Waikato District Health Board Research Articles

Epidemiology of Diabetic Ketoacidosis in the Waikato Region of New Zealand: 2000-2019.

Diabetic ketoacidosis (DKA) is not well characterised in New Zealand. This study is aimed at characterising the change in epidemiology and severity of DKA from 2000 to 2019 at a tertiary hospital in the Waikato region of New Zealand. A retrospective clinical data review of all patients admitted to Waikato District Health Board hospitals with DKA was undertaken. Characteristics and severity of DKA were assessed by type of DKA admission (diagnosed at admission, nonrecurrent, and recurrent), ethnicity, social deprivation, intensive care unit (ICU) admission, and length of hospital stay, with linear regression reporting on changes over time. There were 1254 admissions for DKA (564 individual patients), two-thirds being recurrent events. Nonrecurrent DKA patients were younger, whilst recurrent admissions for DKA were associated with T1D, female gender, greater socioeconomic deprivation, and rural living (all P values < 0.01). DKA admission increased 8-fold between 2000 and 2019, mostly due to an increased number of recurrent events, particularly in Māori and female patients (P < 0.001). ICU admissions increased over time (P < 0.001) whilst length of hospital stay trended down (P = 0.031). The rise in recurrent DKA is concerning, particularly in youth and indigenous Māori. Healthcare inequities need to be addressed, including adequate access to mental health support to ensure optimal outcomes for all patients with diabetes.

Creating an environment to inform, build, and sustain a Māori health research workforce

ABSTRACT Ensuring the growth and development of the Māori health research workforce is key to achieving health equity for Māori and enabling positive change for all New Zealanders. The purpose of this study was to identify enablers and barriers to research for Māori staff in a large health organisation, and to understand how research is developed and undertaken. A Kaupapa Māori mixed-methods study was undertaken, using an electronic survey comprised of quantitative data and open-ended responses delivered to all Māori staff at the Waikato District Health Board. Following the survey were 10 one on one interviews. Survey data were analysed using descriptive statistics and open-ended responses summarised. A descriptive thematic analysis was undertaken of the interview data. Each of the interview responses was coded and five themes emerged. Frontline Māori staff affirmed their desire to conduct, design, and undertake health research. Challenges to staff included a lack of information on research opportunities, unclear processes for initiating research, and lack of support and resource. The evidence from participants provides insights into Māori health research priorities, considerations for those wanting to undertake research, and solutions for informing, building, and sustaining the Māori health research workforce. Glossary of Māori words: Aotearoa: Māori name for New Zealand; āwhinatia i tāku hapū: help my hapū; hapū: sub-tribe; iwi: tribe; kaumatua: elder; Kaupapa Māori: Māori ideology incorporating the knowledge, skills, attitudes and values of Māori society; kia ora: greeting; koinā te whakamaatauranga nēra: power of knowledge; hohā: nuisance; hui: meeting; Kaitiaki: Māori cultural support team for patients; Kīngitanga: Māori King movement; Māori: Indigenous peoples of Aotearoa; marae: ancestral meeting house; mōhio ki tēra mahi: knowledgeable in that area; Te Ao Māori: Māori world view; Te Ika-a-Māui: North Island; Te Reo Māori: Māori language; Te Tiriti o Waitangi: The Treaty of Waitangi; Te Whatu Ora: Health New Zealand; whakahoki ki tāku marae: to go back to my marae; wānanga: workshop; whanau: family

Acute calcium pyrophosphate crystal arthritis is associated with an increased rate of hip and knee joint surgery.

Acute calcium pyrophosphate (CPP) crystal arthritis is a distinct manifestation of calcium pyrophosphate crystal deposition (CPPD). No studies have specifically examined whether acute CPP crystal arthritis is associated with progressive structural joint damage. The objective of this retrospective cohort study was to evaluate the relative rate of hip and knee joint arthroplasties as an estimate of structural joint damage accrual, in a population of patients with acute CPP crystal arthritis. Data were collected from Waikato District Health Board (WDHB) to identify an acute CPP crystal arthritis cohort with clinical episodes highly characteristic of acute CPP crystal arthritis. Data on hip and knee joint arthroplasties were collected from the New Zealand Orthopaedic Association's Joint Registry. The rate of arthroplasties in the cohort was compared with the age-ethnicity-matched New Zealand population. Additional analysis was performed for age, obesity (BMI) and ethnicity. The acute CPP crystal arthritis cohort included 99 patients; 63 were male and the median age was 77 years (interquartile range, 71-82). The obesity rate was 36% with a median BMI of 28.4 kg/m2 (interquartile range, 25.8-32.2), comparable to the New Zealand population. The standardized surgical rate ratio in the cohort vs the age-ethnicity-matched New Zealand population was 2.54 (95% CI: 1.39, 4.27). Our study identified a considerable increase in the rate of hip and knee joint arthroplasties in patients with episodes of acute CPP crystal arthritis. This suggests CPP crystal arthritis may be a chronic condition, leading to progressive joint damage.

