Managed care in New Zealand: managed competition or managed collaboration?

Managed care is making major progress in New Zealand through independent practice associations (IPAs) now representing more than 50% of general practitioners. It is also being implemented by community groups, especially Maori, who see great potential in improving the health status of their people through this strategy. However, a significant conflict appears to be developing between achieving managed care through managed competition on the one hand and managed collaboration on the other. There appear to be fundamental flaws in the concept of managed competition. Evidence is emerging that managed collaboration is far more likely to be effective in achieving the Government's goals of improving health status and access and more cost-effective healthcare.     

Fact or fallacy? Immunisation arguments in the New Zealand print media

Objective: To explore New Zealand's four major daily newspapers' coverage of immunisation with regards to errors of fact and fallacy in construction of immunisation‐related arguments. Methods: All articles from 2002 to 2007 were assessed for errors of fact and logic. Fact was defined as that which was supported by the most current evidence‐based medical literature. Errors of logic were assessed using a classical taxonomy broadly based in Aristotle's classifications. Results: Numerous errors of both fact and logic were identified, predominantly used by anti‐immunisation proponents, but occasionally by health authorities. The proportion of media articles reporting exclusively fact changes over time during the life of a vaccine where new vaccines incur little fallacious reporting and established vaccines generate inaccurate claims. Fallacious arguments can be deconstructed and classified into a classical taxonomy including non sequitur and argumentum ad Hominem. Conclusion: Most media ‘balance’ given to immunisation relies on ‘he said, she said’ arguments using quotes from opposing spokespersons with a failure to verify the scientific validity of both the material and the source. Implications: Health professionals and media need training so that recognising and critiquing public health arguments becomes accepted practice: Stronger public relations strategies should challenge poor quality articles to journalists' code of ethics and the health sector needs to be proactive in predicting and pre‐empting the expected responses to introduction of new public health initiatives such as a new vaccine.     

Are breast-fed infants and toddlers in New Zealand at risk of iodine deficiency?

OBJECTIVE: This study assessed the iodine status of New Zealand infants and toddlers and explored factors that might influence their iodine status. METHODS: A community-based, cross-sectional survey of 6- to 24-mo-old children was conducted in three cities in the South Island of New Zealand. Iodine status was determined by a casual urine sample. Breast-feeding mothers were asked to provide a breast milk sample for iodine determination. Caregivers collected a 3-d weighed diet record from their children to investigate associations between dietary patterns and urinary iodine excretion. RESULTS: The median urinary iodine concentration for the group (n = 230) was 67 microg/L (interquartile range 37-115) with 37% (95% confidence interval 30.5-43.4) of children having a urinary iodine concentration lower than 50 microg/L. When children were classified by current feeding method, those children who were currently formula-fed had a significantly higher median urinary iodine concentration (99 microg/L) than did children who were currently breast-fed (44 microg/L; P < 0.000). The mean iodine concentration in breast milk was 22 microg/L (n = 39). After multivariate analysis using estimates from 3-d diet records, only percentage of energy from infant formula was significantly associated with urinary iodine concentration (P = 0.005). CONCLUSIONS: This study found mild iodine deficiency in a group of New Zealand infants and toddlers. Children who consumed infant formula, which is fortified with iodine, had better iodine status than did children who were currently breast-fed because breast milk contained low levels of iodine.     

Tobacco consumption in New Zealand: why did it fall?

