Emergency department crowding is not being caused by increased inappropriate presentations.

Contrary to the prevailing wisdom, there may be little or no room to move with respect to reducing emergency department (ED) utilisation, as ED utilisation in Aotearoa New Zealand is low by world standards and is not driven by patients presenting inappropriately with minor conditions. We should continue the excellent work done in the primary care sector to maintain our low ED presentation rate and support primary and urgent care providers to provide alternatives to the ED for people with minor conditions. However, to reduce the system pressure and harms caused by ED crowding due to access block for admitted patients, we also need to adequately resource our hospital-based inpatient teams and EDs so that the (appropriate) acute care workload can be managed safely.

Initial insights on the impact of COVID-19 on boat-based recreational fishing in Western Australia.

The COVID-19 global pandemic and subsequent implementation of measures to reduce contact within the community have affected fisheries worldwide, yet few studies have reported the impacts on recreational fisheries. This study investigates boat-based recreational fishing in Western Australia from March to August 2020, where COVID-19 measures relevant to recreational fishers included various travel restrictions, and social and physical distancing measures. Information from surveys of licensed recreational fishers and fisheries compliance officers, and camera footage from key boat ramps is presented. A lower proportion of Perth metropolitan fishers went fishing compared with regional fishers. Metropolitan fishers also reported fewer days fished and lower participation in demersal and shore-based line fishing than regional fishers. In contrast, compliance officers observed more fishing activity in both metropolitan and regional locations. Fishing plans were mostly affected by travel restrictions with more metropolitan fishers affected compared with regional fishers. Daily recreational vessel retrievals at key boat ramps varied between locations, with metropolitan fishers initially unable to travel to regional centres. There was no decline in vessel retrievals at metropolitan boat ramps during the most rigid restrictions and northern regional boat ramps experienced substantial increases in recreational vessel activity once travel restrictions eased. Studies of this kind highlight the value of utilising established recreational fishing monitoring programmes to provide a responsive and scientific basis for policymakers to address societal behavioural changes associated with atypical events such as COVID-19.

Retrospective review of abdominal aortic aneurysm deaths in New Zealand: what proportion of deaths is potentially preventable by a screening programme in the contemporary setting?

OBJECTIVES: To describe the proportions of people dying from abdominal aortic aneurysm (AAA) who might have benefited from a formal screening programme for AAA. DESIGN: Retrospective cross-sectional review of deaths. SETTING AND STUDY POPULATIONS: All AAA deaths registered in New Zealand from 2010 to 2014 in the absence of a national AAA screening programme. MAIN OUTCOME MEASURES: Known history of AAA prior to the acute event leading to AAA death, prognosis limiting comorbidities, history of prior abdominal imaging and a validated multimorbidity measure (M3-index scores). RESULTS: 1094 AAA deaths were registered in the 5 years between 2010 and 2014 in New Zealand. Prior to the acute AAA event resulting in death, 31.3% of the cohort had a known AAA diagnosis, and 10.9% had a previous AAA procedure. On average, the AAA diagnosis was known 3.7 years prior to death. At least 77% of the people dying from AAA also had one or more other prognosis limiting diagnosis. The hazard of 1-year mortality associated with the non-AAA related comorbidities for the AAA cohort aged 65 or above were 1.5-2.6 times higher than to the age matched general population based on M3-index scores. In 2014, overall AAA deaths accounted for only 0.7% of total deaths, and 1.0% of deaths among men aged 65 or above in New Zealand. At most, 20% of people dying from AAA in New Zealand between 2010 and 2014 might have had the potential to derive full benefit from a screening programme. About 51% of cases would have derived no or very limited benefit from a screening programme. CONCLUSION: Falling AAA mortality, and high prevalence of competing comorbidities and/or prior AAA diagnosis and procedure raises the question about the likely value of a national AAA screening programme in a country such as New Zealand.

Molecular tools for identification of shark species involved in depredation incidents in Western Australian fisheries.

