Impact of removing prescription co-payments on the use of costly health services: a pragmatic randomised controlled trial.

OBJECTIVES: To determine whether exempting people (with high health needs and living in areas of high deprivation) from a $5 prescription charge reduces hospital use. DESIGN: Two-group parallel prospective randomised controlled trial. SETTING: People living in the community in various regions of New Zealand. PARTICIPANTS: One thousand sixty one people who lived in areas of high socioeconomic deprivation, and either took medicines for diabetes, took antipsychotic medicines, or had chronic obstructive pulmonary disease (COPD). Of the 1053 who completed the study, just under half (49%) were Maori. INTERVENTIONS: Participants were individually randomized (1-1 ratio) to either be exempted from the standard $5 charge per prescription item for one year (2019-2020) (n = 591) or usual care (n = 469). Those in the intervention group did not pay the standard NZ$5 charge, and pharmacies billed the study for these. Participants continued to pay any other costs for prescription medicines. Those in the control group continued to pay all prescription charges for the year although they may have received one-off assistance from other agencies. MAIN OUTCOME MEASURES: The primary outcome was length of stay (hospital bed-days). Secondary outcomes presented in this paper included: all-cause hospitalisations, hospitalisations for diabetes/mental health problems/COPD, deaths, and emergency department visits. RESULTS: The trial was under-powered because the recruitment target was not met. There was no statistically significant reduction in the primary outcome, hospital bed-days (IRR = 0.68, CI: 0.54 to 1.05). Participants in the intervention group were significantly less likely to be hospitalised during the study year than those in the control group (OR = 0.70, CI: 0.54 to 0.90). There were statistically significant reductions in the number of hospital admissions for mental health problems (IRR = 0.39, CI: 0.17 to 0.92), the number of admissions for COPD (IRR = 0.37, CI: 0.16 to 0.85), and length of stay for COPD (IRR 0.20, CI: 0.07 to 0.60). Apart from all-cause mortality and diabetes length of stay, all measures were better for the intervention group than the control group. CONCLUSIONS: Eliminating a small co-payment appears to have had a substantial effect on patients' risk of being hospitalised. Given the small amount of revenue gathered from the charges, and the comparative large costs of hospitalisations, the results suggest that these charges are likely to increase the overall cost of healthcare, as well as exacerbate ethnic inequalities. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618001486213 registered on 04/09/2018.

Impact of legislative reform on worker fatalities in New Zealand workplaces: a 30-year retrospective population-level analysis.

OBJECTIVES: To determine the impact of major legislative changes to New Zealand's Occupational Health and Safety (OHS) legislation with the adoption of the Robens model as a means to control occupational risks on the burden and risk of work-related fatal injury (WRFI). METHODS: Population-based comparison of WRFI to workers aged 15-84 years occurring during three periods: before (pre:1985-1992), after legislative reform (post-1:1993-2002) and after subsequent amendment (post-2:2003-2014). Annual age-industry standardised rates were calculated with 95% CI. Multivariable Poisson regression was used to estimate age-adjusted annual percentage changes (APC) for each period, overall and stratified by high-risk industry and occupational groups. RESULTS: Over the 30-year period, 2053 worker deaths met the eligibility criteria. Age-adjusted APC in rates of worker WRFI changed little between periods: pre (-2.8%, 95% CI 0.0% to -5.5%); post-1 (-2.9%, 95% CI -1.3% to -4.5%) and post-2 (-2.9%, 95% CI -1.3% to -4.4%). There was no evidence of differences in slope. Variable trends in worker WRFI were observed for historically high-risk industry and occupational groups. CONCLUSIONS: The rate of worker WRFI decreased steadily over the 30-year period under examination and there was no evidence that this pattern of declining WRFI was substantially altered with the introduction of Robens-styled OHS legislative reforms. Beyond headline figures, historically high-risk groups had highly variable progress in reducing worker WRFI following legislative reform. This study demonstrates the value in including prereform data and high-risk subgroup analysis when assessing the performance of OHS legislative reforms to control occupational risks.

