Impact of a comprehensive digital health programme on HbA1c and weight after 12 months for people with diabetes and prediabetes: a randomised controlled trial.

AIMS/HYPOTHESIS: The aim of this RCT was to evaluate the effectiveness of a digital health programme (BetaMe/Melon) vs usual care in improving the control of type 2 diabetes and prediabetes in a primary care population. METHODS: We conducted a randomised parallel-group two-arm single-blinded superiority trial in the primary care setting in two regions of New Zealand. Eligible participants were identified through Primary Health Organisations and participating practices. Eligibility criteria were as follows: age 18-75 years, HbA1c 41-70 mmol/mol (5.9-8.6%), not taking insulin, and daily access to the internet. BetaMe/Melon is a 12 month mobile-device and web-based programme with four components: health coaching; evidence-based resources; peer support; and goal tracking. Participants were randomised into the intervention or control arm (1:1 allocation) based upon baseline HbA1c (prediabetes or diabetes range), stratified by practice and ethnicity. Research nurses and the study biostatistician were blind to study arm. Primary outcomes of the study were changes in HbA1c and weight at 12 months, using an intention-to-treat analysis. RESULTS: Four hundred and twenty-nine individuals were recruited between 20 June 2017 and 11 May 2018 (n = 215 intervention arm, n = 214 control arm), most of whom were included in analyses of co-primary outcomes (n = 210/215, 97.7% and n = 213/214, 99.5%). HbA1c levels at 12 months did not differ between study arms: mean difference was -0.9 mmol/mol (95% CI -2.9, 1.1) (-0.1% [95% CI -0.3, 0.1]) for the diabetes group and was 0.0 mmol/mol (95% CI -0.9, 0.9) (0.0% [95% CI -0.1, 0.1]) for the prediabetes group. Weight reduced slightly at 12 months for participants in both study arms, with no difference between arms (mean difference -0.4 kg [95% CI -1.3, 0.5]). CONCLUSIONS/INTERPRETATION: This study did not demonstrate clinical effectiveness for this particular programme. Given their high costs, technology-assisted self-management programmes need to be individually assessed for their effectiveness in improving clinical outcomes for people with diabetes. TRIAL REGISTRATION: www.anzctr.org.au ACTRN12617000549325 (universal trial number U1111-1189-9094) FUNDING: This study was funded by the Health Research Council of New Zealand, the Ministry of Health New Zealand and the Healthier Lives National Science Challenge. Graphical abstract.

Health benefits and costs of weight-loss dietary counselling by nurses in primary care: a cost-effectiveness analysis.

OBJECTIVE: We aimed to estimate the cost-effectiveness of brief weight-loss counselling by dietitian-trained practice nurses, in a high-income-country case study. DESIGN: A literature search of the impact of dietary counselling on BMI was performed to source the 'best' effect size for use in modelling. This was combined with multiple other input parameters (e.g. epidemiological and cost parameters for obesity-related diseases, likely uptake of counselling) in an established multistate life-table model with fourteen parallel BMI-related disease life tables using a 3 % discount rate. SETTING: New Zealand (NZ). PARTICIPANTS: We calculated quality-adjusted life-years (QALY) gained and health-system costs over the remainder of the lifespan of the NZ population alive in 2011 (n 4·4 million). RESULTS: Counselling was estimated to result in an increase of 250 QALY (95 % uncertainty interval -70, 560 QALY) over the population's lifetime. The incremental cost-effectiveness ratio was 2011 $NZ 138 200 per QALY gained (2018 $US 102 700). Per capita QALY gains were higher for Maori (Indigenous population) than for non-Maori, but were still not cost-effective. If willingness-to-pay was set to the level of gross domestic product per capita per QALY gained (i.e. 2011 $NZ 45 000 or 2018 $US 33 400), the probability that the intervention would be cost-effective was 2 %. CONCLUSIONS: The study provides modelling-level evidence that brief dietary counselling for weight loss in primary care generates relatively small health gains at the population level and is unlikely to be cost-effective.

