The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study.

BACKGROUND: Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown. METHODS: A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade. RESULTS: Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Maori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and Maori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology. CONCLUSION: Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Maori children. Understanding the pre-hospital factors that influence the timing of presentation can better inform health-system improvements.

Incidence and outcomes of major trauma patients with thoracic injuries and rib fractures in Aotearoa New Zealand.

INTRODUCTION: Thoracic trauma represents a significant burden of disease in Aotearoa, New Zealand (AoNZ). To date, no study has examined the incidence or outcomes of patients suffering major thoracic trauma, or major trauma and rib fractures in AoNZ. METHODS: A 6 year retrospective study of all major trauma (Injury Severity Score >12) patients in AoNZ was performed. The National Trauma Registry was searched to identify patients. The National Minimum Data Set was searched for all ICD-10 codes associated with surgical stabilisation of rib fractures (SSRF). Poisson regression was used to determine the change in incidence rate over the study period adjusted for age with the logarithm of population size as the offset variable. The incidence rate ratios (IRR) with 95% confidence intervals (CI) were reported. RESULTS: 12,218 patients sustained major trauma. 7,059 (57.8%) of these patients sustained thoracic injuries. Of these patients, 5,585 (79.1%) sustained rib fractures, and 180 (3.2%) proceeded to SSRF. A flail segment was observed in 16% of patients with rib fractures. Transport was the mechanism of injury in 53% of patients. During the study the incidence (cases per 100,000 people per year) of major trauma increased from 39.5 to 49.3 (IRR 1.05, 95%CI 1.04 to 1.07, <0.001), the incidence of thoracic injuries from 21.3 to 28.7 (1.07, 95% CI 1.05 to 1.08, <0.001) and the incidence of rib fractures from 16.0 to 22.9 (1.08, 95% CI 1.06 to 1.09, <0.001). SSRF was performed in 3.2% of patients with rib fractures and increased from 0.2 to 0.8 cases per 100,000 people per year (1.27, 95% CI 1.15 to 1.41, <0.001) during the study. CONCLUSION: This study reports the incidence of major trauma patients with thoracic injury, major trauma patients with rib fractures and the incidence of SSRF in AoNZ. Transport related injuries are the predominant mechanism of injury. The incidence of SSRF was low across AoNZ. To improve the quality of care in AoNZ for major trauma patients with rib fractures, consideration should be made to create national guidelines and robust referral pathways to specialist centres that provide multidisciplinary care including performing SSRF.

Colonic Investigation following acute diverticulitis in Northland, New Zealand.

AIM: Diverticulitis is common and increasing in incidence. The risk of malignancy in those with uncomplicated diverticulitis is estimated to be 0.7%, compared with 10% in complicated diverticulitis. Newer guidelines suggest colonic investigation in patients with complicated diverticulitis only. We aim to investigate which patients in Northland undergo colonic investigation following an episode of diverticulitis, define malignancy detection rate and aid in the formulation of local guidelines. METHODS: A retrospective review of adults admitted to Whangarei Hospital with diverticulitis between 2015 and 2019. Patients were classified as complicated or uncomplicated based on the Hinchey classification radiologically or intra-operatively. Patients were followed up to a minimum of 24 months. RESULTS: Three hundred and forty-nine patients were included. One hundred and eighty-two (48%) patients underwent colonic investigation following admission with diverticulitis; 50 with complicated and 132 with uncomplicated disease. The rate of colonic investigation between the groups was similar, at 53% and 47% respectively. Two patients (1.1%) were found to have a colonic malignancy, both in the uncomplicated group. The performance of a colonic investigation was not associated with complicated disease, ethnicity, gender or age on univariate or multivariate analysis. CONCLUSION: Colonic investigation following an admission for acute diverticulitis in Northland is not aligned with recently published guidelines. The rate of colonic malignancy found was low. Larger local studies are needed to guide clinicians and maximise efficiency of resource utilisation.

Characterising nationwide reasons for unplanned hospital readmission after colorectal cancer surgery.

