Towards general practice-led integrated healthcare in New Zealand.

New Zealand's recent painful experience of health system reforms has shown that professional incentives are more powerful than market incentives, and that medical leadership, with accountability for both cost and quality, may be the key to success.

Service management: an epidemiological model of health services organization.

The New Zealand health system is undergoing a major paradigm shift. Services and programs have largely replaced hospitals and other institutions as the basic organizational framework, with each service having an epidemiologically defined responsibility for the provision of integrated personal and public health services for the population it serves. Primary health care as the infrastructure service is being implemented in some areas. These changes are being reinforced by the National Government's continuing reform process in which population-based and funded regional health authorities are purchasing all health services--primary, secondary, personal, public, acute and continuing--from a capitated and capped budget based on meeting the health needs of their populations.

The cost-effectiveness of treating mild-to-moderate hypertension: a reappraisal.

The cost-effectiveness of treating mild-to-moderate hypertension (diastolic blood pressures, 90-114 mmHg) was evaluated using the latest available information on both costs and benefits. The net health care costs of lifelong treatment for hypertension, at a 5% discount rate, ranged from 1491 pounds to 2752 pounds in men and from 1568 pounds to 2850 pounds in women in New Zealand in 1988 (1.00 pounds = $NZ 2.81). These figures take into account the savings in health care costs arising from stroke prevention. The net health care benefits, measured in quality-adjusted life years (QALYs) discounted at 5%, ranged from--2 days (a net negative effect of treatment) to 64 days in men and from--18 days to 35 days in women. The cost-effectiveness of antihypertensive therapy discounted at 5% (excluding categories of patients for whom the ratio was undefined due to a net negative effect of treatment on QALYs) ranged from 11,058 pounds to 63,760 pounds per QALY gained in men and from 22,060 pounds to 194,989 pounds per QALY gained in women. Treatment was more cost-effective in men than in women, in older age groups and at higher levels of pretreatment diastolic blood pressure. The cost-effectiveness ratios were highly sensitive to the discount rate used (with the majority of ratios in women being undefined at a 10% discount rate) and the costs of the regimen used (diuretic monotherapy being the most cost-effective, followed by beta-blockers, then angiotensin-converting enzyme inhibitors), as well as to the assumptions made about the impact of medication side effects on patient quality of life. These results call for a re-examination of resource allocation to antihypertensive treatment and point to the need to make assessments of the cost-effectiveness of alternative, non-pharmacological approaches to stroke prevention.

Epidemiological factors in postneonatal mortality in New Zealand.

Nine hundred and sixty-two postneonatal deaths for 1981-83 were matched to their birth registration forms. Deaths were divided into three categories, sudden infant death syndrome (SIDS) 65.4%, other preventable, 12.8%, and nonpreventable causes, 21.8%, to determine the rates of death as related to known and available risk factors. The risk factor profile for other preventable causes and SIDS was similar, the only exceptions being that other preventable causes showed no north-south gradient and had a higher incidence in the neonatal period (31.2% v 4.7% for SIDS). The most important risk factors for other preventable causes were found to be the mother being Maori (RR 4.35, CI 3.12-6.06), having a low birth weight infant (RR 3.56, CI 2.07-6.13) and being unmarried (RR 3.45, CI 2.47-4.82). These risk factors point to the possibility of selectively targeting of interventions both prenatally as well as postnatally for those who are at high risk.

Treating mild to moderate hypertension: cost-effectiveness and policy implications.

