A qualitative evaluation of rural and provincial surgery wananga to enhance cultural safety among surgical registrars in Taranaki, New Zealand.

BACKGROUND: The Royal Australasian College of Surgeons (RACS) recently instituted cultural safety and cultural competency as its 10th competency with formalized cultural safety training yet to be instituted. Wananga are Indigenous Maori teaching institutions that can be used contemporarily for cultural safety training. METHODS: In 2022, surgical registrars based at Taranaki Base Hospital (TBH) held in-hospital wananga ranging from 1 to 3 h focussed on cultural safety, professionalism and wellbeing. This study explores the perspectives of these registrars who attended wananga using a Kaupapa Maori aligned methodological stance and interpretive phenomenological analysis. RESULTS: Twenty-six wananga were held from March 22nd 2022 to January 30th 2023. Six registrars provided their perspectives with four major themes emerging from their stories including: cultural safety; unity; time, place and person; and a new era. Registrars valued the wananga which was scheduled for Friday afternoons after daily clinical duties. Wananga facilitated unity and understanding with registrars being able to reflect on the context within which they are practicing - describing it as a new era of surgical training. 'Time' was the biggest barrier to attend wananga however, the number of wananga held was testament to the commitment of the registrars. CONCLUSIONS: Regular wananga set up by, and for, surgical registrars cultural safety development is feasible and well subscribed in a rural or provincial NZ setting. We present one coalface method of regular cultural safety training and development for surgical registrars and trainees in NZ.

A retrospective cohort study of incidental abdominal aortic aneurysms on routine abdominal computed tomography scans in Te Tairawhiti (2018-2019).

AIM: Ruptured abdominal aortic aneurysm (rAAA) is associated with a high mortality rate which, is especially significant in rural and provincial regions. In Aotearoa New Zealand, Maori experience higher rates of AAA and worse overall medium-term survival following AAA repair. This study aimed to understand the prevalence of incidental AAA on routine abdominal computed tomography (CT) scans over 12 months. METHOD: A retrospective review of all abdominal CT scans performed on patients ≥50 years at Gisborne Hospital between 1 December 2018-1 December 2019 was performed. RESULTS: A total of 811 scans were reviewed, with 42 incidental AAA detected (5.2%). The majority of incidental AAA were in males aged ≥65 (65.8%), with a higher prevalence for Maori compared to New Zealand European (NZE) (16.2% vs 8.1%, p=0.052). This pattern was also seen in females, aged ≥65 (10.9% in Maori vs 3.8% in NZE, p=0.047). CONCLUSION: The detection of AAA on routine abdominal CT scans appears to be a useful adjunct in lieu of targeted AAA screening in our region. A high prevalence of incidental AAA (5.2%) over 12 months, with a significantly higher prevalence noted in Maori males and females ≥65 years (16.2% and 10.9%), was observed.

Lessons following implementation of a colorectal enhanced recovery after surgery (ERAS) protocol in a rural hospital setting.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs have become increasingly popular in the management of patients undergoing colorectal resection. However, the validity of ERAS in rural hospital settings without intensive care facilities has not been primarily evaluated. This study aimed to assess an ERAS protocol in a rural surgical department based in Invercargill New Zealand. METHODS: Ten years of prospectively collected data were analysed retrospectively from an ERAS database of all patients undergoing open, converted, or laparoscopic colorectal resections. Data were collected between two time periods: before the implementation of an ERAS protocol, from January 2011 to December 2013; as well as after the implementation of an ERAS protocol, from January 2014 to December 2020. The primary outcome measures were hospital length of stay (LOS) and LOS in the critical care unit (LOS-CCU). Secondary outcomes were compliance with ERAS protocol, mortality, readmission, and reoperation rates. RESULTS: A total of 118 and 558 colorectal resections were performed in the pre-ERAS and ERAS groups respectively. A statistically significant reduction in hospital LOS was achieved from a median of 8 to 7 days (P = 0.038) when comparing pre-ERAS to ERAS groups respectively. Furthermore, a significant reduction in re-operation rates was observed (7.6% vs. 3% in the ERAS group, P = 0.033) which was seen without a rise in readmission rates (13.6% vs. 13.6% in the ERAS group). CONCLUSION: The implementation of ERAS in a rural surgical setting is feasible, and these initial findings suggest ERAS adds value in optimizing the colorectal patient's surgical journey.