BACKGROUND: Readmissions after colorectal cancer surgery are common, despite advancements in surgical care, and have a significant impact on both individual patients and overall healthcare costs. The aim of this study was to determine the 30-and 90 days readmission rate after colorectal cancer surgery, and to investigate the risk factors and clinical reasons for unplanned readmissions. METHOD: A multicenter, population-based study including all patients discharged after index colorectal cancer resection from 2010 to 2020 in Aotearoa New Zealand (AoNZ) was completed. The Ministry of Health National Minimum Dataset was used. Rates of readmission at 30 days and 90 days were calculated. Mixed-effect logistic regression models were built to investigate factors associated with unplanned readmission. Reasons for readmission were described. RESULTS: Data were obtained on 16,885 patients. Unplanned 30-day and 90-day hospital readmission rates were 15.1% and 23.7% respectively. The main readmission risk factors were comorbidities, advanced disease, and postoperative complications. Hospital level variation was not present. Despite risk adjustment, R2 value of models was low (30 days: 4.3%, 90 days: 5.2%). The most common reasons for readmission were gastrointestinal causes (32.1%) and wound complications (14.4%). Rates of readmission did not improve over the 11 years study period (p = 0.876). CONCLUSION: Readmissions following colorectal resections in AoNZ are higher than other comparable healthcare systems and rates have remained constant over time. While patient comorbidities and postoperative complications are associated with readmission, the explanatory value of these variables is poor. To reduce unplanned readmissions, efforts should be focused on prevention and early detection of post-discharge complications.

Trauma Teams in Aotearoa New Zealand-a national survey.

AIMS: Improved survival of trauma patients has been shown when a multidisciplinary trauma team is available. The aim of this study is to investigate the composition of trauma teams, trauma call criteria and the role of anaesthetists in trauma care across New Zealand. METHODS: A survey was distributed using the modified Dillman's technique. Data was collected and aggregated using an online platform. The survey consisted of two streams of questions depending on trauma team availability. Trauma nurse specialists were the first contact point and if not available, direct contact with the hospital was made for completion of the survey. RESULTS: Seventy-five percent of hospitals had a trauma team and trauma call system and correlated to size of the hospital. The number of trauma team members ranged from six to 17, with a median of 10. Trauma call activation criteria encompassed physiological criteria, injury pattern and injury mechanism criteria. Physiological criterial of GCS, heart rate, blood pressure and respiratory rate were universally used. Sixty-two percent of trauma teams had involvement of anaesthetists. CONCLUSIONS: Trauma teams in New Zealand are common in regional and tertiary trauma hospitals. There is a wide variation in member numbers and criteria to trigger a trauma call. Anaesthetist involvement was in over half of trauma teams with regional variation noted. There is potential for trauma team composition and activation criteria to be standardised in New Zealand.

Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand.

BACKGROUND: Small intestinal Neuroendocrine Neoplasms (SI-NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI-NEN in Auckland, Aotearoa New Zealand (AoNZ). METHODS: A retrospective study of all patients diagnosed with a jejunal or ileal SI-NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data. RESULTS: One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10-year disease-specific survival for all patients was 66.1% (95% CI 56.5-75.7%) and 61.8% (95% CI 51.8-71.8%), respectively. Ten-year disease-specific survival was 100% for stage I and II, 74% (95%CI 61.7-84.4%) for stage III and 33.9% (95%CI 16.9-35.6%) for stage IV SI-NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92-5.5) nor distant resection (HR 1.72, 95% CI 0.63-4.7) were significantly associated with a disease-specific or overall survival benefit. CONCLUSION: This study demonstrates that stage at SI-NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.

The effect of rurality and ethnicity in patients with acute cholecystitis in Northland, New Zealand.