Shark depredation is an issue of concern in some Western Australian recreational and commercial fisheries where it can have economic, social and ecological consequences. Knowledge of the shark species involved is fundamental to developing effective management strategies to mitigate the impacts of depredation. Identification of the species responsible is difficult as direct observation of depredation events is uncommon and evaluating bite marks on fish has a high degree of uncertainty. The use of trace DNA techniques has provided an alternative method for species identification. We demonstrate proof of concept for a targeted DNA barcoding approach to identify shark species using trace DNA found at bite marks on recovered remains of hooked fish. Following laboratory validation, forensic analysis of swabs collected from samples of bitten demersal fish, led to the definitive identification of shark species involved in 100% of the incidences of depredation (n = 16).

Accuracy and efficiency of detection dogs: a powerful new tool for koala conservation and management.

Accurate data on presence/absence and spatial distribution for fauna species is key to their conservation. Collecting such data, however, can be time consuming, laborious and costly, in particular for fauna species characterised by low densities, large home ranges, cryptic or elusive behaviour. For such species, including koalas (Phascolarctos cinereus), indicators of species presence can be a useful shortcut: faecal pellets (scats), for instance, are widely used. Scat surveys are not without their difficulties and often contain a high false negative rate. We used experimental and field-based trials to investigate the accuracy and efficiency of the first dog specifically trained for koala scats. The detection dog consistently out-performed human-only teams. Off-leash, the dog detection rate was 100%. The dog was also 19 times more efficient than current scat survey methods and 153% more accurate (the dog found koala scats where the human-only team did not). This clearly demonstrates that the use of detection dogs decreases false negatives and survey time, thus allowing for a significant improvement in the quality and quantity of data collection. Given these unequivocal results, we argue that to improve koala conservation, detection dog surveys for koala scats could in the future replace human-only teams.

Variation in gout care in Aotearoa New Zealand: a national analysis of quality markers.

AIM: To examine whether there was variation in markers for the quality of gout care using national linked data for the entire Aotearoa New Zealand population. METHOD: Data drawn for the New Zealand Atlas of Healthcare Variation was used to examine regularity of allopurinol dispensing, laboratory testing for serum urate, and acute hospitalisation for gout. Standardised rates by age, gender, ethnicity and District Health Board (DHB) of domicile were calculated. RESULTS: For New Zealanders aged 20-79 years with gout, 57% were dispensed allopurinol in 2010/11. Of these, 69% were receiving allopurinol regularly, and only 34% of people dispensed allopurinol had serum urate testing in a 6-month period. The annual hospitalisation rate was 1% of people with gout. Maori and Pacific people with gout were less likely to be on regular allopurinol treatment, despite having more than twice the chance of being hospitalised with acute gout. CONCLUSION: We have demonstrated that routinely collected health data can be used to monitor the quality of care for people with gout at a high level. Primary care initiatives that focus on ensuring a continuous supply of urate-lowering therapy to achieve therapeutic serum urate targets are required to improve the impact of gout in Aotearoa New Zealand.

Variation in benzodiazepine and antipsychotic use in people aged 65 years and over in New Zealand.

AIMS: To examine the variation in the dispensing of antipsychotic and benzodiazepine medicines in the elderly (aged 65+) across New Zealand. METHODS: Data drawn from the New Zealand Pharmaceutical Collection for the New Zealand Atlas of Healthcare Variation was used to establish a regression model to examine dispensing rates by age, gender, district health board (DHB) of domicile and aged residential care usage rates over a 4 year period 2008/09 to 2011/12. RESULTS: On average 24 per 1000 people aged 65+ in New Zealand were dispensed an antipsychotic in any given quarter. Benzodiazepine dispensing rates were even higher, at 109 per 1000 aged 65+. Both rates climbed steeply with age, were higher in females, and had a 1.6 to 1.8 fold variation across DHBs. Rates did not vary significantly with rest home and private hospital residential care usage, but antipsychotic rates appeared related to the use of psychogeriatric and dementia beds. CONCLUSION: Given the evident harms associated with the use of antipsychotic and benzodiazepine medicines in the elderly, and the relatively poor efficacy of antipsychotics in dementia care, prescribing of these medicines should be reassessed. DHBs should examine the causes of the high rates in their area and design interventions to reduce the rates.

The future of population registers: linking routine health datasets to assess a population's current glycaemic status for quality improvement.

