Receipt of mastectomy and adjuvant radiotherapy following breast conserving surgery (BCS) in New Zealand women with BCS-eligible breast cancer, 2010-2015: an observational study focusing on ethnic differences.

BACKGROUND: Women with early breast cancer who meet guideline-based criteria should be offered breast conserving surgery (BCS) with adjuvant radiotherapy as an alternative to mastectomy. New Zealand (NZ) has documented ethnic disparities in screening access and in breast cancer treatment pathways. This study aimed to determine whether, among BCS-eligible women, rates of receipt of mastectomy or radiotherapy differed by ethnicity and other factors. METHODS: The study assessed management of women with early breast cancer (ductal carcinoma in situ [DCIS] and invasive stages I-IIIA) registered between 2010 and 2015, extracted from the recently consolidated New Zealand Breast Cancer Registry (now Te Rehita Mate Utaetae NZBCF National Breast Cancer Register). Specific criteria were applied to determine women eligible for BCS. Uni- and multivariable analyses were undertaken to examine differences by demographic and clinicopathological factors with a primary focus on ethnicity (Maori, Pacific, Asian, and Other; the latter is defined as NZ European, Other European, and Middle Eastern Latin American and African). RESULTS: Overall 22.2% of 5520 BCS-eligible women were treated with mastectomy, and 91.1% of 3807 women who undertook BCS received adjuvant radiotherapy (93.5% for invasive cancer, and 78.3% for DCIS). Asian ethnicity was associated with a higher mastectomy rate in the invasive cancer group (OR 2.18; 95%CI 1.72-2.75), compared to Other ethnicity, along with older age, symptomatic diagnosis, advanced stage, larger tumour, HER2-positive, and hormone receptor-negative groups. Pacific ethnicity was associated with a lower adjuvant radiotherapy rate, compared to Other ethnicity, in both invasive and DCIS groups, along with older age, symptomatic diagnosis, and lower grade tumour in the invasive group. Both mastectomy and adjuvant radiotherapy rates decreased over time. For those who did not receive radiotherapy, non-referral by a clinician was the most common documented reason (8%), followed by patient decline after being referred (5%). CONCLUSION: Rates of radiotherapy use are high by international standards. Further research is required to understand differences by ethnicity in both rates of mastectomy and lower rates of radiotherapy after BCS for Pacific women, and the reasons for non-referral by clinicians.

Variation in public-funded bariatric surgery intervention rate by New Zealand region.

Inequitable access to bariatric surgery by geographical region has been reported internationally, but comparable data on provision of bariatric surgery have not previously been reported in New Zealand. We examined allocated funding and provision of bariatric surgery amongst different regions in New Zealand in the 2013/14 year, and found that there was large variation in both. This highlights that public funded bariatric surgery needs to take into account population prevalence of morbid obesity to reduce inequities by geographical region.

Are ethnic inequalities in 30-day ischaemic stroke survival emerging as treatment becomes more effective?

AIM: Studies of ethnic differences in stroke survival have produced inconsistent findings. As treatment becomes more effective, inequalities may increase. We examine time trends in ischaemic stroke case fatality in New Zealand. METHOD: The 30-day case fatality rate (CFR) of ischaemic stroke in New Zealand was calculated from routinely collected data for two 5-year periods (2000-2004 and 2010-2014) in Maori, Pacific, Asian and European people. A Poisson regression model tested ethnic inequalities between Europeans and people of other ethnicities in each time period. RESULTS: From 2000-2004 to 2010-2014, the age-sex standardised CFR in Europeans fell from 13.4% (95% CI 13.0 to 13.9%) to 10.7% (10.3 to 11.1%). In Pacific and Asian people, the CFR rose between the two periods, and in Maori there was a drop from 18.2% to 16.2%; neither of these differences were statistically significant. After controlling for socio-demographic variables, service factors and comorbidities, the CFR was higher for Maori than Europeans in 2000-2004, and for all ethnic groups compared with Europeans in 2010-2014. CFR ethnic inequality rose over that time-the change being statistically significant for Pacific (p=0.033) and Asian (p=0.010), and of borderline significance for Maori (p=0.053). CONCLUSIONS: Ethnic inequalities in 30-day ischaemic stroke survival have increased significantly in the last 10 years. This may be due to differences in severity at presentation, or in access and utilisation of the increasingly effective acute and hyper-acute stroke interventions.

Can formal collaborative methodologies improve quality in primary health care in New Zealand? Insights from the EQUIPPED Auckland Collaborative.

INTRODUCTION: Auckland District Health Board was one of four District Health Boards to trial the Breakthrough Series (BTS) methodology to improve the management of long-term conditions in New Zealand, with support from the Ministry of Health. AIM: To improve clinical outcomes, facilitate planned care and promote quality improvement within participating practices in Auckland. METHODS: Implementation of the Collaborative followed the improvement model / Institute for Healthcare Improvement methodology. Three topic areas were selected: system redesign, cardio-vascular disease/diabetes, and self-management support. An expert advisory group and the Improvement Foundation Australia helped guide project development and implementation. Primary Health Organisation facilitators were trained in the methodology and 15 practice teams participated in the three learning workshops and action periods over 12 months. An independent evaluation study using both quantitative and qualitative methods was conducted. RESULTS: Improvements were recorded in cardiovascular disease risk assessment, practice-level systems of care, self-management systems and follow-up and coordination for patients. Qualitative research found improvements in coordination and teamwork, knowledge of practice populations and understanding of managing long-term conditions. CONCLUSION: The Collaborative process delivered some real improvements in the systems of care for people with long-term conditions and a change in culture among participating practices. The findings suggest that by strengthening facilitation processes, improving access to comprehensive population audit tools and lengthening the time frame, the process has the potential to make significant improvements in practice. Other organisations should consider this approach when investigating quality improvement programmes.

Emergency Department utilisation: a natural experiment.

AIM: In February 2005 a new Emergency Department (ED) was opened at Waitakere Hospital in West Auckland, New Zealand. Part of the rationale for this was the expectation that it would reduce attendances to the four established EDs in the Auckland region. This study was undertaken to determine whether this happened. METHOD: A retrospective analysis of ED presentations to Auckland City, Starship and North Shore hospitals for the 2 years prior to the opening of Waitakere ED (February 2005) was conducted. This was compared with the attendances to all hospitals in the 2 years following the opening of the new ED. The effect of the opening of Waitakere ED on ED presentations to other hospitals was assessed using control charts. Presentations to Middlemore Hospital during the same time period were used as a control. RESULTS: ED attendance to hospitals in the Auckland District Health Board (DHB) area increased by 9% over the study period (Auckland Hospital = 13%, Starship Children's Hospital = 2%), similarly ED attendance to Middlemore Hospital increased by 6%, consistent with population growth. However ED attendance to hospitals in the Waitemata DHB area (North Shore and Waitakere Hospitals) increased by 74%, disproportionate to population growth (8%). CONCLUSION: The opening of a new ED may have contributed to an increase in total ED presentations seen within the region overall, with no corresponding reduction in attendances at neighbouring hospitals.