Ethnic variation in access to publicly funded care for unintentional injuries in older adults in Aotearoa New Zealand: a retrospective study.

BACKGROUND: Maori (the Indigenous people of Aotearoa New Zealand (NZ)) are more likely to experience injury than non-Maori, but less likely to have effective access to publicly funded injury care services. It is unknown if this pattern extends into older age. This retrospective study analysed Accident Compensation Corporation (ACC; national no-fault injury compensation scheme) claims data to investigate ethnic variation in unintentional injury claims and related costs for older adults (≥50 years). METHODS: Injury claims data for older adults residing in two regions of NZ between January 2014 and December 2018 were reviewed. Age-standardised claims rates (per person year) standardised rate ratios were calculated and compared between Maori and non-Maori. ACC claim costs (medical treatment; earning-related compensation) were estimated, with total and average costs per claim compared between the two groups. RESULTS: There were 149 275 ACC claims (18 369 Maori; 130 906 non-Maori) among 64 238 individuals (9284 Maori; 54 954 non-Maori). The age-standardised rate of ACC claims for unintentional injury was 46% higher among non-Maori (95% CI 44% to 48%) than Maori. The ACC spend for non-Maori was NZ$155 277 962 compared with NZ$30 446 673 for Maori. Maori had a significantly higher average cost per claim (NZ$1658 vs NZ$1186, p<0.001). CONCLUSIONS: Results of this study highlight differences in the manner in which different groups of older adults access injury compensation in NZ, indicating the need to invest in injury prevention initiatives that target older Maori, as well as initiatives supporting improved ACC access for older Maori.

Comparing primary caregivers' reported injury data with routinely recorded injury data to assess predictors of childhood injury.

BACKGROUND: Linking self-reported data collected from longitudinal studies with administrative health records is timely and cost-effective, provides the opportunity to augment information contained in each and can offset some of the limitations of both data sources. The aim of this study was to compare maternal-reported child injury data with administrative injury records and assess the level of agreement. METHODS: A deterministic linkage was undertaken to link injury-related data from the Growing up in New Zealand (GUiNZ) study to routinely collected injury records from New Zealand's Accident Compensation Corporation (ACC) for preschool children. The analyses compared: (i) the characteristics of mothers with linked data vs. those without, (ii) injury incidences from maternal recall with those recorded in ACC injury claims, and (iii) the demographic characteristics of concordant and discordant injury reports, including the validity and reliability of injury records from both data sources. RESULTS: Of all mothers who responded to the injury questions in the GUiNZ study (n = 5836), more than 95% (n = 5637) agreed to have their child's record linked to routine administrative health records. The overall discordance in injury reports showed an increasing trend as children grew older (9% at 9 M to 29% at 54 M). The mothers of children with discordance between maternal injury reports and ACC records were more likely to be younger, of Pacific ethnicity, with lower educational attainment, and live in areas of high deprivation (p < 0.001). The level of agreement between maternal injury recall and ACC injury record decreased (κ = 0.83 to κ = 0.42) as the cohort moved through their preschool years. CONCLUSIONS: In general, the findings of this study identified that there was underreporting and discordance of the maternal injury recall, which varied by the demographic characteristics of mothers and their child's age. Therefore, linking the routinely gathered injury data with maternal self-report child injury data has the potential to augment longitudinal birth cohort study data to investigate risk or protective factors associated with childhood injury.

Antenatal and early childhood exposures associated with non-fatal infant injury: evidence from a longitudinal birth cohort in New Zealand.

OBJECTIVE: To identify antenatal and early childhood exposures of unintentional injury among infants in New Zealand (NZ). METHOD: The theoretical life-course framework of child injury prevention domains was utilised to analyse data from a prospective longitudinal NZ birth cohort (Growing Up in NZ). Risk and protective factors for injury were identified using Robust Poisson regression models. RESULT: Among children included for the analysis(n=6304), 52% were male, 55% were born to European mothers, and 37% lived in a household with high levels of deprivation. Mothers reported that 6% of infants (n=406) had sustained at least one injury by 9 months. Multivariate analysis showed injury risk among single mothers with antenatal depression were more than twice that (IRR=2.20) of children of mothers with partners and without depression. CONCLUSION: Understanding antenatal risk and protective factors for infant injury will assist in implementing injury prevention programmes or modifying the existing policies that affect these vulnerable age groups.