APE2 promotes DNA damage response pathway from a single-strand break.

As the most common type of DNA damage, DNA single-strand breaks (SSBs) are primarily repaired by the SSB repair mechanism. If not repaired properly or promptly, unrepaired SSBs lead to genome stability and have been implicated in cancer and neurodegenerative diseases. However, it remains unknown how unrepaired SSBs are recognized by DNA damage response (DDR) pathway, largely because of the lack of a feasible experimental system. Here, we demonstrate evidence showing that an ATR-dependent checkpoint signaling is activated by a defined plasmid-based site-specific SSB structure in Xenopus HSS (high-speed supernatant) system. Notably, the distinct SSB signaling requires APE2 and canonical checkpoint proteins, including ATR, ATRIP, TopBP1, Rad9 and Claspin. Importantly, the SSB-induced ATR DDR is essential for SSB repair. We and others show that APE2 interacts with PCNA via its PIP box and preferentially interacts with ssDNA via its C-terminus Zf-GRF domain, a conserved motif found in >100 proteins involved in DNA/RNA metabolism. Here, we identify a novel mode of APE2-PCNA interaction via APE2 Zf-GRF and PCNA C-terminus. Mechanistically, the APE2 Zf-GRF-PCNA interaction facilitates 3'-5' SSB end resection, checkpoint protein complex assembly, and SSB-induced DDR pathway. Together, we propose that APE2 promotes ATR-Chk1 DDR pathway from a single-strand break.

A Mobile- and Web-Based Health Intervention Program for Diabetes and Prediabetes Self-Management (BetaMe/Melon): Process Evaluation Following a Randomized Controlled Trial.

BACKGROUND: Technology-assisted self-management programs are increasingly recommended to patients with long-term conditions such as diabetes. However, there are a number of personal and external factors that affect patients' abilities to engage with and effectively utilize such programs. A randomized controlled trial of a multi-modal online program for diabetes self-management (BetaMe/Melon) was conducted in a primary care setting, and a process evaluation was completed at the end of the study period. OBJECTIVE: This process evaluation aimed to examine the utilization patterns of BetaMe/Melon, identify which components participants found most (and least) useful, and identify areas of future improvement. METHODS: Process evaluation data were collected for intervention arm participants from 3 sources: (1) the mobile/web platform (to identify key usage patterns over the 16-week core program), (2) an online questionnaire completed during the final study assessment, and (3) interviews conducted with a subset of participants following the study period. Participants were classified as "actively engaged" if any usage data was recorded for the participant (in any week), and patterns were reported by age, gender, ethnicity, and diabetes/prediabetes status. The online questionnaire asked participants about the usefulness of the program and whether they would recommend BetaMe/Melon to others according to a 5-point Likert Scale. Of 23 invited participants, 18 participated in a digitally recorded, semistructured telephone interview. Interview data were thematically analyzed. RESULTS: Out of the 215 participants, 198 (92%) received an initial health coaching session, and 160 (74%) were actively engaged with the program at some point during the 16-week core program. Engagement varied by demographic, with women, younger participants, and ethnic majority populations having higher rates of engagement. Usage steadily declined from 50% at Week 0 to 23% at Week 15. Participants ranked component usefulness as education resources (63.7%), health coaches (59.2%), goal tracking (48.8%), and online peer support (42.1%). Although 53% agreed that the program was easy to use, 64% would recommend the program to others. Interview participants found BetaMe/Melon useful overall, with most identifying beneficial outcomes such as increased knowledge, behavioral changes, and weight loss. Barriers to engagement were program functionality, internet connectivity, incomplete delivery of all program components, and participant motivation. Participants suggested a range of improvements to the BetaMe/Melon program. CONCLUSIONS: The program was generally well received by participants; active engagement was initially high, although it declined steadily. Maintaining participant engagement over time, individualizing programs, and addressing technical barriers are important to maximize potential health benefits from online diabetes self-management programs. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12617000549325; https://tinyurl.com/y622b27q.

