Management of type 2 diabetes in New Zealand: a scoping review of interventions with measurable clinical outcomes.

OBJECTIVE: This review aimed to assess the effectiveness of interventions for type 2 diabetes (T2D) management in New Zealand on clinical outcomes, and explore the factors impacting their feasibility and acceptability. STUDY DESIGN: Scoping review. METHODS: Three databases (PubMed, Web of Science and Scopus) were searched between January 2000 and July 2023. Reference lists of included studies were hand searched to identify additional articles. RESULTS: The search yielded 550 publications, of which 11 were included in the final review. Most interventions (n = 10) focussed on education and seven were delivered by health professionals. Supporting factors for interventions included clinical/peer support (n = 8) and whanau (family) involvement (n = 6). Hindering factors included non-adherence (n = 4) and high drop-out (n = 4). Most studies reported modest improvement in HbA1c and weight at six months, but minimal change in HbA1c, weight, lipids, renal profile, and blood pressure by two years. CONCLUSION: Future interventions should involve culturally appropriate approaches to improve engagement and acceptability while addressing lifestyle and medication adherence for T2D management. T2D interventions not widely disseminated via academic channels need to be further identified.

The relationship between maternal 25-hydroxyvitamin D status in pregnancy and childhood adiposity and allergy: an observational study.

BACKGROUND: Vitamin D insufficiency (defined as <75 nmol l-1) is widespread among pregnant women around the world and has been proposed to influence offspring outcomes in childhood and into adult life, including adiposity and allergy. Disorders, including asthma and eczema, are on the rise among children. Our aim was to investigate the relationship between maternal 25-hydroxyvitamin D status in pregnancy and offspring adiposity, asthma and eczema in childhood. SUBJECTS AND METHODS: Maternal 25-hydroxyvitamin D concentrations were analysed in serum samples collected at 15 weeks' gestation from 1710 participants of the prospective Screening for Pregnancy Endpoints cohort study. The offspring of 1208 mothers were followed up at age 5-6 years. Data collected included height, weight, percentage body fat (PBF, measured by bioimpedance) and history of asthma and eczema. Multivariable analysis controlled for maternal body mass index (BMI), age and sex of the child and season of serum sampling. RESULTS: Complete data were available for 922 mother-child pairs. Each 10 nmol l-1 increase in maternal 25-hydroxyvitamin D concentration at 15 weeks' gestation was associated with a decrease in offspring PBF of 0.2% (95% confidence interval 0.04-0.36%, P=0.01) after adjustment for confounders but was not related to child BMI z-score. Maternal mean (±s.d.) 25-hydroxyvitamin D concentration was similar in children who did and did not have asthma (71.7±26.1 vs 73.3±27.1 nmol l-1, P=0.5), severe asthma (68.6±28.6 vs 73.3±26.8 nmol l-1, P=0.2) and eczema (71.9±27.0 vs 73.2±27.0 nmol l-1, P=0.5). CONCLUSIONS: The finding of a relationship between maternal vitamin D status and adiposity in childhood is important, particularly because vitamin D insufficiency in pregnancy is highly prevalent. The association between maternal vitamin D supplementation in pregnancy and adiposity in the offspring merits examination in randomised controlled trials.

Ethnicity and risk of lower limb amputation in people with Type 2 diabetes: a prospective cohort study.

