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BACKGROUND: Clinical indicators are increasingly used to improve the quality of care, particularly with the emergence of "big data", but physicians views regarding their utility in practice is unclear. We reviewed the published literature investigating physicians' perspectives, focusing on the following objectives in relation to quality improvement: 1) the role of clinical indicators, 2) what is needed to strengthen them, 3) their key attributes and 4) the best tool(s) for assessing their quality. METHODS: A systematic literature search (up to November 2022) was carried out using: Medline, EMBASE, Scopus, CINAHL, PsycInfo and Web of Science. Articles that met all of the following inclusion criteria were included: reported on physicians' perspectives on clinical indicators and/or tools for assessing the quality of clinical indicators, addressing at least one of the four review objectives; the clinical indicators related to care at least partially delivered by physicians; and published in a peer-reviewed journal. Data extracted from eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) tool. A thematic synthesis of data was conducted using NVivo software. Descriptive themes were inductively derived from codes, which were grouped into analytical themes answering each objective. RESULTS: A total of 14 studies were included, with 17 analytical themes identified for objectives 1-3 and no data identified for objective 4. Results showed that indicators can play an important motivating role for physicians to improve the quality of care and show where changes need to be made. For indicators to be effective, physicians should be involved in indicator development, recording relevant data should be straightforward, indicator feedback must be meaningful to physicians, and clinical teams need to be adequately resourced to act on findings. Effective indicators need to focus on the most important areas for quality improvement, be consistent with good medical care, and measure aspects of care within the control of physicians. Studies cautioned against using indicators primarily as punitive measures, and there were concerns that an overreliance on indicators can lead to narrowed perspectives of quality of care. CONCLUSIONS: This review identifies facilitators and barriers to meaningfully engaging physicians in developing and using clinical indicators to improve the quality of health care.
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OBJECTIVE: This study aimed to understand the reasons behind evidence-practice gaps and inequities in cardiovascular care for Maori and Pacific people, as evidenced by the experiences and perspectives of patients and their families. METHODS: The research was guided by Maori and Pacific worldviews, incorporating Kaupapa Maori Theory and Pacific conceptual frameworks and research methodologies. Template analysis was used to analyse interview data from 61 Maori and Pacific people who had experienced a cardiovascular disease (CVD) risk assessment, acute coronary syndrome, and/or heart failure. RESULTS: The range of experiences relating to participants' heart health journeys are presented in five main themes: Context, Mana (maintaining control and dignity), Condition, People and Journey. CONCLUSIONS: Maori and Pacific people want to take charge of their heart health but face challenges. Participants described important obligations to family, community and tikanga (the culturally correct way of doing things). Participants described times when health care undermined existing responsibilities, their dignity and/or their mana, and they felt excluded from treatment as a result. IMPLICATIONS FOR PUBLIC HEALTH: Good reciprocal communication, stemming from a high-quality relationship is essential for successful outcomes. A workforce that is representative of the population it serves and is culturally safe lays the foundation for excellence in care.
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Enfermedades Cardiovasculares , Investigación Cualitativa , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Cardiovasculares/etnología , Enfermedades Cardiovasculares/terapia , Familia/psicología , Familia/etnología , Entrevistas como Asunto , Pueblo Maorí , Nueva Zelanda , Pueblos Isleños del PacíficoRESUMEN
INTRODUCTION: Māori (the Indigenous Peoples of Aotearoa New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD health care. Rural Māori experience additional barriers to treatment access, poorer health outcomes and a greater burden of CVD risk factors compared to Non-Māori and Māori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous Peoples in other nations impacted by colonisation. Given the scarcity of available literature, a systematic scoping review was conducted on literature exploring barriers and facilitators in accessing CVD health care for rural Māori and other Indigenous Peoples in nations impacted by colonisation. METHODS: The review was underpinned by Kaupapa Māori Research methodology and was conducted utilising Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org was used to explore empirical research literature. A grey literature search was also conducted. Literature based in any healthcare setting providing care to adults for CVD was included. Rural or remote Indigenous Peoples from New Zealand, Australia, Canada, and the US were included. Literature was included if it addressed cardiovascular conditions and reported barriers and facilitators to healthcare access in any care setting. RESULTS: A total of 363 articles were identified from the database search. An additional 19 reports were identified in the grey literature search. Following screening, 16 articles were included from the database search and 5 articles from the grey literature search. The literature was summarised using the Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles: tino rangatiratanga (self-determination), partnership, active protection, equity and options. Themes elucidated from the literature were described as key drivers of CVD healthcare access for rural Indigenous Peoples. Key driver themes included input from rural Indigenous Peoples on healthcare service design and delivery, adequate resourcing and support of indigenous and rural healthcare services, addressing systemic racism and historical trauma, providing culturally appropriate health care, rural Indigenous Peoples' access to family and wellbeing support, rural Indigenous Peoples' differential access to the wider social determinants of health, effective interservice linkages and communication, and equity-driven and congruent data systems. CONCLUSION: The findings are consistent with other literature exploring access to health care for rural Indigenous Peoples. This review offers a novel approach to summarising literature by situating the themes within the context of equity and rights for Indigenous Peoples. This review also highlighted the need for further research in this area to be conducted in the context of Aotearoa New Zealand.
