Co-design of youth appropriate services for young people with rheumatic fever/rheumatic heart disease in Counties Manukau District.

AIM: To co-design a rheumatic fever service model which enables young people with acute rheumatic fever/rheumatic heart disease (ARF/RHD) and their families to access the health and wellbeing services they need. METHOD: Co-design, a collaborative and participatory approach, was used to gather experiences and ideas from 21 consumers and 30 health professionals. Thematic analysis was undertaken. RESULTS: Maori and Pacific patients and their whanau/aiga identified the importance of whanau/aiga support and involvement throughout their ARF/RHD journey. They described that the way care was delivered was often frustrating, fragmented and lacked effective communication. Participants expressed the need for information to improve their understanding of ARF/RHD. Health professionals identified the need for better continuity of care and felt that they were currently working siloed from other professionals with little visibility of other roles or opportunity for collaboration. The ideas for improvement were grouped into themes and resulted in development and prototyping of peer support groups, patient and staff education resources, clinical dashboard and pathway development, and an enhanced model of care for delivery to patients receiving penicillin prophylaxis. CONCLUSION: The co-design process enabled consumers and staff of ARF/RHD services to share experiences, identify ideas for improvement, co-design prototypes and test initiatives to better support the needs of those delivering and receiving ARF/RHD services.

Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening.

OBJECTIVE: Examine the health and economic impact of extending screening intervals in people with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM) without diabetes-related retinopathy (DR). SETTING: Diabetic Eye Screening Wales (DESW). STUDY DESIGN: Retrospective observational study with cost-utility analysis (CUA) and Decremental Cost-Effectiveness Ratios (DCER) study. INTERVENTION: Biennial screening versus usual care (annual screening). INPUTS: Anonymised data from DESW were linked to primary care data for people with two prior screening events with no DR. Transition probabilities for progression to DR were estimated based on a subset of 26,812 and 1232 people with T2DM and T1DM, respectively. DCER above £20,000 per QALY was considered cost-effective. RESULTS: The base case analysis DCER results of £71,243 and £23,446 per QALY for T2DM and T1DM respectively at a 3.5% discount rate and £56,822 and £14,221 respectively when discounted at 1.5%. Diabetes management represented by the mean HbA1c was 7.5% for those with T2DM and 8.7% for T1DM. SENSITIVITY ANALYSIS: Extending screening to biennial based on HbA1c, being the strongest predictor of progression of DR, at three levels of HbA1c 6.5%, 8.0% and 9.5% lost one QALY saving the NHS £106,075; £58,653 and £31,626 respectively for T2DM and £94,696, £37,646 and £11,089 respectively for T1DM. In addition, extending screening to biennial based on the duration of diabetes > 6 years for T2DM per QALY lost, saving the NHS £54,106 and for 6-12 and > 12 years for T1DM saving £83,856, £23,446 and £13,340 respectively. CONCLUSIONS: Base case and sensitivity analyses indicate biennial screening to be cost-effective for T2DM irrespective of HbA1c and duration of diabetes. However, the uncertainty around the DCER indicates that annual screening should be maintained for those with T1DM especially when the HbA1c exceeds 80 mmol/mol (9.5%) and duration of diabetes is greater than 12 years.

Poisoning due to tutin in honey-a report of an outbreak in New Zealand.

AIM: In autumn 2008, an outbreak of toxic honey poisoning was identified. The outbreak was not recognised initially until three cases from one family group presented to hospital, with a common factor of recent consumption of locally produced honey. The aim of this study was to investigate potential cases of this honey poisoning and determine which toxin was involved. METHOD: The incident was investigated retrospectively by Waikato District Health Board's Population Health unit and the New Zealand Food Safety Authority (NZFSA). Identified patients were followed up by questionnaire to gather case information. HortResearch (now Plant and Food Research) tested honey samples for toxins. RESULTS: The causative agent was identified as tutin, which comes from the New Zealand native plant tutu (Coriaria arborea) which has long been known as a potential source of contamination of honey produced in the warmer parts of New Zealand. Retrospective case investigation identified a total of 22 possible or probable cases, based on a clinical case definition. The spectrum of toxic effects reported were broadly similar to those previously described for tutin, derived either directly from the plant itself or indirectly from honey. There were 13 samples of honey, linked to symptomatic individuals, which were available for testing. Of these, 10 were positive for tutin and its hydroxy metabolite hyenanchin (hydroxytutin) and one was positive for hyenanchin alone. CONCLUSION: Toxic honey production is a significant risk in parts of New Zealand. Beekeepers and health professionals need to be informed of this risk and know how best to manage it. Due to this poisoning incident, public and professional awareness of honey poisoning has been substantially enhanced. This incident led to development of new food safety standards for New Zealand honey.