Dual versus single long-acting bronchodilator use could raise acute coronary syndrome risk by over 50%: A population-based nested case-control study.

BACKGROUND: Coronary heart disease occurs more frequently among patients with chronic obstructive pulmonary disease (COPD) compared to those without COPD. While some research suggests that long-acting bronchodilators might confer an additional risk of acute coronary syndrome (ACS), information from real-world clinical practice about the cardiovascular impact of using two versus one long-acting bronchodilator for COPD is limited. We undertook a population-based nested case-control study to estimate the risk of ACS in users of both a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-agonist (LABA) relative to users of a LAMA. METHODS: The study was based on the primary care PREDICT Cardiovascular Disease Cohort and linked data from regional laboratories and the New Zealand Ministry of Health's national data collections. The underlying cohort (n = 29,993) comprised patients aged 45-84 years, who initiated treatment with a LAMA and/or LABA for COPD between 1 February 2006 and 11 October 2016. 1490 ACS cases were matched to 13,550 controls by date of birth, sex, date of cohort entry (first long-acting bronchodilator dispensing), and COPD severity. RESULTS: Relative to current use of LAMA therapy, current use of LAMA and LABA dual therapy was associated with a significantly higher risk of ACS (adjusted OR = 1.72; [95% CI: 1.28-2.31]). CONCLUSION: Dual long-acting bronchodilator therapy, rather than LAMA mono-therapy, could increase the risk of ACS by more than 50%. This has important implications for decisions about the potential benefit/harm ratio of COPD treatment intensification, given the modest benefits of dual therapy.

Decade of fatal injuries in workers in New Zealand: insights from a comprehensive national observational study.

INTRODUCTION: Current priorities and strategies to prevent work-related fatal injury (WRFI) in New Zealand (NZ) are based on incomplete data capture. This paper provides an overview of key results from a comprehensive 10-year NZ study of worker fatalities using coronial records. METHODS: A data set of workers, aged 15-84 years at the time of death who died in the period 2005-2014, was created using coronial records. Data collection involved: (1) identifying possible cases from mortality records using selected external cause of injury codes; (2) linking these to coronial records; (3) retrieving and reviewing records for work-relatedness; and (4) coding work-related cases. Frequencies, percentages and rates were calculated. Analyses were stratified into workplace and work-traffic settings. RESULTS: Over the decade, 955 workers were fatally injured, giving a rate of 4.8 (95% CI 5.6 to 6.3) per 100 000 worker-years. High rates of worker fatalities were observed for workers aged 70-84 years, indigenous Maori and for males. Workers employed in mining had the highest rate in workplace settings while transport, postal and warehousing employees had the highest rate in work-traffic settings. Vehicle-related mechanisms dominated the mechanism and vehicles and environmental agents dominated the breakdown agencies contributing to worker fatalities. DISCUSSION: This study shows the rates of worker fatalities vary widely by age, sex, ethnicity, occupation and industry and are a very serious problem for particular groups. Future efforts to address NZ's high rates of WRFI should use these findings to aid understanding where preventive actions should be prioritised.

Antidepressant dispensing before, during, and after pregnancy in New Zealand, 2005-2014.

BACKGROUND: Depression during pregnancy is associated with a number of negative impacts on maternal and infant health, therefore good control of depression in pregnant women is crucial. There is a lack of population-level information about patterns of antidepressant use during pregnancy in New Zealand. AIM: To describe antidepressant dispensing patterns before, during, and after pregnancy in New Zealand, 2005-2014. MATERIALS AND METHODS: Antidepressant dispensing records from 270 days prior to pregnancy through to 360 days after pregnancy end were linked with 805 990 pregnancies in the New Zealand Pregnancy Cohort. Proportions (and 95% confidence intervals) with at least one dispensing were calculated for the periods before, during, and after pregnancy and compared over time and by maternal characteristics. RESULTS: Dispensing during the first trimester was lower than in the pre-pregnancy and post-pregnancy periods, and dropped further in later trimesters. The proportion of pregnancies during which an antidepressant was dispensed rose from 3.1 to 4.9% over the study years. Around 80% of those with a dispensing received a selective serotonin reuptake inhibitor. Dispensing before, during, and after pregnancy varied by ethnicity, age, smoking status, and body mass index. Among women taking an antidepressant before pregnancy, younger women and those of Maori, Pacific, or Asian ethnicity were less likely to continue therapy during pregnancy. CONCLUSIONS: This study has established a baseline for antidepressant use around pregnancy in New Zealand, documented increasing use over time, and demonstrated that known ethnic differences in antidepressant use are also evident in the pregnant population.

