute gout. CONCLUSION: We have demonstrated that routinely collected health data can be used to monitor the quality of care for people with gout at a high level. Primary care initiatives that focus on ensuring a continuous supply of urate-lowering therapy to achieve therapeutic serum urate targets are required to improve the impact of gout in Aotearoa New Zealand.

Developing a tool to monitor potentially avoidable and ambulatory care sensitive hospitalisations in New Zealand children.

BACKGROUND: In New Zealand there has been increasing interest in reducing avoidable hospitalisations, particularly from conditions treatable in primary care. To date avoidable hospitalisations in children have been monitored using adult tools which contain many conditions irrelevant to children. Further, New Zealand has large socioeconomic gradients in hospitalisations for many paediatric conditions, suggesting that the social determinants of health also heavily influence avoidable hospitalisations in this age group. AIMS: (1) To develop a tool to monitor potentially avoidable hospitalisations in New Zealand children which includes the socioeconomic determinants of health within the conceptualisation of "avoidable"; and (2) Within this broader framework, to identify a sub-set of conditions which are amenable to intervention in primary care. METHODS: Five selection criteria were developed to define Potentially Avoidable Hospitalisations (PAH), and a further two criteria were used to define a subset of Ambulatory Care Sensitive Hospitalisations (ACSH). The principal diagnoses for all acute hospitalisations in New Zealand children (1 month-14 years) during 2003-2005 were then reviewed, and a list of 42 conditions created. This list was sent to 17 health professionals with experience in child health, who were asked to score each condition against the 5 PAH and 2 ACSH criteria. RESULTS: Twenty-six conditions contributing to PAH were identified, along with 18 contributing to ACSH. PAH tended to be infectious or respiratory in nature, with hospitalisations for chronic medical conditions or surgical problems being viewed as non-avoidable. While a similar pattern was seen for ACSH, viral infections were viewed as non-ambulatory care sensitive. CONCLUSIONS: While the tools developed are a considerable improvement on those used to date, the use of diagnostic coding algorithms to monitor ACSH and by inference, the performance of primary care, remains problematic for a number of reasons. Nevertheless, the broadening of PAH to encompass the wider determinants of health, serves to highlight the role Government social and other policies might play in reducing the large burden of avoidable morbidity currently being experienced in this age group.

Measuring potentially avoidable and ambulatory care sensitive hospitalisations in New Zealand children using a newly developed tool.

OBJECTIVES: To use a newly developed tool to measure Potentially Avoidable (PAH) and Ambulatory Care Sensitive (ACSH) Hospitalisations in New Zealand children. To consider whether these tools provide any insights into the role policies or programmes which address the underlying determinants of health (e.g. poor housing, exposure to cigarette smoke, child poverty) might play in reducing hospitalisations in this age group. METHODS: All acute and semi acute (<1 week of referral) hospitalisations in New Zealand children aged 29 days-14 years, during 2000-2009 were included, along with all hospitalisations for selected dental conditions. The newly developed PAH and ACSH tools were used to determine category membership, with explanatory variables including age, gender, ethnicity and NZ Deprivation index decile. RESULTS: During 2005-2009, 47.4% of all acute paediatric hospitalisations were considered to be PAH, 34.3% to be ACSH, and 9.7% to be non-avoidable. A further 42.9% were for non-classified conditions. Dental conditions and gastroenteritis were the leading causes of both PAH and ACSH. PAH and ACSH were highest in infants and one year olds, while non-avoidable hospitalisations were more evenly distributed throughout childhood. PAH and ACSH were higher for those from deprived areas and for Pacific and Maori children. Socioeconomic differences for non-avoidable hospitalisations were less marked, with rates being lowest in Maori and Asian children. DISCUSSION: Large social gradients in ACSH suggest that New Zealand needs to implement policies to increase access to primary care for Pacific and Maori children and those living in more deprived areas. With the majority of presentations being for acute onset infectious and respiratory diseases, such policies must take into account the need for immediate (i.e. same day) and after hours access to primary care. The narrow windows of opportunity (hours-days) available for primary care to prevent hospitalisations for ambulatory sensitive conditions also suggests that New Zealand needs to develop policies and strategies to reduce the underlying burden of disease in the community.