Zealand District Research Articles

Automated Insulin Delivery for Young People with Type 1 Diabetes and Elevated A1c

BackgroundAutomated insulin delivery is the treatment of choice in adults with type 1 diabetes. Data are needed on the efficacy and safety of automated insulin delivery for children and youth with diabetes and elevated glycated hemoglobin levels.MethodsIn this multicenter, open-label randomized controlled trial, we assigned patients with type 1 diabetes in a 1:1 ratio either to use an automated insulin delivery system (MiniMed 780G) or to receive usual diabetes care of multiple daily injections or non-automated pump therapy (control). The patients were children and youth (defined as 7 to 25 years of age) with elevated glycemia (glycated hemoglobin ≥8.5% with no upper limit). The primary outcome was the baseline-adjusted between-group difference in glycated hemoglobin at 13 weeks.ResultsA total of 80 patients underwent randomization (37 to automated insulin delivery and 43 to control) and all patients completed the trial. At 13 weeks, the mean (±SD) glycated hemoglobin decreased from 10.5±1.9% to 8.1±1.8% in the automated insulin delivery group but remained relatively consistent in the control group, changing from 10.4±1.6% to 10.6±1.8% (baseline-adjusted between-group difference, −2.5 percentage points; 95% confidence interval [CI], −3.1 to −1.8; P<0.001). Patients in the automated insulin delivery group spent on average 8.4 hours more in the target glucose range of 70 to 180 mg/dl than those in the control group. One severe hypoglycemia event and two diabetic ketoacidosis events occurred in the control group, with no such events in the automated insulin delivery group.ConclusionsIn this trial of 80 children and youth with elevated glycated hemoglobin, automated insulin delivery significantly reduced glycated hemoglobin compared with usual diabetes care, without resulting in severe hypoglycemia or diabetic ketoacidosis events. (Funded by Lions Clubs New Zealand District 202F and others; Australian New Zealand Clinical Trials Registry number, ACTRN12622001454763.)

Preliminary image evaluation performance of radiographers in one New Zealand District: A 6‐month prospective study

Preliminary image evaluation performance of radiographers in one New Zealand District: A 6‐month prospective study

Preliminary image evaluation performance of radiographers in one New Zealand District: a 6-month prospective study.

Preliminary image evaluation (PIE) is a system where radiographers alert emergency department referrers to the presence or absence of abnormalities on acute extremity X-ray examinations. PIE and similar systems have been utilised in the United Kingdom (UK) and Australia due to a shortage of radiologists to provide a timely report. As New Zealand (NZ) faces a similar shortage, PIE should be considered to address the negative impact this has on patients. The aim of this study was to determine the effect of regular feedback and education on radiographers' performance when detecting and describing acute abnormalities on extremity X-ray examinations in ED. A prospective longitudinal study design was utilised for this study. The sensitivity, specificity, accuracy, and accuracy of PIEs performed by seven radiographers at a public provincial district in NZ were assessed over a 6-month period, with the participants provided monthly results along with regular e-mailed feedback on common errors. The mean for sensitivity, specificity, and accuracy calculated with a 95% confidence interval over the 6-month period were 92.8% (89.9, 95.8), 94.9 (93.1, 96.8), and 94.2 (91.9, 96.5), respectively. When the month-to-month results were analysed, the results demonstrated an improvement in participants' sensitivity, specificity, and accuracy over the 6-month period. The results of this study demonstrated that radiographers who participated in the study can perform PIE to a high standard that is comparable with the findings from international studies and demonstrated an improvement over 6 months. Therefore, PIE may be useful in NZ to aid ED clinicians in their clinical decisions when a radiology report is unavailable.

Do adjustment costs constrain public healthcare providers' technical efficiency? Evidence from the New Zealand Public Healthcare System.