A screening program to test and treat for Helicobacter pylori infection: Cost-utility analysis by age, sex and ethnicity.

BACKGROUND: The World Health Organization recommends all countries consider screening for H. pylori to prevent gastric cancer. We therefore aimed to estimate the cost-effectiveness of a H. pylori serology-based screening program in New Zealand, a country that includes population groups with relatively high gastric cancer rates. METHODS: A Markov model was developed using life-tables and morbidity data from a national burden of disease study. The modelled screening program reduced the incidence of non-cardia gastric cancer attributable to H. pylori, if infection was identified by serology screening, and for the population expected to be reached by the screening program. A health system perspective was taken and detailed individual-level costing data was used. RESULTS: For adults aged 25-69 years old, nation-wide screening for H. pylori was found to have an incremental cost of US$196 million (95% uncertainty interval [95% UI]: $182-$211 million) with health gains of 14,200 QALYs (95% UI: 5,100-26,300). Cost per QALY gained was US$16,500 ($7,600-$38,400) in the total population and 17% (6%-29%) of future gastric cancer cases could be averted with lifetime follow-up. A targeted screening program for Maori only (indigenous population), was more cost-effective at US$8,000 ($3,800-$18,500) per QALY. CONCLUSIONS: This modeling study found that H. pylori screening was likely to be cost-effective in this high-income country, particularly for the indigenous population. While further research is needed to help clarify the precise benefits, costs and adverse effects of such screening programs, there seems a reasonable case for policy-makers to give pilot programs consideration, particularly for any population groups with relatively elevated rates of gastric cancer.

Correction: Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand.

[This corrects the article DOI: 10.1371/journal.pmed.1001856.].

Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up.

BACKGROUND: Cancer makes up a large and increasing proportion of excess mortality for indigenous, marginalised and socioeconomically deprived populations, and much of this inequality is preventable. This study aimed to determine which cancers give rise to changing ethnic inequalities over time. METHODS: New Zealand census data from 1981, 1986, 1991, 1996, 2001, and 2006, were all probabilistically linked to three to five subsequent years of mortality (68 million person-years) and cancer registrations (87 million person years) and weighted for linkage bias. Age-standardised rate differences (SRDs) for Maori (indigenous) and Pacific peoples, each compared to European/Other, were decomposed by cancer type. RESULTS: The absolute size and percentage of the cancer contribution to excess mortality increased from 1981-86 to 2006-11 in Maori males (SRD 72.5 to 102.0 per 100,000) and females (SRD 72.2 to 109.4), and Pacific females (SRD -9.8 to 42.2) each compared to European/Other. Specifically, excess mortality (SRDs) increased for breast cancer in Maori females (linear trend p < 0.01) and prostate (p < 0.01) and colorectal cancers (p < 0.01) in Maori males. The incidence gap (SRDs) increased for breast (Maori and Pacific females p < 0.01), endometrial (Pacific females p < 0.01) and liver cancers (Maori males p = 0.04), and for cervical cancer it decreased (Maori females p = 0.03). The colorectal cancer incidence gap which formerly favoured Maori, decreased for Maori males and females (p < 0.01). The greatest contributors to absolute inequalities (SRDs) in mortality in 2006-11 were lung cancer (Maori males 50 %, Maori females 44 %, Pacific males 81 %), breast cancer (Maori females 18 %, Pacific females 23 %) and stomach cancers (Maori males 9 %, Pacific males 16 %, Pacific females 20 %). The top contributors to the ethnic gap in cancer incidence were lung, breast, stomach, endometrial and liver cancer. CONCLUSIONS: A transition is occurring in what diseases contribute to inequalities. The increasing excess incidence and mortality rates in several obesity- and health care access-related cancers provide a sentinel warning of the emerging drivers of ethnic inequalities. Action to further address inequalities in cancer burden needs to be multi-pronged with attention to enhanced control of tobacco, obesity, and carcinogenic infectious agents, and focus on addressing access to effective screening and quality health care.

Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand.

BACKGROUND: Countries are increasingly considering how to reduce or even end tobacco consumption, and raising tobacco taxes is a potential strategy to achieve these goals. We estimated the impacts on health, health inequalities, and health system costs of ongoing tobacco tax increases (10% annually from 2011 to 2031, compared to no tax increases from 2011 ["business as usual," BAU]), in a country (New Zealand) with large ethnic inequalities in smoking-related and noncommunicable disease (NCD) burden. METHODS AND FINDINGS: We modeled 16 tobacco-related diseases in parallel, using rich national data by sex, age, and ethnicity, to estimate undiscounted quality-adjusted life-years (QALYs) gained and net health system costs over the remaining life of the 2011 population (n = 4.4 million). A total of 260,000 (95% uncertainty interval [UI]: 155,000-419,000) QALYs were gained among the 2011 cohort exposed to annual tobacco tax increases, compared to BAU, and cost savings were US$2,550 million (95% UI: US$1,480 to US$4,000). QALY gains and cost savings took 50 y to peak, owing to such factors as the price sensitivity of youth and young adult smokers. The QALY gains per capita were 3.7 times greater for Maori (indigenous population) compared to non-Maori because of higher background smoking prevalence and price sensitivity in Maori. Health inequalities measured by differences in 45+ y-old standardized mortality rates between Maori and non-Maori were projected to be 2.31% (95% UI: 1.49% to 3.41%) less in 2041 with ongoing tax rises, compared to BAU. Percentage reductions in inequalities in 2041 were maximal for 45-64-y-old women (3.01%). As with all such modeling, there were limitations pertaining to the model structure and input parameters. CONCLUSIONS: Ongoing tobacco tax increases deliver sizeable health gains and health sector cost savings and are likely to reduce health inequalities. However, if policy makers are to achieve more rapid reductions in the NCD burden and health inequalities, they will also need to complement tobacco tax increases with additional tobacco control interventions focused on cessation.

REV1 is important for the ATR-Chk1 DNA damage response pathway in Xenopus egg extracts.

The translesion DNA synthesis (TLS) polymerase REV1 is implicated in the bypass of the irreparable DNA damage such as interstrand crosslinks (ICLs). However, the potential role of REV1 in DNA damage response (DDR) pathway has not been determined. In this research communication, we provide evidence to demonstrate that REV1 plays a previously unidentified but important role in the ATR-Chk1 checkpoint activation in response to mitomycin C (MMC)-induced ICLs in Xenopus egg extracts. We further pinpointed that REV1 plays a downstream role of a checkpoint protein complex assembly including ATR, ATRIP, TopBP1 and the Rad9-Rad1-Hus1 complex to MMC-induced ICLs on chromatin in the DDR pathway. Notably, domain dissection analysis demonstrates that a C-terminal domain, but not the individual ubiquitin binding motifs, of REV1 is important for the binding of REV1 to MMC-damaged chromatin and the MMC-induced Chk1 phosphorylation. Yet, the ATR-Chk1 DDR pathway appears to be dispensable for the preferential association of REV1 to MMC-damaged chromatin. Taken together, REV1 is important for the DDR pathway in Xenopus egg extracts.

How much might a society spend on life-saving interventions at different ages while remaining cost-effective? A case study in a country with detailed data.

