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.

Service planning implications of estimating Primary Health Organisation enrolment rate based on a Health Service Utilisation population rather than a Census-derived population.

AIM: Estimating Primary Health Organisation (PHO) enrolment rates with a census-derived estimated resident population denominator may provide misleading results because of numerator and denominator mismatch. This study uses the Health Service Utilisation (HSU) population denominator as an alternative. METHOD: A HSU population was generated by record linkage of routinely collected datasets from the Ministry of Health via encrypted National Health Index (NHI). We compare PHO enrolment rates by age and ethnicity in Counties Manukau District Health Board (CMDHB) in 2013. RESULTS: In CMDHB, 98% of people who had utilised publicly-funded health services in 2013 were enrolled in a PHO in 2013. Using the HSU population as a denominator, PHO enrolment rates for Maaori, Pacific, Asian, New Zealand European/Other population groups were 98.3%, 97.7%, 97.6%, and 98.3% respectively. Just under 4% of people discharged from CMDHB inpatient facilities were not enrolled in a PHO within a month from the day of discharge in 2013. CONCLUSION: Using the HSU population as a proxy of health services need, PHO enrolment rates were similar across ethnicities in the CMDHB population. Support to improve PHO enrolment coverage would be more efficient if the HSU population were used to target people who are not yet enrolled in a PHO.

Urate testing in gout: why, when and how.

Urate is a frequently measured blood test in people with gout and those at risk of gout. Although gout is potentially curable with long-term urate lowering therapy, confusion about the details of urate measurement has contributed to suboptimal care. In this article, we provide recommendations regarding urate testing in gout, focusing on the use of this test in clinical practice.

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.

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.

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.

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.

Putting population health into practice through primary health care.

The introduction of the Primary Health Care Strategy has offered opportunities to take a population health approach to the planning and delivery of primary health care. The lack of a common understanding of population health between primary care and public health has been the prompt for a group of academics and practitioners to join forces and produce this statement on a population health approach to primary care, through primary health care. This paper takes the position that the features of a population health approach (such as a concern for equity, community participation, teamwork and attention to the determinants of health) enhance general practice care rather than undermine it. We conclude that the contribution of the health sector towards population health goals can be achieved through collaboration between GPs, nurses, other primary health care workers, and communities, together with health promotion and public health practitioners. Finding common language and understanding is an important step towards improving that collaboration.

Debunking the myths to provide 21st Century management of gout.

Epidemiologic and recent qualitative research suggests that the impact of under-treated gout is far more significant than many health professionals realise. The magnitude of this impact for Maaori and Pacific men of working age has been identified as a particular concern by the recently formed Maaori Gout Action Group in Counties Manukau District Health Board (South Auckland, New Zealand). The Group has identified that to achieve modern management of gout, those with gout need to be supported by primary care practitioners who are aware of the need for early intervention with allopurinol, as well as whaanau/families and communities who understand the impact and causes of gout and the lifestyle changes that are needed alongside long-term allopurinol. The Group wishes to support further research into the impact and causes of gout, particularly for Maaori, and to develop strategic alliances to ensure that the treatment and prevention of gout is advocated by those working with conditions such as diabetes and cardiovascular disease where gout is a frequent comorbidity.