AIM: Lower limb amputation is a serious complication of diabetic foot disease and there are unexplained ethnic variations in incidence. This study investigates the risk of amputation among different ethnic groups after adjusting for demographic, socio-economic status and clinical variables. METHODS: We used primary care data from a large national multi-ethnic cohort of patients with Type 2 diabetes in New Zealand and linked hospital records. The primary outcome was time from initial data collection to first lower limb amputation. Demographic variables included age of onset and duration since diabetes diagnosis, gender, ethnicity and socio-economic status. Clinical variables included smoking status, height and weight, blood pressure, HbA1c , total cholesterol/HDL ratio and albuminuria. Cox proportional hazards models were used. RESULTS: There were 892 lower limb amputations recorded among 62 002 patients (2.11 amputations per 1000 person-years), followed for a median of 7.14 years (422 357 person-years). After adjusting for demographic and socio-economic variables and compared with Europeans, Maori had the highest risk [hazard ratio (HR) 1.84 (95%CI:1.54-2.19)], whereas East Asians [HR 0.18, (0.08-0.44)] and South Asians [HR 0.39 (0.22-0.67)] had the lowest risk. Adjusting for available clinical variables reduced the differences but they remained substantial [HR 1.61 (1.35-1.93), 0.23 (0.10-0.56) and 0.48 (0.27-0.83), respectively]. CONCLUSIONS: Ethnic groups had significantly different risk of lower limb amputation, even after adjusting for demographic and some major clinical risk factors. Barriers to care should be addressed and intensive prevention strategies known to reduce the incidence of lower limb amputations could be prioritized to those at greatest risk.

Does a diabetes annual review make a difference?

AIMS: To determine whether a diabetes annual review, independently of other care processes, is followed by improved patient clinical measurements. METHODS: Audits conducted independently of the diabetes annual review were analysed for a time-trend in patient clinical measures. An interaction variable between the review and the year of audit was used to test for a change in gradient before and after a diabetes annual review. Each patient formed their own control. RESULTS: The data included 9471 audits on 3397 patients from 92 practices, and diabetes annual reviews from 2003 to mid-2008. Percentages of patients with raised HbA(1c) , systolic blood pressure and lipids improved from first to last audit. Predicted means after a diabetes annual review for HbA(1c) decreased by 0.13% (1.0 mmol/mol), for HDL cholesterol increased by 0.04 mmol/L and for triglyceride decreased by 0.2 mmol/L. Predicted systolic and diastolic blood pressure, total cholesterol and urinary albumin:creatinine ratio did not change significantly. CONCLUSIONS: Metabolic control improved over time but this was largely independently of the diabetes annual review, which appears to add little clinical value to existing New Zealand general practice care processes. Currently, general practitioners are paid to undertake a diabetes annual review and report the measurements collected. We would argue that payment needs to be directed to demonstrating appropriate changes in clinical management or achieving meaningful clinical goals, and that the annual review results should be part of systematic feedback to general practitioners, particularly directed at clinical inertia.

Glycated haemoglobin and cardiovascular outcomes in people with Type 2 diabetes: a large prospective cohort study.

AIMS: To investigate the association between long-term glycaemic control, measured by glycated haemoglobin (HbA(1c)), and time to first cardiovascular disease (CVD) event for people with Type 2 diabetes in New Zealand. METHODS: A prospective cohort study including people with Type 2 diabetes but no previous CVD. The primary outcome measure was time to first recorded fatal or non-fatal CVD event (ischaemic heart disease, cerebrovascular accident, transient ischaemic attack or peripheral vascular disease) as identified from linked primary care, hospital and mortality records between January 2000 and December 2005. A Cox proportional hazards model was used to examine the association between HbA(1c) and time to CVD event, adjusting for age at diagnosis, duration of diabetes, gender, ethnicity, socio-economic status, smoking, blood pressure (BP), serum total cholesterol : high-density lipoprotein ratio, body mass index (BMI) and urine albumin : creatinine ratio. RESULTS: Participants included 48 444 people with Type 2 diabetes. Fifty-one per cent (n = 24 721) were women, median age 60 years. Median duration of diabetes was 3 years, median BMI 31 kg/m(2), median HbA(1c) 7.1% and mean BP was 138/81 mmHg. During the study period (median follow-up 2.4 years), there were 5667 first CVD events (11.7% of cohort). Each 1% increase in HbA(1c) was associated with an increase in hazard ratio (HR) for CVD of 1.08 (95% confidence interval 1.06-1.10, P < 0.001), myocardial infarction [HR 1.08 (1.04, 1.11)] and stroke [HR 1.09 (1.04, 1.13)]. CONCLUSION: This study has confirmed in a large prospective cohort that increased HbA(1c) is an independent risk factor for cardiovascular disease after controlling for traditional risk factors.

An association between ethnicity and cardiovascular outcomes for people with Type 2 diabetes in New Zealand.