OBJECTIVE: We aimed to estimate the maximum intervention cost (EMIC) a society could invest in a life-saving intervention at different ages while remaining cost-effective according to a user-specified cost-effectiveness threshold. METHODS: New Zealand (NZ) was used as a case study, and a health system perspective was taken. Data from NZ life tables and morbidity data from a burden of disease study were used to estimate health-adjusted life-years (HALYs) gained by a life-saving intervention. Health system costs were estimated from a national database of all publicly funded health events (hospitalizations, outpatient events, pharmaceuticals, etc.). For illustrative purposes we followed the WHO-CHOICE approach and used a cost-effectiveness threshold of the gross domestic product (GDP) per capita (NZ$45,000 or US$30,000 per HALY). We then calculated EMICs for an "ideal" life-saving intervention that fully returned survivors to the same average morbidity, mortality, and cost trajectories as the rest of their cohort. FINDINGS: The EMIC of the "ideal" life-saving intervention varied markedly by age: NZ$1.3 million (US$880,000) for an intervention to save the life of a child, NZ$0.8 million (US$540,000) for a 50-year-old, and NZ$0.235 million (US$158,000) for an 80-year-old. These results were predictably very sensitive to the choice of discount rate and to the selected cost-effectiveness threshold. Using WHO data, we produced an online calculator to allow the performance of similar calculations for all other countries. CONCLUSIONS: We present an approach to estimating maximal cost-effective investment in life-saving health interventions, under various assumptions. Our online calculator allows this approach to be applied in other countries. Policymakers could use these estimates as a rapid screening tool to determine if more detailed cost-effectiveness analyses of potential life-saving interventions might be worthwhile or which proposed life-saving interventions are very unlikely to benefit from such additional research.

Limited sex-biased neural gene expression patterns across strains in Zebrafish (Danio rerio).

BACKGROUND: Male and female vertebrates typically differ in a range of characteristics, from morphology to physiology to behavior, which are influenced by factors such as the social environment and the internal hormonal and genetic milieu. However, sex differences in gene expression profiles in the brains of vertebrates are only beginning to be understood. Fishes provide a unique complement to studies of sex differences in mammals and birds given that fish show extreme plasticity and lability of sexually dimorphic characters and behaviors during development and even adulthood. Hence, teleost models can give additional insight into sexual differentiation. The goal of this study is to identify neurotranscriptomic mechanisms for sex differences in the brain. RESULTS: In this study we examined whole-brain sex-biased gene expression through RNA-sequencing across four strains of zebrafish. We subsequently conducted systems level analyses by examining gene network dynamics between the sexes using weighted gene coexpression network analysis. Surprisingly, only 61 genes (approximately 0.4% of genes analyzed) showed a significant sex effect across all four strains, and 48 of these differences were male-biased. Several of these genes are associated with steroid hormone biosynthesis. Despite sex differences in a display of stress-related behaviors, basal transcript levels did not predict the intensity of the behavioral display. WGCNA revealed only one module that was significantly associated with sex. Intriguingly, comparing intermodule dynamics between the sexes revealed only moderate preservation. Further we identify sex-specific gene modules. CONCLUSIONS: Despite differences in morphology, physiology, and behavior, there is limited sex-biased neural gene expression in zebrafish. Further, genes found to be sex-biased are associated with hormone biosynthesis, suggesting that sex steroid hormones may be key contributors to sexual behavioral plasticity seen in teleosts. A possible mechanism is through regulating specific brain gene networks.

Why equal treatment is not always equitable: the impact of existing ethnic health inequalities in cost-effectiveness modeling.

BACKGROUND: A critical first step toward incorporating equity into cost-effectiveness analyses is to appropriately model interventions by population subgroups. In this paper we use a standardized treatment intervention to examine the impact of using ethnic-specific (Maori and non-Maori) data in cost-utility analyses for three cancers. METHODS: We estimate gains in health-adjusted life years (HALYs) for a simple intervention (20% reduction in excess cancer mortality) for lung, female breast, and colon cancers, using Markov modeling. Base models include ethnic-specific cancer incidence with other parameters either turned off or set to non-Maori levels for both groups. Subsequent models add ethnic-specific cancer survival, morbidity, and life expectancy. Costs include intervention and downstream health system costs. RESULTS: For the three cancers, including existing inequalities in background parameters (population mortality and comorbidities) for Maori attributes less value to a year of life saved compared to non-Maori and lowers the relative health gains for Maori. In contrast, ethnic inequalities in cancer parameters have less predictable effects. Despite Maori having higher excess mortality from all three cancers, modeled health gains for Maori were less from the lung cancer intervention than for non-Maori but higher for the breast and colon interventions. CONCLUSIONS: Cost-effectiveness modeling is a useful tool in the prioritization of health services. But there are important (and sometimes counterintuitive) implications of including ethnic-specific background and disease parameters. In order to avoid perpetuating existing ethnic inequalities in health, such analyses should be undertaken with care.

