Systematic Review of Models of Effective Community Specialist Palliative Care Services for Evidence of Improved Patient-Related Outcomes, Equity, Integration, and Health Service Utilization.

Background: The benefits of palliative care programs are well documented. However, the effectiveness of specialist palliative care services is not well established. The previous lack of consensus on criteria for defining and characterizing models of care has restrained direct comparison between these models and limited the evidence base to inform policy makers. A rapid review for studies published up to 2012 was unable to find an effective model. Aim: To identify effective models of community specialist palliative care services. Design: A mixed-method synthesis design reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Prospero: CRD42020151840. Data sources: Medline, PubMed, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews were searched in September 2019 for primary research and review articles from 2012 to 2019. Supplementary search was conducted on Google in 2020 for policy documents to identify additional relevant studies. Results: The search yielded 2255 articles; 36 articles satisfied the eligibility criteria and 6 additional articles were identified from other sources. Eight systematic reviews and 34 primary studies were identified: observational studies (n = 24), randomized controlled trials (n = 5), and qualitative studies (n = 5). Community specialist palliative care was found to improve symptom burden/quality of life and to reduce secondary service utilization across cancer and noncancer diagnoses. Much of this evidence relates to face-to-face care in home-based settings with both round-the-clock and episodic care. There were few studies addressing pediatric populations or minority groups. Findings from qualitative studies revealed that care coordination, provision of practical help, after-hours support, and medical crisis management were some of the factors contributing to patients' and caregivers' positive experience. Conclusion: Strong evidence exists for community specialist palliative care to improve quality of life and reducing secondary service utilization. Future research should focus on equity outcomes and the interface between generalist and specialist care.

Are we just dishing out pills constantly to mask their pain? Kaiawhina Maori health workers' perspectives on pain management for Maori.

AIM: To explore kaiawhina (Maori community health workers) perspectives on supporting whanau Maori with chronic pain, and to understand their views on the use of online resources for pain management. METHOD: A Maori-centred, qualitative design using focus groups as the primary data collection method. Analysis using the general inductive approach. RESULTS: Thirteen kaiawhina working in the Greater Wellington region took part in the focus groups. Four key themes were identified: (1) treatment of chronic pain in primary health relies exclusively on medication, (2) health literacy approaches to pain management are urgently required, (3) Maori have significant unmet need for culturally responsive pain management, and (4) the availability of, and referral practices to, specialist pain services are inadequate for Maori communities. CONCLUSION: Current chronic pain management was predominantly biomedical, and educational strategies lack health literacy approaches. Primary health services exclude traditional Maori methods of treating chronic pain and do not focus on whanau wellbeing. The lack of referral for Maori to specialist services highlights the existing health inequities for Maori. Developing new initiatives (both in-person and online) to address chronic pain management for Maori must be Maori-led and co-designed with whanau to result in holistic solutions for Maori.

Disparities in post-operative mortality between Maori and non-Indigenous ethnic groups in New Zealand.

AIM: To describe disparities in post-operative mortality experienced by Indigenous Maori compared to non-Indigenous New Zealanders. METHODS: We completed a national study of all those undergoing a surgical procedure between 2005 and 2017 in New Zealand. We examined 30-day and 90-day post-operative mortality for all surgical specialties and by common procedures. We compared age-standardised rates between ethnic groups (Maori, Pacific, Asian, European, MELAA/Other) and calculated hazard ratios (HRs) using Cox proportional hazards regression modelling adjusted for age, sex, deprivation, rurality, comorbidity, ASA score, anaesthetic type, procedure risk and procedure specialty. RESULTS: From nearly 3.9 million surgical procedures (876,976 acute, 2,990,726 elective/waiting list), we observed ethnic disparities in post-operative mortality across procedures, with the largest disparities occurring between Maori and Europeans. Maori had higher rates of 30- and 90-day post-operative mortality across most broad procedure categories, with the disparity between Maori and Europeans strongest for elective/waiting list procedures (eg, elective/waiting list musculoskeletal procedures, 30-day mortality: adj. HR 1.93, 95% CI 1.56-2.39). CONCLUSIONS: The disparities we observed are likely driven by a combination of healthcare system, process and clinical team factors, and we have presented the key mechanisms within these factors.

Life during lockdown: a qualitative study of low-income New Zealanders' experience during the COVID-19 pandemic.