Efficiency analysis is crucial in healthcare to optimise resource allocation and enhance patient outcomes. However, the prompt adaptation of inputs can be hindered by adjustment costs, which impact Long-Run Technical Efficiency (LRTE). To bridge this gap in healthcare literature, this research employs a Bayesian Dynamic Stochastic Frontier Model to estimate parameters and explore healthcare efficiency dynamics over time. The study reveals the LRTE for New Zealand District Health Boards (DHBs) as 0.76, indicating around 32% more input utilisation due to adjustment costs. Most DHBs exhibit consistent short-run operational efficiency, with the national Short-Run Technical Efficiency (SRTE) very close to the LRTE. Among the tertiary providers, Auckland and Capital & Coast DHBs operate below the LRTE level, setting them apart from other tertiary providers. Similarly, Tairawhiti and West Coast DHBs also fall below the LRTE level, as indicated by their SRTE scores, potentially influenced by their unique healthcare settings and resource challenges. This research brings a new perspective to policy discussions by incorporating the temporal dynamics of decision-making and considering adjustment costs. It underscores the need to balance short-term and long-term technical efficiency, underlining their collective significance in fostering a sustainable and efficient healthcare system in New Zealand.

Dynamic analysis of healthcare providers’ cost efficiency

ABSTRACT This study uses quarterly longitudinal data to examine the cost efficiency of 20 New Zealand District Health Boards between 2011 and 2018. A random-effects dynamic stochastic frontier model is applied to estimate the persistence of Health Boards’ cost efficiency while considering both observed and unobserved heterogeneity. The findings reveal that New Zealand Health Boards, on average, spent approximately 7.5% more than the estimated costs of efficient operation, primarily due to high persistence in cost inefficiency. Notably, Health Boards serving rural areas faced even higher levels of long-run cost inefficiency, resulting in an overspending of about 15% of annual budgets. The results of this study highlight that most Health Boards demonstrated excellent short-term performance relative to the long-run equilibrium level of cost inefficiency. However, the more significant concern lies in high long-run cost inefficiency within the sector attributed to structural and regulatory issues. Policymakers are urged to address these underlying problems to improve overall cost efficiency in the health sector.

What drives the productivity growth of New Zealand district health boards: technology, efficiency, or scale?

Using the longitudinal data on New Zealand District Health Boards (DHBs) for the period 2011-2018, the total factor productivity (TFP) change and its components are evaluated using an input distance function and a cost function. The empirical results indicate that TFP decreased at an average rate of between 0.73 and 0.98 per cent annually, mainly due to the deterioration of the technological component, which averaged close to −2 per cent between 2011 and 2018. However, contrary to the technological component, the scale component improved every year at an average rate of 1–1.16 per cent, thus cushioning some of the effects of the deteriorating technological component of the TFP. The TFP also posted a one-off positive growth in 2016, following the nationwide implementation of an ‘elective initiative’ programme in the 2015–2016 year, which raised both the scale and efficiency (technical and cost) components to their highest levels. Furthermore, the study also demonstrates the consistency in the effect of scale and technological change components on the TFP under both primal and dual approaches.

Impact of COVID-19 on the Health Response to Family Violence in Aotearoa New Zealand: A Qualitative Study.

COVID-19 pandemic planning and response has resulted in unprecedented upheaval within health systems internationally. With a concern for increasing frequency and escalation of family violence, the so called "shadow pandemic," we wondered how health system violence intervention programs were operating during this time. In Aotearoa New Zealand, the Ministry of Health Violence Intervention Program (VIP), using a systems approach, seeks to reduce and prevent the health impacts of family violence and abuse through early identification, assessment, and referral of victims presenting to designated health services. In this qualitative descriptive study, we explored how the VIP program was impacted during the first year of the COVID-19 pandemic. Forty-one VIP coordinators and managers representing 15 of the 20 New Zealand District Health Boards and the National VIP Team participated. Across 12 focus groups (8 face to face and 4 via Zoom) and 7 individual interviews (all via Zoom) participants shared their experience navigating systems to support frontline health providers' responsiveness to people impacted by family violence during the pandemic. In our reflexive thematic analysis, we generated 3 themes: Responding to the moment, valuing relationships, and reflecting on the status quo. Our findings demonstrate the dynamic environment in which participants found creative ways to adapt to the uncertainty and engage with communities to re-shape interventions and ensure continued implementation of the program. At the same time, challenges within the system prior to the pandemic were brought into view and highlighted the need for action. These included, for example, the need for improved engagement with Māori (Indigenous people of Aotearoa New Zealand) to address long-standing health inequities. Having quality essential services for those impacted by family violence that engages with local knowledge and networks and routinely copes with uncertainty will strengthen our systems to minimize risk of harm during emergencies.

