Counting the cost of major infection and sepsis in New Zealand: an exploratory study using the National Minimum Data Set.

AIM: To explore the population-at-risk and potential cost of a sepsis episode in New Zealand. METHOD: Retrospective analysis of the National Minimum Data Set using two code-based algorithms selecting (i) an inclusive cohort of hospitalised patients diagnosed with a 'major infection' with the potential to cause sepsis and (ii) a restricted subset of these patients with a high likelihood of clinical sepsis based on the presence of both a primary admission diagnosis of infection and at least one sepsis-associated organ failure. RESULTS: In 2016, 24% of all inpatient episodes were associated with diagnosis of a major infection. The sepsis coding algorithm identified a subset of 1,868 discharges. The median (IQR) reimbursement associated with these episodes was $10,381 ($6,093-$10,964). In both groups, 30-day readmission was common (26.7% and 11% respectively). CONCLUSIONS: Infectious diseases with the potential to cause sepsis are common among hospital inpatients. Direct treatment costs are high for those who present with or progress to sepsis due to these infections.

Potential for public health success in tackling the hepatitis C virus epidemic.

New Zealand and Australia both now have the potential for a major public health success in controlling the hepatitis C virus epidemic. The burden of advanced liver disease and drug-related harm is increasing. However, a new range of anti-viral therapies have become available which offer a potential cure for most people with few side-effects. The epidemic is potentially preventable and hepatitis C is now curable. Although public health strategies for blood-borne viruses have been updated, they fall short of what is needed and should be upgraded with more emphasis on prevention, in order to achieve control of this epidemic.

Projected costs of colorectal cancer treatment in New Zealand in the absence of population screening.

AIM: To estimate volumes and costs of health services required for new cases of colorectal cancers in New Zealand from 2014 to 2026 in the absence of population screening. METHOD: Annual incidence of colorectal cancer, by stage, location and age was estimated for 2006-2026 based on NZ cancer registry data for 2001-2005. Treatment protocols were determined based on current best practice. An economics forecasting model was developed to estimate annual volumes and costs of health services to treat new cases of colorectal cancer expected to present each year from 2014 to 2026. Survival rates and other model parameters were drawn from the literature. Costs are presented at 2011 prices. RESULTS: Annual health service costs of new colorectal cancer presentations in New Zealand are estimated to increase from approximately $83.6 million in 2014 to $100.2 million by 2026, if no systematic screening programme is introduced. The majority of these costs will be for surgery and colonoscopies. CONCLUSION: These results provide a baseline against which to compare the level of resources required if a population screening programme is introduced. Planning is necessary to manage costs and services for colorectal cancer, even without a systematic population screening programme.

Estimated community costs of an outbreak of campylobacteriosis resulting from contamination of a public water supply in Darfield, New Zealand.

AIM: To estimate the economic costs to the community of an outbreak of campylobacteriosis in August 2012 resulting from contamination of a public water supply in Darfield, New Zealand. METHOD: Probable incidence of waterborne disease was estimated. Reported cases were scrutinised to identify symptoms, duration, hospital admissions and those in the paid workforce. Extra public health and local authority costs were calculated. Estimated time off work was multiplied by the average wage to obtain a conservative estimate of lost production. Sensitivity analysis was used to estimate unreported cases and their associated costs. RESULTS: There were 138 cases of confirmed or probable campylobacter, of whom 46 sought a medical consultation. Taking into account the usual pyramid of non-notified cases, estimates of the population infected range between approximately 828 and 1987. The dominant societal cost is lost production from time off paid work. Forty-six per cent were in the paid workforce, indicating a total estimated economic cost of at least $714,527 but it could have been as high as $1.26 million, depending on estimates of unreported cases. CONCLUSION: The likely cause of the Darfield outbreak was faecal contamination of the water supply, which with a multi-barrier approach would have been entirely preventable. The results provide economic evidence to support upgrading of water supplies to provide safe water and prevent waterborne disease.

A cohort study comparing cardiovascular risk factors in rural Maori, urban Maori and non-Maori communities in New Zealand.