AIMS: To investigate the association between ethnicity and risk of first cardiovascular (CV) event for people with Type 2 diabetes in New Zealand. METHODS: A prospective cohort study using routinely collected data from a national primary health care diabetes annual review programme linked to national hospital admission and mortality data. Ethnicity was recorded as European, Maori, Pacific, Indo-Asian, East-Asian or Other. A Cox proportional hazards model was used to investigate factors associated with first CV event. Data was collected from 48,444 patients with Type 2 diabetes, with first data collected between 1 January 2000 and 20 December 2005, no previous cardiovascular event at entry and with complete measurements. Risk factors included ethnicity, gender, socio-economic status, body mass index, smoking, age at diagnosis, duration of diabetes, systolic blood pressure, serum lipids, glycated haemoglobin and urine albumin : creatinine ratio. The main outcome measures were time to first fatal or non-fatal CV event. RESULTS: Median follow-up was 2.4 years. Using combined European and Other ethnicities as a reference, hazard ratios for first CV event were 1.30 for Maori (95% confidence interval 1.19-1.41), 1.04 for Pacific (0.95-1.13), 1.06 for Indo-Asian (0.91-1.24) and 0.73 for East-Asian (0.62-0.85) after controlling for all other risk factors. CONCLUSIONS: Ethnicity was independently associated with time to first CV event in people with Type 2 diabetes. Maori were at 30% higher risk of first CV event and East-Asian 27% lower risk compared with European/Other, with no significant difference in risk for Pacific and Indo-Asian peoples.

The TAR model: use of therapeutic state transitions for quality assurance reporting in chronic disease management.

Chronic disease management represents one of the challenges for health informatics and demands the appropriate application of information technology for improved patient care. This paper presents an approach to quality assurance reporting wherein the recommendations of evidence-based clinical practice guidelines are considered in the context of empirical therapeutic state-transitions (in terms of changes in individual patient prescriptions over time). We apply a Transition-based Audit Report (TAR) model to antihypertensive prescribing and related data as stored in a New Zealand General Practice Management System database. The results provide a set of quality indicators and specific patient cohorts for potential practice quality improvement with strong linkage to the selected guidelines and observed practice patterns. We see the TAR model primarily as a tool to enable internal quality improvement efforts, but also to be of relevance for focusing pay-for-performance programs.

Antibiotics for the common cold and acute purulent rhinitis.

BACKGROUND: It has long been believed that antibiotics have no role in treating common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections. Given the increasing concerns about antibiotic resistance it is important to examine the evidence for the benefit of antibiotics for the common cold. OBJECTIVES: To determine:(1) the efficacy of antibiotics, in comparison with placebo, for reducing general symptoms and specific nasopharyngeal symptoms of acute upper respiratory tract infections; (2) if antibiotics have any influence on acute purulent rhinitis; (3) whether antibiotics cause significant adverse outcomes in patients with acute upper respiratory tract infections. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005); MEDLINE (January 1966 to March, Week 1, 2005); EMBASE (1980 to December 2004), the Family Medicine Database (1908, volume 1 to 1993, volume 13; this database was discontinued in 1993), and reference lists of articles, and we contacted principal investigators. SELECTION CRITERIA: Randomised trials comparing any antibiotic therapy against placebo in people with acute upper respiratory tract infections and with less than seven days of symptoms, or acute purulent rhinitis less than ten days in duration. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. MAIN RESULTS: All analyses used the fixed-effect model unless otherwise stated. The overall quality of the included trials was variable. People receiving antibiotics did no better in terms of lack of cure or persistence of symptoms than those on placebo (relative risk (RR) 0.89, 95% confidence interval (CI) 0.77 to 1.04), based on a pooled analysis of six trials with a total of 1147 patients. Overall, the relative risk of adverse effects in the antibiotic group was RR 1.8 (95% CI 1.01 to 3.21), using a random-effects model. Adult patients had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random-effects model) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63). The pooled relative risk for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.57 (95% CI 0.37 to 0.87) (random-effects model), based on 6 studies with 772 participants. AUTHORS' CONCLUSIONS: There is insufficient evidence of benefit to warrant the use of antibiotics for upper respiratory tract infections in children or adults. Antibiotics cause significant adverse effects in adults. The evidence on acute purulent rhinitis and acute clear rhinitis suggests a benefit for antibiotics for these conditions but their routine use is not recommended.

