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| Journal of the New Zealand Medical Association,
29-June-2012, Vol 125 No 1357
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This Issue in the Journal
The most deprived Auckland City Hospital patients
(2005–2009) are 10 years younger and have a 50% increased mortality
following discharge from a cardiac or vascular admission when compared to the
least deprived patients
Chris Ellis, Andie Pryce, Garth MacLeod, Greg Gamble We looked at the 19,500 patients discharged from Auckland
City Hospital from July 2005 to December 2009, who were admitted with a cardiac
(heart) or vascular (artery, vein) cause. Socioeconomic deprivation (SED) was
assessed for patients, and those most deprived (poorer) were 10 years
younger at admission than those least deprived (richer). After discharge,
the most deprived patients had a 50% increased mortality compared to the
least deprived, after adjustment for age and gender. Despite our current efforts
to minimise health disparities, further effort is needed to improve on health
inequalities in New Zealand.
The use of troponin in general
practice
Sally Aldous, Peter Gent, Graham McGeoch, Denise Nicholson General Practitioners (GP) are able to measure a blood test
called cardiac troponin (cTn) in order to help triage patients with symptoms
suspicious of a heart attack. This study showed that 8.3% of patients tested by
their GP had abnormal cTn levels, most were admitted to hospital and
approximately half of these abnormal tests were due to a heart attack. Those
with abnormal results were at higher risk of adverse events within the following
6 months than those without (death rates 8.5% versus 1.1%, heart attack rates
2.2% versus 1.2% and heart failure rates 3.1% versus 1.0%). Those with normal
cTn levels were low risk and can be managed in the community although the GP may
feel admission in some is still necessary. It can take up to 10 hours before the
cTn becomes abnormal and therefore repeat testing in patients presenting soon
after symptom onset is recommended. Only 12.1% had repeat testing in this
study.
Availability of troponin testing for cardiac
patients in New Zealand 2002 to 2011: implications for patient
care
Mohammad Latif, Chris Ellis, Alexei Chataline, Greg Gamble, Cam Kyle, Harvey White The modern diagnosis of a heart attack includes a blood test
to detect troponin: a heart protein released when the heart is damaged by a
blocked artery. The 2 types of troponins released (troponin T and I) can be
assessed by various laboratory machines (analysers), produced by various
companies. We reviewed troponin tests available at New Zealand hospitals which
admitted heart attack patients from 2002 to 2011, and found in 2010–2011
that there were 9 different troponin analysers in 43 hospitals provided by 5
companies. Hence test thresholds and units vary, even for the same test, which
can confuse the diagnosis of a heart attack, especially if a patient is
transferred across Health Boards. We consider that this situation is
sub-optimal. We suggest that a coordinated national approach is needed with the
development of new biochemical tests, such as troponins, which may result in
better use of resources and better patient care.
Mortality by ethnic group to 2006: is extending
census-mortality linkage robust?
Lavinia Tan, Tony A Blakely Mortality rates continued to fall for all ethnic groups up
to 2006. Gaps in death rates for all diseases for Māori compared to
European/Other over this time were probably stable in relative or percentage
terms. But gaps in cardiovascular disease death rates for Māori compared to
European/Other probably decreased—which is good news. Linkage of mortality
data to census data up to 5 years after the last census seems viable, but we
suspect increasing underestimation of Pacific and Asian mortality rates with
increasing time between the census and death due to migration out of New
Zealand. Mortality data for 2006–11 will soon be linked to the 2006
census, allowing a more recent update.
Improving healthcare through the use of
co-design
Hilary Boyd, Stephen McKernon, Bernie Mullin, Andrew Old Co-design is a way of actively in involving patients in the
design of services by focussing on understanding and improving patient
experiences. Through its Patient Co-design of Breast Service Project, Waitemata
District Health Board worked with patients and staff to improve the breast
journey and, on a small scale, trial a methodology that had, at the time, not
been widely acknowledged or used in New Zealand in the health sector. Using
patient journey mapping, experience-based surveys and co-design workshops, we
identified four key issue for patients: timely/accessible information,
compassionate communication, navigation and coordination, and a pleasant, easy
navigable physical environment. Improvements made included a patient information
folder, patient leaflets, a patient held record and patient journey guide.