Study of dog control strategies.

OBJECTIVES: (1) To explore the relationship between regionally implemented dog control strategies and dog bite injuries (DBIs) and (2) to evaluate current implementation of dog control strategies. METHODS: Observational study using a nationwide online survey of territorial authorities (TAs). Domains of interest included complaints for attacks on people, dog population, primary and secondary prevention strategies, resourcing and perspectives of current strategies. Quantitative variables were compared with DBI Accident Compensation Corporation (ACC) claims by region from 2014 to 2018. RESULTS: Two-thirds of TAs (70%; n=47/67) responded to the survey. No clear relationship was observed between DBIs and: registered dog population, proportion sterilisations or microchipping, classifications due to dog behaviour, or existing limited resourcing. Legislated breeds and infringements for failure to control a dog or non-registration were higher in areas with greater DBIs. Educational messages varied widely and were predominantly victim directed (67%; n=71/106). Complaints for dog attacks on people were lower than DBIs in most areas, with no formal cross-agency notification policies. Few prosecutions or dog destruction orders were made. CONCLUSIONS: Regional inequity in DBIs could not be explained by differences in the registered dog population or dog control strategies. Minimal and inequitable resourcing exists to implement current dog control strategies and provide owner-directed education. Gaps in legislation include environmental barrier requirements for all dogs (leash/muzzle use, adequate fencing), notification of incidents and child protection. Partnership with the Indigenous community (Maori) and other community groups will be required to implement these measures successfully.

Manifold child, family and social variables are associated with injury among New Zealand preschool children.

AIM: Approaches to understanding child injury tend to focus on short-term proximal influences. Previous analyses have found higher rates of injury among Maori and Pacific children in Aotearoa New Zealand (NZ). This study aimed to investigate how combinations of situations and multiple events act across the life-course to either protect preschool children from, or place them at risk of, repeated injuries requiring medical attention. METHODS: Longitudinal data were used to identify parent-reported injuries requiring medical attention among 6114 preschool NZ children. The environments experienced by children with multiple and/or severe injury were explored using multivariable analyses. RESULTS: Eight percent of children (n=505) experienced 1-3 injuries with at least one hospitalisation or ≥4 injuries (high injury group) from birth to 4.5 years of age. After accounting for antenatal, sociodemographic and psychosocial variables, children of Maori mothers (OR=0.7, 95% CI 0.5 to 0.97) and children of Asian mothers (OR=0.5, 95% CI 0.3 to 0.7) were less likely to be in the high injury group than children of European mothers. After adjusting for maternal ethnicity and child variables (gender, temperament, level of activity and behaviour difficulties), cumulative exposure to factors in four domains was associated with injury category: maternal, family, social and service use. CONCLUSION: This study identified social and economic opportunities to lower rates of injury among preschool children, that might reduce associated direct and indirect costs. Our findings in relation to ethnicity go against the standard public rhetoric and provide support for shifting the apportioning of blame for child injury from individuals to wider environmental exposures for which public health and societal solutions are required.

Maternal postures for fetal malposition in labour for improving the health of mothers and their infants.

