Cohort profile: The Trauma Outcomes Project, a prospective study of New Zealanders experiencing major trauma.

PURPOSE: Patient-reported outcome measures (PROMs) are useful for trauma registries interested in monitoring patient outcomes and trauma care quality. PROMs had not previously been collected by the New Zealand Trauma Registry (NZTR). More than 2500 New Zealanders are admitted to hospital for major trauma annually. The Trauma Outcomes Project (TOP) collected PROMs postinjury from three of New Zealand's (NZ's) major trauma regions. This cohort profile paper aims to provide a thorough description of preinjury and 6 month postinjury characteristics of the TOP cohort, including specifically for Maori (Indigenous population in Aotearoa me Te Waipounamu/NZ). PARTICIPANTS: Between July 2019 and June 2020, 2533 NZ trauma patients were admitted to one of 22 hospitals nationwide for major trauma and included on the NZTR. TOP invited trauma patients (aged ≥16 years) to be interviewed from three regions; one region (Midlands) declined to participate. Interviews included questions about health-related quality of life, disability, injury recovery, healthcare access and household income adequacy. FINDINGS TO DATE: TOP recruited 870 participants, including 119 Maori. At 6 months postinjury, most (85%) reported that the injury still affected them, 88% reported problems with≥1 of five EQ-5D-5L dimensions (eg, 75% reported problems with pain or discomfort, 71% reported problems with usual activities and 52% reported problems with mobility). Considerable disability (World Health Organization Disability Assessment Schedule, WHODAS II, score ≥10) was reported by 45% of participants. The prevalence of disability among Maori participants was 53%; for non-Maori it was 44%. Over a quarter of participants (28%) reported trouble accessing healthcare services for their injury. Participation in paid work decreased from 63% preinjury to 45% 6 months postinjury. FUTURE PLANS: The 12 and 24 month postinjury data collection has recently been completed; analyses of 12 month outcomes are underway. There is potential for longer-term follow-up interviews with the existing cohort in future. TOP findings are intended to inform the National Trauma Network's quality improvement processes. TOP will identify key aspects that aid in improving postinjury outcomes for people experiencing serious injury, including importantly for Maori.

Epidemiology of Diabetic Ketoacidosis in the Waikato Region of New Zealand: 2000-2019.

Aims: Diabetic ketoacidosis (DKA) is not well characterised in New Zealand. This study is aimed at characterising the change in epidemiology and severity of DKA from 2000 to 2019 at a tertiary hospital in the Waikato region of New Zealand. Methods: A retrospective clinical data review of all patients admitted to Waikato District Health Board hospitals with DKA was undertaken. Characteristics and severity of DKA were assessed by type of DKA admission (diagnosed at admission, nonrecurrent, and recurrent), ethnicity, social deprivation, intensive care unit (ICU) admission, and length of hospital stay, with linear regression reporting on changes over time. Results: There were 1254 admissions for DKA (564 individual patients), two-thirds being recurrent events. Nonrecurrent DKA patients were younger, whilst recurrent admissions for DKA were associated with T1D, female gender, greater socioeconomic deprivation, and rural living (all P values < 0.01). DKA admission increased 8-fold between 2000 and 2019, mostly due to an increased number of recurrent events, particularly in Maori and female patients (P < 0.001). ICU admissions increased over time (P < 0.001) whilst length of hospital stay trended down (P = 0.031). Conclusions: The rise in recurrent DKA is concerning, particularly in youth and indigenous Maori. Healthcare inequities need to be addressed, including adequate access to mental health support to ensure optimal outcomes for all patients with diabetes.

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

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

Incidence and predictors of new-onset atrial fibrillation after cardiac surgery at Auckland City Hospital.

AIM: To describe the incidence, ethnic differences in incidence, and predictors of post-operative atrial fibrillation (POAF) after cardiac surgery in a New Zealand hospital. METHOD: Analysis of registry data on 1,630 adults without previous atrial fibrillation having coronary artery bypass grafting and/or valve surgery was used to determine the incidence of POAF. Univariate analysis identified risk factors and stepwise logistic regression was used to create the most parsimonious model to predict POAF. RESULTS: Overall POAF incidence was 29% (n=465) and differed by surgery type (25% after isolated coronary artery bypass surgery (CABG) vs 42% after combined CABG+valve). Incidence was highest in Maori (35%) and NZ/Other Europeans (32%). Maori and Pasifika with POAF were on average ten years younger than NZ/Other Europeans. Independent risk factors were age (OR 1.05, 95%CI 1.04-1.06), body mass index (OR 1.04, 95%CI 1.02-1.06), history of heart failure (OR 2.08, 95%CI 1.47-2.95), and valve surgeries (isolated valve OR 1.51, 95%CI 1.16-1.95; CABG+valve OR 1.59, 95%CI 1.11-2.28), but the model had poor discrimination (AUC 0.67). CONCLUSION: POAF in a New Zealand hospital occurs at comparable rates to international settings. Risk models using routinely measured factors offer poor predictive accuracy, meaning risk stratification is unlikely to adequately inform targeted POAF prevention in clinical practice.