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Enfermedades Cardiovasculares , Accesibilidad a los Servicios de Salud , Población Rural , Humanos , Enfermedades Cardiovasculares/terapia , Enfermedades Cardiovasculares/etnología , Accesibilidad a los Servicios de Salud/organización & administración , Servicios de Salud del Indígena/organización & administración , Pueblos Indígenas , Nueva Zelanda/epidemiología , Servicios de Salud Rural/organización & administración , Población Rural/estadística & datos numéricos , Pueblo MaoríRESUMEN
AIMS: Multiple health administrative databases can be individually linked in Aotearoa New Zealand, using encrypted identifiers. These databases were used to develop cardiovascular risk prediction equations for patients with known cardiovascular disease (CVD). METHODS AND RESULTS: Administrative health databases were linked to identify all people aged 18-84 years with known CVD, living in Auckland and Northland, Aotearoa New Zealand, on 1 January 2014. The cohort was followed until study outcome, death, or 5 years. The study outcome was death or hospitalization due to ischaemic heart disease, stroke, heart failure, or peripheral vascular disease. Sex-specific 5-year CVD risk prediction equations were developed using multivariable Fine and Gray models. A total of 43 862 men {median age: 67 years [interquartile range (IQR): 59-75]} and 32 724 women [median age: 70 years (IQR: 60-77)] had 14 252 and 9551 cardiovascular events, respectively. Equations were well calibrated with good discrimination. Increasing age and deprivation, recent cardiovascular hospitalization, Mori ethnicity, smoking history, heart failure, diabetes, chronic renal disease, atrial fibrillation, use of blood pressure lowering and anti-thrombotic drugs, haemoglobin A1c, total cholesterol/HDL cholesterol, and creatinine were statistically significant independent predictors of the study outcome. Fourteen per cent of men and 23% of women had predicted 5-year cardiovascular risk <15%, while 28 and 24% had ≥40% risk. CONCLUSION: Robust cardiovascular risk prediction equations were developed from linked routine health databases, a currently underutilized resource worldwide. The marked heterogeneity demonstrated in predicted risk suggests that preventive therapy in people with known CVD would be better informed by risk stratification beyond a one-size-fits-all high-risk categorization.
Using regionwide New Zealand health databases, methods of predicting hospitalization risk in patients with existing heart disease were developed. Using only data from health databases, it was possible to predict the risk accurately.Among patients with existing heart disease, the predicted risk varied markedly which could help improve preventive strategies.
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Enfermedades Cardiovasculares , Insuficiencia Cardíaca , Masculino , Humanos , Femenino , Anciano , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control , Factores de Riesgo , Medición de Riesgo/métodos , Factores de Riesgo de Enfermedad Cardiaca , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiologíaRESUMEN
AIM: To determine Pacific patients' reasons for Emergency Department (ED) use for non-urgent conditions by Pacific people at Counties Manukau Health. METHODS: Patients who self-presented to Counties Manukau ED with a non-urgent condition in June 2019 were surveyed. Responses to open-ended questions were analysed using a general inductive approach, in discussion with key stakeholders. RESULTS: Of 353 participants with ethnicity reported, 139 (39%) were Pacific, 66 (19%) Maori and 148 (42%) were non-Maori non-Pacific, nMnP. A total of 58 (42%) of Pacific participants had been to their general practitioner prior to presenting to the ED; this proportion was similar for Maori (19 [30%]) and nMnP (59 [40%]) (p=0.215). The most common reasons for ED attendance among Pacific (as well as other) participants were 1) advice by a health professional (41%, 95% CI 33-50%), 2) usual care unavailable (28%, 20-36%), 3) symptoms not improving (21%, 14-28%), and 4) symptoms too severe to be managed elsewhere (19%, 12-26%). CONCLUSIONS: Multiple reasons underlie non-urgent use of EDs by Pacific and other ethnic groups. These reasons need to be considered simultaneously in the design, implementation, and evaluation of multi-dimensional initiatives that discourage non-urgent use of EDs to ensure that such initiatives are effective, equitable, and unintended consequences are avoided.