OBJECTIVES: To determine the diabetes screening levels and known glycaemic status of all individuals by age, gender and ethnicity within a defined geographic location in a timely and consistent way to potentially facilitate systematic disease prevention and management. DESIGN: Retrospective observational study. SETTING: Auckland region of New Zealand. PARTICIPANTS: 1 475 347 people who had utilised publicly funded health service in New Zealand and domicile in the Auckland region of New Zealand in 2010. The health service utilisation population was individually linked to a comprehensive regional laboratory repository dating back to 2004. OUTCOME MEASURES: The two outcomes measures were glycaemia-related blood testing coverage (glycated haemoglobin (HbA1c), fasting and random glucose and glucose tolerance tests), and the proportions and number of people with known dysglycaemia in 2010 using modified American Diabetes Association (ADA) and WHO criteria. RESULTS: Within the health service utilisation population, 792 560 people had had at least one glucose or HbA1c blood test in the previous 5.5 years. Overall, 81% of males (n=198 086) and 87% of females (n=128 982) in the recommended age groups for diabetes screening had a blood test to assess their glycaemic status. The estimated age-standardised prevalence of dysglycaemia was highest in people of Pacific Island ethnicity at 11.4% (95% CI 11.2% to 11.5%) for males and 11.6% (11.4% to 11.8%) for females, followed closely by people of Indian ethnicity at 10.8% (10.6% to 11.1%) and 9.3% (9.1% to 9.6%), respectively. Among the indigenous Maori population, the prevalence was 8.2% (7.9% to 8.4%) and 7% (6.8% to 7.2%), while for 'Others' (mainly Europeans) it was 3% (3% to 3.1%) and 2.2% (2.1% to 2.2%), respectively. CONCLUSIONS: We have demonstrated that the data linkage between a laboratory repository and national administrative datasets has the potential to provide a systematic and consistent individual level clinical information that is relevant to medical auditing for a large geographically defined population.

Developing a tool to monitor potentially avoidable and ambulatory care sensitive hospitalisations in New Zealand children.

BACKGROUND: In New Zealand there has been increasing interest in reducing avoidable hospitalisations, particularly from conditions treatable in primary care. To date avoidable hospitalisations in children have been monitored using adult tools which contain many conditions irrelevant to children. Further, New Zealand has large socioeconomic gradients in hospitalisations for many paediatric conditions, suggesting that the social determinants of health also heavily influence avoidable hospitalisations in this age group. AIMS: (1) To develop a tool to monitor potentially avoidable hospitalisations in New Zealand children which includes the socioeconomic determinants of health within the conceptualisation of "avoidable"; and (2) Within this broader framework, to identify a sub-set of conditions which are amenable to intervention in primary care. METHODS: Five selection criteria were developed to define Potentially Avoidable Hospitalisations (PAH), and a further two criteria were used to define a subset of Ambulatory Care Sensitive Hospitalisations (ACSH). The principal diagnoses for all acute hospitalisations in New Zealand children (1 month-14 years) during 2003-2005 were then reviewed, and a list of 42 conditions created. This list was sent to 17 health professionals with experience in child health, who were asked to score each condition against the 5 PAH and 2 ACSH criteria. RESULTS: Twenty-six conditions contributing to PAH were identified, along with 18 contributing to ACSH. PAH tended to be infectious or respiratory in nature, with hospitalisations for chronic medical conditions or surgical problems being viewed as non-avoidable. While a similar pattern was seen for ACSH, viral infections were viewed as non-ambulatory care sensitive. CONCLUSIONS: While the tools developed are a considerable improvement on those used to date, the use of diagnostic coding algorithms to monitor ACSH and by inference, the performance of primary care, remains problematic for a number of reasons. Nevertheless, the broadening of PAH to encompass the wider determinants of health, serves to highlight the role Government social and other policies might play in reducing the large burden of avoidable morbidity currently being experienced in this age group.

Measuring potentially avoidable and ambulatory care sensitive hospitalisations in New Zealand children using a newly developed tool.