OBJECTIVES: To understand health disparities in cardiovascular disease (CVD) in the indigenous Maori of New Zealand, diagnosed and undiagnosed CVD risk factors were compared in rural Maori in an area remote from health services with urban Maori and non-Maori in a city well served with health services. DESIGN: Prospective cohort study. SETTING: Hauora Manawa is a cohort study of diagnosed and previously undiagnosed CVD, diabetes and risk factors, based on random selection from electoral rolls of the rural Wairoa District and Christchurch City, New Zealand. PARTICIPANTS: Screening clinics were attended by 252 rural Maori, 243 urban Maori and 256 urban non-Maori, aged 20-64 years. MAIN OUTCOME MEASURES: The study documented personal and family medical history, blood pressure, anthropometrics, fasting lipids, insulin, glucose, HbA1c and urate to identify risk factors in common and those that differ among the three communities. RESULTS: Mean age (SD) was 45.7 (11.5) versus 42.6 (11.2) versus 43.6 (11.5) years in rural Maori, urban Maori and non-Maori, respectively. Age-adjusted rates of diagnosed cardiac disease were not significantly different across the cohorts (7.5% vs 5.8% vs 2.8%, p=0.073). However, rural Maori had significantly higher levels of type-2 diabetes (10.7% vs 3.7% vs 2.4%, p<0.001), diagnosed hypertension (25.0% vs 14.9% vs 10.7%, p<0.001), treated dyslipidaemia (15.7% vs 7.1% vs 2.8%, p<0.001), current smoking (42.8% vs 30.5% vs 15.2%, p<0.001) and age-adjusted body mass index (30.7 (7.3) vs 29.1 (6.4) vs 26.1 (4.5) kg/m(2), p<0.001). Similarly high rates of previously undocumented elevated blood pressure (22.2% vs 23.5% vs 17.6%, p=0.235) and high cholesterol (42.1% vs 54.3% vs 42.2%, p=0.008) were observed across all cohorts. CONCLUSIONS: Supporting integrated rural healthcare to provide screening and management of CVD risk factors would reduce health disparities in this indigenous population.

Community screening for cardiovascular risk factors and levels of treatment in a rural Maori cohort.

OBJECTIVES: To document levels of cardiovascular disease (CVD), diagnosed and undiagnosed risk factors and clinical management of CVD risk in rural Maori. METHODS: Participants (aged 20-64 years), of Maori descent and self-report, were randomly sampled to be representative of age and gender profiles of the community. Screening clinics included health questionnaires, fasting blood samples, blood pressure and anthropometric measures. Data were obtained from participants' primary care physicians regarding prior diagnoses and current clinical management. New Zealand Cardiovascular Guidelines were used to identify new diagnoses at screening and Bestpractice electronic-decision support software used to estimate 5-year CVD risk. RESULTS: Mean age of participants (n=252) was 45.7 ± 0.7, 8% reported a history of cardiac disease, 43% were current smokers, 22% had a healthy BMI, 30% were overweight and 48% obese. Hypertension was previously diagnosed in 25%; an additional 22% were hypertensive at screening. Dyslipidaemia was previously diagnosed in 14% and an additional 43% were dyslipidaemic at screening. Type-2 diabetes was previously diagnosed in 11%. Glycaemic control was achieved in only 21% of those with type-2 diabetes. Blood pressure and cholesterol were above recommended targets in more than half of those with diagnosed CVD risk factors. CONCLUSIONS: High levels of diagnosed and undiagnosed CVD risk factors, especially hypertension, dyslipidaemia and diabetes were identified in this rural Maori community. IMPLICATIONS: There is a need for opportunistic screening and intensified management of CVD risk factors in this indigenous population group.

A Kaupapa Maori approach to a community cohort study of heart disease in New Zealand.

OBJECTIVE: To report the processes and protocols that were developed in the design and implementation of the Hauora Manawa Project, a cohort study of heart disease in New Zealand and to report the participation at baseline. METHODS: This study utilised application of a Kaupapa Maori Methodology in gaining tribal and health community engagement, design of the project and random selection of participants from territorial electoral rolls, to obtain three cohorts: rural Maori, urban Maori and urban non-Maori. Logistic regression was used to model response rates. RESULTS: Time invested in gaining tribal and health community engagement assisted in the development and design of clear protocols and processes for the study. Response rates were 57.6%, 48.3% and 57.2%. Co-operation rates (participation among those with whom contact was established) were 74.7%, 66.6% and 71.4%. CONCLUSIONS: Use of electoral rolls enables straightforward sampling but results in low response rates because electors have moved. Co-operation rates highlight the acceptability of this research project to the participants; they indicate the strength of Kaupapa Maori Methodologies in engaging Maori participants and community. IMPLICATIONS: This study provides a model for conducting clinical/biomedical research projects that are compatible with cultural protocols and methodologies, in which the primary aim of the research was Maori health gain.

Renal stone disease in Christchurch, New Zealand. Part 1: presentation and epidemiology.