BACKGROUND: Fetal malposition (occipito-posterior and persistent occipito-transverse) in labour is associated with adverse maternal and infant outcomes. Whether use of maternal postures can improve these outcomes is unclear. This Cochrane Review of maternal posture in labour is one of two new reviews replacing a 2007 review of maternal postures in pregnancy and labour. OBJECTIVES: To assess the effect of specified maternal postures for women with fetal malposition in labour on maternal and infant morbidity compared to other postures.  SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (13 July 2021), and reference lists of retrieved studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or cluster-RCTs conducted among labouring women with a fetal malposition confirmed by ultrasound or clinical examination, comparing a specified maternal posture with another posture. Quasi-RCTs and cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, risk of bias, and performed data extraction. We used mean difference (MD) for continuous variables, and risk ratios (RRs) for dichotomous variables, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included eight eligible studies with 1766 women.  All studies reported some form of random sequence generation but were at high risk of performance bias due to lack of blinding. There was a high risk of selection bias in one study, detection bias in two studies, attrition bias in two studies, and reporting bias in two studies. Hands and knees The use of hands and knees posture may have little to no effect on operative birth (average RR 1.14, 95% CI 0.87 to 1.50; 3 trials, 721 women; low-certainty evidence) and caesarean section (RR 1.34, 95% CI 0.96 to 1.87; 3 trials, 721 women; low-certainty evidence) but the evidence is uncertain; and very uncertain for epidural use (average RR 0.74, 95% CI 0.41 to 1.31; 2 trials, 282 women; very low-certainty evidence), instrumental vaginal birth (average RR 1.04, 95% CI 0.57 to 1.90; 3 trials, 721 women; very low-certainty evidence), severe perineal tears (average RR 0.88, 95% CI 0.03 to 22.30; 2 trials, 586 women; very low-certainty evidence), maternal satisfaction (average RR 1.02, 95% CI 0.68 to 1.54; 3 trials, 350 women; very low-certainty evidence), and Apgar scores less than seven at five minutes (RR 0.71, 95% CI 0.21 to 2.34; 2 trials, 586 babies; very low-certainty evidence).  No data were reported for the hands and knees comparisons for postpartum haemorrhage, serious neonatal morbidity, death (stillbirth or death of liveborn infant), admission to neonatal intensive care, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy.  Lateral postures The use of lateral postures may have little to no effect on reducing operative birth (average RR 0.72, 95% CI 0.43 to 1.19; 4 trials, 871 women; low-certainty evidence), caesarean section (average RR 0.78, 95% CI 0.44 to 1.39; 4 trials, 871 women; low-certainty evidence), instrumental vaginal birth (average RR 0.73, 95% CI 0.39 to 1.36; 4 trials, 871 women; low-certainty evidence), and maternal satisfaction (RR 0.96, 95% CI 0.84 to 1.09; 2 trials, 451 women; low-certainty evidence), but the evidence is uncertain. The evidence is very uncertain about the effect of lateral postures on severe perineal tears (RR 0.66, 95% CI 0.17 to 2.48; 3 trials, 609 women; very low-certainty evidence), postpartum haemorrhage (RR 0.90, 95% CI 0.48 to 1.70; 1 trial, 322 women; very low-certainty evidence), serious neonatal morbidity (RR 1.41, 95% CI 0.64 to 3.12; 3 trials, 752 babies; very low-certainty evidence), Apgar scores less than seven at five minutes (RR 0.25, 95% CI 0.03 to 2.24; 1 trial, 322 babies; very low-certainty evidence), admissions to neonatal intensive care (RR 1.41, 95% CI 0.64 to 3.12; 2 trials, 542 babies; very low-certainty evidence) and neonatal death (stillbirth or death of liveborn) (1 trial, 210 women and their babies; no events).  For the lateral posture comparisons, no data were reported for epidural use, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy. We were not able to estimate the outcome death (stillbirth or death of liveborn infant) due to no events (1 trial, 210 participants).  AUTHORS' CONCLUSIONS: We found low- and very low-certainty evidence which indicated that the use of hands and knees posture or lateral postures in women in labour with a fetal malposition may have little or no effect on health outcomes of the mother or her infant. If a woman finds the use of hands and knees or lateral postures in labour comfortable there is no reason why they should not choose to use them. Further research is needed on the use of hands and knees and lateral postures for women with a malposition in labour. Trials should include further assessment of semi-prone postures, same-side-as-fetus lateral postures with or without hip hyperflexion, or both, and consider interventions of longer duration or that involve the early second stage of labour.

Prospective longitudinal study investigating predictors of childhood injuries from Growing Up in New Zealand cohort: study protocol.

BACKGROUND: Injury is one of the leading causes of mortality and morbidity worldwide and yet preventable and predictable. In New Zealand (NZ), unintentional injury is the leading cause of emergency department visits, hospitalisations and death among children, making it a significant public health concern. OBJECTIVE: To identify the factors that place young children in NZ at an increased risk of unintentional injury. METHODS: This study will investigate injuries among children from the prospective Growing Up in NZ birth cohort of 6853 children and their families. The primary outcome of interest is injury events where medical treatment was sought. The data sources include parental reports of child injury and Accident Compensation Corporation-NZ's no-fault injury compensation system-injury claims. The linked datasets will be utilised to examine the distribution of life course exposures and outcome data using descriptive statistics. A temporal multilevel model will then be developed to examine relationships between neighbourhood, child and family characteristics and injury from birth to 5 years of age for all children for whom parental consent to link data were obtained. DISCUSSION: The findings of this research will help to identify how the multiplicity of influences between children, family and their broader societal context acting across time affect their risk of experiencing a preschool injury. This information will provide an evidence base to inform context-relevant strategies to reduce and prevent childhood injuries.

