Comparison of cancer mortality and incidence in New Zealand and Australia

AIMS: To compare cancer mortality and incidence data from New Zealand and Australia, in order to gauge the potential for reducing deaths from cancer in New Zealand. METHODS: For 1996 and 1997, numbers of deaths from cancer, numbers of new cases, and population data were stratified in 5-year age-groups. Numbers observed in New Zealand were compared with numbers expected from Australian rates. Age-standardized mortality and incidence rates for each sex were analysed. RESULTS: New Zealanders of both sexes experienced more deaths from cancer than expected in every age group. If Australian rates had applied, there would have been 215 fewer cancer deaths per year in New Zealand males, and 616 fewer in females. The largest differences related to breast cancer and lung cancer in women, and colorectal cancer in both sexes. The overall incidence of cancer was higher in New Zealand, but mortality/incidence ratios were also higher for many sites--suggesting that survival after treatment has been poorer in New Zealand than in Australia. CONCLUSIONS: Considerable scope exists for reducing cancer mortality in New Zealand. For a national cancer control strategy, it will be essential to clarify reasons for the high incidence of cancer and to study survival following treatment.     

"The view from the bottom of the cliff." Old age psychiatry services in New Zealand: the patients and the resources

AIM: Despite the continual restructuring of New Zealand's health services in recent years, the development of mental health services for older people has been neglected as a strategic planning issue. METHODS: In 1998/9, the New Zealand branch of the Faculty of Psychiatry of Old Age (FPOA) of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) initiated a national survey to obtain an overview of patient needs and national resources, with the aim of providing information to assist planning. Data were collected from eleven Old Age Psychiatry services nationwide, covering a total catchment of 2,800,000 New Zealanders. RESULTS: Patients were mostly over 70 years of age, female and with high co-morbidity for both medical and psychiatric illnesses. New Zealand resources directed to meet the needs are low by international standards. CONCLUSIONS: The results clarify the range of patient problems that Old Age Psychiatry services manage and the resources available. Most New Zealand services conform to World Health Organization recommendations.     

Increased mesothelioma incidence in New Zealand: the asbestos-cancer epidemic has started

AIMS: To examine the incidence and mortality patterns for malignant mesothelioma and pleural cancer in New Zealand between 1962-1996, and relate these to past use of asbestos. METHODS: Data concerning cases of mesothelioma 1962-1996, deaths from pleural and lung cancers 1974-1996, and data on imports of raw asbestos and asbestos products were obtained from government registers and publications. Time trends were analysed using different models. RESULTS: Mesothelioma incidence rates have increased progressively in New Zealand since the 1960s, and reached 25 per million for men in 1995. The increase follows an exponential model departing from a crude 'background rate' of 1-2 per million in 1984, and is particularly steep in males 50 to 60 years of age. The incidence is expected to double by 2010. CONCLUSION: New Zealand has entered an unrivalled period of occupational cancer deaths resulting from past workplace exposure to airborne asbestos fibres. The steep rise in mesothelioma incidence is likely to be accompanied by increases in other asbestos related diseases such as lung cancer. The unique causal association between mesothelioma and asbestos may be used to monitor changes in the public health impact of these exposures. The notification by medical practitioners of all potential asbestos related conditions/exposures to the Occupational Safety and Health (OSH) service is of great importance.     

Gastro-oesophageal malignancy in New Zealand: 1995-97

AIM: To assess the incidence, treatment and survival of patients with oesophago-gastric carcinoma in New Zealand. METHODS: All cases of oesophageal or gastric carcinoma diagnosed in 1995-97 were retrieved from the national cancer registry. Linked data describing all episodes of inpatient treatment for these patients were obtained from the New Zealand Health Information System. An analysis of demographics, treatment and survival was performed. RESULTS: A total of 1791 cases were recorded (616 oesophageal, 1175 gastric). Carcinomas of the gastrooesophageal junction made up the majority of cases. 1138 were male. The median age was 71 years. 78.6% were of European descent, 10.4% Maori, 3.6% Pacific Islanders and 7.4% of other ethnic backgrounds. There were a total of 3403 hospital admissions (median 1.0 per patient). Overall, 29% underwent a surgical resection (15% oesophageal, 36% gastric). Exploratory surgery alone was performed in 14% operated on for oesophageal cancer and 12.3% for gastric neoplasms. Following resection 90 day mortality was 11.8% (10.5% oesophageal, 12% gastric). Overall median survival was 6.3 months (5.8 months oesophageal, 6.6 months gastric) with 16.7% of patients alive at three years. Following resection median survival was 17.8 months ( 16.2 months oesophageal, 18.1 months gastric) with 35.8% of patients alive at three years (34.7% oesophageal, 36% gastric). CONCLUSIONS: These data provide a baseline for future studies of the evaluation and treatment of gastrooesophageal malignancy in New Zealand.     