AIM: To document the modes of presentation and the epidemiology of radiologically diagnosed renal stone disease over a 1-year period in the region of Christchurch, New Zealand. METHOD: Data on the presentation and epidemiology of renal stone disease was prospectively collected in a 1-year cohort of patients who had a new radiological diagnosis of renal stone disease. RESULTS: The incidence of new renal stone diagnoses was 105 per 100,000 per annum. Renal stone disease was more common in men than women, most common in the three decades from 30 to 59 years, and more common in people in trades or machine operating jobs. There was no significant difference in incidence by ethnicity or season. 58% of people presented with stones located in the ureter. Renal stones tended to be larger and were more likely to present incidentally or with haematuria, whilst ureteric stones were smaller and presented more typically with pain. 33% had a personal history of previous renal stone episodes and 20% had a family history of previous stones. CONCLUSIONS: Kidney stone disease is a significant health condition that affects people of predominantly working ages and men more than women. Both personal and family history are significant risk factors. Patients presenting with pain are more likely to have stones located in the ureter. Renal stones are more likely to present with haematuria or incidentally.

Renal stone disease in Christchurch, New Zealand. Part 2: a community study on the burden of renal stone disease.

AIM: To quantify the annual burden of a 12-month cohort of newly diagnosed renal stones in the defined community of Christchurch, New Zealand, and to assess this burden by stone size and position. METHOD: In this prospective study of stone burden, patients in the Christchurch region of New Zealand with newly diagnosed renal stones maintained a weekly diary for a 12-month period to record the utilisation of health services and financial and social costs to families and partners. Patient records were matched with diagnostic and clinical information to provide a comprehensive database. The economic costs of the various services were estimated. RESULTS: From November 2001 to November 2002, 422 newly diagnosed renal stones were detected--an annual incidence of 105 per 100,000 population. The annual mean cost of these stones was NZ$4274 per person in the first 12 months. The greatest costs were those for emergency visits, hospitalisations and for operative procedures (23.8%, 22.7%, and 21.8% of total financial burden respectively). Patient workdays lost accounted for 10.9% of total costs. Ureteric stones caused greater social burden than kidney stones. Costs were influenced by stone location and size, being significantly higher for ureteric stones and for larger stones. CONCLUSIONS: Renal stone disease places a considerable burden on the community. The main burdens were related to health service costs, with personal and pharmaceutical costs representing only a small component. The financial burden to society is estimated at $450,000 per 100,000 population ($NZ in 2001/02).

Hospital expenditure on treating complications of diabetes and the potential for deferring complications in Canterbury, New Zealand.

AIM: To investigate annual expenditure by a major district health board in New Zealand on hospital admissions for treating the various complications of diabetes. METHODS: Actual costs were analysed for 2005/06, for all inpatient hospital admissions in Canterbury, New Zealand, where diabetes was recorded as a primary or secondary diagnosis. Costs and lengths of stay for all such admissions were included for ICD-10 codes using the criteria from Australian studies of potentially avoidable hospitalisations. ICD-10 codes were used to identify the major types of complications of diabetes resulting in hospital admissions. RESULTS: Total costs of all hospital admissions where diabetes was recorded as a primary or secondary diagnosis amounted to $10.1 million in 2005/06, and 9511 days stay in hospital; 69% of these costs were for admissions where diabetes was a secondary diagnosis, with the majority of such costs being for treatment of admissions for cardiovascular disease. CONCLUSIONS: The results generally indicated that diabetes associated with hospital admissions is a major factor, which is still under-reported, and which involves considerable costs of treating the longer term consequences of diabetes. The largest proportion of these costs is for cardiovascular disease, where diabetes is the secondary diagnosis.

Issues in the assessment of cardiovascular risk in selected general practices in Canterbury, New Zealand.

AIMS: The aim was to audit patient records at selected general practices in Canterbury, New Zealand to assess the potential: (a) to improve identification and management of people with risk factors for cardiovascular disease (CVD); and (b) to develop a geographically distinct community database of CVD risk factor prevalence that could be used to plan public health programmes to improve cardiovascular health. METHODS: Patient records were audited in three general practices in a Canterbury rural town and information on cardiovascular risk factors recommended for the screening and management of CVD by the New Zealand Guidelines Group was extracted and entered into an electronic database. The data was analysed to assess the extent of recording of information on recommended risk factors. RESULTS: Most patient records contained information on smoking, blood pressure and lipid profiles. Low levels of information recording were found for physical activity, body mass index (BMI), and family history. There were statistically significant differences between general practices in the type and coverage of information recorded, even for patients with diagnosed cardiovascular disease. Because of deficiencies in information, it was not possible to calculate CVD risk using the guidelines for 43% of patients. Some practices remain reliant on paper records which make it extremely difficult to undertake a systematic programme of screening and management of CVD risk factors. CONCLUSIONS: Before it is practical to undertake a systematic screening programme for CVD risk factors in primary care, it is necessary to reduce reliance on paper records and to fully implement computerised patient management systems that allow for information storage and retrieval. In addition, it is essential to improve the systematic collection of key information in primary care that is used to assess risk of CVD.

