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Issue

Vol 125 No 1357: 29 June 2012

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Issue Summary

SUMMARY

Dabigatran: rational dose individualisation and monitoring guidance is needed

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 There seems to be a general feeling that warfarin, with its requisite dose adjustments and blood monitoring, is an outdated drug and should be shelved in favour of this novel agent.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.

SUMMARY

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.

SUMMARY

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.

SUMMARY

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 M ori 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.

SUMMARY

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.

SUMMARY

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.

SUMMARY

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 M ori compared to European/Other over this time were probably stable in relative or percentage terms. But gaps in cardiovascular disease death rates for M ori compared to European/Other probably decreasedwhich 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.

SUMMARY

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.

SUMMARY

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.

ALL ARTICLES
SUMMARY

Medical image. Microfilaria in a facial mass--a coincidental finding in fine needle aspiration cytology.

Dilip C Barman, Tapan D Bairagya

Dabigatran: rational dose individualisation and monitoring guidance is needed

Stephen B Duffull, Daniel F B Wright, Hesham S Al-Sallami, Paul J Zufferey, James M Faed

Improving hand hygiene in New Zealand hospitals to increase patient safety and reduce costs: results from the first hand hygiene national compliance audit for 2012

Joshua T Freeman, Christine Sieczkowski, Tania Anderson, Arthur J Morris, Andrew Keenan, Sally A Roberts

Majority support among the public, youth and smokers for retail-level controls to help end tobacco use in New Zealand

Richard Edwards, Jo Peace, Janet Hoek, Nick Wilson, George Thomson, Louise Marsh

Spontaneous gastroduodenal artery aneurysm rupture in acute surgery

Jessica Savage, Li Hsee

The use of troponin testing in primary care

Stewart Mann, Lynn McBain

Assessment of health and potential for milk-based intervention to improve the nutrient intake of toddlers in New Zealand

Natalie G Martin, Cameron C Grant, Peter W Reed, Judy Rowden, Clare R Wall, Trecia Wouldes, Suzanne Purdy, Keryn Blunt, Lorraine Heteraka-Stevens, Michal Noonan

New Zealand 2012 guidelines for the management of non ST-elevation acute coronary syndromes

Non ST-Elevation Acute Coronary Syndrome Guidelines Group and the New Zealand Branch of the Cardiac Society of Australia and New Zealand

Beyond equity of access to equity of outcome

Andrew W Hamer, Andrew J Kerr

The use of troponin in general practice

Sally Aldous, Peter Gent, Graham McGeoch, Denise Nicholson

University of Otago Faculty of Medicine Freemasons Postgraduate Fellowships in Paediatrics and Child Health for 2013

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

New Zealand’s smokefree prison policy appears to be working well: one year on

Lucie Collinson, Nick Wilson, Richard Edwards, George Thomson, Simon Thornley

Use of a reminder sticker improvesa20559

Laurence Teoh, Mohammad Latif, Philip Choi, Scott Wu, Cheuk Yan Chan, Gregory Plowman, Arthur Nahill, Simon Briggs

Editorial: genius and insanity

Establishment of the New Zealand Drivers Study

John Langley, Dorothy Begg, Rebecca Brookland, Shanthi Ameratunga, Anna McDowell, John Broughton

Doctors and the nurse endoscopist issue in New Zealand

Mohammad I Khan, Robert Khan, Wanda Owen

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

Mortality by ethnic group to 2006: is extending census-mortality linkage robust?

Lavinia Tan, Tony A Blakely

Improving healthcare through the use of co-design

Hilary Boyd, Stephen McKernon, Bernie Mullin, Andrew Old

Christchurch earthquakes: how did former refugees cope?

Mohamud Osman, Andrew Hornblow, Sandy Macleod, Pat Coope

SUMMARY

Dabigatran: rational dose individualisation and monitoring guidance is needed

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.

SUMMARY

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.

SUMMARY

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.

SUMMARY

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 M ori 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.

SUMMARY

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.

SUMMARY

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.

SUMMARY

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 M ori compared to European/Other over this time were probably stable in relative or percentage terms. But gaps in cardiovascular disease death rates for M ori compared to European/Other probably decreasedwhich 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.

SUMMARY

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.

SUMMARY

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.

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