Chronic Care Management evolves towards Integrated Care in Counties Manukau, New Zealand

Despite anecdotes of many chronic care management and integrated care projects around New Zealand, there is no formal process to collect and share relevant learning within (but especially between) District Health Boards (DHBs). We wish to share our experiences and hope to stimulate a productive exchange of ongoing learning. We define chronic care management and integrated care, then summarise current theory and evidence. We describe national policy development (relevant to integrated care, since 2000) including the New Zealand Health Strategy, the NZ Primary Care Strategy, the development of Primary Health Organisations (PHOs), capitation payments, Care Plus, and Services to Improve Access funding. We then describe chronic care management in Counties Manukau, which evolved both prior to and during the international refinement of theory and evidence and the national policy development and implementation. We reflect on local progress to date and opportunities for (and barriers to) future improvements, aided by comparative reflections on the United Kingdom (UK). Our most important messages are addressed as follows: To policymakers and funders--a fragile culture change towards teamwork in the health system is taking place in New Zealand; this change needs to be specifically and actively supported. To PHOs--general practices need help to align their internal (within-practice) financial signals with the new world of capitation and integrated care. To primary and secondary care doctors, nurses, and other carers - systematic chronic care management and integrated care can improve patient quality of life; and if healthcare structures and systems are properly managed to support integration, then healthcare provider professional and personal satisfaction will improve.     

Through the looking glass: toward a brighter future for long-term care in a greying New Zealand

In the USA, a recent report produced to inform the work of the National Commission for Quality Long-Term Care--Out of the Shadows: Envisioning a Brighter Future for Long-Term Care in America--should be of interest not only to US observers, but to policymakers, providers, and users of long-term care within New Zealand. Despite differences in financing and organisation, both the US and New Zealand face similar challenges in meeting the long-term care needs of an ageing population. Information technology systems in long-term care need to be adopted to better enable improvements in quality and efficiency; increased attention needs to be given to recruiting and retaining a well-trained, stable workforce; and continued development of home- and community-based alternatives to residential care must be pursued. The quickly developing culture change movement, which aims to improve the way chronically frail and disabled people live and are treated, must also be encouraged and supported. New Zealand has many advantages over the USA in its policy context for long-term care. It is critical that New Zealand build upon these advantages in the short term to ensure that the longer term implications of the ageing population can be met.     

SF-36v2 norms for New Zealanders aged 55-69 years

Owing to an ageing population there is growing interest in research to improve the health of older New Zealanders. To facilitate the use of the internationally used SF-36 (version 2) measure of health and quality of life for this work in New Zealand we provide norms and comparative data from the first wave in a longitudinal study of a representative sample of New Zealanders aged 55-69 years. The use of the normative data from this study will facilitate comparisons of results from small clinical samples of older people with the general New Zealand population and international populations. The norms are also available for use in calculating summary physical and mental health summary scores for data from clinical trials and national surveys.     

Mortality after hip fracture: regional variations in New Zealand.

AIM: To determine the 35-day and one-year mortality rates following a hospital admission for hip fracture, among individuals aged 60 years or older in New Zealand. METHODS: New Zealand Health Information Service mortality data for the years 1988 to 1992 were examined to determine the case fatality rate among individuals aged 60 years or older admitted to hospital for fractures of the neck of femur (ICD-9 N-code 820). Case fatality rates assessed at 35 days and one year after admission to hospital were examined by age, gender, year of admission, place of residence, area health board region and cause of death. RESULTS: Between 1988 and 1992, the case fatality rate was 8% within 35 days of admission to hospital and 24% within one year of admission. Case fatality rates were found to be twice as high in men compared to women and four to five times higher in individuals aged 85 years and older, compared to people aged between 60 and 64 years. The only regional difference in hip fracture mortality was found in the Canterbury area health board region, which had a 30% higher rate of hip fracture mortality compared to all regions combined. The two main cited underlying causes of death after hip fracture were accidental falls (ICD E880-E888) and ischaemic heart disease (ICD 410-414). CONCLUSION: Over three-quarters of individuals aged 60 years or older who are hospitalised with a hip fracture in New Zealand survive for at least one year after admission. However, significant variations in mortality exist with age and gender. These data highlight the importance of preventive strategies for hip fracture in older people and the need to identify ways of improving post-admission care.     