Quality‐efficiency trade‐off when the state is the sole provider of hospital services: Evidence from New Zealand

AbstractThe purpose of this study is to explore the trade‐off between technical efficiency and the quality of hospital services when the state is the sole provider. Data from 20 New Zealand District Health Boards from 2011 to 2017 is used to estimate technical efficiency using the data envelopment analysis technique, which employs an additive inverse formulation for undesirable outcomes. The estimated average quality‐adjusted technical efficiency score is 0.69. In comparison, when the quality variable was removed, the efficiency declined to 0.66. More importantly, the ranking of district health boards stays consistent across both models, indicating that there is very little trade‐off between quality and efficiency. A sensitivity analysis also confirms the lack of a trade‐off between quality and efficiency.

Maintenance ECT treatment in New Zealand: Local and national data.

To retrospectively analyse patients receiving maintenance Electroconvulsive therapy (ECT), patterns of ECT treatment administration and impact on hospitalisation before and during treatment, in a single New Zealand District Health Board catchment. We also asked other District Health Boards in New Zealand for annual data on their use of maintenance ECT. Regional analysis: retrospective analysis of patient-level data over 9 years. National analysis: survey of maintenance ECT/year. Regionally, 14 patients received maintenance ECT over 9 years. Patients were 50% male, with mean age 59 years, and principal diagnoses included schizophrenia, bipolar disorder and major depressive disorder. The time between ECT treatments tended to be shorter for patients with schizophrenia compared with those with mood disorders. Duration of time in hospital during maintenance ECT, compared with pre-ECT, was reduced by 52% for all patients, with greater reductions for patients with mood disorders compared with those with schizophrenia. Nationally, 19.7% of all ECT treatments in New Zealand (range 4-57%) were for maintenance treatment. Regional and national use patterns of maintenance ECT in New Zealand resemble those reported internationally. The RANZCP section of neurostimulation is planning ECT standards which would assist with ensuring coherence and quality of High-dose contrast-enhanced computed tomography/modified electroconvulsive therapy practice in New Zealand.

2021 Assessment of New Zealand district health boards' institutional healthy food and drink policies: the HealthY Policy Evaluation (HYPE) study.

To assess adoption of the voluntary National Healthy Food and Drink Policy (NHFDP) and the alignment of individual institutional healthy food and drink policies with the NHFDP. All 20 district health boards (DHBs) and two national government agencies participated. Policies of those organisations that had not fully adopted the NHFDP were assessed across three domains: nutrition standards; promotion of a healthy food and beverages environment; and policy communication, implementation and evaluation. Three weighted domain scores out of 10, and a total score out of 30 were calculated. Nine of the 22 organisations reported adopting the NHFDP in full. Of the remaining 13, six referred to the NHFDP when developing their institutional policy and three were working toward full adoption of the NHFDP. Mean scores (SD) were 8.7 (1.0), 6.1 (2.6) and 3.8 (2.2) for the three domains, and 18.6 (4.8) in total. Most individual institutional policies were not as comprehensive as the NHFDP. However, some contained stricter/additional clauses that would be useful to incorporate into the NHFDP. Since a similar policy analysis in 2018, most DHBs have adopted the NHFDP and/or strengthened their own nutrition policies. Regional inconsistency remains and a uniform mandatory NHFDP should be implemented that incorporates improvements identified in individual institutional policies.

Postpartum anaemia in three New Zealand district health board regions: An observational study of incidence and management.