Comparing return of bowel function after right versus extended right hemicolectomy: a retrospective analysis.

BACKGROUND: Prolonged postoperative ileus (PPOI) is associated with higher morbidity and extended inpatient stay. Although evidence suggests that PPOI is more common following right-sided resections, it is uncertain if return to bowel function is similar following extended right (ERH) versus right hemicolectomy (RH). METHODS: The recovery of patients undergoing ERH and RH in a regional hospital in New Zealand was retrospectively compared, from 2012 to 2021. Rates of PPOI, return of bowel function and postoperative complications were compared. Other factors potentially relating to PPOI were analysed. RESULTS: 293 patients were included (42 who underwent ERH, and 251 RH). PPOI was more common following ERH than RH (43% vs. 25%, P = 0.02). When accounting for the operative approach, rate of PPOI was not significantly different (42% open ERH vs. 36% open RH; P = 0.56). Excluding PPOI, return of bowel function did not differ between groups. Patient undergoing ERH versus RH had significantly higher length of stay (1 day) and Hb drop (2.5 g/L) postoperatively. CONCLUSION: Higher rates of PPOI have been demonstrated in ERH versus RH however when controlling for approach, there was not a significant difference. Further interrogation into rates of PPOI (particularly after laparoscopic surgery) are warranted to tailor locoregional ERAS protocols.

Investigating the distribution of primary and secondary care referrals for public-funded bariatric surgery at Counties Manukau Health (CMH).

AIMS: This study investigated variations in referral rates for bariatric surgery from primary and secondary care providers across the Counties Manukau district health board (CMDHB), with the aim of identifying "hot spots" for referrals so that intervention to help achieve equitable access to bariatric surgery can be implemented. METHODS: Referral data was gathered from hospital referral records from January 2017 to January 2019 (n=1,440). Referral rate per geographical location within the CMDHB catchment was calculated using 2018 census figures. RESULTS: Of the 1,195 referrals included, 1040 (87%) referrals were from primary care. The referrals came from 328 general practitioners (GPs) across 158 practices. There was considerable regional variation in referral rates per 1000 people, from a peak of 71.5/1000 to a low of 0.2/1000. Eighty-six percent of secondary care referrals were received from the public system and the remainder from private practice. The most common referral specialty was diabetes, followed by general surgery and orthopaedics. Out of these referrals, 434 (36%) proceeded to bariatric surgery. Pakeha (50%) were more likely to proceed to surgery than Maori (31%) and Pasifika (22%), despite similar referral numbers. CONCLUSION: There is significant variation in referrals for bariatric surgery across CMDHB. Systematic discussion of bariatric surgery with every patient who is likely to benefit is not occurring, given relatively low referral volumes.

The Surgical Sisterhood - The Experiences of wahine Maori and Pasifika Aspiring Surgeons.

The establishment of a culturally diverse surgical workforce, largely on the basis of gender, has been highly promoted in Australasia in the last decade. Despite this, discussions of gender diversity in surgery have largely excluded Indigenous women. This study presents the experiences of wahine Maori and Pasifika doctors in Aotearoa, who formed a surgical sisterhood to support them towards applying for advanced surgical training. Utilising mana wahine and Masi methodologies, semi-structured interpersonal interviews were undertaken with five wahine who formed the surgical sisterhood. Following transcription and analysis of all interviews, four key themes were identified. These were mana wahine, unity, our why and change on the horizon. These themes illustrate the complex and varied experiences of wahine Maori and Pasifika and how they have navigated their surgical pathways amidst multiple layers of discrimination towards being in a position to apply for advanced surgical training.

Understanding surgical disease and care for Maori in Aotearoa: protocol for a scoping review.