Changing patterns of otitis media in the Waikato region during the COVID-19 pandemic.

Introduction Acute otitis media (AOM) is a common condition of children encountered in general practice. A proportion of children develop otitis media with effusion (OME), which may require tympanostomy and ventilation tube insertion. Aim The aim of the study was to compare the incidence of AOM in Māori and New Zealand (NZ) European children in general practice and the referral practices to secondary care for tympanostomy and ventilation tube insertion. Methods The study was conducted in two parts: (1) an analysis of the incidence of AOM and OME in a rural Waikato general practice (Ōtorohanga) with a high Māori population over a 2-year period; and (2) an analysis of all referrals to the otorhinolaryngology (ORL) department at Waikato District Health Board and tympanostomy and ventilation tube insertion by this service over the same period. Results The incidence of AOM was similar in Māori compared with NZ European children. The incidence declined significantly between 2019 and 2020 and 50% of children with AOM were treated with antibiotics. Referral rates to the ORL department were greater for Māori compared with NZ European children as were tympanostomy and ventilation tube insertion rates. Discussion Although AOM is common, OME was rarely diagnosed. The clinical guidelines regarding antibiotic use for common conditions are not being readily adopted and further research is needed into this matter. The COVID-19 pandemic had a substantial effect on demand both in general practice and in the hospital sector. This may have been due to a reduction in the incidence of AOM or due to system changes caused by the pandemic.

Incidence of Young Onset Dementia in Waikato, New Zealand: A Population-Based Study.

There is limited epidemiological research on the incidence of young onset dementia (YOD). Estimates of YOD incidence in New Zealand are extrapolated from international studies that do not reflect New Zealand's population and ethnic diversity. To determine the incidence of YOD in the geographical area served by the Waikato District Health BoardMethods: All new inpatient and outpatient in the age range 30-64 years with a documented diagnosis of dementia at Waikato Hospital between 1 January 2014 -31 December 2016 were identified. Incidence rates were calculated by 5-year age-band, sex, and ethnicity. 64 incident cases of YOD were included. Incidence rates for all cause YOD were 13.3 (95% CI 10.3-17.0) and 22.7 (95% CI 17.5-29.1) per 100,000 person-years in the age range 30-64 years and 45-64 years respectively. The incidence rate in Māori (20.0, 95% CI 11.4-32.4) was higher compared to non-Māori (12.0, 95% CI 8.9-15.9), but this difference was not statistically significant (p = 0.09). The incidence of YOD in this study is similar to global estimates. Incidence may be higher in Māori compared to non-Māori, highlighting the need for culturally appropriate approaches to dementia prevention, intervention, and care.

Hapū Wānanga: A Kaupapa Māori childbirth education class for Māori and non-Māori māmā hapū and whānau

Global studies attest that early engagement with childbirth education (CBE) classes enhances maternal and infant health outcomes. In Aotearoa New Zealand, Māori participation rates in CBE classes are lower than those of their non-Māori counterparts. Current CBE classes are designed and delivered using a predominantly Western medicalised approach that negates Māori birthing knowledge, expertise, and values. However, sporadically, Kaupapa Māori CBE classes are being delivered. This article draws on a wider study that explores the Hapū Wānanga (HW) CBE programme, a by Māori, for Māori pregnancy and parenting initiative. This mixed-method interpretive study used retrospective post-course survey data of 1,152 participants over a three-year period from the HW based in the Waikato District Health Board region. Data explored the programme’s quality, the impact on levels of knowledge and understanding, and the overall experiences and views of participants. This artice interrogates the factors that shaped participation, engagement and acceptability of the HW for participants.

Microvascular reconstruction outcomes from a New Zealand Oral and Maxillofacial Surgery Unit.