AIM: Acute cholecystitis is a common reason for emergency admission. Rurality and ethnicity are associated with poorer surgical outcomes, but data in benign disease is sparse. This study aims to assess the effect of rurality and ethnicity on the severity, management, and outcomes of acute cholecystitis. METHODS: A five-year retrospective cohort study was conducted, including all adults admitted to Northland hospitals with acute cholecystitis. The primary cohort was identified using coding. Severity and outcome data was obtained. Severity was defined according to the Tokyo Guidelines 2018 (TG18). Primary outcomes of interest were the difference in severity of acute cholecystitis, and clinical management between groups. RESULTS: Three hundred and seventy-seven patients were included. There were no significant differences in the severity of acute cholecystitis, rate of acute cholecystectomy, elective cholecystectomy, or non-operative management by rurality or ethnicity. Maori patients presented at a significantly younger age and were more likely to re-present while on the waiting list for elective surgery. CONCLUSION: This study found similar clinical severity, management and outcomes comparing rural and urban patients. Maori patients presented at a significantly younger age.

Cost analysis of index versus delayed cholecystectomy for acute cholecystitis in a New Zealand Provincial Centre.

BACKGROUND: Evidence suggests index cholecystectomy (IC) in patients with acute cholecystitis is safe, has decreased hospital stay and is cheaper than delayed cholecystectomy (DC). Costs of cholecystectomy have not previously been investigated in New Zealand. The aim of this study was to compare cost of IC with DC for patients with acute cholecystitis. METHODS: A retrospective analysis of adults admitted to Northland hospitals with acute cholecystitis between 1 January 2015 and 31 December 2019 who underwent subsequent cholecystectomy, was performed. Actual patient-level costs were utilized for cost comparison between IC and DC. Factors associated with increased costs were assessed using multivariate analysis. RESULTS: Two hundred and eleven patients were included in the study; 72 (34%) underwent IC and 139 (65%) DC. There was no significant difference in total cost for IC ($12 767) versus DC ($12 029) (p = 0.192); this persisted on multivariate analysis. Patients having IC had more severe cholecystitis, and 90-day representation rate following DC was 35%. Costs were increased by severity of cholecystitis, age, American Society of Anesthesiology score (ASA) and travel distance. CONCLUSION: This study showed there is no significant difference in cost between IC and DC for patients with acute cholecystitis in Northland, New Zealand. Severity, increasing age, ASA and travel distance were drivers of costs. To recognize the cost benefits of IC, it is likely that increased rates of IC are needed.

Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study.

AIM: Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ. METHODS: A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia. RESULTS: Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Maori and 85% non-Maori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Maori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block. CONCLUSION: This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Maori and elderly patients was found which needs further investigation.

Outcomes in patients with fractured ribs: middle aged at same risk of complications as the elderly.

AIMS: Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand. METHOD: A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old. RESULTS: 170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome. CONCLUSION: This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45-64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Impact of rurality and ethnicity on complexity of acute diverticulitis in Northland, New Zealand.

BACKGROUND: Acute diverticulitis is a common general surgical condition associated with significant costs and healthcare burden. It is unknown if rurality represents a barrier to healthcare and whether ethnic disparities exist in Northland, New Zealand. This study, therefore, aims to assess the impact of rurality and ethnicity on complexity, management, and outcomes in patients with acute diverticulitis. METHODS: A retrospective observational study of all adults aged >18 years admitted with acute diverticulitis to any Northland District Health Board hospital between 1 January 2015 and 31 December 2019 was performed. Diverticulitis complexity was assessed using the modified Hinchey classification. The primary outcome was the effect of rurality and ethnicity on complexity of diverticulitis. Multivariable logistic regression was performed. RESULTS: A total of 397 patients (mean age 60.3 years (standard deviation (SD) 13.8); 48.7% female) were included. Overall, 134 patients had complicated diverticulitis. Rurality nor distance from the hospital were not associated with complexity of diverticulitis or clinical outcomes (p > 0.05). Maori patients presented younger than non-Maori (mean 51 vs. 63 years, p < 0.001) but there was no difference in complications, management, or clinical outcomes (p > 0.05). On multivariable analysis, rurality status and Maori ethnicity were not associated with more complicated diverticulitis. CONCLUSION: This study found that rurality and ethnicity were not significant predictors of the complexity of diverticulitis.

Prehospital barriers for rural New Zealand parents in paediatric appendicitis: a qualitative analysis.