Prescription medicines with potential for foetal harm: dispensing before and during pregnancy in New Zealand, 2005-2015.

PURPOSE: This study describes dispensing of potentially teratogenic prescription medicines before and during pregnancy in New Zealand over the period 2005-2015. METHODS: Records in a national dispensing database were linked with the members of the New Zealand Pregnancy Cohort to determine the proportion of pregnancies with at least one dispensing of a Category D or X medicine, using the Australian pregnancy risk categorisation system. Exposure was examined from 270 days prior to conception through to the end of pregnancy. Pregnancy outcomes of D/X-exposed pregnancies were reviewed. RESULTS: In the study, 874,884 pregnancies were included. Overall, Category D and X medicines were dispensed during 4.3% and 0.058% of pregnancies, respectively. After excluding misoprostol, X exposure decreased to 0.035%. Generally, dispensing declined through the 270-day pre-pregnancy period and continued to decline throughout pregnancy. Dispensing of X medicines increased over the study timeframe, whereas dispensing of D medicines increased from 2005 to 2011 then declined slightly. Smokers were more likely than non-smokers to have been dispensed a D/X medicine, and compared with European women, Maori and Pacific women were less likely to have been dispensed a D/X medicine. Excluding misoprostol, pregnancies exposed to an X medicine were more likely than D/X-unexposed pregnancies to have ended in termination. CONCLUSION: Dispensing of potentially harmful medicines in pregnancy in New Zealand was low, particularly for Category X medicines. However, exposure did increase over the study timeframe. The inclusion of pregnancies that did not progress past early pregnancy better reflects population-level pregnancy exposure to potentially teratogenic medicines.

Decade of variable progress: trends in fatal injury in workers in New Zealand from a national observational study.

INTRODUCTION: Analyses of secular trends in work-related fatal injury in New Zealand have previously only considered the total working population, potentially hiding trends for important subgroups of workers. This paper examines trends in work-related fatalities in worker subgroups between 2005 and 2014 to indicate where workplace safety action should be prioritised. METHODS: A dataset of fatally injured workers was created; all persons aged 15-84 years, fatally injured in the period 2005-2014, were identified from mortality records, linked to coronial records which were then reviewed for work relatedness. Poisson regression modelling was used to estimate annual percentage change in rates by age, sex, ethnicity, employment status, industry and occupation. RESULTS: Overall, worker fatalities decreased by 2.4% (95% CI 0.0% to 4.6%) annually; an average reduction of 18 deaths per year from baseline (2005). Significant declines in annual rates were observed for younger workers (15-29 and 30-49 years), indigenous Maori, those in the public administration and service sector, and those in community and personal service occupations. Increases in annual rates occurred for workers in agriculture and forestry and fisheries sectors and for labourers. Rates of worker deaths in work-traffic settings declined faster than in workplace settings. DISCUSSION: Although overall age-standardised rates of work-related fatal injury have been declining, these trends were variable. Sources of injury risk in identifiable subgroups with increases in annual rates need to be urgently addressed. This study demonstrates the need for regular, detailed examination of the secular trends to identify those subgroups of workers requiring further workplace safety attention.

Generation of a pregnancy cohort for medicine utilisation and medicine safety studies in New Zealand.