AIM: This research explores the experience of low-income New Zealanders during the COVID-19 pandemic lockdown and their advice to the Government about addressing future pandemics. New Zealand had a rapid and effective lockdown that meant the virtual elimination of community transmission. METHOD: Twenty-seven semi-structured interviews were undertaken with low-income people in June-July 2020 immediately after lockdown was lifted. RESULTS: Life during lockdown was challenging for study participants. They were fearful of the virus and experienced mental distress and isolation. Most participants felt safe at home and reported coping financially while still experiencing financial stress. Participants were resourceful and resilient. They coped with lockdown by using technology, self-help techniques and support from others. New Zealand's welfare state ensured participants had access to health services and welfare payments, but there were challenges. Welfare payments did not fully meet participants' needs, and support from charitable organisations was critical. Participants were overwhelmingly positive about the Government's response and advised the Government to take the same approach in the future. This is a particularly reassuring finding from some of the most vulnerable New Zealanders. CONCLUSIONS: An early and hard lockdown, the welfare state, compassion and clearly communicated leadership were keys to a successful lockdown for the low-income people in this study. Research of the experience of low-income people during pandemics is critical to ensuring inequities in pandemic impact are mitigated.

New Zealand COPD Guidelines: Quick Reference Guide.

The purpose of the Asthma and Respiratory Foundation of New Zealand's COPD Guidelines: Quick Reference Guide is to provide simple, practical, evidence-based recommendations for the diagnosis, assessment, and management of chronic obstructive pulmonary disease (COPD) in clinical practice. The intended users are health professionals responsible for delivering acute and chronic COPD care in community and hospital settings, and those responsible for the training of such health professionals.

Clinical and cost-effectiveness of an online-delivered group-based pain management programme in improving pain-related disability for people with persistent pain-protocol for a non-inferiority randomised controlled trial (iSelf-help trial).

INTRODUCTION: Persistent non-cancer pain affects one in five adults and is more common in Maori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability. METHODS AND ANALYSIS: Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA). ETHICS AND DISSEMINATION: The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent. TRIAL REGISTRATION NUMBER: ACTRN 12619000771156.

Effect of multimorbidity on health service utilisation and health care experiences.

INTRODUCTION Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians. AIM To understand the experiences of people with multimorbidity in the NZ health care system. METHODS A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey. RESULTS Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population. DISCUSSION Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.

Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines: a quick reference guide.

The purpose of the New Zealand Child and adolescent asthma guidelines: a quick reference guide is to provide simple, practical, evidence-based recommendations for the diagnosis, assessment and management of asthma in children and adolescents in New Zealand, with the aim of improving outcomes and reducing inequities. The intended users are health professionals responsible for delivering asthma care in the community and hospital emergency department settings, and those responsible for the training of such health professionals.

The role and potential of community-based cancer care for Maori in Aotearoa/New Zealand.

AIM: To investigate the contribution to cancer care and prevention by Maori health provider organisations (MHPs) in Aotearoa/New Zealand. METHODS: A nationwide postal survey of all MHPs (n=253) was undertaken in 2011. The response rate was 55%. RESULTS: We found that MHPs are delivering a wide range of programmes including cancer prevention services focussed on health promotion, advocacy, information and support. MHPs identified financial hardship, transport difficulties, and lack of information as the greatest barriers to cancer care. Culturally safe care by mainstream providers would improve cancer service provision overall. The importance of trust and long-term relationships, with a focus on families rather than individual-based care, was highlighted. CONCLUSION: These findings could lead to substantial improvements in quality of life for Maori cancer patients. This is the first study to show how indigenous health providers contribute to cancer care and prevention in Aotearoa/New Zealand.

Warm homes for older people: aims and methods of a randomised community-based trial for people with COPD.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is of increasing importance with about one in four people estimated to be diagnosed with COPD during their lifetime. None of the existing medications for COPD has been shown to have much effect on the long-term decline in lung function and there have been few recent pharmacotherapeutic advances. Identifying preventive interventions that can reduce the frequency and severity of exacerbations could have important public health benefits. The Warm Homes for Elder New Zealanders study is a community-based trial, designed to test whether a NZ$500 electricity voucher paid into the electricity account of older people with COPD, with the expressed aim of enabling them to keep their homes warm, results in reduced exacerbations and hospitalisation rates. It will also examine whether these subsidies are cost-beneficial. METHODS: Participants had a clinician diagnosis of COPD and had either been hospitalised or taken steroids or antibiotics for COPD in the previous three years; their median age was 71 years. Participants were recruited from three communities between 2009 to early 2011. Where possible, participants' houses were retrofitted with insulation. After baseline data were received, participants were randomised to either 'early' or 'late' intervention groups. The intervention was a voucher of $500 directly credited to the participants' electricity company account. Early group participants received the voucher the first winter they were enrolled in the study, late participants during the second winter. Objective measures included spirometry and indoor temperatures and subjective measures included questions about participant health and wellbeing, heating, medication and visits to health professionals. Objective health care usage data included hospitalisation and primary care visits. Assessments of electricity use were obtained through electricity companies using unique customer numbers. DISCUSSION: This community trial has successfully enrolled 522 older people with COPD. Baseline data showed that, despite having a chronic respiratory illness, participants are frequently cold in their houses and economise on heating. TRIAL REGISTRATION: The clinical trial registration is http://NCT01627418.