BACKGROUND: Appendicitis is the most common reason children undergo emergency general surgery. Worse appendicitis outcomes have been demonstrated in rural, lower socioeconomic, and indigenous populations. These findings are hypothesised to be a result of differential access and delay in presentation to hospital. However, no qualitative study has investigated why prehospital delay may exist. METHODS: We conducted individual, semi-structured interviews with the parents of 11 rural children who presented with acute appendicitis between June 2019-January 2020. Utilising grounded theory methodology, we created an exploratory framework. RESULTS: Participating families travelled a mean distance of 50.4 km to access hospital, and the median prehospital symptom duration was 42 h. Families with reduced financial or social resources were more likely to 'watch and wait' due to the increased relative burden of access. Key considerations were travel, organising childcare and parental income loss in a rural environment. Structural healthcare barriers further dissuaded prompt access and subsequent engagement. These included poor cultural safety, maldistribution of rural health services, and contradictory public health messages. Several families sought informal community-based health advice to mitigate these barriers, leading to earlier hospital presentation. CONCLUSION: Prehospital delay in rural families occurred most frequently due to an extended decision-making phase where families evaluated the costs and benefits of accessing hospital-level care. The utilisation of informal community expertise and whanau advocacy helped circumvent reduced access to health facilities. Cultural safety remains problematic and hinders engagement with Maori families.

Effect of rurality and ethnicity in severity and outcomes in patients with acute pancreatitis.

BACKGROUND: Previous studies have demonstrated a high incidence of acute pancreatitis (AP) in New Zealand, with Maori having the highest reported incidence worldwide. It is possible that barriers to healthcare exist for rural and Maori patients, leading to poorer outcomes. The aim of this study is to compare differences in severity and outcomes in patients with AP with regards to rurality and ethnicity. METHODS: Multicentre retrospective study of all adults aged >16 years who were admitted to any hospital with AP in Northland between 1 January 2014 and 31 December 2018 was performed. Pancreatitis severity was classified using the Revised Atlanta classification. The primary outcome of interest was the difference in severity of pancreatitis with regards to rurality and ethnicity. Secondary outcomes of interest included clinical outcomes, aetiology of AP and re-presentation rates. RESULTS: A total of 468 patients were included. There was no difference found between rural and urban or Maori and non-Maori patients with regards to disease severity, length of stay, mortality or intensive care unit admission rate. A significant difference in aetiology was found between Maori and non-Maori patients, with a higher rate of gallstone pancreatitis in Maori. There was no difference in local complications or number of re-presentations between groups. CONCLUSION: This study showed no difference in the severity or outcomes of AP across rural and urban patients in the Northland region of New Zealand. Secondary outcomes were broadly comparable between groups, with a higher rate of gallstone pancreatitis found in Maori compared to non-Maori.

Incidence, outcomes and effect of delayed intervention in patients with hollow viscus injury due to major trauma in the Northern region of New Zealand.

BACKGROUND: Patients with hollow viscus injury (HVI) are often a cause for diagnostic uncertainty. The incidence and outcomes of patients suffering hollow viscus injury secondary to major trauma have not been previously described in New Zealand. These metrics are important to guide quality improvement and resource allocation. The aim of our study is to define the incidence, outcomes and effect of delayed intervention on patients admitted to hospital with hollow viscus injury secondary to blunt abdominal trauma in the Northern region of New Zealand. METHODS: A 4-year multicentre retrospective study was performed in the Northern region of New Zealand between 1 July 2015 and 30 June 2019. A primary cohort of patients with confirmed hollow viscus injury secondary to blunt abdominal injury, who underwent a laparotomy, were assessed. The primary outcome measures were incidence, 30-day mortality and morbidity. Secondary outcomes included the effect of timing of surgical intervention. RESULTS: The incidence of hollow viscus injury in the region was 2.03 per 100 000. The 30-day mortality rate was 5% and the 30-day morbidity rate was 82%. Immediate surgical intervention was carried out in 36%, early surgical intervention in 56% and delayed surgical intervention in 8%. CONCLUSION: The incidence of hollow viscus injury is in keeping with similar studies, but with lower mortality and higher morbidity. The rate of immediate or early surgical intervention was high. These findings are important to clinicians managing patients with major trauma and those involved in planning and allocation of resources.