Support for and potential impacts of key Smokefree 2025 strategies among Maori who smoke.

AIM: The recently passed Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act has the potential to profoundly reduce smoking prevalence and related health inequities experienced among Maori. This study examined support for, and potential impacts of, key measures included within the legislation. METHOD: Data came from Wave 1 (2017-2019) of the Te Ara Auahi Kore longitudinal study, which was conducted in partnership with five primary health organisations serving Maori communities. Participants were 701 Maori who smoked. Analysis included both descriptive analysis and logistic regression. RESULTS: More Maori participants supported than did not support the Smokefree 2025 (SF2025) goal of reducing smoking prevalence to below 5%, and the key associated measures. Support was greatest for mandating very low nicotine cigarettes (VLNCs). Participants also believed VLNCs would prompt high rates of quitting. Participants who had made more quit attempts or reported less control over their life were more likely to support VLNCs. CONCLUSION: There was support for the SF2025 goal and for key measures that could achieve it. In particular, VLNCs may have significant potential to reduce smoking prevalence among Maori. As part of developing and implementing these measures it will be important to engage with Maori who smoke and their communities.

The prescribing of cardioprotective medications and the impact on survival for patients with peripheral artery disease that undergo intervention.

BACKGROUND: Cardiovascular disease guidelines recommend that patients with established peripheral artery disease (PAD) are prescribed antihypertensive, lipid-lowering, and antiplatelet medication to reduce cardiovascular ischaemic events. However, the prescribing of these medications for patients with PAD within New Zealand (NZ) remains undefined. METHODS: This was a retrospective observational cohort study of patients in the Midland region of NZ, that underwent PAD-related percutaneous and surgical intervention between 1st January 2010 and 31st December 2021. Patient level data was collected. The primary outcome was prescribing of cardioprotective medications either before or within 1 year of incident procedure. Secondary outcome was overall survival. RESULTS: There were 2547 patients included. Antihypertensive prescription occurred in 80.7%, lipid-lowering in 77.4% and antithrombotic in 89.9%. Concomitant ischaemic heart disease increased prescription of cardioprotective medications. Women were prescribed less lipid-lowering medication compared to men. Maori men were prescribed less antiplatelet medication compared to non-Maori men. On univariate analysis lipid-lowering and antiplatelet medication showed survival advantage, while antihypertensive and anticoagulation did not. After adjustment for age, sex, end stage renal failure and presence of chronic limb-threatening ischaemia, best medical therapy was associated with better survival (HR 0.88, 95% CI 0.79-0.98, P = 0.02). CONCLUSION: This study highlights areas of deficiency in prescribing of cardioprotective medication in this high-risk group. These could be targets for national quality improvement initiatives.

Characteristics of Atypical Sleep Durations Among Older Compared to Younger Adults: Evidence from the New Zealand Health Survey.

BACKGROUND: Understanding and supporting sleep is important across the life span. Disparities in sleep status are well documented in mid-life but under-explored among older populations. METHODS: Data from 40,659 adults pooled from the New Zealand Health Surveys were used; 24.2% were "older adults" (aged ≥65 years), 57% were female, and 20.5% of Maori ethnicity. "Long," "short," or "typical" sleep categories were based on age-related National Sleep Foundation guidelines. Multinomial logistic regression examined predictors of atypical sleep, including sociodemographic characteristics, lifestyle factors, and health status. RESULTS: Prevalence of short and long sleep among older adults was 296 (3.0%) and 723 (7.4%), respectively. Correspondingly, prevalence among younger adults was 2 521 (8.2%) and 364 (1.2%). Atypical sleep was more significantly associated with indicators of reduced socioeconomic status and ethnicity among younger rather than older adults. Within both age groups, lower physical activity was associated with long sleep status. Higher physical activity and smoking were related to short sleep status among younger adults only. Within both age groups, atypical sleep was associated with SF-12 scores indicating poorer physical and mental health. Having ≥3 health conditions was related to short sleep among the older adults, while for young adults, it was related to both atypical durations. CONCLUSIONS: Indicators of negative lifestyle and health factors remain consistent predictors of atypical sleep with aging. However, demographic disparities are less apparent among older atypical sleepers. This study highlights individual and contextual factors associated with atypical sleep patterns which may be important for age-appropriate recognition and management of sleep problems.