The Oral and Maxillofacial Surgery (OMS) Department at Waikato District Health Board (WDHB) is the only current OMS unit within New Zealand to reconstruct oral cavity defects with microvascular free flaps. The primary objective of the study was to retrospectively analyse the demographics, outcomes and complications of free flap surgery patients at WDHB.An OMS reconstruction database was developed and data collected retrospectively. 75 free flaps were performed on 74 patients between 2012 and 2020. There were 34 females and 40 males, with a mean and median age of 62 and 64 respectively. The tongue was the most common site of resection, and squamous cell carcinoma was the most frequent diagnosis. The radial forearm free flap was used most often followed by the fibula and anterolateral thigh flaps. The Clavien-Dindo classification was used to classify complications, with 10 patients having "major" complications and 34 patients having "minor" complications. Flap success rate was 98.7%, which meets internationally accepted standards of care.

Prevalence of gestational diabetes in the Waikato region of New Zealand.

Gestational diabetes mellitus (GDM) during pregnancy is associated with health complications for both mother and infant, but patient numbers in the Waikato District Health Board region of New Zealand have not been well characterised. This study reviewed the full 2018 cohort of Waikato District Health Board hospital births (n = 4970) to report on GDM prevalence by ethnicity and age. The overall prevalence of GDM was 5.7% and is more likely to affect Asian, Pacific and Māori women as well as those of advanced maternal age.

Body site locations of basal cell carcinoma, squamous cell carcinoma and actinic keratosis in patients referred to the Waikato District Health Board teledermoscopy clinic.

Introduction Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and actinic keratosis (AK) are usually located on sun-exposed areas of the body. Aims Our main aims were to identify the common body site locations of BCC, SCC and AK in patients attending the Waikato District Health Board teledermoscopy clinic, also known as the Waikato Virtual Lesion Clinic, as well as to analyse whether the distribution of location changes with age and sex. Methods This is a retrospective study where the body site location of 3272 keratinocytic lesions was determined and analysed in 1864 patients attending the Waikato District Health Board teledermoscopy clinics between 2010 and 2021. Results All three types of lesion were most commonly located in the head and neck region (40.9% of BCCs, 38% of SCCs, 83.2% of AKs), followed by 26.8% on the trunk for BCC, 32.3% on the lower extremities for SCC, and 11.6% on the upper extremities for AK. Discussion Our findings of body site locations for keratinocytic lesions were consistent with other studies. Patients were commonly diagnosed with multiple keratinocytic lesions.

Navigating our way through a hospital ransomware attack: ethical considerations in delivering acute orthopaedic care

Ransomware attacks on healthcare systems are becoming more prevalent globally. In May 2021, Waikato District Health Board in New Zealand was devastated by a major attack that crippled its information...

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis

BackgroundNew Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis.MethodsThis study is a retrospective analysis of e-referral data for patients aged 30–70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015–31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression.Results6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Māori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Māori having a colonoscopy was 0.66 (95% CI 0.60–0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35–2.07) for men compared to women, and 2.34 (95% CI 1.70–3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed.ConclusionsIf a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Māori are less likely to receive a colonoscopy following referral from general practice.

Māori health outcomes in an intensive care unit in Aotearoa New Zealand.

Māori are the indigenous people of New Zealand, and suffer disparate health outcomes compared to non-Māori. Waikato District Health Board provides level III intensive care unit services to New Zealand's Midland region. In 2016, our institution formalised a corporate strategy to eliminate health inequities for Māori. Our study aimed to describe Māori health outcomes in our intensive care unit and identify inequities. We performed a retrospective audit of prospectively entered data in the Australian and New Zealand Intensive Care Society database for all general intensive care unit admissions over 15 years of age to Waikato Hospital from 2014 to 2018 (n = 3009). Primary outcomes were in-intensive care unit and in-hospital mortality. The secondary outcome was one-year mortality. In our study, Māori were over-represented relative to the general population. Compared to non-Māori, Māori patients were younger (51 versus 61 years, P < 0.001), and were more likely to reside outside of the Waikato region (37.2% versus 28.0%, P < 0.001) and in areas of higher deprivation (P < 0.001). Māori had higher admission rates for trauma and sepsis (P < 0.001 overall) and required more renal replacement therapy (P < 0.001). There was no difference in crude and adjusted mortality in-intensive care unit (16.8% versus 16.5%, P = 0.853; adjusted odds ratio 0.98 (95% confidence interval 0.68 to 1.40)) or in-hospital (23.7% versus 25.7%, P = 0.269; adjusted odds ratio 0.84 (95% confidence interval 0.60 to 1.18)). One-year mortality was similar (26.1% versus 27.1%, P=0.6823). Our study found significant ethnic inequity in the intensive care unit for Māori, who require more renal replacement therapy and are over-represented in admissions, especially for trauma and sepsis. These findings suggest upstream factors increasing Māori risk for critical illness. There was no difference in mortality outcomes.

