Valgus-impacted subcapital neck of femur fractures: a systematic review, meta-analysis with cost analysis of fixation in-situ versus nonoperative management.

BACKGROUND: The management of the valgus-impacted neck of femur fracture (AO/OTA 31-B1) remains contentious. The objective of this study was to determine whether operative intervention is cost-effective. METHODS: We conducted a systematic review using electronic databases (Medline, Embase, Cochrane, Ebsco, Scholar) identifying studies published in the English language concerning valgus-impacted neck of femur fractures until June 2022. Additional studies were identified through hand searches of major orthopaedic journals, and bibliographies of major orthopaedic textbooks. MeSH terms (hip fracture and femoral neck fracture) and keywords (undisplaced, valgus-impacted, valgus, subcapital, Garden) connected by the Boolean operators "AND" and "OR" were used to identify studies. 2 reviewers independently extracted the data using standardised forms and recording spreadsheet. Methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument. Meta-analysis was undertaken. Outcome measures were rate of displacement, avascular necrosis, non-union, mortality and requirement of further operative intervention. A cost utility analysis was then conducted to compare the 2 groups on the basis of the cost of initial treatment and the potential requirement of secondary intervention to hemiarthroplasty. RESULTS: 47 studies met the inclusion criteria. Meta-analysis data demonstrated a significant difference in the displacement rate of 22.8% and 2.8% between the nonoperative and internal fixation groups respectively (p = 0.05). The overall incidence of further operative intervention for each group was 23% and 10% respectively. There was no significant difference with respect to avascular necrosis, mortality or union rates. The cost utility analysis revealed nonoperative management to be approximately 60% more costly than initial internal fixation when the costs of subsequent surgery were included. CONCLUSIONS: This meta-analysis of the existing literature concludes that whilst nonoperative management is possible for valgus impacted neck of femur fractures, it is associated with higher complication rates and greater expense than management by internal fixation.

Centralisation of specialist cancer surgery: an assessment of patient preferences for location of care in the upper South Island of New Zealand.

BACKGROUND: A positive association between volume and outcome for certain operations has led to increasing centralization. The latter is associated with a greater travel burden for patients. This study investigated patient preferences for location of care for cancer surgery. METHODS: Two hundred and one participants were recruited from those who have had recent cancer surgery and from general practice or outpatient clinics in both urban and rural locations in the upper South Island of New Zealand. A questionnaire presented participants with a hypothetical scenario of needing cancer surgery and they were asked to indicate their preference of either a hospital 1 or 5 h away. Scenarios evolved in risk of mortality, complications and need for hospital transfer due to a complication. RESULTS: The majority of participants preferred surgery at the closer hospital when there was a negligible difference in risk. Preference shifted to the distant hospital in a linear relationship as the risk of mortality or complications at the closer hospital increased. Respondents were more likely to prefer the distant hospital from the outset if there was a risk of requiring transfer. CONCLUSION: The majority of participants preferred surgery at the closer hospital if risks were comparable but chose to travel as the risk increased and to avoid hospital transfer due to a complication. New Zealand's unique geography and population make it impossible to replicate centralization models from other countries. The drive for improved outcomes must take equity and patient values into consideration.

Assessing the Mortality Rate After Primary Total Knee Arthroplasty: An Observational Study to Inform Future Economic Analysis.

BACKGROUND: Previous research has focused on the perioperative or short-term (<1 year) mortality rate of total knee arthroplasty (TKA), leaving the long-term (>1 year) mortality rate unresolved. In this study, we calculated the mortality rate up to 15 years after primary TKA. METHODS: Data from the New Zealand Joint Registry from April 1998 to December 2021 were analyzed. Patients aged 45 years or older who underwent TKA for osteoarthritis were included. Mortality data were linked with national records from births, deaths, and marriages. To determine the expected mortality rates in the general population, age-sex-specific life tables from statistics New Zealand were used. Mortality rate was presented as standardized mortality ratios (SMRs) - a comparison of relative mortality rate between the TKA and general populations. In total, 98,156 patients with a median follow-up of 7.25 years (range, 0.00 to 23.74) were included. RESULTS: Over the entire follow-up period, 22,938 patients (23.4%) had died. The overall SMR for the TKA cohort was 1.08 (95% confidence interval (CI): 1.06 to 1.09), suggesting that TKA patients have an 8% higher mortality rate compared to the general population. However, a reduction in short-term mortality rate was observed for TKA patients up to 5 years post TKA (SMR 5 years post TKA; 0.59 95% CI: 0.57 to 0.60]). On the contrary, a significantly increased long-term mortality rate was observed in TKA patients with greater than 11 years of follow-up, particularly in men over the age of 75 years (SMR 11 to 15 years post TKA for males ≥ 75 years; 3.13 [95% CI: 2.95 to 3.31]). CONCLUSION: The results suggest a reduction in short-term mortality rate for patients who undergo primary TKA. However, there is an increased long-term mortality rate particularly in men over the age of 75 years. Importantly, the mortality rates observed in this study cannot be causally attributed to TKA alone.

Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study.

OBJECTIVES: To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic chest pain pathway in rural general practice using point-of-care troponin to identify patients at low risk of acute myocardial infarction, avoiding unnecessary patient transfer to hospital and enabling early discharge home. DESIGN: A prospective observational pilot evaluation. SETTING: Twelve rural general (family) practices in the Midlands region of New Zealand. PARTICIPANTS: Patients aged ≥18 years who presented acutely to rural general practice with suspected ischaemic chest pain for whom the doctor intended transfer to hospital for serial troponin measurement. OUTCOME MEASURES: The proportion of patients managed using the low-risk pathway without transfer to hospital and without 30-day major adverse cardiac event (MACE); pathway adherence; rate of 30-day MACE; patient satisfaction with care; and agreement between point-of-care and laboratory measured troponin concentrations. RESULTS: A total of 180 patients were assessed by the pathway. The pathway classified 111 patients (61.7%) as low-risk and all were managed in rural general practice with no 30-day MACE (0%, 95% CI 0.0% to 3.3%). Adherence to the low-risk pathway was 95.5% (106 out of 111). Of the 56 patients classified as non-low-risk and referred to hospital, 9 (16.1%) had a 30-day MACE. A further 13 non-low-risk patients were not transferred to hospital, with no events. The sensitivity of the pathway for 30-day MACE was 100.0% (95% CI 70.1% to 100%). Of low-risk patients, 94% reported good to excellent satisfaction with care. Good concordance was observed between point-of-care and duplicate laboratory measured troponin concentrations. CONCLUSIONS: The use of an accelerated diagnostic chest pain pathway incorporating point-of-care troponin in a rural general practice setting was feasible and acceptable, with preliminary results suggesting that it may safely and effectively reduce the urgent transfer of low-risk patients to hospital.

Development and Validation of a Self-management Skills Assessment Tool for Children With Inflammatory Bowel Disease: The Inflammatory Bowel Disease-Skills Tasks and Abilities Record (IBD-STAR).

OBJECTIVES: For children with inflammatory bowel disease (IBD), the development of self-management skills has the potential to improve disease outcomes. No assessment tools are aimed at measuring self-management skills in this population. A tool was developed called the IBD-Skills Tasks and Abilities Record (IBD-STAR) which measures children's allocation of responsibility for specific skills. IBD-STAR contains 18 items, scored whether completed independently (score 2), with help (score 1) or not at all (score 0). METHODS: Children with IBD completed IBD-STAR; one parent and a gastroenterologist completed a series of visual analogue scales that corresponded with each IBD-STAR section. Children's IBD-STAR scores were examined against independent variables and compared with the parent and clinician visual analogue scale scores. Reliability was calculated using Cronbach's alpha. RESULTS: Twenty-five Cronbach's alpha with IBD participated, mean age 14 years (standard deviation (SD) 1.7), 14 (56%) were boys, and 21 (84%) had Crohn's disease. The mean IBD-STAR score was 27.1 (SD 5.7), equivalent to a score of 75%. Age was the only independent variable significantly associated with scores (P = 0.017). Parents consistently underestimated their children in all sections, but clinician assessments were more closely aligned. Reliability for IBD-STAR was good with an overall Cronbach's alpha of 0.84. CONCLUSION: IBD-STAR reports the allocation of responsibility for self-management skills with good agreement between children and clinician, and with comprehensible differences with their parents. Such a tool may be used to identify children with IBD in need of support or to measure the efficacy of targeted interventions.

Validation of a Revised Knowledge Assessment Tool for Children with Inflammatory Bowel Disease (IBD-KID2).