Policy approaches to decarbonising the transport sector in Aotearoa New Zealand: modelling equity, population health, and health-system effects.

BACKGROUND: Health co-benefits are a key potential advantage of transport decarbonisation policy. However, health effects will occur in the context of existing transport-health inequities and decarbonisation policies will themselves affect inequities. This research examines the effects of national decarbonisation pathways for transport on population health, health inequity, and health-system costs in Aotearoa New Zealand. METHODS: We modelled the health, health-system, and environmental impacts of two pathways to net zero for transport developed by the New Zealand Climate Change Commission using a proportional multistate lifetable model. The behaviour pathway emphasises a mixed approach, including reduced driving, increased cycling and use of public transport, and light vehicle electrification, and the technology pathway focuses on vehicle electrification. We used data from transport, environmental, population health, and health-care sources to populate the model. We simulated changes in health effects through the pathways of physical activity, air pollution (PM2·5 and NO2), and injury for the Aotearoa New Zealand population from 2018 to 2050. We modelled impacts for Maori (the Indigenous People of Aotearoa) and non-Maori. For each pathway to net zero, we calculated changes in overall health-adjusted life-years (HALYs), age-standardised HALYs, and rate ratios for Maori and non-Maori. We also calculated changes in health-system costs and transport greenhouse gas emissions. 95% uncertainty intervals (95% UIs) were derived for all model outputs by use of a Monte Carlo simulation. FINDINGS: Both pathways show improvements in population health, reductions in health-system costs, and reduced lifecycle greenhouse gas emissions compared with baseline, although health gains were substantially larger in the behaviour pathway. For example, an extra 2100 HALYs (95% UI 1500-3100) were gained in the behaviour scenario compared with baseline. Health gains were 20-30% larger for Maori than non-Maori in both pathways, although more HALYs were gained by Maori in the behaviour pathway. For the cohort aged 0-4 years in 2018, healthy life expectancy differences between Maori and non-Maori reduced by 0·5% in the behaviour pathway over their lifetime. HALYs gained by Maori and non-Maori were altered substantially depending on assumptions about the equity of the implemented pathway. INTERPRETATION: Decarbonising transport might improve overall population health, save the health system money, and reduce health inequities between Maori and non-Maori. Pathways that increase physical activity have a larger effect on population health than those that rely on low-emission vehicles. The effects on inequity between Maori and non-Maori are larger in the behaviour pathway than in the technology pathway but dependent on how equitably policies supporting decarbonisation are implemented. FUNDING: Health Research Council of New Zealand and University of Otago.

Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Evolving swabbing practices for COVID-19 in a New Zealand emergency department during the early stages of an emerging pandemic.