PURPOSE: The aim of this study was to use national health databases to assemble a pregnancy cohort for undertaking medicine utilisation and safety studies in New Zealand. METHOD: Pregnancies conceived between January 2005 and March 2015 were identified in the National Maternity Collection, the National Minimum Dataset, the Mortality Collection, and the Laboratory Claims Collection. Pregnancy start and end dates were calculated and used in conjunction with the National Health Index number to merge the records from the four collections to create the New Zealand Pregnancy Cohort. Records of live born and stillborn infants identified in the National Maternity Collection and the Mortality Collection that were linkable with a cohort member formed the baby cohort. RESULTS: The cohort consists of 941 468 pregnancies to 491 272 women. One-third of the pregnancies, predominantly early pregnancy losses and terminations, were not found in the National Maternity Collection. Records of 632 090 live born or stillborn infants are linked with 623 099 pregnancies. CONCLUSIONS: The New Zealand Pregnancy Cohort is a comprehensive collection of virtually all pregnancies which ended in a live or stillbirth and many, though not all, which ended as early pregnancy losses or terminations in New Zealand over the past decade, and better represents the pregnant population than a cohort generated from the National Maternity Collection alone would do. This cohort will be valuable for investigating patterns of medicine use during pregnancy in New Zealand and developing a fuller understanding of potential impacts of foetal exposure in early pregnancy.

Patterns of use of long-acting bronchodilators in patients with COPD: A nationwide follow-up study of new users in New Zealand.

BACKGROUND AND OBJECTIVE: While several studies have found that prescribing practices do not conform to chronic obstructive pulmonary disease (COPD) treatment guidelines, none have examined longitudinal patterns of use of long-acting beta2 -agonist (LABA) and long-acting muscarinic antagonist (LAMA) therapy across an entire country. We undertook a nationwide follow-up study to describe treatment patterns in new users of long-acting bronchodilators. METHODS: National health and pharmaceutical dispensing data were used to identify patients aged ≥45 years who initiated LABA and/or LAMA therapy for COPD between 1 February 2006 and 31 December 2013. Dispensings of LABAs, LAMAs and inhaled corticosteroids (ICSs) were aggregated into episodes of use of therapeutic regimens. Kaplan-Meier curves, sunburst plots and sequence index plots were generated to summarize, respectively, the duration of the first regimen, the sequences in which unique regimens were used and the patterns of use and non-use during follow-up. RESULTS: The study cohort included 83 435 patients with 290 400 person-years of follow-up. The most commonly initiated regimen was a LABA with an ICS. ICS use was inconsistent with international guidelines: over- and under-treatment occurred in patients with infrequent and frequent exacerbations, respectively, and ICS monotherapy was common. The median duration of the first regimen was 46 days. Many patients used multiple regimens over time and periods of non-use were common. CONCLUSION: In this nationwide study, patterns of use of LABAs, LAMAs and ICSs were complex and often did not comply with treatment guidelines. Further work is required to address the discrepancy between guidelines and prescribing practices.

Are some health professionals more cognizant of clinical governance development concepts than others? Findings from a New Zealand study.

BACKGROUND: Clinical governance has been promoted in recent years as core to improving patient safety. Effective clinical governance requires partnerships between 'management' and health professionals as well as equal involvement of all professional groups. Professionals must also be willing to engage in clinical governance activities such as working to improve care systems and patient safety. There is limited research into the relative understanding of core clinical governance concepts amongst different professional groups or the extent to which professionals are prepared to take up opportunities to 'change the system'. METHODS: A 2012 national survey study of health professionals employed in New Zealand health boards sought to probe understanding of and commitment to clinical governance following introduction of a 2009 policy. RESULTS: Respondent data showed only limited policy implementation had occurred. Regression analyses revealed statistically significant differences in perceptions of knowledge of clinical governance concepts and structures by gender, age, experience and profession, as well as in seeking opportunities to change the system. CONCLUSIONS: These findings have implications for policy makers in terms of ensuring that clinical governance implementation provides equal opportunity for engendering involvement of different health professionals.

What motivates doctors to leave the UK NHS for a "life in the sun" in New Zealand; and, once there, why don't they stay?