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Servicio de Urgencia en Hospital , Pueblo Maorí , Aceptación de la Atención de Salud , Humanos , Etnicidad , Nueva ZelandaRESUMEN
BACKGROUND: Given advances in the management of cancer, it is increasingly important for clinicians to appropriately manage the risk of cardiovascular disease (CVD) among cancer survivors. It is unclear whether CVD risk is increased among cancer survivors overall, and there is inconsistency in evidence to date about CVD incidence and mortality by cancer type. METHODS: Patients aged 30-74 years entered an open cohort study at the time of first CVD risk assessment, between 2004 and 2018, in primary care in New Zealand. Patients with established CVD or cancer within 2 years prior to study entry were excluded. Cancer diagnosis (1995-2016) was determined from a national cancer registry. Cause-specific hazard models were used to examine the association between history of cancer and two outcomes: (1) CVD-related hospitalization and/or death and (2) CVD death. RESULTS: The study included 446,384 patients, of whom 14,263 (3.2%) were cancer survivors. Risk of CVD hospitalization and/or death was increased among cancer survivors compared with patients without cancer at cohort entry (multivariable-adjusted hazard ratio, mHR, 1.11, 95% CI 1.05-1.18), more so for CVD death (1.31, 1.14-1.52). Risk of CVD hospitalization and/or death was increased in patients with myeloma (2.66, 1.60-4.42), lung cancer (2.19, 1.48-3.24) and non-Hodgkin lymphoma (1.90, 1.42-2.54), but not for some cancers (e.g., colorectal, 0.87, 0.71-1.06). Risk of CVD death was increased in several cancer types including melanoma (1.73, 1.25-2.38) and breast cancer (1.56, 1.16-2.11). CONCLUSION: CVD risk management needs to be prioritized among cancer survivors overall, and particularly in those with myeloma, lung cancer and non-Hodgkin lymphoma given consistent evidence of increased risk.
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Supervivientes de Cáncer , Enfermedades Cardiovasculares , Neoplasias Pulmonares , Linfoma no Hodgkin , Mieloma Múltiple , Humanos , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etiología , Estudios de Cohortes , Mieloma Múltiple/complicaciones , Nueva Zelanda/epidemiología , Linfoma no Hodgkin/complicaciones , Neoplasias Pulmonares/complicaciones , Atención Primaria de Salud , Factores de RiesgoRESUMEN
OBJECTIVE: The recommended duration of dual anti-platelet therapy (DAPT) following acute coronary syndrome (ACS) varies from 1 month to 1 year depending on the balance of risks of ischaemia and major bleeding. We designed paired ischaemic and major bleeding risk scores to inform this decision. METHODS: New Zealand (NZ) patients with ACS investigated with coronary angiography are recorded in the All NZ ACS Quality Improvement registry and linked to national health datasets. Patients were aged 18-84 years (2012-2020), event free at 28 days postdischarge and without atrial fibrillation. Two 28-day to 1-year postdischarge multivariable risk prediction scores were developed: (1) cardiovascular mortality/rehospitalisation with myocardial infarction or ischaemic stroke (ischaemic score) and (2) bleeding mortality/rehospitalisation with bleeding (bleeding score). FINDINGS: In 27 755 patients, there were 1200 (4.3%) ischaemic and 548 (2.0%) major bleeding events. Both scores were well calibrated with moderate discrimination performance (Harrell's c-statistic 0.75 (95% CI, 0.74 to 0.77) and 0.69 (95% CI, 0.67 to 0 .71), respectively). Applying these scores to the 2020 European Society of Cardiology ACS antithrombotic treatment algorithm, the 31% of the cohort at elevated (>2%) bleeding and ischaemic risk would be considered for an abbreviated DAPT duration. For those at low bleeding risk, but elevated ischaemic risk (37% of the cohort), prolonged DAPT may be appropriate, and for those with low bleeding and ischaemic risk (29% of the cohort) short duration DAPT may be justified. CONCLUSION: We present a pair of ischaemic and bleeding risk scores specifically to assist clinicians and their patients in deciding on DAPT duration beyond the first month post-ACS.