Systematic review of dog bite prevention strategies.

BACKGROUND: The prevention of dog bites is an increasingly important public health topic, as the incidence of serious injury continues to rise. OBJECTIVES: To evaluate the effectiveness of interventions to prevent dog bites and aggression. METHODS: Online databases were searched (PubMed, Cochrane Library, Embase and Google Scholar), using the search terms: dog/s, canine, canis, kuri, bite/s, bitten, aggression, attack, death, fatal, mortality, injury/ies, prevention, intervention, for studies between 1960 and 2021. All study designs were considered. Outcomes of interest were the incidence of dog bites or dog aggression. Non-English studies, and those without full-text access were excluded. RESULTS: Forty-three studies met the review criteria, including 15 observational and 27 interventional studies. Fifteen studies investigating dog-control legislation, including leash laws, stray dog control and infringements indicated this can reduce dog bite rates. Breed-specific legislation had less of an effect. Six studies investigating sterilisation, showed while this may reduce dog bites through a reduction in the dog population, the effect on dog aggression was unclear. An alcohol reduction programme showed a significant reduction in dog bite rates in one study. Seven studies assessing educational approaches found that intensive adult-directed education may be effective, with one study showing child-directed education was not effective. Eight studies on dog training (two police-dog related), and six evaluating dog medication or diet were generally low quality and inconclusive. CONCLUSIONS: Multiple strategies including effective engagement with indigenous communities and organisations will be required to reduce dog-bites and other incidents involving dog aggression. This review provides some evidence that legislated dog control strategies reduce dog bite rates. Available evidence suggests greater restrictions should be made for all dogs, rather than based on breed alone. Due to a burden of child injury, protection of children should be a focus of legislation and further investigations. Prevention strategies in children require redirection away from a focus on child-directed education and future research should investigate the effectiveness of engineering barriers and reporting strategies.

Access to advanced-level hospital care: differences in prehospital times calculated using incident locations compared with patients' usual residence.

Studies estimate that 84% of the USA and New Zealand's (NZ) resident populations have timely access (within 60 min) to advanced-level hospital care. Our aim was to assess whether usual residence (ie, home address) is a suitable proxy for location of injury incidence. In this observational study, injury fatalities registered in NZ's Mortality Collection during 2008-2012 were linked to Coronial files. Estimated access times via emergency medical services were calculated using locations of incident and home. Using incident locations, 73% (n=4445/6104) had timely access to care compared with 77% when using home location. Access calculations using patients' home locations overestimated timely access, especially for those injured in industrial/construction areas (18%; 95% CI 6% to 29%) and from drowning (14%; 95% CI 7% to 22%). When considering timely access to definitive care, using the location of the injury as the origin provides important information for health system planning.

Feasibility and acceptability of a paearahi (Indigenous Whanau Ora navigator) intervention for unintentional injury prevention for older Maori: non-randomised, non-comparator trial study protocol.

BACKGROUND: Maori (the Indigenous population of Aotearoa New Zealand) experience increased burden of unintentional injury and reduced access to publicly funded injury prevention and rehabilitation services, compared with non-Maori. Maori-led models of care have been shown to improve outcomes for Maori. Paearahi navigate across sectors (including health, education, housing and employment) to advocate for the best possible outcomes for individuals and families. This study aims to (1) test the acceptability and feasibility and (2) undertake exploratory efficacy analysis of a paearahi injury intervention for Maori older adults. METHODS: A prospective non-randomised, non-comparator study with preintervention and postintervention measurements of predefined outcomes. Eligible participants who consented to participate (Maori, 55+ years, community-dwelling and enrolled in one of three study general practices) will undergo a multivisit paearahi intervention. The intervention includes home-hazard assessment, basic health screening, teaching of strength and balance exercises, education relating to injury prevention and access to injury-related, referral and connection to other health and social services) and participants can choose to have whanau (family) involved in the intervention. OUTCOMES: The primary outcome of interest is participant, whanau and paearahi acceptability of the intervention. Secondary outcomes include intervention feasibility, cost-effectiveness and exploratory efficacy (including preintervention and postintervention unintentional injury-related hospitalisation, primary care access and public injury-related claims). DISCUSSION: The findings of this intervention research will be used to inform injury care models for older Maori and process for Maori-led health intervention development more generally. TRIAL REGISTRATION NUMBER: ACTRN12621001691831p.