Results from major clinical trials reported during the 1980s have led to renewed debate about the costs and benefits of treating mild to moderate hypertension. There is general agreement that existing cost-effectiveness analyses of antihypertensive therapy are outdated, and in need of reappraisal. Based on the pooled results of clinical trials, the benefits of treating mild to moderate hypertension [diastolic blood pressure (DBP) of 90-114 mm Hg] were re-examined. Using actuarial methods and estimates of health state utilities, the benefits of treatment were expressed in "quality-adjusted life years" (QALYs). After lifelong treatment for hypertension, the gain in QALYs ranged from 1.8 to 11.5 months in men and from 2.5 to 11.3 months in women. The cost-effectiveness ratios ranged from $30,200 per QALY gained (for 50-year-old men with DBP of 110 mm Hg) to $547,700 per QALY gained (for 30-year-old women with DBP of 110 mm Hg), in 1988 New Zealand dollars, discounted at 5%. In several categories of patients, the analysis suggested a net negative impact on QALYs, i.e., the adverse effects of drug treatment outweighed the benefits. These results have policy implications for both resource allocation and clinical practice.

Variability in antihypertensive drug therapy in general practice: results from a random national survey.

A random national survey of 50 general practitioners was undertaken to ascertain current trends in the pharmacological management of hypertension. Forty general practitioners entered the study, and scripts written by them over a two month period in 1988 were collected and recorded by the pharmaceutical pricing offices of the health department. The general practitioners provided details on whether the script had been written for hypertension, as well as the age and sex of the patients. Information from 37 general practitioners was available for study, involving 2675 scripts written for hypertension for 1858 patients. Sixty point two percent of the treated hypertensives were female, and 58.9% were aged over 60 years. The most commonly prescribed antihypertensives were the diuretics (47.1% of patients) and beta blockers (47.9%). They were followed by angiotensin converting enzyme inhibitors (18.2%) and calcium antagonists (9.7%). There was substantial variability in the prescription of antihypertensives with respect to the age and sex of the patients treated; the mean costs and duration of supply of different generic drug types; and the prescribing habits of general practitioners. By generic type, the mean monthly costs of therapy ranged from $3.77 (diuretics) to $48.19 (calcium antagonists). The age and sex adjusted geometric mean script costs ranged from $17.78 to $49.11 per month (median: $29.30). It seems unlikely that the observed degree of variability is explained by differences in the severity of hypertension between general practice populations.

The benefits of treating mild to moderate hypertension. A quantitative estimation of the life expectancy gains from pharmacological reduction of blood pressure.

A quantitative assessment of the benefits of pharmacological treatment of mild to moderate hypertension (diastolic blood pressure 90-114 mmHg) in patients aged 30-60 years was performed, based on the pooled results of nine major clinical trials. The benefits were expressed as added "quality-adjusted life-years" (QALYs), using life-table methods and utility valuations of health states. The expected gains in QALYs were found to be quite small, ranging from 2.3-11.4 months in males, and 1.4-7.6 months in females. Previous attempts to estimate the nature and magnitude of the benefits of antihypertensive therapy have all been based on extrapolations from epidemiological data, instead of on the actual achieved reductions in mortality and morbidity demonstrated in clinical trials. The former method considerably overestimates the potential direct benefits from drug treatment of mild to moderate hypertension.

The rising expenditure on antihypertensive drugs in New Zealand, 1981-1987.

The rising cost of treating hypertension has become an issue of concern in several countries, including the United States, parts of Europe, and more recently, New Zealand. In New Zealand between 1981 and 1987, the total inflation-adjusted expenditure on antihypertensive drugs increased by 61.7%, from $21.4 million to $34.6 million in constant 1981 dollars. The major part (56.3%) of this increase in overall expenditure was explained by the rise in real cost of drug treatment, while the number of patients on drug therapy remained virtually static over the same period. The average cost of a prescription for hypertension was estimated to have risen by 46.1% between 1981 and 1987, i.e. from $7.30 to $10.66 in constant 1981 dollars. Pardoxically the mean inflation-adjusted price of antihypertensive drugs fell by 10.8% over the same period. Changing patterns of prescription and the entry of new drugs into the market accounted for most of the rise in average cost per prescription over the study period. Unless the rising expenditure can be justified by demonstrable improvements in treatment outcome, continuation of these trends will have profound effects on the cost-effectiveness of antihypertensive therapy.