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Síndrome Coronario Agudo , Isquemia Encefálica , Intervención Coronaria Percutánea , Accidente Cerebrovascular , Humanos , Inhibidores de Agregación Plaquetaria/efectos adversos , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/epidemiología , Síndrome Coronario Agudo/tratamiento farmacológico , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiología , Isquemia Encefálica/etiología , Cuidados Posteriores , Medición de Riesgo , Alta del Paciente , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Factores de Riesgo , Isquemia/tratamiento farmacológico , Quimioterapia Combinada , Resultado del TratamientoRESUMEN
Background: Patients with invasive melanoma are at increased risk of developing subsequent invasive melanoma, but the risks for those with primary in situ melanoma are unclear. Objectives: To assess and compare the cumulative risk of subsequent invasive melanoma after primary invasive or in situ melanoma. To estimate the standardized incidence ratio (SIR) of subsequent invasive melanoma compared to population incidence in both cohorts. Methods: Patients with a first diagnosis of melanoma (invasive or in situ) between 2001 and 2017 were identified from the New Zealand national cancer registry, and any subsequent invasive melanoma during follow-up to the end of 2017 identified. Cumulative risk of subsequent invasive melanoma was estimated by Kaplan-Meier analysis separately for primary invasive and in situ cohorts. Risk of subsequent invasive melanoma was assessed using Cox proportional hazard models. SIR was assessed, allowing for age, sex, ethnicity, year of diagnosis and follow up time. Results: Among 33 284 primary invasive and 27 978 primary in situ melanoma patients, median follow up time was 5.5 and 5.7 years, respectively. A subsequent invasive melanoma developed in 1777 (5%) of the invasive and 1469 (5%) of the in situ cohort, with the same median interval (2.5 years) from initial to first subsequent lesion in both cohorts. The cumulative incidence of subsequent invasive melanoma at 5 years was similar in the two cohorts (invasive 4.2%, in situ 3.8%); the cumulative incidence increased linearly over time in both cohorts. The risk of subsequent invasive melanoma was marginally higher for primary invasive compared to in situ melanoma after adjustment for age, sex, ethnicity and body site of the initial lesion (hazard ratio 1.11, 95% CI 1.02-1.21). Compared to population incidence, the SIR of invasive melanoma was 4.6 (95% CI 4.3-4.9) for the primary invasive and 4 (95% CI 3.7-4.2) for the primary in situ melanoma cohorts. Conclusions: The risk of subsequent invasive melanoma is similar whether patients present with in situ or invasive melanoma. Thus follow-up surveillance for new lesions should be similar, although patients with invasive melanoma require more surveillance for recurrence.
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Importance: Intimate partner violence (IPV) is increasingly recognized as a contributing factor for long-term health problems; however, few studies have assessed these health outcomes using consistent and comprehensive IPV measures or representative population-based samples. Objective: To examine associations between women's lifetime IPV exposure and self-reported health outcomes. Design, Setting, and Participants: The cross-sectional, retrospective 2019 New Zealand Family Violence Study, adapted from the World Health Organization's Multi-Country Study on Violence Against Women, assessed data from 1431 ever-partnered women (63.7% of eligible women contacted) in New Zealand. The survey was conducted from March 2017 to March 2019, across 3 regions, which accounted for approximately 40% of the New Zealand population. Data analysis was performed from March to June 2022. Exposures: Exposures were lifetime IPV by types (physical [severe/any], sexual, psychological, controlling behaviors, and economic abuse), any IPV (at least 1 type), and number of IPV types. Main Outcomes and Measures: Outcome measures were poor general health, recent pain or discomfort, recent pain medication use, frequent pain medication use, recent health care consultation, any diagnosed physical health condition, and any diagnosed mental health condition. Weighted proportions were used to describe the prevalence of IPV by sociodemographic characteristics; bivariate and multivariable logistic regressions were used for the odds of experiencing health outcomes by IPV exposure. Results: The sample comprised 1431 ever-partnered women (mean [SD] age, 52.2 [17.1] years). The sample was closely comparable with New Zealand's ethnic and area deprivation composition, although younger women were slightly underrepresented. More than half of the women (54.7%) reported any lifetime IPV exposure, of whom 58.8% experienced 2 or more IPV types. Compared with all other sociodemographic subgroups, women who reported food insecurity had the highest IPV prevalence for any IPV (69.9%) and all specific types. Exposure to any IPV and specific IPV types was significantly associated with increased likelihood of reporting adverse health outcomes. Compared with those unexposed to IPV, women who experienced any IPV were more likely to report poor general health (adjusted odds ratio [AOR], 2.02; 95% CI, 1.46-2.78), recent pain or discomfort (AOR, 1.81; 95% CI, 1.34-2.46), recent health care consultation (AOR, 1.29; 95% CI, 1.01-1.65), any diagnosed physical health condition (AOR, 1.49; 95% CI, 1.13-1.96), and any mental health condition (AOR, 2.78; 95% CI, 2.05-3.77). Findings suggested a cumulative or dose-response association because women who experienced multiple IPV types were more likely to report poorer health outcomes. Conclusions and Relevance: In this cross-sectional study of women in New Zealand, IPV exposure was prevalent and associated with an increased likelihood of experiencing adverse health. Health care systems need to be mobilized to address IPV as a priority health issue.