Diet, serum cholesterol and the prevention of coronary heart disease in New Zealand

A combination of the population strategy and the high risk strategy has been recommended for the prevention and control of coronary heart disease in New Zealand. In this paper, using data from a variety of sources, we estimate the potential relative benefits of these two strategies to reduce the contribution of diet and high blood cholesterol to coronary heart disease mortality in New Zealand. It is estimated that diet is responsible, at a minimum for between 22% (1600 deaths) and 39% (2800 deaths) of the coronary heart disease mortality in New Zealand each year. Achievement of the suggested short term dietary goals for the New Zealand population would have at least the same benefit as the identification and successful treatment of all people in the top 10% of the serum cholesterol distribution. This indicates that the population strategy should have higher priority in efforts to prevent and control coronary heart disease. Decisions concerning the level at which elevated blood cholesterol levels are treated pharmacologically will have important logistic and cost implications; national guidelines are required for the management of people with high blood cholesterol levels.     

The ABC of New Zealand's Ten Year Vision for Pharmacists: awareness,barriers and consultation

Objectives This study aimed to determine New Zealand pharmacists' awareness of, recall of consultation about, and potential barriers to the implementation of the Focus on the Future: Ten Year Vision for Pharmacists in New Zealand: 2004–2014 document. Method A national postal survey was carried out in New Zealand of practising pharmacists registered with the Pharmacy Council of New Zealand (n = 1892). The survey was conducted between September and December 2006. Key findings The response rate was 51.8% (n = 980 usable surveys). Approximately three‐quarters (73.4%) reported being aware of the 10‐year vision document and 40.9% recall being consulted. Fewer than one‐third (29.8%) had read the document prior to completing the survey. Thirty‐two variables describing potential barriers to implementing the 10‐year vision were reduced, through factor analysis, to seven factors with significant eigenvalues (>1.0). The factors describe the underlying themes of barriers identified in the survey, including pharmacist humanistic, integrated systems of care and teamwork, funder stakeholder relationships and remuneration, lack of appreciation of knowledge and skills, lack of research support, current expertise and continuing professional development, and lack of voice. The majority of barrier variables within the seven factors were rated as extremely or quite important. Conclusions There was a high level of awareness and moderate level of recall of consultation on the document among respondents. Although 40% recall being consulted on the document, fewer than one‐third reported having read the document prior to completing our survey. Pharmacists highlighted a significant number of potential barriers to the implementation of the 10‐year vision. If the pharmacy profession in New Zealand is to move forward towards the state described in the 10‐year vision document then these potential barriers need to be better understood and addressed.     

Rural hospitals in New Zealand.

AIM: To produce a list of New Zealand rural hospitals, including information on acute bed numbers, population served, average driving time to base hospital, and number and payment of rural hospital doctors. METHODS: Information about rural hospitals was obtained from local doctors and/or administrators, and reflected conditions at June 15, 1998. A 'rural hospital' was defined as a facility with no resident medical specialists, where acutely ill patients are admitted and cared for solely by generalist doctors, either general practitioners or medical officers of special scale. RESULTS: Varying definitions for acute 'facilities' and 'beds' made analysis difficult. There were a total of 36 'rural hospitals' in New Zealand at June 15, 1998 containing 293 acute beds and serving a population of about 340000. Patient care was provided by a total of 131 generalists (general practitioners or medical officers of special scale) equivalent to 40 full-time rural hospital doctors. CONCLUSIONS: Approximately 10% of the New Zealand population are served by rural hospitals. Discrepancies exist between the list of rural hospitals provided in this study and that provided by the Government's recent 'Hospital Services Plan'.     