Decentralisation trends in the management of New Zealand's health services.

New Zealand is in the process of implementing major changes in the organisation and funding of its health services. Central to these changes is a largely elected area health board responsible for the funding and coordination of all services for a defined population, both public as well as non-government. Four different models of decentralisation, deconcentration (administrative), devolution (political), corporatisation (functional) and privatisation (non-government), have been used to describe and analyse these changes. There is expected to be a major devolution of powers to area health boards from central government, reversing the centralising tendencies which have occurred over the past century. Within boards a pluralistic system of service management, incorporating the above models of decentralisation, is being implemented to replace the present system of institutional administration and to give greater decision-making responsibility to health professionals, non-government agencies and community groups. These initiatives are associated with population-based funding of hospital boards complemented by service planning guidelines. Of particular importance has been the recent government decision to place the funding and management of primary health care under area health boards. However, there are serious concerns as to whether such radical changes, which could put New Zealand ahead of the rest of the world in achieving an integrated health system, can be implemented given the management expertise needed.

Recent trends in drug prescribing rates and costs in New Zealand.

Pharmaceutical benefit expenditure has grown rapidly and disproportionately in recent years to nearly 15% of Vote Health. Annual average increases in prescribed drugs of 3.1% by volume and of 6.9% in real prices have occurred since 1981. For the 1986/87 year volume and real price increases were 5.7% and 11.5% respectively, possibly due to the lifting of the price freeze and the effect of extending prescribing to three months from February 1985. Factors explaining these trends include the growth in numbers of general practitioners and the availability of new and more expensive drugs supported by promotional activities of pharmaceutical companies. There are almost no effective managerial, professional or educational strategies on the part of government to counter these influences. Pharmaceutical benefit expenditure and its growth is almost totally unmanaged and uncontrolled. With severe limits on government expenditure this growth could threaten other areas of health expenditure. Major changes are required in its management including a substantial part charge to the user, decentralisation to area health boards of primary health care services and funding, and professional mechanisms for better prescribing, supported by national policies for a comprehensive, computerised pharmaceutical and primary health care information system.

Is the pharmacological treatment of mild to moderate hypertension cost effective in stroke prevention?

Pooled data from clinical trials show that the incidence of fatal and nonfatal strokes combined is reduced by approximately 39% (95% CI: -48% to -28%) with antihypertensive treatment. However, given the relatively low incidence of stroke, it can be calculated that about 530 to 1375 mild to moderate hypertensive patients would need to be treated per year to prevent one stroke. Applying these results to the health service costs, both public and private, of treating mild to moderate hypertension in New Zealand we have estimated that the cost of preventing one stroke in those aged 35-64 years at between $110,900 and $285,400 in 1982 dollars. The offsetting hospital and community care costs to the health services of treating a stroke, was approximately $6500 giving a net cost of between $104,000 and $279,000 per stroke prevented. The cost of preventing a death from stroke was estimated to be between $356,000 and $1,822,000. Per year of life saved, this appears to be well in excess of such costly interventions as coronary artery bypass, heart transplantation and renal dialysis. Greater use should be made of inexpensive diuretics and nonpharmacological methods for the management of hypertension. A population strategy, rather than the present expensive high risk approach, could be far more cost effective in stroke prevention.

Availability and utilisation of mental illness and mental handicap beds in New Zealand.

Using data from a variety of sources the availability and utilisation of beds for the treatment of the mental illness and mental handicap for hospital board populations have been determined. There is a wide variation in bed availability between such populations and this is significantly correlated with utilisation variables such as rates of first and total admissions, bed days and length of stay. There is little evidence of underprovision in low availability areas. On the other hand provision above the average is associated with both population-based overfunding and the possibility of serious detrimental effects due to institutionalisation. Excess beds may therefore lead to both expensive and poorer quality care. Guideline figures for New Zealand are suggested which are well below current provision.