Avoidable hospitalisations: potential for primary and public health initiatives in Canterbury, New Zealand.

AIM: To investigate the extent of potentially "avoidable hospitalisations" in the Canterbury District Health Board area; specifically, to identify the leading causes, recent trends, and estimated costs of avoidable hospitalisations. METHODS: All hospitalisations in Christchurch Hospital from 2000 to 2004 were analysed and potentially "avoidable admissions" were categorised using ICD10 clinical codes. Costs of these admissions were estimated for the financial year ending 30 June 2003 using diagnostic-related groups (DRGs). RESULTS: The leading causes of potentially "avoidable hospitalisations" in Christchurch Hospital were cardiovascular disease, stroke, respiratory, gastrointestinal, and urinary disorders. The total estimated costs of avoidable hospitalisations in 2003 were NZ 96.6 million dollars, accounting for an estimated 94,462 bed days. The estimated costs of cardiovascular admissions (excluding stroke) were 50.6 million dollars, with stroke accounting for an additional 6.2 million dollars. CONCLUSION: Potentially "avoidable admissions" to Christchurch Hospital comprised 31% of all hospital admissions. There is considerable opportunity to invest in public and primary health initiatives aimed at early detection and intervention, with the major opportunities being identified as cardiovascular disease, stroke, respiratory, gastrointestinal, and urinary disorders.

Reduction in crime by drug users on a methadone maintenance therapy programme in New Zealand.

AIM: The study aimed to estimate changes in drug use, crime, imprisonment and societal costs among a sample of Maori and non-Maori injecting drug users (IDUs) on a methadone maintenance therapy (MMT) programme in Christchurch, New Zealand. METHODS: Fifty-one non-Maori and 34 Maori IDUs were interviewed to obtain a self-reported history of drug use, crime, imprisonment, and effects on personal health. Information was obtained on drug use and crime before starting MMT and also after stabilisation on MMT. Follow-up interviews were conducted 18 months (mean) after the first interview. RESULTS: Considerable reductions in the frequency of crime occurred--with 60% of participants reporting they committed crimes every day before MMT, compared with only 1% at interview. Large reductions were reported in both expenditure on illicit drugs and income from illegal activities. Reductions in opioid use and crime were similar for both Maori and non-Maori. A significant minority of participants reported continuing some form of crime while on MMT; 29% reported committing at least one offence during the week prior to interview. CONCLUSIONS: MMT is associated with a large reduction in the costs of crime and imprisonment among IDUs. This reduction in crime is similar for both Maori and non-Maori.

The costs of not treating hepatitis C virus infection in injecting drug users in New Zealand.

This paper estimates future health service costs of the current practice in New Zealand of not funding treatment of hepatitis C virus (HCV) infections. Costs are estimated separately for Maori and non-Maori, male and female IDUs. Markov modelling is used to track the infection and progression of HCV to severe liver disease and death, and accumulated costs are estimated for the life of the cohort. Upper and lower estimates of costs are calculated based on different assumptions of the rate of progression of HCV to more severe liver disease. Costs are estimated at dollars 24.6 million per 1000 non-Maori men IDUs (discounted at 3%), under progression assumptions based on liver clinic studies, compared with dollars 10.3 million per 1000 using lower rates of progression based on community studies. Similarly, corresponding costs for non-Maori women are estimated at dollars 27.6 million and $11.2 million per 1000 IDUs. Costs for women are higher because their greater life expectancy is associated with more cases of liver cirrhosis (LC) at older ages. Future costs for Maori are lower than non-Maori, because Maori are more likely to die at younger ages and hence fewer progress to more advanced liver disease. The current situation in New Zealand of not treating HCV infections will result in considerable future costs as some people with HCV progress to more severe liver disease. Provisional estimates are that the accumulated costs of HCV-related liver disease for all IDUs currently infected will be between dollars 166 million at lower rates of disease progression (discounted at 3%) to dollars 400 million at upper rates. Some of the associated morbidity and mortality could have been avoided if the HCV infections had been treated.