Evaluating the impact of prehospital care on mortality following major trauma in New Zealand: a retrospective cohort study.

BACKGROUND: Injury is a leading cause of death and health loss in New Zealand and internationally. The potentially fatal or severe consequences of many injuries can be reduced through an optimally structured prehospital trauma care system that can provide timely and appropriate care. OBJECTIVE: To investigate the relationship between emergency medical services (EMS) care and survival to hospital for major trauma cases in New Zealand. METHODS: This project is a retrospective cohort study of New Zealand major trauma cases attended by EMS providers over a 2-year period. Outcomes include survival to hospital and survival in hospital for at least 24 hours. The project has three phases: (1) identification of the cohort and assembling a bespoke longitudinal dataset linking EMS, New Zealand Major Trauma Registry and Coronial data; (2) describing the pathways and processes of care to inform an investigation of the relationships between types of EMS care and survival using propensity score modelling to adjust for case-mix differences; (3) assessment of the implications for future practice, policy and research. DISCUSSION: The study findings will help identify opportunities to optimise the delivery of EMS care in New Zealand by informing the development or revision of existing major trauma EMS policies and guidelines, and to provide a baseline for monitoring the impact of future initiatives. Establishing an evidence-base will support a whole-of-system appraisal that could include broader complex variables relating to healthcare services throughout the continuum of trauma care.

Perineal trauma management and follow-up: Are we meeting the standard of care?

BACKGROUND: Birth-related third- and fourth-degree perineal trauma is common and associated with short- and long-term complications. AIM: To conduct a review of clinical audits investigating management of women with perineal trauma. MATERIALS AND METHODS: We identified all audits undertaken in eight New Zealand public hospitals between 2005 and 2014 that investigated whether women with birth-related third- and fourth-degree perineal trauma were receiving care according to clinical guidelines. We aggregated audit results and calculated the proportion of women receiving the recommended standard of care. RESULTS: During the review period, 25 audits investigated intra-operative (n = 11), post-operative (n = 14) and outpatient care (n = 18). Baseline audits showed variation in care by site; intra-operative care (range 39-96% for repair conducted under anaesthesia, 60-96% for repair by or under supervision of a senior clinician, and 33-54% for completion of Accident Compensation Corporation forms); post-operative care (range 40-93% for prescribed antibiotics and 33-96% for stool softeners) and outpatient care (45-84% for referral to outpatient clinic and 54-78% for physiotherapy follow-up). Sustained high quality of care and improvements in adherence with recommendations were seen for most of the follow-up audits (eg 90% adherence for prescribed stool softeners over three audits; over 50% increase in prescribed antibiotics over seven years). CONCLUSIONS: These clinical audits exemplify the need to measure patient care against standards, learn from the findings, implement changes to improve patient experience and reduce life-long sequelae from perineal trauma. This review showed some progress in some care services and highlighted where further changes are needed to close evidence-practice gaps.

Potential survivability of prehospital injury deaths in New Zealand: a cross-sectional study.

INTRODUCTION: Acknowledging a notable gap in available evidence, this study aimed to assess the survivability of prehospital injury deaths in New Zealand. METHODS: A cross-sectional review of prehospital injury death postmortems (PM) undertaken during 2009-2012. Deaths without physical injuries (eg, drownings, suffocations, poisonings), where there was an incomplete body, or insufficient information in the PM, were excluded. Documented injuries were scored using the AIS and an ISS derived. Cases were classified as survivable (ISS <25), potentially survivable (ISS 25-49) and non-survivable (ISS >49). RESULTS: Of the 1796 cases able to be ISS scored, 11% (n=193) had injuries classified as survivable, 28% (n=501) potentially survivable and 61% (n=1102) non-survivable. There were significant differences in survivability by age (p=0.017) and intent (p<0.0001). No difference in survivability was observed by sex, ethnicity, day of week, seasonality or distance to advanced-level hospital care. 'Non-survivable' injuries occurred more commonly among those with multiple injuries, transport-related injuries and aged 15-29 year. The majority of 'survivable' cases were deceased when found. Among those alive when found, around half had received either emergency medical services (EMS) or bystander care. One in five survivable cases were classified as having delays in receiving care. DISCUSSION: In New Zealand, the majority of injured people who die before reaching hospital do so from non-survivable injuries. More than one third have either survivable or potentially survivable injuries, suggesting an increased need for appropriate bystander first aid, timeliness of EMS care and access to advanced-level hospital care.