OBJECTIVES: To use a newly developed tool to measure Potentially Avoidable (PAH) and Ambulatory Care Sensitive (ACSH) Hospitalisations in New Zealand children. To consider whether these tools provide any insights into the role policies or programmes which address the underlying determinants of health (e.g. poor housing, exposure to cigarette smoke, child poverty) might play in reducing hospitalisations in this age group. METHODS: All acute and semi acute (<1 week of referral) hospitalisations in New Zealand children aged 29 days-14 years, during 2000-2009 were included, along with all hospitalisations for selected dental conditions. The newly developed PAH and ACSH tools were used to determine category membership, with explanatory variables including age, gender, ethnicity and NZ Deprivation index decile. RESULTS: During 2005-2009, 47.4% of all acute paediatric hospitalisations were considered to be PAH, 34.3% to be ACSH, and 9.7% to be non-avoidable. A further 42.9% were for non-classified conditions. Dental conditions and gastroenteritis were the leading causes of both PAH and ACSH. PAH and ACSH were highest in infants and one year olds, while non-avoidable hospitalisations were more evenly distributed throughout childhood. PAH and ACSH were higher for those from deprived areas and for Pacific and Maori children. Socioeconomic differences for non-avoidable hospitalisations were less marked, with rates being lowest in Maori and Asian children. DISCUSSION: Large social gradients in ACSH suggest that New Zealand needs to implement policies to increase access to primary care for Pacific and Maori children and those living in more deprived areas. With the majority of presentations being for acute onset infectious and respiratory diseases, such policies must take into account the need for immediate (i.e. same day) and after hours access to primary care. The narrow windows of opportunity (hours-days) available for primary care to prevent hospitalisations for ambulatory sensitive conditions also suggests that New Zealand needs to develop policies and strategies to reduce the underlying burden of disease in the community.

Potential unmet need for gout diagnosis and treatment: capture-recapture analysis of a national administrative dataset.

OBJECTIVE: To estimate the degree of undercount of people diagnosed with gout in administrative datasets using capture-recapture methods. METHODS: Hospitalization and drug dispensing claims (allopurinol or colchicine) data for all Aotearoa New Zealand were used to estimate the prevalence of gout in 2009 (n = 4 295 296). As a comparison, we calculated gout prevalence using a large primary care dataset using general practitioner diagnosis and prescribing records (n = 555 313). For each of these datasets, we estimated the undercount through capture-recapture analysis using a Poisson regression model. A two-list model was used, which included covariates such as age, gender, ethnic groups and New Zealand deprivation quintiles. RESULTS: The crude prevalence of diagnosed gout in the Aotearoa New Zealand population aged ≥ 20 years was 3.75%. The covariate-adjusted capture-recapture estimate of those not recorded but likely to have gout was 0.92%, giving an overall estimated prevalence of 4.67% (95% CI 4.49, 4.90%) for the population aged ≥ 20 years. This amounts to 80% of people with gout being identified by the algorithm for the Aotearoa New Zealand data-that is being recorded in either lists of dispensing of allopurinol or colchicine or hospital discharge. After capture-recapture, gout prevalence for all males aged ≥ 20 years was 7.3% and in older (≥ 65 years) Maori and Pacific men was >30%. CONCLUSION: Capture-recapture analysis of administrative datasets provides a readily available method for estimating an aspect of unmet need in the population-in this instance potentially 20% of those with gout not being identified and treated specifically for this condition.

National prevalence of gout derived from administrative health data in Aotearoa New Zealand.