Diabetic nephropathy and microalbuminuria in the community. The South Auckland Diabetes Survey.

OBJECTIVE: To compare the clinical, anthropometric, and metabolic characteristics of New Zealand Europeans, Maori, and Pacific Islanders with non-insulin-dependent diabetes mellitus (NIDDM) with emphasis on risk factors for the development of diabetic nephropathy. RESEARCH DESIGN AND METHODS: A cross-sectional survey of 555 (74% of 750 available) diabetic patients attending diabetes clinics and randomly selected primary care centers was conducted in Auckland, New Zealand. RESULTS: Among those with NIDDM, Maori and Pacific Islanders were younger at diagnosis, more obese, and had poorer glucose control when compared with the Europeans (fructosamine in mumol/l: Maori 335 +/- 78, Pacific Islanders 367 +/- 90, Europeans 318 +/- 55; overall P < 0.001). Systolic blood pressure (sBP) was higher in Maori (145 +/- 31 mmHg) and lower in Pacific Islanders (135 +/- 25 mmHg) when compared with Europeans (141 +/- 25 mmHg; overall P < 0.005). Mean estimated daily urinary albumin excretion (UAE) was 18.2 (15.5-1.3) mg/day in Europeans, 94.8 (60.5-148.7) mg/day in Maori, and 44.2 (32.3-60.3) mg/day in Pacific Islanders. The prevalence of proteinuria and end-stage renal failure were also higher in Maori and Pacific Islanders. The excess prevalence of microalbuminuria and proteinuria in Maori was present within 5 years of diagnosis. Europeans with impaired renal function were least likely to have associated proteinuria or microalbuminuria. Microalbuminuria and nephropathy were not consistently associated with either higher blood pressure or worse glucose control. CONCLUSIONS: NIDDM in Maori and Pacific Islanders is associated with a greater degree of proteinuria and end-stage renal failure than that in Europeans. This observation is not explained by conventional risk factors.

Antibiotics for the common cold.

BACKGROUND: The common cold is caused by viruses which cannot be helped by antibiotics. OBJECTIVES: The objective of this review was to assess the effects of antibiotics for the common cold. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, the Family Medicine Database, and reference lists of articles, and we contacted principal investigators. The most recent search was in December 1998. SELECTION CRITERIA: Randomised trials comparing any antibiotic therapy with placebo in acute upper respiratory tract infections. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Main results: Seven trials involving 2056 people aged between six months and 49 years were included. The overall quality of the included trials was variable. People receiving antibiotics did not do better in terms of cure or improvement than those on placebo (odds ratio 0.95, 95% confidence interval 0.70 to 1.28 fixed effects model). One study found a significant benefit for antibiotics compared with placebo for runny nose (clear or purulent). The only other study to evaluate purulent nasal discharge found no significant benefit for antibiotics. Only one study reported work time lost with 22% of those on antibiotic treatment and 25% of those on placebo but this was not significant. Patients treated with antibiotics had a significant increase in side effects (odds ratio 2.72, 95% confidence interval 1.02 to 7.27, random effects model). REVIEWERS' CONCLUSIONS: There is not enough evidence of important benefits from the treatment of upper respiratory tract infections with antibiotics and there is a significant increase in adverse effects associated with antibiotic use.

Antibiotics for the common cold.