Doctors and the nurse endoscopist issue in New
Zealand
Mohammad I Khan, Robert Khan, Wanda Owen Training and recruitment of Nurse Endoscopists (NEs) is
currently actively debated in medical circles. The aim of this survey was to
obtain the views of doctors regarding the role of NEs in New Zealand. Fifty
percent of the 84 respondents worked in tertiary hospitals. Only 30% had a
positive attitude towards the introduction of NEs in NZ. The majority (62%)
believed that doctors would deliver better quality of endoscopy services than
NEs. Only 37% thought that the introduction of NEs will reduce the cost of
services. Forty one percent thought it was inappropriate for the NEs to be
enrolled in the Bowel Cancer Screening Programme and only 6 doctors (18%)
thought that NEs should be allowed to perform therapeutic endoscopic procedures.
In conclusion only a minority of doctors had a positive attitude towards the
role of NEs. The majority considered doctors to deliver ‘higher’
quality of service and only a minority thought that the introduction of NEs will
lower the cost of services.
Establishment of the New Zealand Drivers
Study
John Langley, Dorothy Begg, Rebecca Brookland, Shanthi Ameratunga, Anna McDowell, John Broughton Despite a significant improvement since graduated licensing
was introduced, traffic-related injury remains the leading cause of death and
hospitalisation among young New Zealanders. The New Zealand Drivers Study (NZDS)
was established to provide information which would lead to an improvement in
this situation. We successfully established a study group of 3992 newly licensed
car drivers (including 825 Māori for separate analyses) including
substantial differences sociodemographic, behavioural, and driving experiences.
So far the response rates to interviews at the restricted and full licence
stages have been very high at 87% and 93%, respectively. The NZDS is well placed
to make a significant contribution to our knowledge of young driver road safety
behaviour. This process has already commenced.
Christchurch earthquakes: how did former refugees
cope?
Mohamud Osman, Andrew Hornblow, Sandy Macleod, Pat Coope Seventy-two former refugees from five ethnic groups
completed a questionnaire regarding the impact of the Christchurch earthquakes,
and how they had coped. Despite high levels of anxiety and concern, greater
among older and married participants, three-quarters of participants reported
that they had coped well; spirituality and religious practice being an important
support. Most (72%) reported that they had not experienced a traumatic event or
natural disaster before. Less than 20% received support from mainstream
agencies. More engagement from local services is needed to strengthen
cooperation between refugee and local communities.
Dabigatran: rational dose individualisation and
monitoring guidance is needed ((viewpoint article))
Stephen B Duffull, Daniel F B Wright, Hesham S Al-Sallami, Paul J Zufferey, James M Faed Dabigatran is the first oral anticoagulant to be introduced
in New Zealand without prescribing restrictions for over 50 years. Not
surprisingly, the drug has created a great deal of interest amongst health care
providers as well as the general public and media. There seems to be a general
feeling that warfarin, with its requisite dose adjustments and blood monitoring,
is an outdated drug and should be shelved in favour of this novel agent. The
assumption is that the newer drug must be better and safer as well as easier to
use. Much of the literature associated with dabigatran encourages this view,
stressing that dabigatran is a ‘game changer’ with the advantage
that the same dose can be used most patients and no need for blood monitoring.
In this paper we question whether dabigatran can really live up to these
expectations. We suggest that the safe and effective prescribing of dabigatran,
like all anticoagulants used in therapeutic doses, will most likely require dose
individualisation and selective blood monitoring. This requirement should not be
viewed as a failure for dabigatran. Rather, the individualisation of dabigatran
dosages should indicate that the needs of patients are being met.
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