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Violencia de Pareja , Humanos , Femenino , Persona de Mediana Edad , Autoinforme , Estudios Transversales , Nueva Zelanda , Estudios RetrospectivosRESUMEN
Importance: Health implications of intimate partner violence (IPV) against men is relatively underexplored, although substantial evidence has identified associations between IPV and long-term physical health problems for women. Given the gendered differences in IPV exposure patterns, exploration of men's IPV exposure and health outcomes using population-based samples is needed. Objective: To assess the association between men's lifetime IPV exposure and self-reported health outcomes. Design, Setting, and Participants: This cross-sectional study analyzed data from the 2019 New Zealand Family Violence Study, which was conducted across 3 regions of New Zealand. The representative sample included ever-partnered men aged 16 years or older. Data analysis was performed between May and September 2022. Exposures: Lifetime IPV against men by types (physical [severe or any], sexual, psychological, controlling behaviors, and economic abuse), any IPV (at least 1 type), and number of IPV types experienced. Main Outcomes and Measures: The 7 health outcomes were poor general health, recent pain or discomfort, recent use of pain medication, frequent use of pain medication, recent health care consultation, any diagnosed physical health condition, and any diagnosed mental health condition. Results: The sample comprised 1355 ever-partnered men (mean [SD] age, 51.3 [16.9] years), who predominantly identified as heterosexual (96.9%; 95% CI, 95.7%-97.8%). Half of the sample (49.9%) reported experiencing any lifetime IPV, of whom 62.1% reported at least 2 types. Of all sociodemographic subgroups, unemployed men had the greatest prevalence of reporting exposure to any IPV (69.2%) and all IPV types. After adjustment for sociodemographic factors, men's exposure to any lifetime IPV was associated with an increased likelihood of reporting 4 of the 7 assessed health outcomes: poor general health (adjusted odds ratio [AOR], 1.78; 95% CI, 1.34-2.38), recent pain or discomfort (AOR, 1.65; 95% CI, 1.21-2.25), recent use of pain medication (AOR, 1.27; 95% CI, 1.00-1.62), and any diagnosed mental health condition (AOR, 1.66; 95% CI, 1.11-2.49). Specific IPV types were inconsistently associated with poor health outcomes. Any physical IPV exposure was associated with poor general health (AOR, 1.80; 95% CI, 1.33-2.43), recent pain or discomfort (AOR, 2.23; 95% CI, 1.64-3.04), and frequent use of pain medication (AOR, 1.69; 95% CI, 1.08-2.63), which appeared to be associated with exposure to severe physical IPV. Exposure to sexual IPV, controlling behaviors, and economic abuse was not associated with any assessed outcomes after sociodemographic adjustment. Experience of a higher number of IPV types did not show a clear stepwise association with number of health outcomes. Conclusions and Relevance: Results of this study indicate that exposure to IPV can adversely affect men's health but is not consistently a factor in men's poor health at the population level. These findings do not warrant routine inquiry for IPV against men in clinical settings, although appropriate care is needed if IPV against men is identified.
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Violencia de Pareja , Masculino , Humanos , Femenino , Persona de Mediana Edad , Autoinforme , Estudios Transversales , Nueva Zelanda/epidemiología , Violencia de Pareja/psicología , Evaluación de Resultado en la Atención de SaludRESUMEN
BACKGROUND: People with cancer have an increased risk of cardiovascular disease. Risk prediction equations developed in New Zealand accurately predict 5-year cardiovascular disease risk in a general primary care population in the country. We assessed the performance of these equations for survivors of cancer in New Zealand. METHODS: For this validation study, patients aged 30-74 years from the PREDICT open cohort study, which was used to develop the New Zealand cardiovascular disease risk prediction equations, were included in the analysis if they had a primary diagnosis of invasive cancer at least 2 years before the date of the first cardiovascular disease risk assessment. The risk prediction equations are sex-specific and include the following predictors: age, ethnicity, socioeconomic deprivation index, family history of cardiovascular disease, smoking status, history of atrial fibrillation and diabetes, systolic blood pressure, total cholesterol to HDL cholesterol ratio, and preventive pharmacotherapy (blood-pressure-lowering, lipid-lowering, and antithrombotic drugs). Calibration was assessed by comparing the mean predicted 5-year cardiovascular disease risk, estimated using the risk prediction equations, with the observed risk across deciles of risk, for men and women, and according to the three clinical 5-year cardiovascular disease risk groups in New Zealand guidelines (<5%, 5% to <15%, and ≥15%). Discrimination was assessed by Harrell's C statistic. FINDINGS: 14â263 patients were included in the study. The mean age was 61 years (SD 9) for men and 60 years (SD 8) for women, with a median follow-up of 5·8 years for men and 5·7 years for women. The observed cardiovascular disease risk was underpredicted by a maximum of 2·5% in male and 3·2% in female decile groups. When patients were grouped according to clinical risk groups, observed cardiovascular disease risk was underpredicted by less than 2% in the lower risk groups and overpredicted by 2·2% for men and 3·3% for women in the highest risk group. Harrell's C statistics were 0·67 (SE 0·01) for men and 0·73 (0·01) for women. INTERPRETATION: The New Zealand cardiovascular disease risk prediction equations reasonably predicted the observed 5-year cardiovascular disease risk in survivors of cancer in the country, in whom risk prediction was considered clinically appropriate. Prediction could be improved by adding cancer-specific variables and considering competing risks. Our findings suggest that the equations are reasonable clinical tools for use in survivors of cancer in New Zealand. FUNDING: Auckland Medical Research Foundation, Health Research Council of New Zealand.