The incidence of postpartum anaemia (PPA) in New Zealand, and the extent of intravenous iron (IV-iron) use in its treatment, are unknown. To report the incidence of PPA in three district health board (DHB) regions and describe current management of moderate to severe PPA, including by ethnicity. Retrospective observational study of PPA (haemoglobin (Hb) <100 g/L) in three DHBs from July-December 2019. Cases with moderate to severe PPA (Hb <90 g/L) were reviewed and management compared to local and national guidance. Logistic regression examined demographic associations of PPA. There were 8849 women who gave birth during the study period: 4076 (46%) had postpartum Hb testing and 1544 (38%) had PPA. Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having PPA (0.46, 95% CI 0.37-0.57, P< 0.01). Of 681 women with Hb <90 g/L, 278 (41%) received IV-iron only, 66 (10%) red blood cell transfusion (RBC-T) only and 155 (23%) both. Of those receiving RBC-T, 40/221 (18%) were actively bleeding. Māori (92/138, 67%) and Pacific (127/188, 68%) women with Hb <90 g/L had the highest incidence of IV-iron use. No guidelines provided recommendations for haemodynamically stable women without active bleeding. The incidence and management of PPA differs by ethnicity but fewer than half of the women had Hb testing, making precise determination of incidence impossible. The majority of women with Hb <90 g/L received IV-iron, with or without RBC-T.

Incorporating the person's voice into their healthcare record - the story of a New Zealand district health board Advance Care Planning service for clinical teams and consumers, promoting joined up person-centred care

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Stigma in Consultation Liaison Psychiatry: A Qualitative Study of Trainee Psychiatrists.

Stigma related to mental illness can impact service-user care and clinician wellbeing. The aim of this study was to explore experiences of stigma in consultation-liaison psychiatry from the perspectives of trainee psychiatrists and suggest interventions to tackle stigma within a hospital environment. Ethics approval and consent were obtained for the study. In-depth interviews were conducted by telephone with six participants in four New Zealand district health boards. De-identified data was analysed using thematic analysis. An independent co-coder was employed to enhance analytic rigour. Participants experienced stigma during their consultation-liaison rotations. Some felt isolated and undervalued. Education, intergration and role clarification within the hospital environment were identified as ways to reduce stigma. Stigma experienced by trainee psychiatrists completing consultation-liaison rotations may lead to them feeling devalued and perceiving service-users to experience poorer care. Multidisciplinary education may potentially combat stigma and contribute to improved integration of services.

What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System

PurposeQuality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers’ accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives.DesignQualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically.Setting and participants.Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education—typically operations managers or process engineers. The latter group was represented by clinical staff—physicians and nurses—who received on-the-job training.ResultsThree themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers.ConclusionsWe differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

Health-Related Quality of Life and Disability Among Older New Zealanders With Kidney Failure: A Prospective Study.

