Journal of the New Zealand Medical Association, 29-June-2012, Vol 125 No 1357
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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