BACKGROUND: At 44%, New Zealand has the highest proportion of international medical graduates (IMGs) in its workforce amongst OECD member countries. Around half of New Zealand's IMGs come from the UK NHS, yet only around 50% stay longer than 1 year post-registration with significant costs to the New Zealand health care system. Why these doctors go to New Zealand and do not stay for long is an important question. METHODS: UK-trained doctors who had gained registration with the Medical Council of New Zealand and currently practising in New Zealand were surveyed (n = 1357) on the motivation for their move to New Zealand, experiences once there and what was prompting any intentions to move away from New Zealand. Multivariate proportional odds models (POM) were used to quantify various associations. RESULTS: The survey had a 47% response (n = 632). Quality of life considerations motivated 96% of respondents to move to New Zealand, although 65% indicated they were pushed by a desire to leave the NHS. POM analyses revealed older respondents were significantly less likely than younger respondents to be motivated by quality of life considerations. Younger doctors were significantly more likely to be seeking to leave the NHS. Seventy-six per cent of respondents signalling an intention to leave New Zealand indicated that the desire to return to the UK was the primary reason for this. CONCLUSION: There is a long history of medical migration from the UK to New Zealand. However, the 65% of respondents in this study seeking to leave the NHS was much higher than found elsewhere, perhaps reflecting increasing workplace and funding pressures in recent years. Of concern to policy makers were the higher odds of seeking to leave the NHS motivating younger doctors. Various changes "down under", in New Zealand as well as Australia, mean their IMG markets may well be tightening up.

Allopurinol use in a New Zealand population: prevalence and adherence.

Allopurinol is effective for the control of gout and its long-term complications when taken consistently. There is evidence that adherence to allopurinol therapy varies across population groups. This may exacerbate differences in the burden of gout on population groups and needs to be accurately assessed. The aim of this study was to describe the prevalence of allopurinol use in a region of New Zealand using community pharmacy dispensing data and to examine the levels of suboptimal adherence in various population groups. Data from all community pharmacy dispensing databases in a New Zealand region were collected for a year covering 2005/2006 giving a near complete picture of dispensings to area residents. Prevalence of allopurinol use in the region by age, sex, ethnicity and socioeconomic position was calculated. Adherence was assessed using the medication possession ratio (MPR), with a MPR of 0.80 indicative of suboptimal adherence. Multiple logistic regression was used to explore variations in suboptimal adherence across population groups. A total of 953 people received allopurinol in the study year (prevalence 3%). Prevalence was higher in males (6%) than in females (1%) and Maori (5%) than non-Maori (3%). The overall MPR during the study was 0.88, with 161 (22%) of patients using allopurinol having suboptimal adherence. Non-Maori were 54% less likely to have suboptimal allopurinol adherence compared to Maori (95% CI 0.30-0.72, p = 0.001). These findings are consistent with those from other studies nationally and internationally and point to the important role for health professionals in improving patient adherence to an effective gout treatment.

Measuring progress with clinical governance development in New Zealand: perceptions of senior doctors in 2010 and 2012.

BACKGROUND: Clinical governance has become a core component of health policy and services management in many countries in recent years. Yet tools for measuring its development are limited. We therefore created the Clinical Governance Development Index (CGDI), aimed to measure implementation of expressed government policy in New Zealand. METHODS: We developed a survey which was distributed in 2010 and again in 2012 to senior doctors employed in public hospitals. Responses to six survey items were weighted and combined to form the CGDI. Final scores for each of New Zealand's District Health Boards (DHBs) were calculated to compare performances between them as well as over time between the two surveys. RESULTS: New Zealand's overall performance in developing clinical governance improved between the two studies from 46% in 2010 to 54% in 2012 with marked differences by DHB. Statistically significant shifts in performance were evident on all but one CGDI item. CONCLUSIONS: The CGDI is a simple yet effective method which probes aspects of organisational commitment to clinical governance, respondent participation in organisational design, quality improvement, and teamwork. It could be adapted for use in other health systems.

Healthcare professional perspectives on quality and safety in New Zealand public hospitals: findings from a national survey.