Background:Disability is prevalent in individuals with kidney failure and can contribute to significantly reduced quality of life and survival. In older individuals with kidney failure, disability can be caused by a combination of factors, including issues directly related to their kidney disease and/or treatment, including weakness, low energy, and low activity. Few studies have investigated health-related quality of life (HRQoL) as a possible predictor of disability among older individuals experiencing kidney failure.Objective:This study aimed to determine if patient-reported HRQoL, and/or other factors at baseline, predicts disability in people with kidney failure, aged ≥65 years, after 12 months of follow-up.Design:The DOS65+ study was an accelerated longitudinal cohort design comprising of both cross-sectional and longitudinal components. Participants were eligible if they were aged ≥65 years, had chronic kidney disease stage 5G (CKD 5G) (estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m2), and had: commenced kidney replacement education, or were on an active conservative pathway, or were newly incident dialysis patients commencing dialysis therapy or prevalent on dialysis.Setting:Three New Zealand District Health Board (DHB) nephrology units (Counties Manukau, Hawke’s Bay, and Southern DHB) were involved in the study.Participants:Participants were eligible if they were aged ≥65 years, had CKD 5G (eGFR <15 ml/min/1.73 m2), and had: commenced kidney replacement education, or were on an active conservative pathway, or were newly incident dialysis patients commencing dialysis therapy or prevalent on dialysis.Measurements:Disability and HRQoL were measured by EQ-5D-3L, a WHO Disability Assessment Schedule (WHODAS) 2.0.Methods:Baseline and 12-month data from our longitudinal dialysis outcomes in older New Zealanders’ study were analyzed to determine if HRQoL at baseline predicted disability outcomes 12 months later.Results:Of the 223 participants at baseline, 157 participants completed a follow-up interview 12 months later. Individuals with “considerable disability” at baseline had a significantly (86%) higher risk of experiencing “considerable disability” at 12 months compared with those with “lesser/no disability” at baseline. Two thirds of those with ≥3 comorbidities were experiencing “considerable disability.” In addition, those with problems with EQ-5D-3L self-care, EQ-5D-3L usual activities, and EQ-5D-3L anxiety/depression reported higher rates of disability.Limitations:Selection bias is likely to have been an issue in this study as participants were excluded from the follow-up interview if they had an intercurrent illness requiring hospitalization within 2 weeks of the survey interview or if the treating nephrologist judged that the individual’s ability to take part was significantly impaired. Sample size meant there were a limited number of explanatory/confounding variables that could be investigated in the multivariable model.Conclusions:EQ-5D-3L mobility and self-care may be useful in predicting subsequent disability for individuals with CKD 5G. Although individuals with kidney failure often experience disability, previous studies have not clearly identified HRQoL or disability as predictors of later disability for individuals with kidney failure. Therefore, we would recommend the assessment of mobility and self-care, in conjunction with existing disabilities in the clinical review and pre-dialysis education of individuals with kidney failure as they approach the need for kidney replacement therapy.Trial registration: the Australian and New Zealand clinical trials registry: ACTRN12611000024943.

Occupational health and safety cases in the New Zealand District Court

Occupational health and safety (OHS) practitioners need to understand prosecutions that have been before the District Court if they are to provide informed guidance about compliance with the New Zealand (NZ) Health and Safety at Work Act (HSWA) to “persons having control of a business or undertaking” (PCBUs). However, if they cannot access academic databases, they may need to rely on individual reports of a few cases but may not have the time or resources to develop their own database. Those who are studying for a tertiary level qualification may also lack the time to find and catalogue more than a few cases.&#x0D; This short article reports on the first stage of the development and analysis of a dataset of prosecutions under NZ OHS legislation. We describe our data sources and a high-level analysis of the dataset and issues to be resolved before proceeding with further data analysis. This work also forms part of research into “grey literature” and its use in practice by OHS practitioners and professionals.&#x0D; We conclude by showing the disparity between prosecutions and deaths due to occupational disease and trauma (leading to an area for further research) and loop back to one of the origins for this research: the meaning of a safe system of work.

Implementing and evaluating the Bridges stroke self-management programme into a New Zealand district health board stroke service: A case study

Implementing and evaluating the Bridges stroke self-management programme into a New Zealand district health board stroke service: A case study

The cost of investigating weight-related comorbidities in children and adolescents in Aotearoa/New Zealand.

Expert recommendations for child/adolescent obesity include extensive investigation for weight-related comorbidities, based on body mass index (BMI) percentile cut-offs. This study aimed to estimate the cost of initial investigations for weight-related comorbidities in children/adolescents with obesity, according to international expert guidelines. The annual mean cost of investigations for weight-related comorbidities in children/adolescents was calculated from a health-funder perspective using 2019 cost data obtained from three New Zealand District Health Boards. Prevalence data for child/adolescent obesity (aged 2-14 years) were obtained from the New Zealand Health Survey (2017/2018), and prevalence of weight-related comorbidities requiring further investigation were obtained from a previous New Zealand study of a cohort of children with obesity. The cost of initial laboratory screening for weight-related comorbidities per child was NZD 28.36. Based on national prevalence data from 2018/2019 for children with BMI greater than the 98th percentile (obesity cut-off), the total annual cost for initial laboratory screening for weight-related comorbidities in children/adolescents aged 2-14 years with obesity was estimated at NZD 2,665,840. The cost of further investigation in the presence of risk factors was estimated at NZD 2,972,934. Investigating weight-related comorbidities in New Zealand according to international expert guidelines is resource-intensive. Ways to further determine who warrants investigation with an individualised approach are required.

