Higher early pregnancy plasma myo-inositol associates with increased postprandial glycaemia later in pregnancy: Secondary analyses of the NiPPeR randomized controlled trial

AIM

Myo-inositol supplementation from ~13 weeks' gestation reportedly improves glycaemia regulation in metabolically at-risk women, with speculation that earlier supplementation might bring further improvement. However, the NiPPeR trial of a myo-inositol-containing supplement starting preconception did not lower gestational glycaemia in generally healthy women. We postulated that the earlier timing of supplementation influences the maternal metabolic adaptation for gestational glycaemia regulation.

METHODS

In total, 585 women were recruited from Singapore, UK and New Zealand for the NiPPeR study. We examined associations of plasma myo-inositol concentrations at 7 and 28 weeks' gestation with 28 weeks plasma glucose (PG; fasting, and 1 h and 2 h in 75 g oral glucose tolerance test) and insulin indices using linear regression adjusting for covariates.

RESULTS

Higher 7-week myo-inositol, but not 28-week myo-inositol, associated with higher 1 h PG [βadj (95% confidence intervals) 0.05 (0.01, 0.09) loge mmol/L per loge μmol/L, p = .022] and 2 h PG [0.08 (0.03, 0.12), p = .001]; equivalent to 0.39 mmol/L increase in 2 h PG for an average 7-week myo-inositol increase of 23.4 μmol/L with myo-inositol supplementation. Higher 7-week myo-inositol associated with a lower 28-week Stumvoll index (first phase), an approximation of insulin secretion [-0.08 (-0.15, -0.01), p = .020] but not with 28-week Matsuda insulin sensitivity index. However, the clinical significance of a 7-week myo-inositol-related increase in glycaemia was limited as there was no association with gestational diabetes risk, birthweight and cord C-peptide levels. In-silico modelling found higher 28-week myo-inositol was associated with lower gestational glycaemia in White, but not Asian, women after controlling for 7-week myo-inositol effects.

CONCLUSION

To our knowledge, our study provides the first evidence that increasing first trimester plasma myo-inositol may slightly exacerbate later pregnancy post-challenge glycaemia, indicating that the optimal timing for starting prenatal myo-inositol supplementation needs further investigation.

Hauora Māori - Māori health: a right to equal outcomes in primary care

BACKGROUND

For more than a century, Māori have experienced poorer health than non-Māori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by "failing to design and administer the current primary health care system to actively address persistent Māori health inequities". Many Māori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Māori-owned practices. We hypothesised patient health outcomes for Māori would differ between models of care.

METHODS

Cross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes.

PRIMARY OUTCOMES

polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Regressions include only Māori patients, across all models of care.

RESULTS

A total of 660,752 Māori patients were enrolled in 924 practices with 124,854 in 65 Māori-owned practices. Māori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points). Māori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients. The average Māori practice had 52% Māori patients compared to 12% across all practices. Māori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity. More Māori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Māori patients were more likely to be dispensed antibiotics or tramadol.

CONCLUSIONS

Māori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Māori, despite increased clinical input. Funding must support under-resourced Māori practices and ensure accountability for the health outcomes of Māori patients in all models of general practice.

Impact of preconception and antenatal supplementation with myo-inositol, probiotics, and micronutrients on offspring BMI and weight gain over the first 2 years

BACKGROUND

Nutritional intervention preconception and throughout pregnancy has been proposed as an approach to promoting healthy postnatal weight gain in the offspring but few randomised trials have examined this.

METHODS

Measurements of weight and length were obtained at multiple time points from birth to 2 years among 576 offspring of women randomised to receive preconception and antenatally either a supplement containing myo-inositol, probiotics, and additional micronutrients (intervention) or a standard micronutrient supplement (control). We examined the influence on age- and sex-standardised BMI at 2 years (WHO standards, adjusting for study site, sex, maternal parity, smoking and pre-pregnancy BMI, and gestational age), together with the change in weight, length, BMI from birth, and weight gain trajectories using latent class growth analysis.

