Treatment drop-in in a contemporary cohort used to derive cardiovascular risk prediction equations.

BACKGROUND: No routinely recommended cardiovascular disease (CVD) risk prediction equations have adjusted for CVD preventive medications initiated during follow-up (treatment drop-in) in their derivation cohorts. This will lead to underestimation of risk when equations are applied in clinical practice if treatment drop-in is common. We aimed to quantify the treatment drop-in in a large contemporary national cohort to determine whether equations are likely to require adjustment. METHODS: Eight de-identified individual-level national health administrative datasets in Aotearoa New Zealand were linked to establish a cohort of almost all New Zealanders without CVD and aged 30-74 years in 2006. Individuals dispensing blood-pressure-lowering and/or lipid-lowering medications between 1 July 2006 and 31 December 2006 (baseline dispensing), and in each 6-month period during 12 years' follow-up to 31 December 2018 (follow-up dispensing), were identified. Person-years of treatment drop-in were determined. RESULTS: A total of 1 399 348 (80%) out of the 1 746 695 individuals in the cohort were not dispensed CVD medications at baseline. Blood-pressure-lowering and/or lipid-lowering treatment drop-in accounted for 14% of follow-up time in the group untreated at baseline and increased significantly with increasing predicted baseline 5-year CVD risk (12%, 31%, 34% and 37% in <5%, 5-9%, 10-14% and ≥15% risk groups, respectively) and with increasing age (8% in 30-44 year-olds to 30% in 60-74 year-olds). CONCLUSIONS: CVD preventive treatment drop-in accounted for approximately one-third of follow-up time among participants typically eligible for preventive treatment (≥5% 5-year predicted risk). Equations derived from cohorts with long-term follow-up that do not adjust for treatment drop-in effect will underestimate CVD risk in higher risk individuals and lead to undertreatment. Future CVD risk prediction studies need to address this potential flaw.

Maori and Pacific families' experiences and perspectives of cardiovascular care; A qualitative study.

OBJECTIVE: This study aimed to understand the reasons behind evidence-practice gaps and inequities in cardiovascular care for Maori and Pacific people, as evidenced by the experiences and perspectives of patients and their families. METHODS: The research was guided by Maori and Pacific worldviews, incorporating Kaupapa Maori Theory and Pacific conceptual frameworks and research methodologies. Template analysis was used to analyse interview data from 61 Maori and Pacific people who had experienced a cardiovascular disease (CVD) risk assessment, acute coronary syndrome, and/or heart failure. RESULTS: The range of experiences relating to participants' heart health journeys are presented in five main themes: Context, Mana (maintaining control and dignity), Condition, People and Journey. CONCLUSIONS: Maori and Pacific people want to take charge of their heart health but face challenges. Participants described important obligations to family, community and tikanga (the culturally correct way of doing things). Participants described times when health care undermined existing responsibilities, their dignity and/or their mana, and they felt excluded from treatment as a result. IMPLICATIONS FOR PUBLIC HEALTH: Good reciprocal communication, stemming from a high-quality relationship is essential for successful outcomes. A workforce that is representative of the population it serves and is culturally safe lays the foundation for excellence in care.

Selective under-representation of Pacific peoples in population estimates for health indicator measurements in Aotearoa New Zealand misinforms policy making.

BACKGROUND: The Census of Populations and Dwellings' is the five yearly population count of Aotearoa New Zealand. Best available populations (BAP) are subnational projections based on census data and demographic assumptions developed for healthcare planning and funding allocation but are also used as the denominator for health indicator monitoring. Pacific people are systematically undercounted, but the impact on health statistics is not well studied. For COVID-19 vaccination coverage, health service user (HSU) data were considered a more reliable denominator than BAP but introduced new biases. We aimed to understand how the choice of denominator population impacts estimates of population size and health system performance for Pacific people at a local level. METHODS: We described how declining census response rates affected population data quality. We compared BAP and HSU data at district level. For the indicators 'access to primary care' and 'cervical cancer screening uptake' we replaced currently used BAP denominators with HSU and examined the impact for different ethnic groups in different geographic districts. RESULTS: Overall Census 2018 response declined by 10%, but for Maori and Pacific people by 21% and 23%, respectively. This inequitably affected BAP accuracy. Census undercount was highest in the district with the largest Pacific populations, where HSU exceeded BAP most. Notably, 'access to primary care' for Pacific people in this district consistently exceeds 100%. Using BAP, both health indicators are currently estimated as highest for Pacific people compared to other ethnic groups, but when based on HSU, they dropped to lowest. Similar, but less pronounced trends occurred in other districts. Changes in trends over time for both indicators coincided mostly with adjustments in BAP, rather than changes in the numerators. CONCLUSIONS: The current use of BAP denominators for health statistics does not enable reliable monitoring of key health indicators for Pacific people. HSU denominators are also unsuitable for monitoring health. Exploring the feasibility of a real-time population register is strongly recommended as a new, transparent, way of obtaining more reliable, timely population data to guide policymaking and underpin a more equitable health system under the health reforms. Meanwhile, reporting of ethnic specific outcomes need to include a clear assessment of the potential for bias due to inaccurate population estimates.