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Enfermedades Cardiovasculares , Neoplasias , Humanos , Masculino , Femenino , Persona de Mediana Edad , Factores de Riesgo , Estudios de Cohortes , Medición de Riesgo , Enfermedades Cardiovasculares/epidemiología , Nueva Zelanda/epidemiología , Estudios Prospectivos , Modelos de Riesgos Proporcionales , Neoplasias/epidemiología , Atención Primaria de SaludRESUMEN
We investigated whether diabetes mellitus (DM) affects the efficacy of a low-dose triple combination pill and usual care among people with mild-moderate hypertension. TRIUMPH (TRIple pill vs Usual care Management for Patients with mild-to-moderate Hypertension) was a randomised controlled open-label trial of patients requiring initiation or escalation of antihypertensive therapy. Patients were randomised to a once-daily low-dose triple combination polypill (telmisartan-20mg/amlodipine-2.5 mg/chlorthalidone-12.5 mg) or usual care. This analysis compared BP reduction in people with and without DM, both in the intervention and control groups over 24-week follow-up. Predicted efficacy of prescribed therapy was calculated (estimation methods of Law et al.). The trial randomised 700 patients (56 ± 11 yrs, 31% DM). There was no difference in the number of drugs prescribed or predicted efficacy of therapy between people with DM and without DM. However, the observed BP reduction from baseline to week 24 was lower in those with DM compared to non-diabetics in both the triple pill (25/11 vs 31/15 mmHg, p ≤ 0.01) and usual care (17/7 vs 22/11 mmHg, p ≤ 0.01) groups, and these differences remained after multivariable adjustment. DM was a negative predictor of change in BP (ß-coefficient -0.08, p = 0.02). In conclusion, patients with DM experienced reduced efficacy of BP lowering therapies as compared to patients without DM, irrespective of the type of BP lowering therapy received.
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Diabetes Mellitus , Hipertensión , Humanos , Antihipertensivos , Presión Sanguínea , Amlodipino , Hipertensión/complicaciones , Hipertensión/tratamiento farmacológico , Hipertensión/inducido químicamente , Clortalidona/uso terapéutico , Clortalidona/farmacología , Combinación de Medicamentos , Diabetes Mellitus/tratamiento farmacológicoRESUMEN
Background: The aggregation of Indigenous peoples from Pacific Island nations as 'Pacific peoples' in literature may mask diversity in the health needs of these different groups. The aim of this study was to examine the heterogeneity of Pacific groups according to ethnicity and country of birth. Methods: Anonymised individual-level linkage of administrative data identified all NZ residents aged 30-74 years on 31 March 2013 with known ethnicity and country of birth. All participants were described according to ethnicity and country of birth. Pacific participants were also described according to the number of ethnicities they identified. Findings: A total of 2,238,039 NZ residents were included, of whom 117,957 (5·0%) were Pacific. Nearly two-thirds of Pacific peoples (65·7%) were born overseas, ranging from 45·3% (Cook Islands Maori) to 82·7% (Fijian) (Maori 2·3%, non-Maori non-Pacific 28·9%). Among NZ-born Pacific peoples, 46·9% (Samoan) to 81·9% (Fijian) were multi-ethnic; the proportion was much lower for overseas-born Pacific peoples (ranging from 3·7% [Tongan] to 23·9% [Tokelauan]). Interpretation: There is substantial heterogeneity among Pacific peoples in their country of birth and identification with sole or multiple ethnicities. Assumptions regarding homogeneity in the needs of Pacific peoples are not appropriate and government statistics should therefore disaggregate Pacific peoples whenever possible. Funding: Supported by the Health Research Council of New Zealand and a part of Manawataki Fatu Fatu, a programme of research funded by the National Heart Foundation of New Zealand and Healthier Lives - He Oranga Hauora - National Science Challenge of New Zealand.