BACKGROUND: Few studies have sought to measure health professional perceptions of quality and safety across an entire system of public hospitals. Therefore, three questions that gauge different aspects of quality and safety were included in a national New Zealand survey of clinical governance. METHODS: Three previously used questions were adapted. A total of 41040 registered health professionals employed in District Health Boards were invited to participate in an online survey. Analyses were performed using the R statistical environment. Proportional odds mixed models were used to quantify associations between demographic variables and responses on five-point scales. Relationships between other questions in the survey and the three quality and safety questions were quantified with the Pearson correlation coefficient. RESULTS: A 25% response rate delivered 10303 surveys. Fifty-seven percent of respondents (95% CI: 56-58%) agreed that health professionals in their District Health Board worked together as a team; 70% respondents (95% CI: 69-70%) agreed that health professionals involved patients and families in efforts to improve patient care; and 69% (95% CI: 68-70%) agreed that it was easy to speak up in their clinical area if they perceived a problem with patient care. Correlations showed links between perceptions of stronger clinical leadership and performances on the three questions, as well as with other survey items. The proportional mixed model also revealed response differences by respondent characteristics. CONCLUSIONS: The findings suggest positive commitment to quality and safety among New Zealand health professionals and their employers, albeit with variations by district, profession, gender and age, but also scope for improvement. The study also contributes to the literature indicating that clinical leadership is an important contributor to quality improvement. WHAT IS KNOWN ABOUT THE TOPIC? Various studies have explored aspects of healthcare quality and safety, generally within a hospital or group of hospitals, using a lengthy tool such as the 'safety climate survey'. WHAT DOES THIS PAPER ADD? We used a simple three-question survey approach (derived from existing measures) to measuring healthcare professionals' perceptions of quality and safety in New Zealand's public hospitals. In doing so, we also collected the first such information on this. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? New Zealand policy makers and health professionals can take some comfort in our findings, but also note that there is considerable scope for improvement. Our finding that more positive perceptions of quality and safety were related to perceptions of stronger clinical leadership adds to the international literature indicating the importance of this. Policy makers and hospital managers should support strong clinical leadership.

Societal burden of work on injury deaths in New Zealand, 2005-14: An observational study.

Background: Work poses increased risk of injury not only for workers but also for the public, yet the broader impact of work-related injury is not quantified. This study, utilising population data from New Zealand, estimates the societal burden of work-related fatal injury (WRFI) by including bystanders and commuters. Methods: This observational study selected deaths due to unintentional injury, in persons aged 0-84 years using International Classification of Disease external cause codes, matched to coronial records, and reviewed for work-relatedness. Work-relatedness was determined by the decedent's circumstances at the time of the incident: working for pay, profit, in kind, or an unpaid capacity (worker); commuting to or from work (commuter); or a bystander to another's work activity (bystander). To estimate the burden of WRFI, frequencies, percentages, rates, and years-of-life lost (YLL) were estimated. Results: In total 7,707 coronial records were reviewed of which 1,884 were identified as work-related, contributing to 24% of the deaths and 23% of the YLL due to injury. Of these deaths close to half (49%) occurred amongst non-working bystanders and commuters. The overall burden of WRFI was widespread across age, sex, ethnic and deprivation sub-groups. Injury deaths due to machinery (97%) and due to being struck by another object (69%) were predominantly work-related. Interpretation: When utilising a more inclusive definition of work-relatedness the contribution of work to the societal burden of fatal injuries is substantial, conservatively estimated at one quarter of all injury deaths in New Zealand. Other estimates of WRFI likely exclude a similar number of fatalities occurring among commuters and bystanders. The findings, also relevant to other OECD nations, can guide where public health efforts can be used, alongside organisational actions, to reduce WRFI for all those impacted.

Ocular Antibiotic Utilisation across Aotearoa/New Zealand.