INTRODUCTION: Maori continue to experience inequitable healthcare and health outcomes compared with other New Zealanders. A narrative review conducted in 2016 described disparities in access to and through the surgical care pathway for Maori from a limited pool of small retrospective cohort studies. This review only targeted studies that specifically investigated surgical care for Maori; however, many other studies have performed subanalyses for Maori as part of bigger ethnographic epidemiological studies and Indigenous health has become more topical in Australasia since this review was conducted. Health disparities and inequities in surgical care for Maori are still not well understood. This scoping review aims to report the nature and extent of disparities in surgical disease and care for Maori. METHODS AND ANALYSIS: A scoping review will be performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist. This study will be informed by Kaupapa Maori research methodology. Electronic searches of PubMed, MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature Plus will be performed between 19 February and 19 March 2022. Two authors will independently identify and retrieve relevant texts in an iterative manner and examine how responsive each of the included studies are to Maori using the recently described Maori framework-a framework designed to guide researcher responsiveness to Maori. ETHICS AND DISSEMINATION: Ethical approval has not been sought as our review will only include published and publicly accessible data. We will publish the review in an open access peer-reviewed surgical journal. This protocol has been registered in Open Science Framework (10.17605/OSF.IO/NP4H3).

Falling through the cracks: Evaluating the role of nonacute surgical liaison personnel during COVID-19-A narrative review.

BACKGROUND: In March 2020, in response to the COVID-19 pandemic, the New Zealand government instituted a 4-level alert system, which resulted in the rapid dissolution of nonurgent surgical services to minimize occupational exposure to both patients and staff, with the primary health sector bearing most of the diverted caseload. Consequently, the study authors sought to collate information around the establishment of a supportive nonacute surgical liaison role in a public hospital surgical department, with an interest in establishing this role in New Zealand. METHODS: The narrative review conducted systematically in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases searched included Pubmed, MEDLINE, Embase, and Cochrane Controlled Register of Trials. A deductive analysis was applied using a demand management model developed by the Institute for Innovation and Improvement at Waitemata District Health Board. All included studies were rated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool. RESULTS: Collation of 19 studies resulted in 3 key findings: first, that a surgical liaison could be utilized at the primary care to specialist interface to improve communication and workflow between services. Second, a liaison could be utilized directly communicating with patients as a means of increasing engagement and self-management. Finally, this service can be offered through multiple modalities including a noncontact telehealth service. CONCLUSION: Evidence of nonacute surgical liaisons both internationally and specifically within New Zealand has been collated to provide evidence for its application.

Variation in publicly funded bariatric surgery in New Zealand by ethnicity: cohort study of 328,739 patients.

BACKGROUND: New Zealand health services are responsible for equitable health service delivery, particularly for Maori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities. OBJECTIVES: To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities. SETTING: New Zealand primary care. METHODS: A cohort study of New Zealanders aged 30-79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities. RESULTS: A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46-62], 54% European, 13% Maori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1-6.9). The likelihood of receipt of bariatric surgery was lower for Maori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69-.96] and .24 [.20-.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality. CONCLUSIONS: Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care.

Patient Experiences of the Emergency Laparotomy Pathway: A Qualitative Study.

INTRODUCTION: Emergency laparotomy (EL) is a commonly performed operation with high rates of morbidity and mortality. Despite a growing body of literature on outcomes from EL, there is sparse literature on the patient experience. The aim of this study is to capture the perspective of patients on their EL experience. Qualitative methodology is used as a platform to allow patients to express their personal experiences and ideas around the EL process. MATERIALS AND METHOD: Participants were consented as a part of a large observational study, established across the three public teaching hospitals in Auckland, New Zealand. Patients who had an EL within the past 4 months were recruited. A recorded interview was conducted either face-to-face or over the telephone, using questions formulated from a previous systematic review on EL outcomes. Transcripts were transported to NVivo and thematically analysed by two reviewers. RESULTS: Fifteen participants were interviewed. The majority of participants were female, New Zealand European and 65 or older. Five important themes were identified. Overall, participants expressed satisfaction with their interactions with hospital staff. However, they wanted more information about their condition, operation and what outcomes might occur. Participants also described post-operative priorities in the acute setting, as well as long-standing physical and emotional impacts. CONCLUSION: This study provides a better understanding of what is important to patients during the EL process. This information is important when considering ways to improve care and communication with patients undergoing EL.

Affirmative action programmes in postgraduate medical and surgical training-A narrative review.