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Objective: The purpose of this study was to explore the experiences of Maori patients and their families accessing care for an acute out-of-hospital cardiac event and to identify any barriers or enablers of timely access to care. Design: Eleven interviews with patients and their families were conducted either face-to-face or using online conferencing. Interviews were audio-recorded and transcribed for thematic analysis using Kaupapa Maori methodology. Results: Data analysis identified three themes: (1) me and the event, (2) the people (3) upholding te mana o te wa or self-determined heart wellbeing. Knowledge of symptoms and a desire to maintain personal dignity at the time of the event affected emergency medical service initiation. Participants described relationships with health professionals, the importance of good quality information, having family support, and drawing on cultural practices as vital for their health care journey. Conclusion: Systemic barriers including racism, discrimination, and inadequate resourcing exist for Maori journeying to and through care following an out of hospital cardiac event. Improving the cultural safety of health professionals, better access to community defibrillation, and improving understanding of the life-long impacts a cardiac event has on patients and whanau is recommended.
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INTRODUCTION: Maori (the Indigenous peoples of New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD healthcare. Rural Maori experience additional barriers to treatment access, poorer health outcomes and a more significant burden of CVD risk factors compared with non-Maori and Maori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous peoples in other nations impacted by colonisation. Given the scarcity of available literature, we are conducting a scoping review of literature exploring barriers and facilitators in accessing quality CVD healthcare for rural Maori and other Indigenous peoples in nations impacted by colonisation. METHODS AND ANALYSIS: A scoping review will be conducted to identify and map the extent of research available and identify any gaps in the literature. This review will be underpinned by Kaupapa Maori Research methodology and will be conducted using Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org will be used to explore empirical research literature. A grey literature search will also be conducted. Two authors will independently review and screen search results in an iterative manner. The New Zealand Ministry of Health Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles will be used as a framework to summarise and construct a narrative of existing literature. Existing literature will also be appraised using the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement. ETHICS AND DISSEMINATION: Ethical approval has not been sought for this review as we are using publicly available data. We will publish this protocol and the findings of our review in an open-access peer-reviewed journal. This protocol has been registered on Open Science Framework (DOI:10.17605/osf.io/xruhy).
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Enfermedades Cardiovasculares , Pueblos Indígenas , Humanos , Nativos de Hawái y Otras Islas del Pacífico , Proyectos de Investigación , Enfermedades Cardiovasculares/terapia , Nueva Zelanda/epidemiología , Literatura de Revisión como AsuntoRESUMEN
Heart failure (HF) is associated with high morbidity and mortality and contributes to substantial burden of disease, significant inequities and high healthcare cost globally as well as in Aotearoa. Management of chronic HF is driven by HF phenotype, defined by left ventricular ejection fraction (EF), as only those with reduced ejection fraction (HFrEF) have been shown to experience reduced mortality and morbidity with long-term pharmacotherapy. To ensure appropriate and equitable implementation of HF management we need to be able to identify clinically relevant cohorts of patients with HF, in particular, those with HFrEF. The ideal HF registry would incorporate and link HF diagnoses and phenotype from primary and secondary care with echocardiography and pharmacotherapy data. In this article we consider several options for identifying such cohorts from electronic health data in Aotearoa, as well as the potential and pitfalls of these options. Given the urgent need to identify people with HF according to EF phenotype, the options for identifying them from electronic health data, and the opportunities presented by health system reform, including a focus on digital solutions, we recommend the following four actions, with oversight from a national HF working group: 1) Establish a HF registry based on random and representative sampling of HF admissions; 2) investigate obtaining HF diagnosis and EF-phenotype from primary care-coded data; 3) amalgamate national echocardiography data; and 4) investigate options to enable the systematic collection of HF diagnosis and EF-phenotype from outpatient attendances. Future work will need to consider reliability and concordance of data across sources. The case for urgent action in Aotearoa is compounded by the stark inequities in the burden of HF, the likely contribution of health service factors to these inequities and the legislative requirement under the Pae Ora (Healthy Futures) Act 2022 that "the health sector should be equitable, which includes ensuring Maori and other population groups - (i) have access to services in proportion to their health needs; and (ii) receive equitable levels of service; and (iii) achieve equitable health outcomes".