Preventable injury deaths: identifying opportunities to improve timeliness and reach of emergency healthcare services in New Zealand.

BACKGROUND: Traumatic injury is a leading cause of premature death and health loss in New Zealand. Outcomes following injury are very time sensitive, and timely access of critically injured patients to advanced hospital trauma care services can improve injury survival. OBJECTIVE: This cross-sectional study will investigate the epidemiology and geographic location of prehospital fatal injury deaths in relation to access to prehospital emergency services for the first time in New Zealand. DESIGN AND STUDY POPULATION: Electronic Coronial case files for the period 2008-2012 will be reviewed to identify cases of prehospital fatal injury across New Zealand. METHODS: The project will combine epidemiological and geospatial methods in three research phases: (1) identification, enumeration, description and geocoding of prehospital injury deaths using existing electronic injury data sets; (2) geocoding of advanced hospital-level care providers and emergency land and air ambulance services to determine the current theoretical service coverage in a specified time period and (3) synthesising of information from phases I and II using geospatial methods to determine the number of prehospital injury deaths located in areas without timely access to advanced-level hospital care. DISCUSSION: The findings of this research will identify opportunities to optimise access to advanced-level hospital care in New Zealand to increase the chances of survival from serious injury. The resulting epidemiological and geospatial analyses will represent an advancement of knowledge for injury prevention and health service quality improvement towards better patient outcomes following serious injury in New Zealand and similar countries.

Paediatric food-induced anaphylaxis hospital presentations in New Zealand.

AIM: Globally, rates of paediatric food-induced anaphylaxis (FIA) are increasing. Little data is available regarding the epidemiology of FIA among New Zealand (NZ) children. This study investigated the incidence of paediatric (0-14 years) FIA hospital presentations in NZ over a 10-year period. METHODS: Ministry of Health public hospital discharge data from 2006 to 2015 were analysed using FIA-related International Classification of Diseases codes (T78.0 - anaphylactic shock due to adverse food reaction and T78.2 - anaphylactic shock unspecified and free text qualifier) to identify acute hospital presentations. RESULTS: The overall annualised FIA hospital presentation rate was 16.2 per 100 000 children. Subgroup analysis indicated a significantly higher rate in males (19.1/100 000) than in females (13.1/100 000), and among children aged less than 2 years of age (50.5/100 000) compared with older children. Rates among Asian and Pacific children were higher than Maori and NZ European children. In 67.7% of cases, a single specific allergen was suggested by the information provided; among these cases, nuts (48%), specifically peanuts (26%), were the most commonly reported allergen, followed by cow's milk (21%). Time trend analysis showed a 2.8-fold increase in the overall annualised rate for the 10-year period. CONCLUSION: These findings are consistent with other international studies indicating increasing rates of FIA in children. These data will provide information for a review of NZ paediatric allergy services to ensure current international standards with regard to the equitable delivery of timely, appropriate and accessible care are being met. Reasons for differences by gender, age and ethnicity require further investigation.

Effectiveness of the YourCall™ text message intervention to reduce harmful drinking in patients discharged from trauma wards: protocol for a randomised controlled trial.

BACKGROUND: Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care. METHODS/DESIGN: Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Maori compared with non-Maori). DISCUSSION: If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking. TRIAL REGISTRATION: Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.

Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand.

AIM: Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI. METHODS: We retrospectively reviewed a random sample of charts of children <15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009. RESULTS: Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006). CONCLUSION: Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent.

Is the delivery of a quality improvement education programme in obstetrics and gynaecology for final year medical students feasible and still effective in a shortened time frame?