Ocular antibiotics are integral to the prevention and treatment of bacterial ocular infections. This study aimed to describe their utilisation across New Zealand according to patient and healthcare factors. Every subsidy-eligible community dispensing of ocular chloramphenicol, fusidic acid and ciprofloxacin in New Zealand, between 2010 and 2019, was included in this analysis. Number of dispensings/1000 population/year was quantified, stratified by patient age and urban/non-urban health districts. Dispensing rates by ethnicity were determined and were age adjusted. The proportion of dispensings by socioeconomic deprivation quintile was also determined. Chloramphenicol was the most commonly dispensed antibiotic; however, its utilisation decreased over time. Ciprofloxacin use was higher in children, while chloramphenicol use was higher in older patients. Ciprofloxacin usage was higher among Maori and Pasifika ethnicities, while fusidic acid use was lower. Chloramphenicol usage was higher among Pasifika. Antibiotic utilisation was higher in urban health districts, and in the most deprived quintile; both were most marked with ciprofloxacin. The utilisation of publicly funded ocular antibiotics across New Zealand varied between patient subgroups. These findings will help improve the prevention, management and outcomes of bacterial ocular infections, and support wider initiatives in antibiotic stewardship and medicine access equity.

Too much and too little? Prevalence and extent of antibiotic use in a New Zealand region.

OBJECTIVES: Although antibiotic use in the community is a significant contributor to resistance, little is known about social patterns of use. This study aimed to explore the use of antibiotics by age, gender, ethnicity, socio-economic status and rurality. METHODS: Data were obtained on all medicines dispensed to ambulatory patients in one isolated town for a year, and data on antibiotics are presented in this paper. Demographic details were obtained from pharmacy records or by matching to a national patient dataset. RESULTS: During the study year, 51% of the population received a prescription for one or more antibiotics, and on average people in the region received 10.15 defined daily doses (DDDs). Prevalence of use was higher for females (ratio, 1.18), and for young people (under 25) and the elderly (75 and over), and the amount in DDDs/person/year broadly followed this pattern. Maori (indigenous New Zealanders) were less likely to receive a prescription (48% of the population) than non-Maori (55%) and received smaller quantities on average. Rural Maori, including rural Maori children, received few prescriptions and low quantities of antibiotics compared with other population groups. CONCLUSIONS: The level of antibiotic use in the general population is high, despite campaigns to try to reduce unnecessary use. The prevalence of acute rheumatic fever is high amongst rural Maori, and consequently treatment guidelines recommend prophylactic use of antibiotics for sore throat in this population. This makes the comparatively very low level of use of antibiotics amongst rural Maori children very concerning.

Treatment pathways in people with type 2 diabetes mellitus: a nationwide cohort study of new users of metformin monotherapy in New Zealand.

OBJECTIVES: The aims of this study were to describe the following: (1) the time to change of therapy in patients with type 2 diabetes who had initiated metformin monotherapy as first-line treatment and (2) the sequence in which subsequent therapeutic regimens were introduced. DESIGN: Cohort study. SETTING: National study based on linked data from the New Zealand Ministry of Health's National Collections of health and pharmaceutical dispensing data. PARTICIPANTS: People with type 2 diabetes mellitus who initiated metformin monotherapy between 1 January 2006 and 30 September 2014 (n=93 874). PRIMARY OUTCOME MEASURES: Cumulative incidence curves were plotted to show the time taken to move from one regimen to another, while sunburst plots were used to illustrate the sequence in which regimens were introduced. RESULTS: About 10% and 35% of cohort members had moved to a second regimen 1 year and 5 years, respectively, after initiating metformin monotherapy; the majority received a regimen recommended by New Zealand treatment guidelines (mostly metformin and a sulphonylurea). Of those who started a recommended second regimen, 37% and 67% had moved to a third regimen after 1 and 5 years, respectively; the corresponding proportions for those who started an 'other' (not listed as recommended) second regimen were 53% and 75%. Most of those who received a third regimen after a recommended second regimen were dispensed an 'other' third regimen. Of those who moved to a third regimen from an 'other' second regimen, similar proportions received recommended and 'other' third regimens. CONCLUSIONS: Real-world type 2 diabetes treatment patterns in New Zealand are complex and not always consistent with guidelines.