BACKGROUND: The common cold is considered to be caused by viruses and it has long been believed that antibiotics have no role in treating this condition. In many countries doctors will often prescribe antibiotics for the common cold in the belief that they may prevent secondary bacterial infection and in some cases to respond to patient demand. There is also increasing concern over the resistance of common bacteria to commonly used antibiotics. A crucial step in reducing the use of antibiotics for the common cold is to examine the evidence to see if there is any benefit or if there is benefit for some subgroups or symptom constellations. OBJECTIVES: (1) To determine the efficacy of antibiotics in comparison with placebo in the treatment of acute upper respiratory tract infections (common colds) in terms of the proportion of patients in whom the clinical outcome was considered to be a reduction in general symptoms and specific nasopharyngeal symptoms. (2) To determine whether there are significant adverse outcomes associated with antibiotic therapy for patients with a clinical diagnosis of acute upper respiratory tract infection. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, the Family Medicine Database, and reference lists of articles, and we contacted principal investigators. The most recent search was in May 2001 SELECTION CRITERIA: Randomised trials comparing any antibiotic therapy with placebo in acute upper respiratory tract infections with less than 7 days of symptoms DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. MAIN RESULTS: All analyses used fixed effects unless otherwise stated Main results: Nine trials involving 2249 (2157 analysed) people aged between two months and 79 years (and adults with no upper age limit) years were included. The overall quality of the included trials was variable. People receiving antibiotics did not do better in terms of lack of cure or persistence of symptoms than those on placebo (odds ratio 0.8, 95% confidence interval (95% CI) 0.59 to 1.08). Only one study Taylor et al (1977) specifically reported persistence of clear rhinitis with a small benefit to those on antibiotics. Two studies found a significant benefit for antibiotics compared with placebo for runny nose (clear) odds ratio 0.42 (0.22-0.78). Two studies also found a significant benefit in patients with sore throat odds ratio 0.27 95% CI (0.10-0.74). Only one study reported work time lost with 22% of those on antibiotic treatment and 25% of those on placebo but this was not significant. Adult patients treated with antibiotics had a significant increase in adverse effects (odds ratio 3.6 95% CI 2.21 to 5.89) while there was no significant increase in children odds ratio 0.90 95% CI (0.44-1.82). REVIEWERS' CONCLUSIONS: There is not enough evidence of important benefits from the treatment of upper respiratory tract infections with antibiotics to warrant their routine use in children or adults and there is a significant increase in adverse effects associated with antibiotic use in adult patients.

Evidence-based medicine: the need for a new definition.

Evidence is defined by its ability to establish or support conclusions. Evidence-based medicine (EBM) equates evidence with scientific evidence and views factors such as clinical expertise as important in moving from evidence to action. In contrast, we suggest that EBM should acknowledge multiple dimensions of evidence including scientific evidence, theoretic evidence, practical evidence, expert evidence, judicial evidence and ethics-based evidence. What EBM loses by not acknowledging these dimensions as evidence is the ability, among other things, to make and defend judgements based on understandings that complement science and are no less important than those science can offer. We argue for a new definition of EBM that, without forced accommodation or unacceptable compromise, acknowledges dimensions of evidence produced within and outside science.

Foot care among diabetic patients in south Auckland.

AIM: To describe footcare among diabetic patients in south Auckland. METHOD: Direct interview of 331 European, 86 Maori and 123 Pacific Islands patients attending local diabetes services and a stratified subsample of general practitioners. Interviews included closed and open questions of diabetes knowledge, demographic and medical history and were followed by a thorough inspection of the feet. RESULTS: Major lesions (amputation, foot ulcer) and predisposing lesions (callus or fungal infection/maceration) were present in 48.5% of patients. Major lesions were particularly common among Pacific Islands patients (9.4%) vs European (3.9%), Maori (5.5%), (p < 0.05). Fungal infection/maceration was less common among Pacific Islands patients (23.0%) vs 42.3%, 42.2% respectively, (p < 0.001). Fungal infection/maceration was more common and callus formation less common among men when compared with women. Forty percent (n = 214) of patients, including eight with either an ulcer or a blister, had not had their feet examined over the preceding 12 months. Good foot care was present in 52.7% Europeans, 31.0% Maori and 26.8% Pacific Islands patients (p < 0.001). Diabetes knowledge was poorest in those with poor foot care among Europeans and Maori. CONCLUSION: While the provision of footcare advice, adherence to such advice and monitoring of footcare remain uneven, the hospital and community costs of the diabetic foot will continue to be high.

Issues relating to early detection and diagnosis of breast cancer in New Zealand general practice.