INTRODUCTION: For children with inflammatory bowel disease (IBD), acquired knowledge of their condition and treatment is integral to their adherence and self-management. Assessing their knowledge is vital to identify deficits that may affect disease management. IBD-KID2 is a knowledge assessment tool written for children aged 8 years and over with IBD. OBJECTIVES: In order to examine validity and reliability, a study was carried out using IBD-KID2 in a paediatric IBD population and a number of comparator groups with established levels of IBD knowledge. METHODS: IBD-KID2 was administered to 4 participant groups in Christchurch Hospital, New Zealand: children with IBD (n = 22), children without IBD (n = 20), medical staff (n = 15), and administration staff (n = 15). Between-group differences were tested using ANOVA and pairwise comparisons made with the IBD group. Repeat assessments by the IBD group determined test-retest reliability (n = 21). RESULTS: The mean age (range) of the paediatric groups were: IBD 13.3 years (8-18), without IBD 11.9 years (8-15). Group mean scores (SD) were: IBD 8.5 (±2.3), without IBD 3.7 (±2.2), medical staff 13.5 (±1.3), administration staff 6.3 (±2.5). Group means were all significantly different to the IBD group. Test-retest mean at baseline (8.4, CI ±2.4) and repeat (9.0, CI ±2.4) were not significant. Intraclass correlation coefficient was 0.82. Internal reliability was 0.85, and item-total statistics showed no improvement by specific item removal. CONCLUSIONS: IBD-KID2 could distinguish between groups with different knowledge levels. Repeat assessment shows comparable scores on retest and good reproducibility. IBD-KID2 is a valid and reliable tool for use in the paediatric IBD population.

Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster-mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public hospitals.

INTRODUCTION: NetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals. METHODS AND ANALYSIS: Our primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews. ETHICS AND DISSEMINATION: We believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143). TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry ID ACTRN12617000017325 and the Universal Trial Number is U1111-1189-3992.

Response pattern analysis of IBD-KID: A knowledge assessment tool for children with inflammatory bowel disease.

AIM: Paediatric inflammatory bowel disease (IBD) is a chronic relapsing condition requiring adherence to complex treatment regimens to achieve best outcomes. Adherence is frequently low in this population but can be improved by increasing disease- and treatment-related knowledge. The IBD-knowledge inventory device (IBD-KID) is a knowledge assessment tool specifically developed and validated for children with IBD. To analyse IBD-KID participant response patterns in order to review the strength of the tool. METHODS: A cohort of children with IBD completed IBD-KID, and their responses were used to assess the tool's validity and feasibility. Item response analysis assessed the item difficulty and the ability of items to discriminate between high/low scorers. The analysis considered item structure, readability and the effectiveness of multiple choice items. RESULTS: A total of 105 completed IBD-KID assessments showed that 12 items (52%) had an acceptable difficulty level, and 17 (74%) were effective at discriminating between high/low scorers. Nine (61%) had good readability, but comprehension levels ranged from 5 to 18 years. Seven (30%) had elevated 'don't know' responses, highlighting the need for content and construction review. Of the 10 multiple choice items, 9 were complex and not functioning efficiently. Internal consistency was acceptable but could be improved by removing two items. CONCLUSIONS: The response analysis metrics were reviewed by an expert panel and provided a framework for IBD-KID improvements with the aim of increasing discrimination and reducing difficulty without adversely affecting reliability. The proposed revisions will address components that may have caused children to answer incorrectly due to confusion rather than lack of knowledge.

Predictors of non-attendance at outpatient endoscopy: a five-year multi-centre observational study from New Zealand.

AIMS: Outpatient endoscopy non-attendance leads to diagnostic delay and increasing wait times. We aimed to analyse endoscopy non-attendance rates and factors associated with it at the Canterbury and Auckland District Health Boards during a five-year period. METHODS: Consecutive appointments between April 2012 and March 2017 were assessed. The following procedures were included: gastroscopy, colonoscopy and endoscopic retrograde cholangiopancreatography. Predictors of non-attendance were assessed using univariate and multivariate binary logistic regression. RESULTS: A total of 58,434 appointments were offered (Canterbury-33,697, Auckland-24,737), of which 2,694 (4.6%) were not attended. Maori (OR 3.0, 95%CI 2.63-3.42) and Pacific Peoples (OR 3.1, 95%CI 2.7-3.55) were significantly more likely to miss appointments compared with Europeans. Patients from socioeconomically most deprived areas (NZDep10) had higher rates of non-attendance (OR 2.13, 95%CI 1.72-2.63) compared with NZDep1. Males (OR 1.43, 95%CI 1.32-1.56) and the Auckland District Health Board patients (OR 2.28, 95%CI 2.08-2.50) had higher non-attendance rates. CONCLUSION: Overall, 4.6% patients did not attend endoscopy appointments. Maori, Pacific Peoples and patients from socioeconomically deprived areas had higher non-attendance rates. Targeted interventions for at-risk groups would potentially lessen health inequalities and optimise utilisation of endoscopy resources.