OBJECTIVE: To review if tests for suspected COVID-19 were performed according to the Ministry of Health (MoH) case definitions, identify patterns associated with testing outside of the case definition, and discuss the potential impacts on hospital services. METHODS: This was a retrospective audit of patients presenting to the Wellington Hospital ED between 24 March 2020 and 27 April 2020 who were swabbed for COVID-19 in ED. Swabs were audited against the March 15th and April 8th MoH COVID-19 case definitions. RESULTS: Five hundred and thirty-six COVID-19 swabs for 518 patients were taken during the study period. There was poor alignment of testing with the March 15th case definition, with only 11.6% of the 164 swabs taken during this period meeting the case definition. Of the 145 swabs that did not meet the case definition, the majority (n = 119, 82.1%) met symptom criteria only. Alignment of testing with the wider April 8th case definition was much higher with 88.2% meeting criteria. Factors associated with being swabbed despite not meeting the case definitions included fever >38°, a diagnosis of cancer, subsequent hospital admission, and for the March case definition only 'contact with a traveller'. CONCLUSION: There were associations found between testing outside of criteria and specific variables potentially perceived as high-risk. Poor alignment of testing with case definitions can impact hospital services through the (mis)use of limited laboratory testing capacity and implications for resource management. Improved communication and feedback between clinicians and policymakers may improve case definition implementation in a clinical setting.

The Epidemiology of Domain-Specific Physical Activity in New Zealand Adults: A Nationally Representative Cross-Sectional Survey.

BACKGROUND: Surveillance of domain-specific physical activity (PA) helps to target interventions to promote PA. We examined the sociodemographic correlates of domain-specific PA in New Zealand adults. METHODS: A nationally representative sample of 13,887 adults completed the International PA Questionnaire-long form in 2019/20. Three measures of total and domain-specific (leisure, travel, home, and work) PA were calculated: (1) weekly participation, (2) mean weekly metabolic energy equivalent minutes (MET-min), and (3) median weekly MET-min among those who undertook PA. Results were weighted to the New Zealand adult population. RESULTS: The average contribution of domain-specific activity to total PA was 37.5% for work activities (participation = 43.6%; median participating MET-min = 2790), 31.9% for home activities (participation = 82.2%; median participating MET-min = 1185), 19.4% for leisure activities (participation = 64.7%; median participating MET-min = 933), and 11.2% for travel activities (participation = 64.0%; median MET-min among participants = 495). Women accumulated more home PA and less work PA than men. Total PA was higher in middle-aged adults, with diverse patterns by age within domains. Maori accumulated less leisure PA than New Zealand Europeans but higher total PA. Asian groups reported lower PA across all domains. Higher area deprivation was negatively associated with leisure PA. Sociodemographic patterns varied by measure. For example, gender was not associated with total PA participation, but men accumulated higher MET-min when taking part in PA than women. CONCLUSIONS: Inequalities in PA varied by domain and sociodemographic group. These results should be used to inform interventions to improve PA.

Ethnicity data audit in a secondary care gastroenterology service.

AIM: To audit the quality of ethnicity data stored under National Health Index (NHI) in the Hutt Hospital database against a fresh collection of self-identified ethnicity to identify the level of (mis)match present between the datasets. METHOD: Self-identified ethnicity data was collected from 200 consecutive patients presenting to outpatient gastroenterology services and compared to National Health Index (NHI) in the Hutt Hospital database, using the process outlined in the Primary Care Ethnicity Data Audit Toolkit. RESULTS: The overall level of match between the individual's self-identified ethnicity and that recorded in the hospital database was 89% (95% CI [83.8-93.0]). Eighteen patients (9%) self-identified as Maori, 16.7% (95% CI [3.6-41.4]) of whom were not recorded as Maori in the hospital database. Three patients were recorded as Maori in the hospital database but did not self-identify as Maori. CONCLUSION: Ethnicity data are fundamental to the monitoring and provision of equitable health and healthcare, with a range of applications in the health sector. Our findings of poor-quality ethnicity data for Maori in a hospital NHI database are consistent with previous studies. The assessment of ethnicity data quality must be done in multiple ways to reflect its multiple uses.

The Impact of Transport on Population Health and Health Equity for Maori in Aotearoa New Zealand: A Prospective Burden of Disease Study.