OBJECTIVE: To estimate the relative contributions of trends in smoking prevalence and trends in smoking intensity (average number of cigarettes smoked per day) to the observed decline in per capita tobacco consumption in New Zealand from 1984 to 2004. METHOD: Tobacco consumption and smoking prevalence time series data were sourced from Statistics New Zealand and the ACNielsen Omnibus Survey respectively and checked for accuracy against other sources. The contribution of changes in smoking prevalence to the observed decline in tobacco consumption was estimated by counterfactual modelling. The corresponding contribution of trends in smoking intensity was then calculated by difference. RESULTS: Changes in smoking prevalence accounted for 48% of the decline in per capita tobacco consumption from 1984-89 and for 39% thereafter. Correspondingly, changes in smoking intensity accounted for 52% of the consumption decline during the first five years of the study period and 61% thereafter (i.e. from 1990 to 2004). DISCUSSION: Understanding the relative contributions of trends in smoking prevalence and smoking intensity to the observed decline in per capita tobacco consumption is important, because the relationship between smoking intensity and health effects is non-linear. Our results indicate that the dramatic fall in tobacco consumption in New Zealand over the past 30 years will not be accompanied by an equivalent reduction in tobacco-attributable morbidity and mortality. Furthermore, our findings raise doubts as to how much longer tobacco consumption will continue to decline, given that smoking intensity is already low. The key message for the tobacco control program is to re-focus on helping smokers to quit and stay quit.     

Rural health care in New Zealand: Poised for renaissance?

ABSTRACT: Despite the idyllic potential, many parts of New Zealand's rural health services have continued to struggle for want of a workforce whose retention is not threatened by demanding rosters, heavy workloads and overwhelming bureaucracy. There may now be a basis for cautious optimism that a plan to integrate recommendations and trialled initiatives from the past decade may attract sufficient government funding to see a renaissance for rural primary health care. This paper outlines the elements contributing to what may be a last hope before crisis takes over.     

'Help, educate, encourage?': Geographical variations in the provision and utilisation of diabetes education in New Zealand

In New Zealand, as elsewhere, it is argued that a diabetes epidemic is underway. With careful management from individuals and professionals and appropriate levels of education, it is possible to prevent many complications of diabetes. The overall objective of the paper is to evaluate the role and impact of Diabetes New Zealand (DNZ), the key voluntary sector provider of diabetes education and support services, with respect to four criteria: (i) the extent to which DNZ is reaching groups most at risk of diabetes; (ii) the degree to which it has encouraged levels of member involvement; (iii) whether voluntary group provision of education is that most preferred by members; and (iv) the extent to which members see the voluntary sector model as being effective in combating the growth of diabetes. A survey of members of six of the 41 affiliated societies of DNZ suggests that such organisations, although having a high proportion of older members, have generally failed to target more deprived groups. While the societies generally score more positively in encouraging member involvement and being perceived as effective by their members, they do not always utilise the preferred form of educational provision. However, there are significant contextual variations by urban-rural location and according to the organisational structure of the societies. Rural societies and those with decentralised organisational structures generally score highest on the above criteria. The results pose a problem for DNZ which, like many other voluntary sector organisations, is facing pressures of increased corporatisation and centralisation. We see this as an important challenge that DNZ needs to address if New Zealand is going to better cope with the emerging diabetes epidemic.     

Secular variations in sperm quality: fact or science fiction?

The debate concerning the possible degradation in human sperm quality began in the 1970s, was revived at the beginning of the 1990s and has continued to mobilize the scientific community ever since. After the meta-analysis by Carlsen et al. (1992) showing a decline in human semen quality over the last 50 years, several groups investigated the sperm characteristics of more or less homogeneous groups of men who had provided semen at the same center for 10 to 20 years. A significant decrease in sperm concentration was reported in some studies, but not in others. Meanwhile, there is an increasing number of reports suggesting that physical and chemical factors introduced and spread by human activity in the environment may have contributed to sperm decline. At the end of the 20th century the debate on declining semen quality is not closed. The lack of certainty and the serious consequences that such a decline would have on the fertility of human populations make this an important public health issue at the start of the 21st century. For this reason, intensive research should be developed in both fundamental and epidemiological domains, particularly in South America, where industrial and agricultural pollution pose a serious threat to the population.     

Does geography explain ethnic inequalities in health in New Zealand?