AIM: This study describes current practice in New Zealand general practice with emphasis on identifying problem areas in the early detection of breast cancer. The study is focused on women outside the age group for the New Zealand breast screening programme (50-64 years). METHOD: Thirty selected general practitioners throughout New Zealand were interviewed in depth to identify the key issues relating to the early detection and diagnosis of breast cancer in the primary care setting. Attitudes to key issues were quantified in a later postal survey of 656 general practitioners randomly sampled from the RNZCGP database. RESULTS: The response rate to the quantitative study was 82%. General practitioners were generally well informed about risk factors for breast cancer and the relative sensitivity and specificity of screening and diagnostic tools. Diagnosis and management were influenced by the limitations of screening and diagnostic tools, as well as access to, and confidence in, services. The appropriate level of investigation and follow-up for young women was an area of uncertainty. CONCLUSION: The study provided data to inform guideline development and a baseline measure of current practice against which the impact of the implementation of guidelines could be measured.

Ethnic differences in diabetes knowledge and education: the South Auckland Diabetes Survey.

AIM: To compare the knowledge of diabetes, and diabetes education provision/preferences among European, Maori and Pacific Islands diabetic patients in south Auckland. METHOD: The 331 European, 86 Maori and 123 Pacific Islands patients who were interviewed attended local diabetes services and a stratified subsample of general practitioners. Interviews included closed and open questions of diabetes knowledge, age, sex, diabetes treatment, employment status, weekly household income, school/further education received and the actual and preferred format of diabetes education. RESULTS: Pacific Islands patients knew least, and Europeans most, about diabetes from both open and closed diabetes knowledge questions. The majority of Pacific Islands patients could not name the nature, symptoms or complications of diabetes. This was unaffected by duration of diabetes, place of birth or time in New Zealand, although insulin treated Pacific Islands patients knew more than noninsulin treated patients (closed score 71 SD (4)% vs 61 SD (2)% p < 0.05). Pacific Islands patients were least likely to have received diabetes education (European 69%, Maori 70%, Pacific Islands 49%, p < 0.001). Knowledge scores were higher in those who had received education at diagnosis. Europeans were least likely to want further education (Europeans 52%, Maori 69%, Pacific Islands 63%, p < 0.01). The preferred sources for ongoing education were the lay educator/diabetes nurse specialist service (Europeans 28%, Maori 37%, Pacific Islands 76%), and the hospital based clinic among Europeans (27%) and Maori (36%). No Pacific Islands patients preferred a hospital based ongoing education service, while few diabetic patients of any ethnic group preferred to receive education via their general practitioner. In all ethnic groups, patients wanting more education knew more than those who did not. CONCLUSION: The local delivery of diabetes education is uneven. Among Pacific Islands people, it is grossly inadequate. In order for all patients to receive such education, the diabetes services need to be better coordinated and integrated with primary health care.

Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial.

OBJECTIVE: To test the use of a delayed prescription compared with instructions to take antibiotics immediately in patients presenting to family physicians with upper respiratory tract infections (common colds). STUDY DESIGN: Randomized controlled single-blind study. POPULATION: Subjects were 129 patients presenting with the common cold who requested antibiotics or whose physicians thought they wanted them. All patients were in a family practice in Auckland, New Zealand, consisting of 15 physicians (9 male, 6 female) who had completed medical school between 1973 and 1992. OUTCOMES MEASURED: Outcomes were antibiotic use (taking at least 1 dose of the antibiotic), symptom scores, and responses to the satisfaction questions asked at the end of the study. RESULTS: Patients in the delayed-prescription group were less likely to use antibiotics (48%, 95% CI, 35%-60%) than were those instructed to take antibiotics immediately (89%, 95% CI, 76%-94%). Daily body temperature was higher in the immediate-prescription group. The lack of difference in the symptom score between the 2 groups suggests that there is no danger in delaying antibiotic prescriptions for the common cold. CONCLUSIONS: Delayed prescriptions are a safe and effective means of reducing antibiotic consumption in patients with the common cold. Clarification of patient expectations for antibiotics may result in a lower prescription rate. When the patient demands a prescription, delaying its delivery has the potential to provide gentle education.