OBJECTIVE: This review aims to identify and summarise the literature pertaining to the implementation of affirmative action programmes (AAP) for selection of ethnic minorities and Indigenous peoples into selective specialist medical and surgical training programmes. METHODS: A systematic literature search was conducted to identify relevant studies reporting on the background, implementation and results of AAP for ethnic minorities and Indigenous peoples into medical and surgical training. MEDLINE, EMBASE, PubMed, Scopus and Google Scholar databases were queried from inception through to 1 February 2020. All included studies were subjected to inductive thematic analysis in order to systematically collate study findings. Articles were read through several times in an iterative manner to allow the identification of themes across the included studies. The themes were cross-compared among the authors to establish their interconnectedness. RESULTS: Forty-five articles described AAP pertaining to ethnic minorities in the United States of America (African-Americans and Hispanic Americans), women and ethnic minorities, Indigenous peoples (New Zealand Maori) and people with low socio-economic status. Four themes were identified. These included the need for social responsiveness in clinical training organisations, justification and criticism of AAP, how clinical training agencies should participate in AAP and what constitutes an effective AAP for specialist medical and surgical training. CONCLUSIONS: Affirmative action programmes have been effective at increasing numbers of ethnic minority medical school graduates but have not been used for specialist medical or surgical training selection. AAP achieve the best results when they are associated with a comprehensive programme of candidate preparation, support and mentorship beginning prior to application, and support and mentorship extending through training and subsequently into the post-training period as an independent professional. The overall aim of any AAP in medical or surgical training must be graduation of significant numbers of minority and Indigenous trainees into successful practice with appointment to faculty member and leadership positions.

Ethnic Disparities in Access to Publicly Funded Bariatric Surgery in South Auckland, New Zealand.

BACKGROUND: In New Zealand (NZ), Indigenous Maori and Pacific peoples experience a higher burden of obesity and obesity-related disease. Counties Manukau Health (CMH) provides the largest public bariatric service in NZ housing a higher proportion (64%) of non-European groups (Asian, Pacific and Maori). This study investigated whether ethnic disparities in the receipt of bariatric surgery exist within one of the most ethnically diverse populations in NZ. METHODS: All patients accepted on to the CMH bariatric programme between 1 January 2011 and 31 December 2017 were identified through hospitalisation records. Logistic regression modelling with multivariate adjustment was utilised to assess the likelihood (odds ratio) of receipt of bariatric surgery by ethnicity. RESULTS: A total of 2519 referrals were received, of which 1051 proceeded to surgery. The proportion of patients referred who eventually underwent bariatric surgery was significantly higher for Other Europeans (68%) and NZ Europeans (63%) compared to Asian (42%), Maori (41%) and Pacific peoples (28%, p < 0.05). The likelihood of receipt of bariatric surgery was significantly lower for Maori (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.42-0.68) and Pacific (OR, 0.3; 95%CI, 0.23-0.40). These disparities were not explained by differences in socio-demographics, comorbidity or attrition. CONCLUSIONS: Ethnic disparities in the receipt of publicly funded bariatric surgery exist where NZ European and Other European patients are more likely to gain access to publicly funded bariatric surgery. These findings challenge current selection criteria and prompt discussion around whether equity targets based on ethnicity need to be established.

Enhancing responsiveness to Maori in a publicly funded bariatric service in Aotearoa New Zealand.

BACKGROUND: Health equity is a fundamental right afforded to all regardless of ethnicity. However, in New Zealand (NZ), health inequities are most compelling for Indigenous Maori who experience inadequate access to services, poorer quality of care and poor health outcomes as a result. Bariatric surgery is the most effective intervention for weight loss and remission of obesity-related disease where all other interventions have been exhausted. This Kaupapa Maori qualitative study presents Maori perspectives of bariatric surgery from the largest public bariatric centre in NZ and offers solutions for enhancing bariatric service responsiveness to Maori. METHODS: This qualitative study was informed by Kaupapa Maori methodology and involved a general inductive thematic analysis of 31 semi-structured interviews with Maori patients who had bariatric surgery at Counties Manukau Health in South Auckland, NZ. RESULTS: Four key themes were identified following analysis: (i) Kaupapa Maori standards of health; (ii) bariatric mentors; (iii) bariatric psychologists; and (iv) community-integrated support. These themes offer four tangible solutions for optimizing bariatric pathways for Maori from the perspectives of Maori bariatric patients. CONCLUSION: Kaupapa Maori, community-centred and greater non-surgeon aspects of bariatric supportive mechanisms comprise key areas of opportunity for public bariatric pathways in NZ. Surgical leadership is required to advance health equity and service responsiveness to Maori.