The Prevalence and Management of Atrial Fibrillation in New Zealand Maori Detected through an Abdominal Aortic Aneurysm Screening Program.

BACKGROUND: Atrial fibrillation (AF) screening was incorporated into an abdominal aortic aneurysm screening (AAA) program for New Zealand (NZ) Maori. METHODS: AF screening was performed as an adjunct to AAA screening of Maori men aged 60-74 years and women aged 65-74 years registered with primary health care practices in Auckland, NZ. Pre-existing AF was determined through coded diagnoses or medications in the participant's primary care record. Subsequent audit of the record assessed accuracy of pre-screening coding, medication use and clinical follow-up. RESULTS: Among 1,933 people successfully screened, the prevalence of AF was 144 (7.4%), of which 46 (2.4% of the cohort) were patients without AF coded in the medical record. More than half of these were revealed to be known AF but that was not coded. Thus, the true prevalence of newly detected AF was 1.1% (n=21). An additional 48 (2.5%) of the cohort had been coded as AF but were not in AF at the time of screening. Among the 19 at-risk screen-detected people with AF, 10 started appropriate anticoagulation therapy within 6 months. Of the nine patients who did not commence anticoagulation therapy, five had a subsequent adverse clinical outcome in the follow-up period, including one with ischaemic stroke; two had contraindications to anticoagulants. Among those with previously diagnosed AF, the proportion receiving anticoagulation therapy rose from 57% pre-screening to 83% at 6 months post-screening (p<0.0001); among newly diagnosed AF the proportion rose from 0% to 53% (p<0.01). CONCLUSIONS: AF screening is a feasible low-cost adjunct to AAA screening with potential to reduce ethnic inequities in stroke incidence. However, effective measures are needed to ensure that high-risk newly diagnosed AF is managed according to best practice guidelines.

2023 position statement on improving management for patients with heart failure in Aotearoa New Zealand.

Heart failure affects 1-3% of the population and remains a major public health problem, with high rates of hospitalisation and mortality. Health inequities in the incidence of heart failure have widened over the last 13 years in Aotearoa New Zealand. Urgent action is required to address the inequitable burden of heart failure among Maori and Pasifika. Regional and international heart failure guidelines now provide clear and consistent guidance on the contemporary approach to management for patients with heart failure. The purpose of this position statement is to ensure that all people in Aotearoa New Zealand have access to optimal healthcare delivery and pharmacotherapy for contemporary management of heart failure. Three main areas are addressed, including: 1) access to evidence-based pharmacotherapy for patients with heart failure, 2) the importance of early initiation and titration of pharmacotherapy, and 3) the workforce required to ensure timely delivery of heart failure therapies. Implementation of evidence-based healthcare will ensure all patients with heart failure in Aotearoa New Zealand have opportunity for substantial improvement in health.

Widening ethnic inequities in heart failure incidence in New Zealand.