OBJECTIVE: To quantify the potential contribution of inter-district relative to intradistrict variation to the Maori disparity in life expectancy in 2000-02, by counterfactual modelling. SETTING, DATA SOURCES AND METHODS: The setting was New Zealand's 21 health districts (District Health Boards, DHBs). All data (population estimates and life expectancy estimates) were sourced from Statistics New Zealand and relate to the 2000-02 period. Maori life expectancy (nationally) was recalculated under the counterfactual that Maori life expectancy in each DHB did not differ from total population life expectancy in the corresponding DHB (so eliminating intra-district variation). The difference between the observed total population and counterfactual Maori life expectancies therefore represents the contribution of inter-district variation to the Maori life expectancy disparity. RESULTS: Observed total population and Maori life expectancies at birth in 2000-02, pooling sexes, were 78.7 and 71.1 years respectively, giving a total disparity of 7.6 years. Under the counterfactual, Maori life expectancy increased to 78.4 years (and total population life expectancy to 79.0 years). Inter-district variation was therefore estimated to potentially contribute only 0.6 years or 8% to the total Maori disparity. Allowing for imprecision, inter-district variation almost certainly accounts for less than 10.5% of the total disparity. CONCLUSION: Inter-district or geographic variation makes only a small contribution to the total Maori disparity in life expectancy. Adjustment or standardisation for district is not necessary when comparing Maori and non-Maori health outcomes. If the policy goal is to reduce ethnic inequalities in health, then the focus of policy (e.g. funding formulae) needs to be on factors directly linked to ethnicity, rather than on geographic variations in health and health care that have an impact on all ethnic groups more-or-less alike.     

Do healthy and unhealthy behaviours cluster in New Zealand?

OBJECTIVE: To describe the co-occurrence and clustering of healthy and unhealthy behaviours in New Zealand. METHOD: Data were sourced from the 2002/03 New Zealand Health Survey. Behaviours selected for analysis were tobacco use, quantity and pattern of alcohol consumption, level of physical activity, and intake of fruit and vegetables. Clustering was defined as co-prevalence of behaviours greater than that expected based on the laws of probability. Co-occurrence was examined using multiple logistic regression modelling, while clustering was examined in a stratified analysis using age and (where appropriate) ethnic standardisation for confounding control. RESULTS: Approximately 29% of adults enjoyed a healthy lifestyle characterised by non-use of tobacco, non- or safe use of alcohol, sufficient physical activity and adequate fruit and vegetable intake. This is only slightly greater than the prevalence expected if all four behaviours were independently distributed through the population i.e. little clustering of healthy behaviours was found. By contrast, 1.5% of adults exhibited all four unhealthy behaviours and 13% exhibited any combination of three of the four unhealthy behaviours. Unhealthy behaviours were more clustered than healthy behaviours, yet Maori exhibited less clustering of unhealthy behaviours than other ethnic groups and no deprivation gradient was seen in clustering. DISCUSSION: The relative lack of clustering of healthy behaviours supports single issue universal health promotion strategies at the population level. Our results also support targeted interventions at the clinical level for the 15% with 'unhealthy lifestyles'. Our finding of only limited clustering of unhealthy behaviours among Maori and no deprivation gradient suggests that clustering does not contribute to the greater burden of disease experienced by these groups.     

Is the major increase in notified campylobacteriosis in New Zealand real?

Notifications of campylobacteriosis by New Zealand medical practitioners have increased steadily in the last two decades. To determine if this increase is real, as opposed to a surveillance artefact, we examined both available notification (1980-2003) and hospitalization data (1995-2003). The similarity in the temporal pattern of increasing hospitalizations for campylobacteriosis, with that of notifications, is suggestive that this increase is indeed real. Although some risk factors for this disease have been identified (e.g. uncooked poultry consumption) it is unclear what the likely causes of the increasing rates are. The overall disease burden is also high compared with other developed countries (an annual notification rate of 396 cases per 100000 population in 2003), with highest rates in children aged 1-4 years, males, Europeans, and those living in urban areas. Given the large disease burden, further research and intervention studies should be public health priorities in this country.     