Interventions to prevent or manage obesity in Maori and Pacific adults: a systematic review and narrative synthesis.

OBJECTIVES: Obesity and its sequelae are an increasing problem, disproportionally affecting Maori and Pacific peoples, secondary to multifactorial systemic causes, including the effects of colonisation and the impact of globalisation. There is limited synthesised evidence on interventions to address obesity in these populations. The objective of this review is to identify evaluated interventions for prevention and management of obesity amongst Maori and Pacific adults, assess the effectiveness of these interventions, and identify enablers and barriers to their uptake. DESIGN: Systematic review of databases (Medline, PubMed, EMBASE, CINAHL, Scopus, CENTRAL), key non-indexed journals, and reference lists of included articles were searched from inception to June 2021. Eligibility criteria defined using a Population, Intervention, Control, Outcome format and study/publication characteristics. Quantitative and qualitative data were extracted and analysed using narrative syntheses. Study quality was assessed using modified GRADE approach. RESULTS: From the 8190 articles identified, 21 were included, with 18 eligible for quantitative and five for qualitative analysis. The studies were heterogenous, with most graded as low quality. Some studies reported small but statistically significant improvements in weight and body mass index. Key enablers identified were social connection, making achievable sustainable lifestyle changes, culturally-centred interventions and incentives including money and enjoyment. Barriers to intervention uptake included difficulty in maintaining adherence to a programme due to intrinsic programme factors such as lack of social support and malfunctioning or lost equipment. CONCLUSIONS: Normal weight trajectory is progressive increase over time. Modest weight loss or no weight gain after several years may have a positive outcome in lowering progression to diabetes, or improvement of glycaemic control in people with diabetes. We recommend urgent implementation of Maori and Pacific-led, culturally-tailored weight loss programmes that promote holistic, small and sustainable lifestyle changes delivered in socially appropriate contexts.

The disproportionately large contribution of the Maori and Pacific Islander community to the healthcare burden of gout in Western Sydney.

BACKGROUND: Gout is a common chronic inflammatory disorder due to monosodium urate deposition, which results in severe inflammatory arthritis. It is particularly common in those of Maori or Pacific Islander heritage. There is a significant number of this at-risk ethnic group in western Sydney. AIMS: To determine the healthcare burden of gout in Western Sydney. METHODS: We characterised patients managed in the emergency departments (EDs) of the four Western Sydney Local Health District (WSLHD) hospitals and those admitted for gout as the primary or secondary diagnosis from 1 January 2017 to 31 December 2018. RESULTS: There were 472 patients managed in ED on 552 occasions at a direct cost to the LHD of A$367 835. Those of Maori or Pacific Islander ethnicity comprised 25.2% (n = 119/472), while half (n = 39/80) of those managed in ED for gout on two or more occasions were of Maori or Pacific Islander ethnicity. Overall, 310 patients were admitted with gout as the principal diagnosis on 413 occasions at a cost of A$1.73 million. Seventy-five (24.2%) of the 310 patients were of Maori or Pacific Islander heritage. A total of 584 WSLHD inpatients had gout as a secondary diagnosis. This was associated with 714 admissions. CONCLUSIONS: The disproportionately large healthcare burden of gout in Western Sydney from the relatively small Maori and Pacific Islander population needs attention. Urgent culturally appropriate interventions to address gout are required to address this inequality.

Using household economic survey data to assess food expenditure patterns and trends in a high-income country with notable health inequities.

This study aimed to identify dietary trends in Aotearoa New Zealand (NZ) and whether inequities in dietary patterns are changing. We extracted data from the Household Economic Survey (HES), which was designed to provide information on impacts of policy-making in NZ, and performed descriptive analyses on food expenditures. Overall, total household food expenditure per capita increased by 0.38% annually over this period. Low-income households spent around three quarters of what high-income households spent on food per capita. High-income households experienced a greater increase in expenditure on nuts and seeds and a greater reduction in expenditure on processed meat. There was increased expenditure over time on fruit and vegetables nuts and seeds, and healthy foods in Maori (Indigenous) households with little variations in non-Maori households. But there was little change in processed meat expenditure for Maori households and expenditure on less healthy foods also increased over time. Routinely collected HES data were useful and cost-effective for understanding trends in food expenditure patterns to inform public health interventions, in the absence of nutrition survey data. Potentially positive expenditure trends for Maori were identified, however, food expenditure inequities in processed meat and less healthy foods by ethnicity and income continue to be substantial.