OBJECTIVE: Ethnic inequities in heart failure (HF) have been documented in several countries. This study describes New Zealand (NZ) trends in incident HF hospitalisation by ethnicity between 2006 and 2018. METHODS: Incident HF hospitalisations in ≥20-year-old subjects were identified through International Classification of Diseases, 10th Revision-coded national hospitalisation records. Incidence was calculated for different ethnic, sex and age groups and were age standardised. Trends were estimated with joinpoint regression. RESULTS: Of 116 113 incident HF hospitalisations, 12.8% were Maori, 5.7% Pacific people, 3.0% Asians and 78.6% Europeans/others. 64% of Maori and Pacific patients were aged <70 years, compared with 37% of Asian and 19% of European/others. In 2018, incidence rate ratios compared with European/others were 6.0 (95% CI 4.9 to 7.3), 7.5 (95% CI 6.0 to 9.4) and 0.5 (95% CI 0.3 to 0.8) for Maori, Pacific people and Asians aged 20-49 years; 3.7 (95% CI 3.4 to 4.0), 3.6 (95% CI 3.2 to 4.1) and 0.5 (95% CI 0.4 to 0.6) for Maori, Pacific people and Asians aged 50-69 years; and 1.5 (95% CI 1.4 to 1.6), 1.5 (95% CI 1.3 to 1.7) and 0.5 (95% CI 0.5 to 0.6) for Maori, Pacific people and Asians aged ≥70 years. Between 2006 and 2018, ethnicity-specific rates diverged in ≥70-year-old subjects due to a decline in European/others (annual percentage change (APC) -2.0%, 95% CI -2.5% to -1.6%) and Asians (APC -3.3%, 95% CI -4.4% to -2.1%), but rates remained unchanged for Maori and Pacific people. In contrast, regardless of ethnicity, rates either increased or remained unchanged in <70-year-old subjects. CONCLUSION: Ethnic inequities in incident HF hospitalisation have widened in NZ over the past 13 years. Urgent action is required to address the predisposing factors that lead to development of HF in Maori and Pacific people.

Development and validation of cardiovascular risk prediction equations in 76 000 people with known cardiovascular disease.

AIMS: Multiple health administrative databases can be individually linked in Aotearoa New Zealand, using encrypted identifiers. These databases were used to develop cardiovascular risk prediction equations for patients with known cardiovascular disease (CVD). METHODS AND RESULTS: Administrative health databases were linked to identify all people aged 18-84 years with known CVD, living in Auckland and Northland, Aotearoa New Zealand, on 1 January 2014. The cohort was followed until study outcome, death, or 5 years. The study outcome was death or hospitalization due to ischaemic heart disease, stroke, heart failure, or peripheral vascular disease. Sex-specific 5-year CVD risk prediction equations were developed using multivariable Fine and Gray models. A total of 43 862 men {median age: 67 years [interquartile range (IQR): 59-75]} and 32 724 women [median age: 70 years (IQR: 60-77)] had 14 252 and 9551 cardiovascular events, respectively. Equations were well calibrated with good discrimination. Increasing age and deprivation, recent cardiovascular hospitalization, Mori ethnicity, smoking history, heart failure, diabetes, chronic renal disease, atrial fibrillation, use of blood pressure lowering and anti-thrombotic drugs, haemoglobin A1c, total cholesterol/HDL cholesterol, and creatinine were statistically significant independent predictors of the study outcome. Fourteen per cent of men and 23% of women had predicted 5-year cardiovascular risk <15%, while 28 and 24% had ≥40% risk. CONCLUSION: Robust cardiovascular risk prediction equations were developed from linked routine health databases, a currently underutilized resource worldwide. The marked heterogeneity demonstrated in predicted risk suggests that preventive therapy in people with known CVD would be better informed by risk stratification beyond a one-size-fits-all high-risk categorization.

Using regionwide New Zealand health databases, methods of predicting hospitalization risk in patients with existing heart disease were developed. Using only data from health databases, it was possible to predict the risk accurately.Among patients with existing heart disease, the predicted risk varied markedly which could help improve preventive strategies.

Investigation and treatment after non-ST segment elevation acute coronary syndrome for patients presenting to rural or urban hospitals in Aotearoa New Zealand: ANZACS-QI 75.