Is a rheumatic fever register the best surveillance tool to evaluate rheumatic fever control in the Auckland region?

AIM: To determine the most accurate data source for acute rheumatic fever (ARF) epidemiology in the Auckland region. METHOD: To assess coverage of the Auckland Regional Rheumatic Fever Register (ARRFR), (1998-2010) for children <15 years and resident in Auckland at the time of illness, register, hospitalisation and notification data were compared. A consistent definition was applied to determine definite and probable cases of ARF using clinical records. (www.heartfoundation.org.nz) RESULTS: Of 559 confirmed (definite and probable) RF cases <15 years (median age 10 years), seven were recurrences. Of 552 first episodes, the ARRFR identified 548 (99%), hospitalisations identified 501 (91%) including four not on the register, and public health notifications identified 384 (70%). Of hospitalisation cases, 33% (245/746), and of notifications 20% (94/478) did not meet the case definition and were therefore excluded. Between 1998-2010, eight cases, initially entered as ARF on the ARRFR, were later removed once further clinical detail was available. CONCLUSION: The ARRFR produced the most accurate information surrounding new cases of ARF (for children <15 years) for the years 1998-2010 in Auckland. This was significantly more accurate than medical officer of health notification and hospitalisation data.

First Presentation Acute Rheumatic Fever is Preventable in a Community Setting: A School-based Intervention.

BACKGROUND: Robust evidence is lacking for community initiatives to prevent first presentation acute rheumatic fever (ARF) by group A streptococcal (GAS) pharyngitis treatment. METHODS: We measured the effect of introducing a sore throat clinic program on first presentation ARF into 61-year 1-8 schools with students 5-13 years of age (population ≈25,000) in Auckland, New Zealand. The study period was 2010-2016. A generalized linear mixed model investigated ARF rate changes before and after the staggered introduction of school clinics. Nurses and lay workers treated culture-proven GAS sore throats (including siblings) with 10 days of amoxicillin. ARF cases were identified from a population-based secondary prophylaxis register. Annual pharyngeal GAS prevalence was assessed in a subset. RESULTS: ARF rates in 5-13 year olds dropped from 88 [95% confidence interval (CI): 79-111] per 100,000 preclinics to 37 (95% CI: 15-83) per 100,000 after 2 years of clinic availability, a 58% reduction. No change in rate was demonstrated before the introduction of clinics [P = 0.88; incidence risk ratio for a 1-year change: 0.98 (95% CI: 0.63-1.52)], but there was a significant decrease of first presentation ARF rates with time after the introduction of the sore throat program [P = 0.008; incidence risk ratio: 0.61 (95% CI: 0.43-0.88)]. Pharyngeal GAS cross-sectional prevalence fell from 22.4% (16.5-30.5) preintervention to 11.9% (8.6-16.5) and 11.4% (8.2-15.7) 1 or 2 years later (P = 0.005). CONCLUSIONS: ARF declined significantly after school-based GAS pharyngitis management using oral amoxicillin paralleled by a decline in pharyngeal GAS prevalence.

Antimicrobial stewardship using pharmacy data for the nurse-led school-based clinics in Counties Manukau District Health Board for management of group A streptococcal pharyngitis and skin infection.

AIM: To evaluate antimicrobial usage in the school-based clinics against operating guidelines. METHOD: Antimicrobial prescribing data (2014) from 10/18 participating pharmacies serving 14,153/23,588 primary school children of the programme were accessible. Prescriptions from 5/10 pharmacies were available for identifying type, amount, and indication of the medicine. One pharmacy serving a defined population (n=3,513) with single healthcare provider delivering the school programme was selected for detailed evaluation and identifying individuals receiving multiple treatments. RESULTS: Data from 10 pharmacies (n=7,889 prescriptions) showed 91.2% of prescriptions were for group A streptococcal-positive throat swab, 8.8% for skin infections. More detail from 5/10 pharmacies showed only 2% of group A streptococcal pharyngitis treatments (107/4,672) were not first-line (56 cephalexin and 51 rifampin prescriptions). Fusidic acid (159/452, 35.18%) or cephalexin (169/452, 37.39%) were most commonly used for skin infection. Analysis in the defined population showed <4% (151/4,325) of assessed skin conditions received antimicrobials, and only 6 individuals received more than one course of oral antimicrobial over the year. CONCLUSION: Antimicrobial administration demonstrates high compliance with the protocol. There was very limited use of second-line antimicrobials for recurrent pharyngitis. Most skin infections did not require antimicrobial treatment. Repeated antimicrobials for individuals were rare.