RESULTS

At 2 years, there was a trend towards lower mean BMI among intervention offspring (adjusted mean difference [aMD] - 0.14 SD [95% CI 0.30, 0.02], p = 0.09), and fewer had a BMI > 95th percentile (i.e. > 1.65 SD, 9.2% vs 18.0%, adjusted risk ratio [aRR] 0.51 [95% CI 0.31, 0.82], p = 0.006). Longitudinal data revealed that intervention offspring had a 24% reduced risk of experiencing rapid weight gain > 0.67 SD in the first year of life (21.9% vs 31.1%, aRR 0.76 [95% CI 0.58, 1.00], p = 0.047). The risk was likewise decreased for sustained weight gain > 1.34 SD in the first 2 years of life (7.7% vs 17.1%, aRR 0.55 [95% CI 0.34, 0.88], p = 0.014). From five weight gain trajectories identified, there were more intervention offspring in the "normal" weight gain trajectory characterised by stable weight SDS around 0 SD from birth to 2 years (38.8% vs 30.1%, RR 1.29 [95% CI 1.03, 1.62], p = 0.029).

CONCLUSIONS

Supplementation with myo-inositol, probiotics, and additional micronutrients preconception and in pregnancy reduced the incidence of rapid weight gain and obesity at 2 years among offspring. Previous reports suggest these effects will likely translate to health benefits, but longer-term follow-up is needed to evaluate this.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02509988 (Universal Trial Number U1111-1171-8056). Registered on 16 July 2015.

Maternal B-vitamin and vitamin D status before, during, and after pregnancy and the influence of supplementation preconception and during pregnancy: Prespecified secondary analysis of the NiPPeR double-blind randomized controlled trial

BACKGROUND

Maternal vitamin status preconception and during pregnancy has important consequences for pregnancy outcome and offspring development. Changes in vitamin status from preconception through early and late pregnancy and postpartum have been inferred from cross-sectional data, but longitudinal data on vitamin status from preconception throughout pregnancy and postdelivery are sparse. As such, the influence of vitamin supplementation on vitamin status during pregnancy remains uncertain. This study presents one prespecified outcome from the randomized controlled NiPPeR trial, aiming to identify longitudinal patterns of maternal vitamin status from preconception, through early and late pregnancy, to 6 months postdelivery, and determine the influence of vitamin supplementation.

METHODS AND FINDINGS

In the NiPPeR trial, 1,729 women (from the United Kingdom, Singapore, and New Zealand) aged 18 to 38 years and planning conception were randomized to receive a standard vitamin supplement (control; n = 859) or an enhanced vitamin supplement (intervention; n = 870) starting in preconception and continued throughout pregnancy, with blinding of participants and research staff. Supplement components common to both treatment groups included folic acid, β-carotene, iron, calcium, and iodine; components additionally included in the intervention group were riboflavin, vitamins B6, B12, and D (in amounts available in over-the-counter supplements), myo-inositol, probiotics, and zinc. The primary outcome of the study was glucose tolerance at 28 weeks' gestation, measured by oral glucose tolerance test. The secondary outcome reported in this study was the reduction in maternal micronutrient insufficiency in riboflavin, vitamin B6, vitamin B12, and vitamin D, before and during pregnancy. We measured maternal plasma concentrations of B-vitamins, vitamin D, and markers of insufficiency/deficiency (homocysteine, hydroxykynurenine-ratio, methylmalonic acid) at recruitment, 1 month after commencing intervention preconception, in early pregnancy (7 to 11 weeks' gestation) and late pregnancy (around 28 weeks' gestation), and postdelivery (6 months after supplement discontinuation). We derived standard deviation scores (SDS) to characterize longitudinal changes among participants in the control group and measured differences between the 2 groups. At recruitment, the proportion of patients with marginal or low plasma status was 29.2% for folate (<13.6 nmol/L), 7.5% and 82.0% for riboflavin (<5 nmol/L and ≤26.5 nmol/L, respectively), 9.1% for vitamin B12 (<221 pmol/L), and 48.7% for vitamin D (<50 nmol/L); these proportions were balanced between the groups. Over 90% of all participants had low or marginal status for one or more of these vitamins at recruitment. Among participants in the control group, plasma concentrations of riboflavin declined through early and late pregnancy, whereas concentrations of 25-hydroxyvitamin D were unchanged in early pregnancy, and concentrations of vitamin B6 and B12 declined throughout pregnancy, becoming >1 SDS lower than baseline by 28 weeks gestation. In the control group, 54.2% of participants developed low late-pregnancy vitamin B6 concentrations (pyridoxal 5-phosphate <20 nmol/L). After 1 month of supplementation, plasma concentrations of supplement components were substantially higher among participants in the intervention group than those in the control group: riboflavin by 0.77 SDS (95% CI 0.68 to 0.87, p < 0.0001), vitamin B6 by 1.07 SDS (0.99 to 1.14, p < 0.0001), vitamin B12 by 0.55 SDS (0.46 to 0.64, p < 0.0001), and vitamin D by 0.51 SDS (0.43 to 0.60, p < 0.0001), with higher levels in the intervention group maintained during pregnancy. Markers of vitamin insufficiency/deficiency were reduced in the intervention group, and the proportion of participants with vitamin D insufficiency (<50 nmol/L) during late pregnancy was lower in the intervention group (35.1% versus 8.5%; p < 0.0001). Plasma vitamin B12 remained higher in the intervention group than in the control group 6 months postdelivery (by 0.30 SDS (0.14, 0.46), p = 0.0003). The main limitation is that generalizability to the global population is limited by the high-resource settings and the lack of African and Amerindian women in particular.