Compression,expansion, or dynamic equilibrium? The evolution of health expectancy in New Zealand

STUDY OBJECTIVE: To evaluate the New Zealand evidence for three theories of population health change: compression of morbidity, expansion of morbidity, and dynamic equilibrium. DESIGN: Using the Sullivan method, repeated cross sectional survey information on functional limitation prevalence was combined with population mortality data and census information on the utilisation of institutional care to produce health expectancy indices for 1981 and 1996. SETTING: The adult population of New Zealand in 1981 and 1996. PARTICIPANTS: 6891 respondents to the 1981 social indicators survey; 8262 respondents to the 1996 household disability survey. MAIN RESULTS: As a proportion of overall life expectancy at age 15 the expectation of non-institutionalised mobility limitations increased from 3.5% to 6% for men, and from 4.5% to 8% for women; the expectation of agility limitation increased from 3% to 7.5% for men and from 4.5% to 8.5% for women, and the expectation of self care limitations increased from 2.0% to 4.5% for men and from 3.0% to 6.0% for women. These changes were primarily attributable to increases in the expectation of moderate functional limitation. CONCLUSION: The dynamic equilibrium scenario provides the best fit to current New Zealand evidence on changes in population health. Although an aging population is likely to lead to an increase in demand for disability support services, the fiscal impact of this increase may be partially offset by a shift from major to moderate limitations, with a consequential reduction in the average levels of support required.     

Did it fall or was it pushed? The contribution of trends in established risk factors to the decline in premature coronary heart disease mortality in New Zealand

OBJECTIVE: To estimate the contribution of trends in three risk factors--systolic blood pressure (SBP), total blood cholesterol (TBC) and cigarette smoking--to the decline in premature coronary heart disease (CHD) mortality in New Zealand from 1980-2004. METHOD: Risk factor prevalence data by 10-year age group (35-64 years) and sex was sourced from six national or Auckland regional health surveys and three population censuses (the latter only for smoking). The data were smoothed using two-point moving averages, then further smoothed by fitting quadratic regression equations (SBP and TBC) or splines (smoking). Risk factor/CHD mortality hazard ratios estimated by expert working groups for the World Health Organization Global Burden of Disease Study 2001 were used to translate average annual changes in risk factor prevalences to the corresponding percentage changes in premature CHD mortality. The expected trends in CHD mortality were then compared with the observed trend to estimate the contribution of each risk factor to the decline. FINDINGS: Approximately 80% (73% for males, 87% for females) of the decline in premature CHD mortality from 1980 to 2004 is estimated to have resulted from the joint trends in population SBP and TBC distributions and smoking prevalence. Overall, approximately 42%, 36% and 22% of the joint risk factor effect was contributed by trends in SBP, TBC and smoking respectively. CONCLUSION: Our estimate for the joint risk factor contribution to the CHD mortality decline of 80% exceeds those of two earlier New Zealand studies, but agrees closely with a similar Australian study. This provides an indicator of the scope that still remains for further reduction in CHD mortality through primary and secondary prevention.     

Management of cardiovascular risk in diabetic patients: evolution or revolution?

Diabetes is associated with a marked increase in the risk of cardiovascular disease. Epidemiological evidence shows that hyperglycemia, hypertension and disorders of both lipid and thrombosis are involved in the etiology of cardiovascular disease in diabetes. Intervention trials on each of such factors have demonstrated a favourable effect in terms of reduction of cardiovascular disease, suggesting that even in diabetic patients in whom blood glucose levels are adequately controlled, other cardiovascular risk factors, such as hyperlipidemia, hypertension and prothrombotic state, should be aggressively treated. The need for an aggressive treatment has been recently underscored by the UKPDS (United Kingdom Prospective Diabetes Study) researchers who suggest that "polypharmacy" is now needed for the prevention of diabetic complications, implying that this approach requires an adequate control of all cardiovascular risk factors even using associations of drugs for each of them. A thorough application of these concepts might appear difficult in particular when the resource cost is considered. However, it has been shown that blood glucose, blood pressure and serum lipid control are advantageous in diabetic patients not only in terms of cost/benefit ratio but also in terms of quality of life. In the present article, we will briefly review this evidence and discuss the ethical and socioeconomic concerns that may subsequently rise.