Therapeutic granulocyte infusion for patients with severe neutropaenia and neutrophilic dysfunction: New Zealand experience.

Studies have shown granulocyte transfusions (GTXs) may be beneficial in neutropaenic patients with severe systemic infections. New Zealand Blood Service has a policy for provision of granulocytes to New Zealand's District Health Boards. We set out to explore utilization of therapeutic granulocyte infusions in New Zealand. Patients who received GTXs in the 16-year period between 2000 and 2016 were identified by the New Zealand electronic blood management system, eProgesa. Information pertaining to recipient demographics, disease-related factors, methods of granulocyte collection and clinical outcomes was obtained by the review of electronic transfusion and clinical records. Forty-five septic patients received granulocyte support for a total of 263 days. The median age of the recipients was 16 (range 0-74) years. Seventy-nine percent of the recipients had an underlying haematological malignancy with 50% having acute leukaemia. The median neutrophil count on the last day of GTX was 0.02 × 109 /L (range 0-16.32). Sixty-three percent (27/43 patients with available data) had persisting severe neutropaenia when the GTXs were stopped. The median duration of support was 3 (range 1-32) days. Forty-six percent of granulocyte collections were performed via apheresis. Of the 44 patients, for whom survival outcome was available, 18 (41%) survived the acute illness. GTXs were infrequently used, most commonly in the setting of an underlying haematological malignancy. This may be explained by the current weak evidence base supporting this therapeutic modality. Procuring a sufficiently large dose of granulocytes for infusion remains an issue for adult recipients.

Management of Adults with Acute Oesophageal Soft Food Bolus and Foreign Body Obstructions at Two New Zealand District Health Boards

Aim1. Investigate the characteristics of adult patients presenting with acute oesophageal soft food bolus obstruction (SFBO) and impacted foreign body (IFB) at two New Zealand district health boards (DHBs). 2. Review current management against international guidelines for SFBO and IFB.MethodsA multicentre retrospective search of the Provation® endoscopy database identified patients presenting with acute oesophageal obstruction. Utilising electronic patient records, key data points including patient demographics, risk factors, pre-endoscopic medical therapies utilised, diagnostic radiological investigations performed and endoscopic complications were identified. Key timepoints and delays in the patient’s hospital journey from oesophageal obstruction to therapeutic endoscopy were recorded. The probability of failing to undergo therapeutic endoscopy for SFBO within the timeframes advised in clinical guidelines as a result of a delay in referral to the endoscopy service was calculated.ResultsOver a cumulative 10.5-year period of data collection, 227 oesophago-gastro-duodenoscopies were performed: 195 SFBO, 16 IFB, 16 no obstruction identified. Median patient age was 57 (15–95) years. 143 male and 84 female patients. Radiographs were performed in 50.9% of uncomplicated SFBO. Pre-endoscopy medical therapies were administered in 41.4% of the cases. Median time delay from onset of obstruction to therapeutic endoscopy varied: SFBO 19h 0min, complete obstruction 17h 45min, impacted batteries 1h 15min, and presumed sharp objects 6h 0min. Three patients presenting with a soft food bolus obstruction failed to undergo therapeutic endoscopy due to a delay in referral to the endoscopy service, probability 0.034 (95% CI 0.012, 0.095). Two patients died of complications secondary to oesophageal obstruction.DiscussionOesophageal obstruction is a common gastroenterological presentation. At two large centres in New Zealand, patients waited considerably longer than the recommended timeframe from obstruction to therapeutic endoscopy. Contributing factors included patient-related delays to presentation, hospital system-related factors and delays in referral for endoscopy contributed to by unnecessary pre-endoscopic medical therapies and radiographic investigations. Education about oesophageal obstruction together with robust local guidelines have potential to reduce delays and length of hospital stay, as well as reduce patient discomfort and complications.