OBJECTIVE: Previous small studies in Aotearoa New Zealand have indicated a high prevalence of gout. This study sought to determine the prevalence of gout in the entire Aotearoa New Zealand population using national-level health data sets. METHODS: We used hospitalization and drug dispensing claims for allopurinol and colchicine for the entire Aotearoa New Zealand population from the Aotearoa New Zealand Health Tracker (ANZHT) to estimate the prevalence of gout in 2009, stratified by age, gender, ethnicity and socio-economic status (n = 4 295 296). RESULTS: were compared with those obtained from an independent large primary care data set (HealthStat, n = 555 313). Results. The all-ages crude prevalence of diagnosed gout in the ANZHT population was 2.69%. A similar prevalence of 2.89% was observed in the HealthStat population standardized to the ANZHT population for age, gender, ethnicity and deprivation. Analysis of the ANZHT population showed that gout was more common in Maori and Pacific people [relative risk (RR) 3.11 and 3.59, respectively], in males (RR 3.58), in those living in the most socio-economically deprived areas (RR 1.41) and in those aged >65 years (RR >40) (P-value for all <0.0001). The prevalence of gout in elderly Maori and Pacific men was particularly high at >25%. CONCLUSION: Applying algorithms to national administrative data sets provides a readily available method for estimating the prevalence of a chronic condition such as gout, where diagnosis and drug treatment are relatively specific for this disease. We have demonstrated high gout prevalence in the entire Aotearoa New Zealand population, particularly among Maori and Pacific people.

Statin use in COPD patients is associated with a reduction in mortality: a national cohort study.

AIMS: To assess whether statin use is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD). METHODS: Hospitalisation, drug dispensing, and mortality records were linked for New Zealanders aged 50-80 years discharged from hospital with a first admission with COPD in 2006. Patients were classified according to whether or not they were prescribed statins prior to admission. Baseline characteristics were compared and hazard ratios calculated for statin users versus statin non-users for all-cause mortality over follow-up of up to 4 years. RESULTS: A total of 1,687 patients (mean age 70.6 years) were followed, including 596 statin users and 1,091 non-users. There were more men in the statin user group (58.4% vs. 48.5%), and statin users were more likely to have a history of cardiovascular disease (58.6% vs. 25.1%), prescription for frusemide as a proxy for heart failure (47.7% vs. 24.5%) or diabetes (35.4% vs.11.6%) than statin non-users (p<0.001). A total of 671 deaths occurred during the follow-up period. After adjustment for age, sex, ethnic group, history of cardiovascular disease, diabetes, and prescription for frusemide, the hazard ratio for statin users vs. statin non-users for all-cause mortality was 0.69 (95% CI 0.58 to 0.84). CONCLUSIONS: Statin use is associated with a 30% reduction in all-cause mortality at 3-4 years after first admission for COPD, irrespective of a past history of cardiovascular disease and diabetes.

Gout, diabetes and cardiovascular disease in the Aotearoa New Zealand adult population: co-prevalence and implications for clinical practice.

AIMS: To determine the co-prevalence of gout, diabetes and cardiovascular disease (CVD) in the entire Aotearoa New Zealand adult population to inform clinical practice. METHODS: Algorithms based on hospital admissions, outpatient visits, drug dispensing, laboratory test data and mortality for the Aotearoa New Zealand Health Tracker (ANZHT) population aged ≥20 years (n = 3,036,093) were used to estimate the prevalence of those identified with gout, diabetes and CVD in 2009. RESULTS: The crude prevalence in the adult ANZHT population of gout was 3.9%, of diabetes was 6.6%, and of CVD was 5.4%. For those identified with gout, 25.6% had diabetes and 22.7% had CVD. Both diabetes and CVD were more prevalent in those identified with gout, compared with those without gout (age-standardised rate (ASR) ratio 3.5 for diabetes and 2.7 for CVD, p for both <0.001). CONCLUSION: By applying algorithms based on hospital coding, community drug dispensing and laboratory test data sets, we have demonstrated a high co-prevalence of gout, diabetes and CVD in the adult population of Aotearoa New Zealand. Health service presentation with gout can be an important opportunity to assess risk and manage co-morbid disease. Prevention and management strategies are reinforcing for these metabolic conditions.

Four out of ten patients are not taking statins regularly during the 12 months after an acute coronary event.