Rate and cost of representation in patients suffering from major trauma in Northland, New Zealand.

INTRODUCTION: The published rate of readmission in major trauma patients in New Zealand has been recorded at 11%. The rate of re-attendances to emergency departments (ED) is currently not reported, but potentially adds significant burden to the healthcare system. The rate, costs and resource implications of these representations have not previously been described in New Zealand. AIM: The aim of this study was to define the rate, costs and resource implications of unplanned representations, re-attendance to ED and readmission in patients who have suffered from major trauma in Northland. METHOD: We undertook a four-year retrospective study including all patients who re-attended the emergency department or who were readmitted within 30 days following discharge after major trauma presentation in Northland. Actual patient costs were calculated using in-hospital patient level costing. Length of hospital stay and utilisation of higher-level care facilities were obtained from the hospital's clinical results reporting system and data warehouse. RESULTS: 420 patients formed the primary cohort. There were 90 total representations in 63 patients (15%). The number of re-attendances to ED and readmissions was 52 (12%) and 38 (9%) respectively. The total cost associated with representation in the primary cohort was $220,914, or $55,229 per year. Median cost of re-attendance to ED was $334, and median cost of readmission was $3,643. Mean length of stay in those admitted was 1.9 days. CONCLUSION: This study defined the rate, costs and resource implications of re-attendance to ED and readmissions in patients following admission due to major trauma. This data will help guide quality improvement and reduce costs.

Association between COVID-19 public health interventions and major trauma presentation in the northern region of New Zealand.

BACKGROUND: The New Zealand government implemented restrictive public health interventions to eradicate Covid-19. Early reports suggest that one downstream ramification is a change in trauma presentations. The aim of this study is to evaluate the effect these public health measures had on major trauma admissions in the Northern Region, New Zealand. METHODS: A retrospective comparative cohort study was performed. Two cohorts were identified: 16 March to 8 June 2020 and the same period in 2019. Data was extracted from the New Zealand Major Trauma Registry which prospectively collects data on all major trauma in New Zealand. All patients who presented to a hospital in the Northern Region with major trauma and met the Registry inclusion criteria were included. RESULTS: There were 163 major trauma admissions in 2019 and 123 in 2020, a reduction of 25% (rate ratio 0.75, 95% confidence interval 0.6-0.95; P = 0.018). There was no significant difference in mechanism of injury (P = 0.442), type of injury (P = 0.062) or intent of injury (P = 0.971). There was a significant difference in place of injury (P = 0.004) with 20% of injuries happening at home in 2019 compared with 35% in 2020. CONCLUSION: This study has shown that public health interventions to prevent the spread of COVID-19 reduced major trauma admissions in the Northern Region of New Zealand. There was a variation in effect a between institutions within the region and a change in pattern of injury.

The effect of national public health interventions for COVID-19 on emergency general surgery in Northland, New Zealand.

BACKGROUND: The New Zealand government instituted escalating public health interventions to prevent the spread of COVID-19. There was concern this would affect health seeking behaviour leading to delayed presentation and worse outcomes. The aim of this study was to examine the effects of these interventions on rate and severity of acute general surgical admissions in Northland, New Zealand. METHODS: A retrospective comparative cohort study was performed. Two cohorts were identified: 28 February to 8 June 2020 and same period in 2019. Data for surgical admissions and operations and emergency department (ED) presentation were obtained from the hospital data warehouse. Three index diagnoses were assessed for severity. RESULTS: There were 650 acute general surgical admissions in 2019 and 627 in 2020 (P 0.353). Operations were performed in 226 and 224 patients respectively (P 0.829). ED presentations decreased from 11 398 to 8743 (P < 0.001). No difference in severity of acute appendicitis (P 0.970), acute diverticulitis (P 0.333) or acute pancreatitis (P 0.803) was detected. Median length-of-stay, 30-day mortality and admission diagnosis were comparable. CONCLUSION: Despite a significant reduction in ED presentations, interventions for COVID-19 did not result in a difference in the rate or severity of acute general surgical admissions.