AIMS: Compare the care patients with non-ST segment elevation acute coronary syndrome (NSTEACS) received in Aotearoa New Zealand depending on the rural-urban category of the hospital they are first admitted to. METHODS: Patients with NSTEACS investigated with invasive coronary angiogram between 1 January 2014 and 31 December 2019 were included. There were three hospital categories (routine access to percutaneous coronary intervention [urban interventional], other urban [urban non-interventional] and rural) and three ethnicity categories (Maori, Pacific and non-Maori/non-Pacific). Clinical performance measures included: angiography ≤3 days, assessment of left ventricular ejection fraction (LVEF) and prescription of secondary prevention medication. RESULTS: Of 26,779 patients, 66.2% presented to urban-interventional, 25.6% to urban non-interventional and 8.2% to rural hospitals. A smaller percentage of patients presenting to urban interventional than urban non-interventional and rural hospitals were Maori (8.1%, 17.0% and 13.0%). Patients presenting to urban interventional hospitals were more likely to receive timely angiography than urban non-interventional or rural hospitals (78.5%, 60.8% and 63.1%). They were also more likely to have a LVEF assessment (78.5%, 65.4% and 66.3%). In contrast, the use of secondary prevention medications at discharge was similar between hospital categories. Maori and Pacific patients presenting to urban interventional hospitals were less likely than non-Maori/non-Pacific to receive timely angiography but more likely to have LVEF assessed. However, LVEF assessment and timely angiography in urban non-interventional and rural hospitals were lower than in urban interventional hospitals for both Maori and non-Maori/non-Pacific. CONCLUSIONS: Patients presenting to urban hospitals without routine interventional access and rural hospitals were less likely to receive LVEF assessment or timely angiography. This disproportionately impacts Maori, who are more likely to live in these hospital catchments.

Call to action-the urgent need for a heart health plan in New Zealand.

Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Maori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.

Ethnic differences of the care pathway following an out-of-hospital cardiac event: A systematic review.

AIM: This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations. METHODS: A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines. RESULTS: Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies. CONCLUSION: The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations.

Reasons for Ethnic Disparities in the Prehospital Care Pathway Following an Out-of-Hospital Cardiac Event: Protocol of a Systematic Review.

BACKGROUND: Substantial inequities in cardiovascular disease occur between and within countries, driving much of the current burden of global health inequities. Despite well-established treatment protocols and clinical interventions, the extent to which the prehospital care pathway for people who have experienced an out-of-hospital cardiac event (OHCE) varies by ethnicity and race is inconsistently documented. Timely access to care in this context is important for good outcomes. Therefore, identifying any barriers and enablers that influence timely prehospital care can inform equity-focused interventions. OBJECTIVE: This systematic review aims to answer the question: Among adults who experience an OHCE, to what extent and why might the care pathways in the community and outcomes differ for minoritized ethnic populations compared to nonminoritized populations? In addition, we will investigate the barriers and enablers that could influence variations in the access to care for minoritized ethnic populations. METHODS: This review will use Kaupapa Maori theory to underpin the process and analysis, thus prioritizing Indigenous knowledge and experiences. A comprehensive search of the CINAHL, Embase, MEDLINE (OVID), PubMed, Scopus, Google Scholar, and Cochrane Library databases will be done using Medical Subject Headings terms themed to the 3 domains of context, health condition, and setting. All identified articles will be managed using an Endnote library. To be included in the research, papers must be published in English; have adult study populations; have an acute, nontraumatic cardiac condition as the primary health condition of interest; and be in the prehospital setting. Studies must also include comparisons by ethnicity or race to be eligible. Those studies considered suitable for inclusion will be critically appraised by multiple authors using the Mixed Methods Appraisal Tool and CONSIDER (Consolidated Criteria for Strengthening the Reporting of Health Research Involving Indigenous Peoples) framework. Risk of bias will be assessed using the Graphic Appraisal Tool for Epidemiology. Disagreements on inclusion or exclusion will be settled by a discussion with all reviewers. Data extraction will be done independently by 2 authors and collated in a Microsoft Excel spreadsheet. The outcomes of interest will include (1) symptom recognition, (2) patient decision-making, (3) health care professional decision-making, (4) the provision of cardiopulmonary resuscitation, (5) access to automated external defibrillator, and (6) witnessed status. Data will be extracted and categorized under key domains. A narrative review of these domains will be conducted using Indigenous data sovereignty approaches as a guide. Findings will be reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. RESULTS: Our research is in progress. We anticipate the systematic review will be completed and submitted for publication in October 2023. CONCLUSIONS: The review findings will inform researchers and health care professionals on the experience of minoritized populations when accessing the OHCE care pathway. TRIAL REGISTRATION: PROSPERO CRD42022279082; https://tinyurl.com/bdf6s4h2. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/40557.

How pharmacist-led health services are tailored to minoritized populations, their acceptability and effectiveness: A scoping literature review.