CONCLUSIONS

Over 90% of the trial participants had marginal or low concentrations of one or more of folate, riboflavin, vitamin B12, or vitamin D during preconception, and many developed markers of vitamin B6 deficiency in late pregnancy. Preconception/pregnancy supplementation in amounts available in over-the-counter supplements substantially reduces the prevalence of vitamin deficiency and depletion markers before and during pregnancy, with higher maternal plasma vitamin B12 maintained during the recommended lactational period.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02509988; U1111-1171-8056.

Prediction of fat-free mass in young children using bioelectrical impedance spectroscopy

BACKGROUND

Bioimpedance devices are practical for measuring body composition in preschool children, but their application is limited by the lack of validated equations.

OBJECTIVES

To develop and validate fat-free mass (FFM) bioimpedance prediction equations among New Zealand 3.5-year olds, with dual-energy X-ray absorptiometry (DXA) as the reference method.

METHODS

Bioelectrical impedance spectroscopy (SFB7, ImpediMed) and DXA (iDXA, GE Lunar) measurements were conducted on 65 children. An equation incorporating weight, sex, ethnicity, and impedance was developed and validated. Performance was compared with published equations and mixture theory prediction.

RESULTS

The equation developed in ~70% (n = 45) of the population (FFM [kg] = 1.39 + 0.30 weight [kg] + 0.39 length²/resistance at 50 kHz [cm²/Ω] + 0.30 sex [M = 1/F = 0] + 0.28 ethnicity [1 = Asian/0 = non-Asian]) explained 88% of the variance in FFM and predicted FFM with a root mean squared error of 0.39 kg (3.4% of mean FFM). When internally validated (n = 20), bias was small (40 g, 0.3% of mean FFM), with limits of agreement (LOA) ±7.6% of mean FFM (95% LOA: -0.82, 0.90 kg). Published equations evaluated had similar LOA, but with marked bias (>12.5% of mean FFM) when validated in our cohort, likely due to DXA differences. Of mixture theory methods assessed, the SFB7 inbuilt equation with personalized body geometry values performed best. However, bias and LOA were larger than with the empirical equations (-0.43 kg [95% LOA: -1.65, 0.79], p < 0.001).

CONCLUSIONS

We developed and validated a bioimpedance equation that can accurately predict FFM. Further external validation of the equation is required.