Surgeon-performed ultrasound-guided fine needle aspiration of thyroid nodules is cost effective and efficient: evaluation of thyroid nodule assessment in a provincial New Zealand hospital.

AIM: Surgeon-performed ultrasound-guided fine needle aspiration cytology (US-FNAC) and radiologist-performed US-FNAC are both accepted forms of thyroid nodule assessment. To date there have been no studies comparing cost of evaluation between these two models. The aim of this study is to compare surgeon-performed thyroid US-FNAC to radiologist-performed US-FNAC. The primary outcome of interest was cost of surgeon-performed US-FNAC compared to cost of radiologist-performed US-FNAC. Secondary outcome of interest was time to treatment decision. METHODS: A retrospective analysis of all thyroid biopsies performed in 2016 and 2017 in a single centre were included. Costs were calculated using labour costs for SMO and allied technical personnel. RESULTS: There were 92 patients included in the analysis. Forty-two underwent surgeon-performed US-FNAC and 50 underwent radiologist-performed US-FNAC. Mean cost in surgeon-performed US-FNAC was $653 compared to $1017 in radiologist-performed US-FNA. Time from first appointment to definitive management plan was 47 days in surgeon-performed USFNAC and 116 days in radiologist-performed US-FNAC. CONCLUSIONS: This study demonstrates surgeon-performed US-FNAC for evaluation of thyroid nodules results in significantly lower costs and improved timeliness of care when compared to radiologist-performed US-FNAC.

Paediatric appendicitis: increased disease severity and complication rates in rural children.

BACKGROUND: Appendicitis is the most common surgical emergency affecting children. Rurality has been shown to be a predictor of worse surgical outcomes in patients with acute appendicitis compared to urban residents. There are no previously published studies investigating this in Australasia. METHODS: A 10-year retrospective study of all patients aged ≤16 years who underwent an acute appendicectomy in Northland, New Zealand, was conducted. The cohort was identified by searching the hospital database for theatre events and admission diagnoses coded as appendicitis. Primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien-Dindo complication rate. The role of ethnicity was also examined. RESULTS: A total of 470 children underwent appendicectomy during this period. On multivariate analysis, increased AAST grade was twice as likely in rural patients (odds ratio 2.04). Post-operatively, rural patients had higher Clavien-Dindo complication grade (P = 0.001), longer median length of stay and increased rates of intra-abdominal collection (19% versus 4%; P = 0.018), 30-day readmission (19% versus 4%; P = 0.020) and perforation (27% versus 19%; P = 0.031). Maori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade. CONCLUSION: Accounting for ethnicity, socio-economic deprivation and age, we implicate rural patient status as being associated with increasing severity and complicated paediatric appendicitis. This work adds to the evolving description of inequities in rural health outcomes. Further prospective studies are needed to confirm these findings at a national level.

Cost and resource implications of introducing intensive nodal surveillance for sentinel node positive melanoma in provincial New Zealand.

AIMS: Two randomised trials have shown that immediate completion lymphadenectomy for sentinel node positive melanoma provides no long-term survival benefit; compared with a follow up regime of intensive nodal surveillance. The aim of this study was to assess the cost and resource implications of introducing this regime for patients with sentinel node positive melanoma in a provincial New Zealand hospital. METHODS: Patients with cutaneous melanoma presenting to Northland District Health Board between 1 January 2012 and 31 December 2014 were identified. The financial and resource burden of standard treatment was assessed, including operative, outpatient and imaging interventions. Theoretical financial and resource costs of intensive nodal observation for a theoretically equivalent cohort were calculated. RESULTS: The cost of standard treatment was $7,147 per patient and the theoretical cost of nodal observation was $5,300 per patient. Standard treatment required more operating theatre time and inpatient treatment. Nodal observation required more outpatient appointments and imaging. CONCLUSIONS: The cost of nodal observation was lower than standard treatment than in our study. There is a shift in resource requirements from operating theatre and inpatient care to outpatient appointment and imaging. The overall resource impact is low and introduction of nodal observation appears achievable.