Nurse-led school-based clinics for rheumatic fever prevention and skin infection management: evaluation of Mana Kidz programme in Counties Manukau.

AIM: To evaluate registered nurse-led school clinics in 61 primary and intermediate schools in Counties Manukau. METHODS: The evaluation (conducted August­December, 2014) collated evidence concerning service delivery, outcomes, value for money and effectiveness. RESULTS: 97% (23,756/24,497) of eligible children were consented, 11% (20,696/191,423) of throat swabs taken (February 2013­September 2014) were culture positive for Group A Streptococcus (GAS); 20,176 were treated. Mana Kidz teams treated (includes cleaning and covering alone) 17,593 skin infections and actioned 4,178 school health referrals. A pre-programme cross sectional GAS pharyngeal prevalence demonstrated a relative risk 1.8 (1.3­2.3) (95%CI) of being pharyngeal GAS positive in 2013 compared to 2014. Hospitalisations for acute rheumatic fever (ARF) and skin infections for children aged 5­12 years living in Counties Manukau are declining and this appears to be temporally related to the introduction of the Mana Kidz programme. Effective engagement with children, parents/ whanau and improved health literacy was demonstrated, especially knowledge about sore throats, ARF, medication adherence and skin infection. The programme was delivered at $280 per participating child in the 2013/14 financial year. CONCLUSION: Mana Kidz is an effective programme with a substantial contribution to health care for children, aged 5­12 years, identified at increased risk of poor health outcomes.

Registered nurse assessment and treatment of skin sepsis in New Zealand schools: the development of protocols.

BACKGROUND: Skin infection is the commonest medical cause of hospitalisation in school children. Disadvantaged children, usually Maori or Pacific, have high rates of preventable diseases. AIM: To improve access to early treatment for skin infections using nurse-led school clinics in South Auckland, including provision of antibiotics under delegated standing orders. METHOD: Evidence-based protocols for the recognition and treatment of skin sepsis were developed following a literature search. A training package was developed for health professionals involved and outcome data were collected from a pilot study in which the protocols were trialled. RESULTS: An algorithm for diagnosis of skin infections was adapted from Steer et al (Bull World Health Organ. 2009;87:173-9). Fusidic acid ointment was recommended as first-line treatment for localised impetigo. Twice daily oral cephalexin was recommended for extensive impetigo and cellulitis, for palatability and simplicity of dosing. Fifty-six episodes of skin infection received treatment under standing orders in the first 15 weeks of the pilot study. CONCLUSION: Robust evidence to determine optimal choice, dosage and duration of antibiotic therapy for skin sepsis in children is lacking. The algorithms described are consistent with available evidence and provide a pragmatic approach for use in registered nurse (RN)-led school clinics.

Nurse-led school-based clinics for skin infections and rheumatic fever prevention: results from a pilot study in South Auckland.

AIM: To assess the acceptability and feasibility of delivering targeted primary health care in a decile one primary school setting. METHOD: A pilot public health nurse (PHN)-led clinic was set up in a South Auckland primary school (roll approximately 400). The clinic was based on a previous sore throat clinic model with modifications aimed at improving programme feasibility and effectiveness. The timely identification and treatment of Group A Streptococcal (GAS) throat infections to prevent rheumatic fever (RF), and the prevention and treatment of four skin infections (cellulitis, impetigo, infected eczema and scabies) were the focus. The pilot ran for 15 weeks from April to July 2011. Evaluation included documentation review, key school and healthcare stakeholder interviews and parent questionnaires. RESULTS: The consent rate was 92.2%. Of a total 722 throat swabs taken from 337 students, 94 were GAS positive. Ninety-eight assessments of skin conditions were completed at which 76 had a skin infection diagnosed, the most common infection being impetigo (n=46). Thirty-one skin infections were diagnosed in the first week of the pilot. PHN workload was high with a total of 539 phone calls, 137 home visits and 51 school-based parent consultations. The approach was highly acceptable to the majority of key stakeholders. Extrapolating pilot costs results in an estimated annual cost of $510 per student for the programme. CONCLUSION: It is likely to be both acceptable and feasible to take this model of delivering targeted primary health care to school aged children and use it on a larger scale. The complexity of providing this type of service should not be underestimated and it is essential that robust processes are in place to ensure smooth, safe running of such a programme. Long-term outcome evaluation will be vital to assess programme effectiveness.

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

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

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

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

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.