BACKGROUND: Worldwide, minoritized populations experience inequitable health risks and outcomes. The importance of offering tailored services to meet the specific needs of target populations should be addressed during service development. Within healthcare systems, pharmacists play a crucial role in supporting patients to manage their medicines and health conditions. OBJECTIVES: This scoping review aims to identify, collate and analyse literature describing pharmacist-led services tailored for minoritized populations in order to strengthen the knowledge base and support for achieving health equity. METHODS: A scoping review was guided by the PRISMA-ScR checklist and the five-stage process outlined by Arksey and O'Malley. Medline, EMBASE, Scopus, CINAHL Plus, International Pharmaceutical Abstracts, and Google Scholar databases, plus grey literature were searched to identify relevant studies published up to October 2022. Texts were included if they reported on a pharmacist-led health service tailored to meet the needs of a minoritized population. The review protocol was registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/E8B7D). RESULTS: Of the 566 records initially identified, 16 full-text articles were assessed for eligibility and 9 articles describing 6 unique services met the criteria and were included in the review. Three services were non-health-condition-specific, 2 targeted type two diabetes and 1 focussed on opioid dependency disorders. Service acceptability was consistently explored, and all services ensured that pharmacists' views were considered. However, only 4 consulted with the people from the group that the service targeted. Where reported, the effectiveness was not comprehensively evaluated. CONCLUSION: There is limited literature in this area and a critical need for more evidence on the effectiveness of pharmacist-led services for minoritized populations. We need a better understanding of how pharmacists contribute to health equity pathways and how to expand this. Doing so will inform future services and contribute towards achieving equitable health outcomes.

Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72.

AIM: This study's aim was to identify differences in invasive angiography performed and health outcomes for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) presenting to either i) a rural hospital, or an urban hospital ii) with or iii) without routine access to percutaneous intervention (PCI) in New Zealand. METHODS: Patients with NSTEACS between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to model each of the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding. RESULTS: There were 42,923 patients included. Compared to urban hospitals with access to PCI, the odds of a patient receiving an angiogram were reduced for rural and urban hospitals without routine access to PCI (odds ratio [OR] 0.82 and 0.75) respectively. There was a small increase in the odds of dying at 2 years (OR 1.16), but not 30 days or 1 year for patients presenting to a rural hospital. CONCLUSION: Patients who present to hospitals without PCI are less likely to receive angiography. Reassuringly there is no difference in mortality, except at 2 years, for patients that present to rural hospitals.

Interventions designed to improve uptake of allopurinol for gout treatment in Aotearoa New Zealand: a scoping review.

Introduction Gout in Aotearoa New Zealand (NZ) remains an equity issue. The prevalence in Pacific and Maori people is one of the highest internationally. Although Pacific and Maori experience earlier onset and higher burden of gout, which can severely impact their quality of life, their management of it is often sub-optimal. Aim To conduct a scoping review of the NZ literature for interventions to improve the uptake/management of allopurinol for gout and their evaluation. Methods Databases Medline, Scopus, Embase, and CINAHL Plus and the grey literature were searched systematically to identify all NZ intervention studies aiming to improve allopurinol uptake for gout treatment. Interventions included: if they were delivered in NZ, aimed to improve allopurinol uptake, and were provided in English. A narrative approach was used to extract and synthesise data. Results Eighteen peer-reviewed and grey literature publications met the search criteria. Interventions clustered into three domains: multifaceted or multi-practitioner; gout app; and online booklets or fact sheets. Serum urate levels improved in multi-faceted or multi-practitioner interventions only, whereas the gout app only improved patients' awareness and understanding of gout and medications. Online fact sheets and booklets need more active utilisation from health professionals to improve gout health literacy. Discussion Most gout interventions in NZ use multifaceted or multi-practitioner approaches. Although most interventions successfully controlled serum urate levels and improved equitable access for gout patients to urate-lowering therapy, these interventions did not sustain retention, completion, and engagement for certain population groups, particularly Pacific and Maori, who experience a higher burden of gout.

The August 2020 COVID-19 outbreak in Aotearoa, New Zealand: Delayed contact tracing for Pacific people contributes to widening health disparities.