Operating time for total knee arthroplasty in public versus private sectors: where does the efficiency lie?

BACKGROUND: Efforts to improve theatre efficiency aim to reduce health costs and maximize productivity. Operating lists in the private sector typically contain more cases than the public sector but it is unclear if this is a result of shorter operative times or reduced times between cases. We aimed to answer the question: Are operating times from skin incision to skin closure shorter in private compared to the public sector for total knee arthroplasty (TKA)? METHOD: The New Zealand Joint Registry was used to compare operating times for primary TKA performed for a diagnosis of osteoarthritis between the public and private sectors. Surgeries included were completed by surgeons who had performed more than 50 TKAs in both sectors. Multivariate analysis was used to control for other variables which may influence operative duration. RESULTS: After adjustment for the variables of patient sex, age, American Society of Anesthesiologists score, body mass index and surgeon effect, a 3-min difference was present between the public and private sectors (public mean: 79.9 min versus private mean: 76.4 min (P < 0.05)). CONCLUSIONS: This study found minimal difference in operating time for TKA between the public and private sectors suggesting differences in overall theatre efficiency between the two sectors are not due to a shorter operative duration.

Magnetic resonance imaging assessment of tibial tuberosity-trochlear groove distance: normal values for males and females.

PURPOSE: The aim of this study was to report normal values of the tibial tuberosity-trochlear groove distance (TTTG) in males and females and assess the reliability of MRI in measuring TTTG. METHODS: Patients presenting with a suspected meniscus injury without any patellofemoral or ligamentous instability, and arthroscopically normal cruciate ligaments and patellofemoral joints were included in the study. K-PACS© was used for MRI analysis and was performed by three observers blinded to each others' measurements. RESULTS: One hundred patients (57 males, 43 females) were recruited from 2006-2010. The mean TTTG in males was 9.91 mm (95% CI 8.9-10.8 mm) and in females 10.04 mm (95% CI 8.9-11.1). The coefficient of variation was <10% for both intra and inter-observer analysis. CONCLUSIONS: The normal TTTG distance is 10 ± 1 mm with MRI being a reliable method of measurement. Literature supports a high degree of variability in reporting TTTG. This study establishes normal TTTG values, which will help in the assessment and treatment of patellofemoral disorders.

Renal stone disease in Christchurch, New Zealand. Part 2: a community study on the burden of renal stone disease.

AIM: To quantify the annual burden of a 12-month cohort of newly diagnosed renal stones in the defined community of Christchurch, New Zealand, and to assess this burden by stone size and position. METHOD: In this prospective study of stone burden, patients in the Christchurch region of New Zealand with newly diagnosed renal stones maintained a weekly diary for a 12-month period to record the utilisation of health services and financial and social costs to families and partners. Patient records were matched with diagnostic and clinical information to provide a comprehensive database. The economic costs of the various services were estimated. RESULTS: From November 2001 to November 2002, 422 newly diagnosed renal stones were detected--an annual incidence of 105 per 100,000 population. The annual mean cost of these stones was NZ$4274 per person in the first 12 months. The greatest costs were those for emergency visits, hospitalisations and for operative procedures (23.8%, 22.7%, and 21.8% of total financial burden respectively). Patient workdays lost accounted for 10.9% of total costs. Ureteric stones caused greater social burden than kidney stones. Costs were influenced by stone location and size, being significantly higher for ureteric stones and for larger stones. CONCLUSIONS: Renal stone disease places a considerable burden on the community. The main burdens were related to health service costs, with personal and pharmaceutical costs representing only a small component. The financial burden to society is estimated at $450,000 per 100,000 population ($NZ in 2001/02).