Quality of care indicators for population-based primary care in New Zealand

AIM: To develop a set of non-invasive, evidence-based, population-based quality of care indicators for primary care in New Zealand and to test their feasibility. METHODS: New Zealand, British and Australian publications were reviewed and a set of quality of care indicators was constructed. These were trialed on data collected from seventeen fully computerised practices from the FirstHealth network of general practices. RESULTS: 28 indicators are proposed in five categories: smoking cessation, preventive health activities, prescribing quality, chronic disease management and data quality. We were able to calculate ten indicators from data already collected routinely, a further twelve could be calculated now with more sophisticated data queries and six would require the trial practices to collect further data. CONCLUSIONS: While any set of indicators is arbitrary there are sufficient research data to support a set of evidence-based, population-focused, quality of care indicators in New Zealand primary health care. In computerised practices these indicators can be calculated from routinely collected data.     

Injury to Maori. I: Fatalities

AIMS: Our aim was to determine the significance in Maori of injury in relation to other health problems, to describe the leading causes of injury, and to determine age specific rates for major classes of injury. METHODS: We used New Zealand Health Information Services mortality data files. The New Zealand Census classification of 'Sole-Maori' was used to determine injury mortality rates. RESULTS: For more than three contiguous decades of life (1-34 yrs) injuries were the leading cause of death. For all age groups combined, unintentional injury accounted for 75% of injury deaths, suicide 17%, and assault 7%. The leading mechanism of death was motor vehicle traffic crashes (49%). Occupants of motor vehicles accounted for the majority of the victims. The occupant fatality rate remained relatively constant for all age groups from 15-24 years. The second most common mechanism of death was suffocation (13%), 76% of which were self-inflicted, all of these being hangings. CONCLUSIONS: There is a need for government agencies with a mandate for injury prevention to develop specific injury prevention goals for Maori.     

Adolescent obesity and physical inactivity

Globally, obesity and physical inactivity are two health issues affecting young people. In New Zealand, the most current statistics indicate that 33.6% of 11 to 14 year olds, and 27% of 15 to 18 year olds, are considered overweight or obese.1,2 Despite these high prevalence levels, only 38% of young people aged 13 to 17 years in New Zealand are considered physically inactive.3 Future effort needs to be directed towards enhancing the existing national surveys to ensure a comprehensive and valid surveillance system of adolescent obesity and inactivity is conducted on a regular basis. This would involve the development of age, sex, and ethnic specific body mass index cut-off thresholds to define overweight and obesity, validation of an adolescent questionnaire that examines physical activity from a broad perspective, and development of physical activity recommendations for youth based on international best practice. Although the main focus of this paper is on obesity and physical inactivity, diet is also a key determinant of obesity. Therefore, to provide an accurate assessment of factors associated with youth obesity in New Zealand, surveillance of diet must occur concurrently with that of obesity and physical activity. The development of accurate measurement tools is critical for (1) determining obesity and inactivity trends, (2) identifying at-risk groups, (3) tracking progress toward national health priorities, and (4) evaluating the efficacy of interventions targeting obesity and physical inactivity. Furthermore, attention needs to be directed towards identifying correlates of inactivity and obesity to help inform the development of comprehensive multisectorial, multisetting, prevention, and management initiatives.     

New Zealand rural general practitioners 1999 survey--part 1: an overview of the rural doctor workforce and their concerns.

AIMS: To obtain current information about New Zealand rural general practitioners (GPs) and their localitites. METHODS: An anonymous postal questionnaire was mailed out to 559 rural and semi-rural GPs in November 1999, and non-responders were sent three reminders. RESULTS: Of the 417 completed questionnaires returned (response rate 75%), 338 were from rural GPs(Rural Ranking Scale score > or = 35 points) and these formed the study group. The mean age was 44 years, 72% were male, and 93% were of New Zealand European ethnicity. Less than 50%had graduated from a New Zealand medical school with Britain (30%) and South Africa (11%) providing most of the foreign- trained rural GPs. Only 59% had received vocational training in general practice. The majority worked fulltime (79%) and owned their practice (78%), while 133 (39%) worked part time as rural hospital doctors and 72 (21%) provided intra-partum obstetric care. Over two thirds rated lack of locum relief, onerous oncall,and rural GP shortages as 'important' or 'very important' problems, with one third stating that more rural GPswere needed in their locality. CONCLUSIONS: This, only the second national survey of rural GPs, provides a comprehensive overview of New Zealand rural general practice in November 1999. It confirms that the major current problem is an under supply of rural GPs, causing overwork and stress in those remaining.     