BACKGROUND: The land transport system influences health via a range of pathways. This study aimed to quantify the amount and distribution of health loss caused by the current land transport system in Aotearoa New Zealand (NZ) through the pathways of road injury, air pollution and physical inactivity. METHODS: We used an existing multi-state life table model to estimate the long-term health impacts (in health-adjusted life years (HALYs)) and changes in health system costs of removing road injury and transport related air pollution and increasing physical activity to recommended levels through active transport. Health equity implications were estimated using relative changes in HALYs and life expectancy for Maori and non-Maori. RESULTS: If the NZ resident population alive in 2011 was exposed to no further air pollution from transport, had no road traffic injuries and achieved at least the recommended weekly amount of physical activity through walking and cycling from 2011 onwards, 1.28 (95% UI: 1.11-1.5) million HALYs would be gained and $7.7 (95% UI: 10.2 to 5.6) billion (2011 NZ Dollars) would be saved from the health system over the lifetime of this cohort. Maori would likely gain more healthy years per capita than non-Maori, which would translate to small but important reductions (2-3%) in the present gaps in life expectancy. CONCLUSION: The current transport system in NZ, like many other car-dominated transport systems, has substantial negative impacts on health, at a similar level to the effects of tobacco and obesity. Transport contributes to health inequity, as Maori bear greater shares of the negative health impacts. Creating a healthier transport system would bring substantial benefits for health, society and the economy.

Anaesthetic choice for hip or knee arthroplasty in New Zealand: Risk of postoperative death and variations in use.

Anaesthetic choice for large joint surgery can impact postoperative outcomes, including mortality. The extent to which the impact of anaesthetic choice on postoperative mortality varies within patient populations and the extent to which anaesthetic choice is changing over time remain under-explored both internationally and in the diverse New Zealand context. In a national study of 199,211 hip and knee replacement procedures conducted between 2005 and 2017, we compared postoperative mortality among those receiving general, regional or general plus regional anaesthesia. Focusing on unilateral (n=86,467) and partial (n=13,889) hip replacements, we assessed whether some groups within the population are more likely to receive general, regional or general plus regional anaesthesia than others, and whether mortality risk varies depending on anaesthetic choice. We also examined temporal changes in anaesthetic choice over time. Those receiving regional alone or general plus regional for unilateral hip replacement appeared at increased risk of 30-day mortality compared to general anaesthesia alone, even after adjusting for differences in terms of age, ethnicity, deprivation, rurality, comorbidity, American Society of Anesthesiologists physical status score and admission type (e.g. general plus regional: adjusted hazard ratio (adj. HR)=1.94, 95% confidence intervals (CI) 1.32 to 2.84). By contrast, we observed lower 30-day mortality among those receiving regional anaesthesia alone compared to general alone for partial hip replacement (adj. HR=0.86, 95% CI 0.75 to 0.97). The latter observation contrasts with declining temporal trends in the use of regional anaesthesia alone for partial hip replacement procedures. However, we recognise that postoperative mortality is one perioperative factor that drives anaesthetic choice.

We still don't count: the under-counting and under-representation of Maori in health and disability sector data.

AIM: To examine ethnicity data quality; in particular, the representation and potential under-counting of Maori in health and disability sector data, as well as implications for inequities. METHODS: Maori and non-Maori ethnicity data are analysed at: 1) a population aggregate level across multiple 2018 datasets (Estimated Resident Population, Census Usually Resident Population, Health Service User (HSU) population and Primary Health Organisation (PHO) enrolments); and 2) an individual level for those linked in PHO and 2018 Census datasets. Ethnicity is drawn from the National Health Index (NHI) in health datasets and variations by age and gender are explored. RESULTS: Aggregate analyses show that Maori are considerably under-represented in HSU and PHO data. In linked analysis Maori were under-counted on the NHI by 16%. Under-representation in data and under-counting occur across both genders but are more pronounced for Maori men with variations by age. CONCLUSION: High quality ethnicity data are fundamental for understanding and monitoring Maori health and health inequities as well as in the provision of targeted services and interventions that are responsive to Maori aspirations and needs. The continued under-counting of Maori in health and disability sector data is a breach of Te Tiriti o Waitangi and must be addressed with urgency.