BACKGROUND: In New Zealand, a setting in which national guidelines recommend statins for all patients with coronary heart disease (CHD) and cost barriers are low, patterns of use of these drugs are unknown. We investigated dispensing rates after hospital discharge for acute CHD event. DESIGN: Retrospective cohort study. METHODS: Drug dispensing, hospital diagnosis, and mortality records were linked by unique identifier for all New Zealanders aged 35-84 years after discharge following acute CHD event in 2007. We defined the statin dispensing ratio (SDR) as the proportion of days that 15,506 patients aged 35-84 years were dispensed such agents during the 12 months post discharge. An SDR ≥0.8 (80% or more days covered) was considered optimal. RESULTS: Overall, 59% of the cohort had an SDR ≥0.8. Of patients dispensed statins in the 3 months before admission (n = 5506), almost all (99%; 5466) continued treatment during follow up and 82% had an SDR ≥0.8. In contrast, for patients not dispensed statins before admission (n = 8014), only two-thirds started statins during follow up and only 44% had an SDR ≥0.8. Of all patients with low statin dispensing (SDR <0.8), about one-quarter were not dispensed any lipid-lowering drugs, one-quarter received alternative lipid-lowering drugs, one-quarter stopped statins, and the remaining quarter were intermittent statin users. CONCLUSION: In a setting with few barriers to statin treatment, about 40% of patients had suboptimal statin dispensing during the year after hospital treatment for CHD. This study has identified four significant categories of suboptimal adherence that could inform quality improvement programmes.

Can the prevalence of diagnosed diabetes be estimated from linked national health records? The validity of a method applied in New Zealand.

INTRODUCTION: With projected global increases in the prevalence of Type 2 diabetes, the health sector requires timely assessments of the prevalence of this disease to monitor trends, plan services, and measure the efficacy of prevention programmes. AIM: To assess the validity of a method to estimate the prevalence of diagnosed diabetes from linked national health records. METHODS: We measured the agreement between a diabetes diagnosis (using combined national lists of drug dispensing, outpatient attendance, laboratory tests (HbA1c) and hospital diagnoses) and a primary care diabetes diagnosis in a (PREDICT™) cohort of 53,911 adult New Zealanders. The completeness of the diagnosis of diabetes in the cohort was estimated using capture-recapture methods. RESULTS: The primary care cohort had a high prevalence of recorded diabetes (20.9%, 11,266/53,911), similar to our derived prevalence of 20.1%. Of the participants with a diagnosis of diabetes, 89% (10,182/11,266) had a similar derived diagnosis, indicating that only about one in 10 people with a primary care diagnosis had not been either admitted to hospital, seen at outpatient clinics, prescribed diabetes drugs or undertaken regular HbA1c tests. The capture-recapture prevalence of diagnosed diabetes in this cohort was 23.7% indicating that primary care diagnoses in the cohort were about 90% complete. DISCUSSION: A method for estimating the prevalence of diagnosed diabetes from national health data shows high-level agreement with primary care records. Linked health data can provide an efficient method for estimating the prevalence of diagnosed diabetes in regions where such records are individually linked.

Healthcare services funded by Counties Manukau District Health Board for people in the last year of life.

INTRODUCTION: The last year of life is often associated with a high level of healthcare utilisation and cost. To date, little information is available regarding the healthcare utilisation patterns in the last year of life in New Zealand. AIM: To describe the healthcare utilisation patterns and costs of the residents of Counties Manukau District Health Board (CMDHB) region in the 1-year period prior to death in 2008. METHOD: CMDHB residents who died in 2008 were identified from the National Mortality Dataset. The health services utilisation patterns and costs in the last year of life were derived from National Minimum Dataset (NMDS), Pharmaceutical Collection, Laboratory Claims Collection, and National Non-Admitted Patient Collection via encrypted NHI linkage. RESULTS: Forty percent of all deaths in 2008 in CMDHB occurred in a publicly funded hospital. Just over 80% of people had at least one inpatient hospital stay in the last year of life. More than 75% of the healthcare costs funded by CMDHB in the last year of life were related to inpatient hospitalisations. The average cumulative length of inpatient stay over the year in the people who had an inpatient event was 20.6 days. Outpatient, pharmaceutical, and laboratory services were received by 84%, 91%, and 86% of people respectively in their last year of life. CONCLUSION: Consistent with the international literature, this study found that CMDHB residents in the last year of life have a high level of health service utilisation. Decisions about the appropriate use of high cost health services in people towards the end of life can be extremely challenging. These decisions are resource allocation decisions as well as clinical decisions and should be based on clinical factors, cost utilities, and patient, family, and society's expectations.