BACKGROUND: Teaching clinical audit skills to nascent health professionals is one strategy to improve frontline care. The undergraduate medical curriculum at the University of Auckland provides improvement science theory and skills in Year 5 teaching, and the opportunity to put this into practice during an Obstetrics and Gynaecology (O&G) clinical attachment in Year 6. In 2015, a revised medical school curriculum at the university resulted in a planned reduction of the O&G attachment from five weeks to four, necessitating revision of the Year 6 Quality Improvement (QI) project. The aim of this study was to evaluate if the revised programme provided an important experiential learning opportunity for medical students without imposing an unsustainable burden on clinical services. METHODS: Based on a CIPP (Context/Input/Process/Product) evaluation model, the study was conducted in several stages to get a sense of the context as the new programme was being planned (Context evaluation), the feasibility of an alternative approach to meet the educational need (Input evaluation), the implementation of the revised programme (Process evaluation) and finally, the programme outcomes (Product evaluation). We used multiple data sources (supervisors, students, academic administrators, and hospital staff) and data collection methods (questionnaires, focus groups, individual interviews, consultative workshops, student reports and oral presentations). RESULTS: The context evaluation revealed the Year 6 QI programme to be valuable and contributed to O&G service improvements, however, the following concerns were identified: time to complete the project, timely topic selection and access to data, recognition of student achievement, and staff workload. The evaluation of the revised QI project indicated improvement in student perceptions of their QI knowledge and skills, and most areas previously identified as challenging, despite the concurrent reduction in the duration of the O&G attachment. CONCLUSIONS: Applying the CIPP model for evaluation to our revised QI programme enabled streamlining of procedures to achieve greater efficiency without compromising the quality of the learning experience, or increasing pressure on staff. A four week clinical rotation is adequate for medical educators to consider opportunities for including QI projects as part of student experiential learning.

Adult food-induced anaphylaxis hospital presentations in New Zealand.

BACKGROUND: Food allergy including anaphylaxis is an increasing clinical problem in many countries. Little information is available regarding prevalence, causative foods and time trends in the New Zealand adult population. OBJECTIVE: This cross-sectional study investigated the incidence of hospital presentation with food-induced anaphylaxis in New Zealand among adults and adolescents over a 10-year period. METHODS: Ministry of Health hospital discharge data from 2002 to 2011 were analysed using food allergy and anaphylaxis-related International Classification of Diseases (ICD) codes to identify acute hospital presentations. RESULTS: There was an average annualised rate of hospital food-induced anaphylaxis presentations of 4.8 per 100 000 adults (aged ≥15 years) for the period reviewed. Subgroup analyses revealed significant differences by gender, age group and ethnicity, notably higher rates in females, younger adults (15-34 years) and Pacific Island populations. Seafood was the most common food allergen group, followed by nuts. Time trend analysis revealed a 1.7-fold increase in the 10-year period, mainly attributable to an increase in rates in the Pacific Island population. CONCLUSIONS: These data confirm food-induced anaphylaxis as an increasing problem in New Zealand and show significant differences in incidence of hospital presentation in different ethnic populations. Future research will be required to understand and address disparities in the incidence of these conditions.

The psychopathology of James Bond and its implications for the revision of the DSM-(00)7.

OBJECTIVE: To develop a more concise, user-friendly edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM advisory board is probably already hard at work on the DSM-6, so this study is focused on the DSM-(00)7 edition. DESIGN: We conducted an observational study, using a mixed methods approach to analyse the 50th edition boxset of James Bond experiences. James Bond was selected as a suitably complex subject for the basis of a trial of simplifying the DSM. SETTING: Researchers' televisions and computers from late January to mid-April in Auckland, New Zealand. RESULTS: Following a review of the 23 James Bond video observations, we identified 32 extreme behaviours exhibited by the subject; these could be aggregated into 13 key domains. A Delphi process identified a cluster of eight behaviours that comprise the Bond Adequacy Disorder (BAD). A novel screening scale was then developed, the Bond Additive Descriptors of Anti-Sociality Scale (BADASS), with a binary diagnostic outcome, BAD v Normality Disorder. We propose that these new diagnoses be adopted as the foundation of the DSM-(00)7. CONCLUSIONS: The proposed DSM-(00)7 has benefits for both patients and clinicians. Patients will experience reduced stigma, as most individuals will meet the criteria for Normality Disorder. This parsimonious diagnostic approach will also mean clinicians have more time to focus on patient management.