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Insuficiencia Cardíaca , Registros Electrónicos de Salud , Humanos , Nueva Zelanda , Pronóstico , Reproducibilidad de los Resultados , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
INTRODUCTION: In New Zealand, significant inequities exist between Maori and Pacific peoples compared with non-Maori, non-Pacific peoples in cardiovascular disease (CVD) risk factors, hospitalisations and management rates. This review will quantify and qualify already-reported gaps in CVD risk assessment and management in primary care for Maori and Pacific peoples compared with non-Maori/non-Pacific peoples in New Zealand. METHODS AND ANALYSIS: We will conduct a systematic search of the following electronic databases and websites from 1 January 2000 to 31 December 2021: MEDLINE (OVID), EMBASE, Scopus, CINAHL Plus, NZresearch.org, National Library Catalogue (Te Puna), Index New Zealand (INNZ), Australia/New Zealand Reference Centre. In addition, we will search relevant websites such as the Ministry of Health and research organisations. Data sources will include published peer reviewed articles, reports and theses employing qualitative, quantitative and mixed methods.Two reviewers will independently screen the titles and abstracts of the citations and grade each as eligible, not eligible or might be eligible. Two reviewers will read each full report, with one medically qualified reviewer reading all reports and two other reviewers reading half each. The final list of included citations will be compiled from the results of the full report reading and agreed on by three reviewers. Data abstracted will include authors, title, year, study characteristics and participant characteristics. Data analysis and interpretation will involve critical inquiry and a strength-based approach that is inclusive of Maori and Pacific values. This means that critical appraisal includes an assessment of quality from an Indigenous perspective. ETHICS AND DISSEMINATION: Ethical approval is not required. The findings will be published in a peer-reviewed journal and shared with stakeholders. This review contributes to a larger project which creates a Quality-Improvement Equity Roadmap to reduce barriers to Maori and Pacific peoples accessing evidence-based CVD care.
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Enfermedades Cardiovasculares , Nativos de Hawái y Otras Islas del Pacífico , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/terapia , Factores de Riesgo de Enfermedad Cardiaca , Humanos , Nueva Zelanda , Atención Primaria de Salud , Medición de Riesgo , Factores de Riesgo , Revisiones Sistemáticas como AsuntoAsunto(s)
Anestesia , Cardiopatías Congénitas , Femenino , Humanos , Embarazo , Primer Trimestre del Embarazo , Ultrasonografía PrenatalRESUMEN
Importance: Cumulative exposure to high blood pressure (BP) is an adverse prognostic marker. Assessments of BP control over time, such as time at target, have been developed but assessments of the effects of BP-lowering interventions on such measures are lacking. Objective: To evaluate whether low-dose triple combination antihypertensive therapy was associated with greater rates of time at target compared with usual care. Design, Setting, and Participants: The Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) trial was a open-label randomized clinical trial of low-dose triple BP therapy vs usual care conducted in urban hospital clinics in Sri Lanka from February 2016 to May 2017. Adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg or in patients with diabetes or chronic kidney disease, systolic BP >130 mm Hg and/or diastolic BP >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy were included. Patients were excluded if they were currently taking 2 or more blood pressure-lowering drugs or had severe or uncontrolled blood pressure, accelerated hypertension or physician-determined need for slower titration of treatment, a contraindication to the triple combination pill therapy, an unstable medical condition, or clinically significant laboratory values deemed by researchers to be unsuitable for the study. All 700 individuals in the original trial were included in the secondary analysis. This post hoc analysis was conducted from December 2020 to December 2021. Intervention: Once-daily fixed-dose triple combination pill (telmisartan 20 mg, amlodipine 2.5 mg, and chlorthalidone 12.5 mg) therapy vs usual care. Main Outcomes and Measures: Between-group differences in time at target were compared over 24 weeks of follow-up, with time at target defined as percentage of time at target BP. Results: There were a total of 700 randomized patients (mean [SD] age, 56 [11] years; 403 [57.6%] women). Patients allocated to the triple pill group (n = 349) had higher time at target compared with those in the usual care group (n = 351) over 24 weeks' follow-up (64% vs 43%; risk difference, 21%; 95% CI, 16-26; P < .001). Almost twice as many patients receiving triple pill therapy achieved more than 50% time at target during follow-up (64% vs 37%; P < .001). The association of the triple pill with an increase in time at target was seen early, with most patients achieving more than 50% time at target by 12 weeks. Those receiving the triple pill achieved a consistently higher time at target at all follow-up periods compared with those receiving usual care (mean [SD]: 0-6 weeks, 36.3% [30.9%] vs 21.7% [28.9%]; P < .001; 6-12 weeks, 55.2% [31.9%] vs 33.7% [33.0%]; P < .001; 12-24 weeks, 66.0% [31.1%] vs 43.5% [34.3%]; P < .001). Conclusions and Relevance: To our knowledge, this analysis provides the first estimate of time at target as an outcome assessing longitudinal BP control in a randomized clinical trial. Among patients with mild to moderate hypertension, treatment with a low-dose triple combination pill was associated with substantially higher time at target compared with usual care.