Metaheuristic Optimization of Insulin Infusion Protocols Using Historical Data with Validation Using a Patient Simulator

Metaheuristic search algorithms are used to develop new protocols for optimal intravenous insulin infusion rate recommendations in scenarios involving hospital in-patients with Type 1 Diabetes. Two metaheuristic search algorithms are used, namely, Particle Swarm Optimization and Covariance Matrix Adaption Evolution Strategy. The Glucose Regulation for Intensive Care Patients (GRIP) serves as the starting point of the optimization process. We base our experiments on a methodology in the literature to evaluate the favorability of insulin protocols, with a dataset of blood glucose level/insulin infusion rate time series records from 16 patients obtained from the Waikato District Health Board. New and significantly better insulin infusion strategies than GRIP are discovered from the data through metaheuristic search. The newly discovered strategies are further validated and show good performance against various competitive benchmarks using a virtual patient simulator.

Ethnic disparities for thyroid surgery.

Significant health disparities exist between Māori and non-Māori patients in New Zealand. Māori patients treated medically for their thyroid disease are less likely to be euthyroid. The prevalence of thyroid disease and characteristics of Māori presenting for thyroid surgery has not been well studied. We aim to assess the differences in ethnic representation for thyroid surgery. A retrospective analysis of cases performed between 2009 and 2019 at the Otolaryngology/Head and Neck Department in Waikato District Health Board (DHB) was completed. All patients who received a thyroid operation were included and divided into Māori and non-Māori groups. Clinical and operation notes were reviewed and the duration of presenting symptoms, weight, volume and diagnosis of the thyroid gland were assessed. A total of 93 patients were included in our study, of whom 71 patients were female and 22 male with 37 being Māori and 56 non-Māori. Māori patients had significantly higher rates of retrosternal extension, compressive symptoms, post-operative complications, delayed presentation and larger thyroid goitres when compared to non-Māori (P < 0.05). Our study confirms that there is a significant ethnic disparity for Māori patients requiring thyroid surgery. This highlights an additional poor health outcome for Māori compared to non-Māori patients.

Time to surgery for fractured neck of femur in the Waikato District Health Board: Comparison between rural and metropolitan hospitals between 2017 and 2019.

The authors declare no conflicts of interest.

The prevalence of mental health medication use in a cohort of New Zealand patients with diabetes

AimsDiabetes is associated with depression, anxiety and psychosis via complex bidirectional relationships that are affected by factors such as the type of diabetes and socioeconomic status. The aim of the study was to estimate the prevalence of mental health conditions in patients with diabetes in a New Zealand primary care population using proxy medication dispensing data. MethodsPrimary care data (July 1 2016 – June 30, 2018) was collected from the Patient Management System of 15 different general practices, and was linked via National Health Index number to clinical records at the Waikato District Health Board and the New Zealand Ministry of Health Pharmaceutical database. ResultsA total of 3978 patients with diabetes were identified from an enrolled patient population of 74,250. Of these, 18.0% of patients with diabetes were dispensed an antidepressant, anxiolytic, or antipsychotic. These medications were prescribed more in New Zealand Europeans (20.9% versus 13.9% in Māori), women, type 2 diabetes, those on insulin, and those with a higher BMI (all P<0.001). ConclusionsApproximately one fifth of patients with diabetes in primary care have mental health disorders. Appropriate management requires concomitant treatment of both the diabetes and the mental health disorder to improve patient outcomes.