Exploring motivation for bariatric surgery among Indigenous Maori women.

INTRODUCTION: Bariatric surgery is the most effective intervention for alleviating obesity and its complications. Indigenous people worldwide experience higher rates of obesity and obesity disease burden. However, few studies exploring bariatric surgery among Indigenous peoples are published. In this study we aimed to explore the motivation of Maori women in coming forward for bariatric surgery. METHODS: Maori women who had bariatric surgery prior to December 31, 2014, were invited to participate in semi-structured interpersonal interviews. Kaupapa Maori research, an Indigenous Maori research methodology, informed this study. Interviews were recorded, transcribed and subject to inductive thematic analysis. RESULTS: Twenty-nine Maori women participated in semi-structured interpersonal interviews. The majority of women reported that the presence of obesity-related disease alongside the desire for a better quality of life served as the greatest sources of motivation for having bariatric surgery. Whanau (family) were key for participants achieving the preoperative milestones needed to be accepted for bariatric surgery. Interpersonal experiences of fat-shaming and yo-yo dieting also impacted their choice to have surgery. CONCLUSION: This study is one of the first to describe the motivations of Indigenous Maori women to have bariatric surgery. Our study conveys the importance of health, a desire to have a better quality of life and whanau in motivating Maori women to come forward for bariatric surgery.

Portrayal of bariatric surgery in the New Zealand print news media.

BACKGROUND: Bariatric surgery has become topical in the media worldwide, influencing wider societal attitudes towards obesity and obesity management. This study aims to explore the media portrayal of bariatric surgery in all print news articles published in New Zealand (NZ) over a decade. METHODS: An electronic search of two databases (Proquest Australia/NZ Newsstream and Newztext) and two NZ news media websites (Stuff and the NZ Herald) was performed to retrieve print news articles reporting stories, opinion pieces or editorials regarding bariatric surgery published between January 2007 to June 2017. Qualitative thematic analysis was performed on all included articles. RESULTS: From January 2007 to December 2017, 252 articles related to bariatric surgery were published. Seven major themes emerged centred around barriers to accessing bariatric surgery, deficit attitudes towards obesity and social justice. These views were driven by articles that debated the limited number of publicly funded bariatric procedures offered in NZ. In addition, healthcare professionals used the media as a platform to challenge discriminatory attitudes towards obesity and bariatric surgery. CONCLUSION: The NZ media is a powerful tool that still bolsters binary perspectives of obesity and bariatric surgery which may work against addressing the obesity epidemic.

Laparoscopic Ventral Hernia Repair in South Auckland, New Zealand-A Retrospective Review.

BACKGROUND: Ethnic disparities in surgical care and outcomes have been previously reported in studies for other surgical procedures. In addition, it has been reported that ethnic differences in postoperative analgesia exist. We aimed to determine ethnic disparities in postoperative outcomes, total opioid analgesia use, and complication rates of all patients who underwent a laparoscopic ventral hernia repair (LVHR) at our institution over a 3-y period. METHODS: A retrospective review of all patients who underwent an LVHR at Counties Manukau Health from January 1, 2013, to December 31, 2015, was performed in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement. RESULTS: A total of 267 ventral hernias were repaired in 254 patients at Counties Manukau Health over the study period, of which most were primary umbilical ventral hernias. The majority of patients in our cohort were New Zealand European and male. Major complications, as per the Clavien-Dindo classification grade 3 and above, were observed in six patients with no deaths (2.4%). There were no statistically significant ethnic disparities in length of stay, receipt of opioid analgesia, and rates of complication observed after linear regression modeling after adjustment for confounding factors. CONCLUSIONS: Our study showed that the majority of patients who had a ventral hernia repaired at our institution were mostly New Zealand European and male. Although significant ethnic disparities in patient characteristics were observed, these were not associated with ethnic disparities in postoperative outcomes after an LVHR.