Background: After COVID-19 arrived in New Zealand, a national system was developed to improve the efficiency of contact tracing. The first outbreak was followed by a period of 'COVID-19 elimination', until a community outbreak occurred in August 2020. We describe the characteristics of cases and their contacts during this outbreak, focused on the results of contact tracing. Methods: COVID-19 case data from the national surveillance database were linked to contacts from the national contact tracing database. Demographic and clinical characteristics of cases, number of contacts, and timeliness of contact tracing were analysed by ethnicity. Findings: Most of the 179 cases were Pacific people (59%) or Maori (25%), living in areas of high socioeconomic deprivation, who had higher rates of comorbidity and accounted for almost all (21/22) hospitalisations, all 8 ICU admissions and all 3 deaths. Only 6% belonged to the European majority ethnic group. Of 2,528 registered contacts, 46% were Pacific, 14% Maori and 19% European. Only contacts that were reached were registered. Overall, 41% of contacts were reached within 4 days of onset of disease of the case, which was significantly lower for Pacific (31%) than for other ethnic groups. Interpretation: Our findings confirm the greater health burden that ethnic minorities face from COVID-19. The significant delay in the timeliness of care for Pacific people shows that the public health response was inequitable for those at highest risk. Tailored public health responses and better registration of marginalised groups are necessary to provide better access to services and to improve insights for optimal future outbreak management.

Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand.

OBJECTIVE: The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported. METHODS: First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity. RESULTS: Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Maori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Maori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log2(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Maori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084. CONCLUSIONS: In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Maori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score. TRIAL REGISTRATION NUMBER: ACTRN12615000676516.

Performance of cardiovascular disease risk prediction equations in more than 14 000 survivors of cancer in New Zealand primary care: a validation study.

BACKGROUND: People with cancer have an increased risk of cardiovascular disease. Risk prediction equations developed in New Zealand accurately predict 5-year cardiovascular disease risk in a general primary care population in the country. We assessed the performance of these equations for survivors of cancer in New Zealand. METHODS: For this validation study, patients aged 30-74 years from the PREDICT open cohort study, which was used to develop the New Zealand cardiovascular disease risk prediction equations, were included in the analysis if they had a primary diagnosis of invasive cancer at least 2 years before the date of the first cardiovascular disease risk assessment. The risk prediction equations are sex-specific and include the following predictors: age, ethnicity, socioeconomic deprivation index, family history of cardiovascular disease, smoking status, history of atrial fibrillation and diabetes, systolic blood pressure, total cholesterol to HDL cholesterol ratio, and preventive pharmacotherapy (blood-pressure-lowering, lipid-lowering, and antithrombotic drugs). Calibration was assessed by comparing the mean predicted 5-year cardiovascular disease risk, estimated using the risk prediction equations, with the observed risk across deciles of risk, for men and women, and according to the three clinical 5-year cardiovascular disease risk groups in New Zealand guidelines (<5%, 5% to <15%, and ≥15%). Discrimination was assessed by Harrell's C statistic. FINDINGS: 14 263 patients were included in the study. The mean age was 61 years (SD 9) for men and 60 years (SD 8) for women, with a median follow-up of 5·8 years for men and 5·7 years for women. The observed cardiovascular disease risk was underpredicted by a maximum of 2·5% in male and 3·2% in female decile groups. When patients were grouped according to clinical risk groups, observed cardiovascular disease risk was underpredicted by less than 2% in the lower risk groups and overpredicted by 2·2% for men and 3·3% for women in the highest risk group. Harrell's C statistics were 0·67 (SE 0·01) for men and 0·73 (0·01) for women. INTERPRETATION: The New Zealand cardiovascular disease risk prediction equations reasonably predicted the observed 5-year cardiovascular disease risk in survivors of cancer in the country, in whom risk prediction was considered clinically appropriate. Prediction could be improved by adding cancer-specific variables and considering competing risks. Our findings suggest that the equations are reasonable clinical tools for use in survivors of cancer in New Zealand. FUNDING: Auckland Medical Research Foundation, Health Research Council of New Zealand.

Who are Pacific peoples in terms of ethnicity and country of birth? A cross sectional study of 2,238,039 adults in Aotearoa New Zealand's Integrated Data Infrastructure.