Coronary angioplasty in New Zealand 1995-1998: a report from the National Coronary Angioplasty Registry

AIMS: To report coronary angioplasty data collected by the New Zealand Coronary Angioplasty Registry from 1995-1998. METHOD: Information on all patients undergoing attempted coronary angioplasty in eight New Zealand institutions was recorded on datasheets at the time of, or soon after, the procedure. These were forwarded to the registry at Green Lane Hospital. RESULTS: Over the four-year period, 8395 angioplasty procedures were performed by 26 cardiologists in eight coronary interventional facilities, with a procedural success rate of 94%. Procedural numbers grew steadily, with 55% more coronary angioplasties performed in 1998 than in 1995 (p = 0.02). The New Zealand national angioplasty rate, which rose from 459/million population in 1995 to 684/million in 1998, remains lower than that of Australia and Western European countries. Excluding those that underwent angioplasty for acute myocardial infarction, the number of peri-procedural deaths was similar, with six in 1995 and four in 1998 (p = 0.30), and the requirement for emergency bypass surgery fell from 22 cases in 1995 to three in 1998 (p < 0.001). The use of stents increased dramatically, with 85% of patients receiving a stent in 1998, compared with 23% in 1995 (370% increase, p < 0.001). This was associated with a reduction in the number of patients requiring repeat percutaneous interventions for restenosis (10.7% in 1995 to 6.4% in 1998, p < 0.001). CONCLUSION: There has been a steady growth in the numbers of patients with coronary artery disease treated by coronary angioplasty, and in the number treated by intracoronary stents from 1995 to 1998. The need for urgent coronary bypass surgery has fallen. Continued submission of complete and accurate data to the coronary angioplasty registry is vital for ongoing audit.     

Screening, diagnosis and services for women with gestational diabetes mellitus (GDM) in New Zealand: a technical report from the National GDM Technical Working Party

Rates of gestational diabetes mellitus (GDM) and Type 2 diabetes in pregnancy are increasing with the epidemic of obesity. GDM is associated with significant perinatal morbidity and future risk of permanent diabetes in the mother and obesity and diabetes in the offspring. The recent Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) has shown maternal and perinatal benefits of managing GDM once diagnosed. The criteria for GDM are under review following the recent completion of the Hyperglycaemia and Adverse Perinatal Outcomes study (HAPO). In New Zealand, the approach to identifying women with GDM or undiagnosed Type 2 diabetes has varied. The National GDM Technical Working Party reviewed the available data in the New Zealand context and recommend that (1) All pregnant women are offered screening for GDM backed up with relevant educational, systems and materials for health professionals and the women; (2) Criteria for GDM should remain unchanged pending further information (which should be actively sought); (3) Women at high risk of undiagnosed Type 2 diabetes in pregnancy should be screened at booking: the HbA1c was recommended as a practical initial screening test, but further research is needed; and (4) A structured, audited, population-based approach to managing women with GDM should be introduced in each district.     

Acute stroke services in New Zealand

AIMS: To obtain an overall picture of the organisation of acute stroke management in hospitals throughout New Zealand. METHODS: A questionnaire was sent to all New Zealand hospitals. The survey included questions about access to organised stroke care, the presence of designated areas for stroke patient management, guidelines for stroke management and audit. RESULTS: Responses were received from all hospitals surveyed, with 41 admitting stroke patients acutely. Five hospitals (four regional and one large urban) had organised inpatient care. Five hospitals (three regional and two large urban) had stroke physicians. Only 40-60% of the New Zealand population had access to hospitals with guidelines for the management of complications following stroke or secondary prevention. Only fifteen of 41 hospitals had audited local stroke care. There were few differences in the management of stroke patients between urban and regional centres, but care in some regional hospitals was 'better' than that in most large urban hospitals. CONCLUSIONS: The development of an organised approach to inpatient stroke care in New Zealand and the training of general physcians, geriatricans and neurologists in stroke medicine must be seen as a priority.