Supporting Child Wellbeing

The Hamilton Children’s Team received its first referral in 2015, with dedicated lead professionals appointed for each child referred. The role of these lead professionals is to assess need, develop a plan for each child, and coordinate a cross-sector Child Action Network to improve care and wellbeing. Challenges were identified in Hamilton for the assessment, identification and coordination of health need within the Children’s Team, particularly for lead professionals from outside the health sector. Therefore, a health assessment package was developed in partnership with the Hamilton Children’s Team, the Waikato District Health Board and other relevant agencies. The use of a standardised and systematic approach, with training and relationship development, resources and referral pathways, resulted in identification of significant unmet need. A number of referrals to the health sector resulted from this assessment and there are implications that such a process can support ongoing attendance at health appointments, monitoring of outcomes from the Children’s Team process, and improvements to physical, emotional and mental wellbeing for families. This approach was well received by lead professionals and families, and future use is likely to enhance the Children’s Team programme and service delivery, and improve wellbeing outcomes.

An Audit to Verify a Key Performance Indicator: Secondary Prevention Medication Prescription: Registry Versus Real-World Rates Post-Acute Coronary Syndromes

Background: The proportion of patients with acute coronary syndromes (ACS) in Waikato District Health Board (WDHB) in 2018 who met the Composite Post-ACS Secondary Prevention Medication indicator (Meds Indicator) was observed on the All New Zealand Acute Coronary Syndrome Quality Improvement [ANZACS-QI] registry to be 64.9% (n = 314/484). The purpose of this audit was to investigate the difference between the registry-reported rates and key performance indicator target rates (>85%) for Meds Indicator adherence. Method: A retrospective analysis of those not meeting the Meds Indicator in the ACS Registry was conducted for all patients with ACS domiciled in WDHB between 1 January and 31 December 2018 (as recorded by ANZACS-QI) and who initially presented to any WDHB hospital (Taumaranui, Te Kuiti, Tokoroa, Thames, and Waikato). Results: After excluding deceased patients and repeat entries, the adjusted Meds Indicator compliance rate was 64.3% (n = 304/473). After the remaining 169 patient discharge summaries and primary care records had been audited, 57 patients were found to have been incorrectly captured, giving a corrected compliance rate of 76.3% (n = 361/473). Conclusion: This audit demonstrates the difference between registry and real-world rates of post-ACS secondary prevention medication prescription at WDHB in 2018. Although the corrected compliance rate is much better than initially reported it still falls short of the recommended target. A repeat audit will be undertaken after a review of processes influencing the quality of captured data and instigating a more rigorous discharge process including implementation of a post-ACS checklist.

Missing a Trick From TREAT: An Audit of P2Y12 Inhibitor Use in Thrombolysed ST-Elevation Myocardial Infarctions in Waikato District Health Board in 2018

Missing a Trick From TREAT: An Audit of P2Y12 Inhibitor Use in Thrombolysed ST-Elevation Myocardial Infarctions in Waikato District Health Board in 2018

Priority setting in health: development and application of a multi-criteria algorithm for the population of New Zealand\u2019s Waikato region

BackgroundPriority setting in a climate of diverse needs and limited resources is one of the most significant challenges faced by health care policymakers. This paper develops and applies a comprehensive multi-criteria algorithm to help determine the relative importance of health conditions that affect a defined population.MethodsOur algorithm is implemented in the context of the Waikato District Health Board (WDHB) in New Zealand, which serves approximately 10% of the New Zealand population. Strategic priorities of the WDHB are operationalized into five criteria along which the algorithm is structured—scale of disease, household financial impact of disease, health equity, cost-effectiveness, and multimorbidity burden. Using national-level data and published literature from New Zealand, the World Health Organization, and other high-income Commonwealth countries, 25 health conditions in Waikato are identified and mapped to these five criteria. These disease-criteria mappings are weighted with data from an ordered choice survey administered to the general public of the Waikato region. The resulting output of health conditions ranked in order of relative importance is validated against an explicit list of health concerns, provided by the survey respondents.ResultsHeart disease and cancerous disorders are assigned highest priority rankings according to both the algorithm and the survey data, suggesting that our model is aligned with the primary health concerns of the general public. All five criteria are weighted near-equal across survey respondents, though the average health equity preference score is 9.2% higher for Māori compared to non-Māori respondents. Older respondents (50 years and above) ranked issues of multimorbidity 4.2% higher than younger respondents.ConclusionsHealth preferences of the general population can be elicited using ordered-choice surveys and can be used to weight data for health conditions across multiple criteria, providing policymakers with a practical tool to inform which health conditions deserve the most attention. Our model connects public health strategic priorities, the health impacts and financial costs of particular health conditions, and the underlying preferences of the general public. We illustrate a practical approach to quantifying the foundational criteria that drive public preferences, for the purpose of relevant, legitimate, and evidence-based priority setting in health.