Background: The aggregation of Indigenous peoples from Pacific Island nations as 'Pacific peoples' in literature may mask diversity in the health needs of these different groups. The aim of this study was to examine the heterogeneity of Pacific groups according to ethnicity and country of birth. Methods: Anonymised individual-level linkage of administrative data identified all NZ residents aged 30-74 years on 31 March 2013 with known ethnicity and country of birth. All participants were described according to ethnicity and country of birth. Pacific participants were also described according to the number of ethnicities they identified. Findings: A total of 2,238,039 NZ residents were included, of whom 117,957 (5·0%) were Pacific. Nearly two-thirds of Pacific peoples (65·7%) were born overseas, ranging from 45·3% (Cook Islands Maori) to 82·7% (Fijian) (Maori 2·3%, non-Maori non-Pacific 28·9%). Among NZ-born Pacific peoples, 46·9% (Samoan) to 81·9% (Fijian) were multi-ethnic; the proportion was much lower for overseas-born Pacific peoples (ranging from 3·7% [Tongan] to 23·9% [Tokelauan]). Interpretation: There is substantial heterogeneity among Pacific peoples in their country of birth and identification with sole or multiple ethnicities. Assumptions regarding homogeneity in the needs of Pacific peoples are not appropriate and government statistics should therefore disaggregate Pacific peoples whenever possible. Funding: Supported by the Health Research Council of New Zealand and a part of Manawataki Fatu Fatu, a programme of research funded by the National Heart Foundation of New Zealand and Healthier Lives - He Oranga Hauora - National Science Challenge of New Zealand.

Upholding te mana o te wa: Maori patients and their families' experiences of accessing care following an out-of-hospital cardiac event.

Objective: The purpose of this study was to explore the experiences of Maori patients and their families accessing care for an acute out-of-hospital cardiac event and to identify any barriers or enablers of timely access to care. Design: Eleven interviews with patients and their families were conducted either face-to-face or using online conferencing. Interviews were audio-recorded and transcribed for thematic analysis using Kaupapa Maori methodology. Results: Data analysis identified three themes: (1) me and the event, (2) the people (3) upholding te mana o te wa or self-determined heart wellbeing. Knowledge of symptoms and a desire to maintain personal dignity at the time of the event affected emergency medical service initiation. Participants described relationships with health professionals, the importance of good quality information, having family support, and drawing on cultural practices as vital for their health care journey. Conclusion: Systemic barriers including racism, discrimination, and inadequate resourcing exist for Maori journeying to and through care following an out of hospital cardiac event. Improving the cultural safety of health professionals, better access to community defibrillation, and improving understanding of the life-long impacts a cardiac event has on patients and whanau is recommended.

Identification of clinically relevant cohorts of people with heart failure from electronic health data in Aotearoa: potential, pitfalls and a plan.

Heart failure (HF) is associated with high morbidity and mortality and contributes to substantial burden of disease, significant inequities and high healthcare cost globally as well as in Aotearoa. Management of chronic HF is driven by HF phenotype, defined by left ventricular ejection fraction (EF), as only those with reduced ejection fraction (HFrEF) have been shown to experience reduced mortality and morbidity with long-term pharmacotherapy. To ensure appropriate and equitable implementation of HF management we need to be able to identify clinically relevant cohorts of patients with HF, in particular, those with HFrEF. The ideal HF registry would incorporate and link HF diagnoses and phenotype from primary and secondary care with echocardiography and pharmacotherapy data. In this article we consider several options for identifying such cohorts from electronic health data in Aotearoa, as well as the potential and pitfalls of these options. Given the urgent need to identify people with HF according to EF phenotype, the options for identifying them from electronic health data, and the opportunities presented by health system reform, including a focus on digital solutions, we recommend the following four actions, with oversight from a national HF working group: 1) Establish a HF registry based on random and representative sampling of HF admissions; 2) investigate obtaining HF diagnosis and EF-phenotype from primary care-coded data; 3) amalgamate national echocardiography data; and 4) investigate options to enable the systematic collection of HF diagnosis and EF-phenotype from outpatient attendances. Future work will need to consider reliability and concordance of data across sources. The case for urgent action in Aotearoa is compounded by the stark inequities in the burden of HF, the likely contribution of health service factors to these inequities and the legislative requirement under the Pae Ora (Healthy Futures) Act 2022 that "the health sector should be equitable, which includes ensuring Maori and other population groups - (i) have access to services in proportion to their health needs; and (ii) receive equitable levels of service; and (iii) achieve equitable health outcomes".