Time-to-conception and clinical pregnancy rate with a myo-inositol, probiotics, and micronutrient supplement: secondary outcomes of the NiPPeR randomized trial

OBJECTIVE

To determine whether a combined myo-inositol, probiotics and micronutrient nutritional supplement impacts time-to-natural-conception and clinical pregnancy rates.

DESIGN

Secondary outcomes of a double-blind randomized controlled trial.

SETTING

Community recruitment.

PATIENTS

Women aged 18 to 38 years planning to conceive in the United Kingdom, Singapore, and New Zealand, excluding those with diabetes mellitus or receiving fertility treatment.

INTERVENTION

A standard (control) supplement (folic acid, iron, calcium, iodine, β-carotene), compared with an intervention additionally containing myo-inositol, probiotics, and other micronutrients (vitamins B2, B6, B12, D, zinc).

MAIN OUTCOME MEASURES

Number of days between randomization and estimated date of natural conception of a clinical pregnancy, as well as cumulative pregnancy rates at 3, 6, and 12 months.

RESULTS

Of 1729 women randomized, 1437 (83%; intervention, n=736; control, n=701) provided data. Kaplan-Meier curves of conception were similar between intervention and control groups; the time at which 20% achieved natural conception was 90.5 days (95% confidence interval: 80.7, 103.5) in the intervention group compared with 92.0 days (76.0, 105.1) in the control group. Cox's proportional hazard ratios (HRs) comparing intervention against control for cumulative achievement of pregnancy (adjusted for site, ethnicity, age, body mass index, and gravidity) were similar at 3, 6, and 12 months. Among both study groups combined, overall time-to-conception lengthened with higher preconception body mass index, and was longer in non-White than in White women. Among women who were overweight the intervention shortened time-to-conception compared with control regardless of ethnicity (12-month HR=1.47 [1.07, 2.02], P=.016; 20% conceived by 84.5 vs. 117.0 days) and improved it to that comparable to nonoverweight/nonobese women (20% conceived by 82.1 days). In contrast, among women with obesity, time-to-conception was lengthened with intervention compared with control (12-month HR=0.69 [0.47, 1.00]; P=.053; 20% conceived by 132.7 vs. 108.5 days); an effect predominantly observed in non-White women with obesity.

CONCLUSIONS

Time-to-natural-conception and clinical pregnancy rates within a year were overall similar in women receiving the intervention supplement compared with control. Overweight women had a longer time-to-conception but there was suggestion that the supplement may shorten their time-to-conception to that comparable to the nonoverweight/nonobese women. Further studies are required to confirm this.

CLINICAL TRIAL REGISTRATION NUMBER

clinicaltrials.gov (NCT02509988).

Is there equity of patient health outcomes across models of general practice in Aotearoa New Zealand? A national cross-sectional study

BACKGROUND

Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care.

METHODS

We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response.

RESULTS

The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes.

CONCLUSIONS

Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care.

The effect of a preconception and antenatal nutritional supplement on children's BMI and weight gain over the first 2 years of life: findings from the NiPPeR randomised controlled trial

BACKGROUND

Nutritional intervention before and throughout pregnancy might promote healthy infant weight gain; however, clinical evidence is scarce. Therefore, we examined whether preconception and antenatal supplementation would affect the body size and growth of children in the first 2 years of life.

METHODS

Women were recruited from the community before conception in the UK, Singapore, and New Zealand, and randomly allocated to either the intervention (myo-inositol, probiotics, and additional micronutrients) or control group (standard micronutrient supplement) with stratification by site and ethnicity. Measurements of weight and length were obtained from 576 children at multiple timepoints in the first 2 years of life. Differences in age and sex standardised BMI at age 2 years (WHO standards) and the change in weight from birth were examined. Written informed consent was obtained from the mothers, and ethics approval was granted by local committees. The NiPPeR trial was registered with ClinicalTrials.gov (NCT02509988) on July 16, 2015 (Universal Trial Number U1111-1171-8056).

FINDINGS

1729 women were recruited between Aug 3, 2015, and May 31, 2017. Of the women randomised, 586 had births at 24 weeks or more of gestation between April, 2016, and January, 2019. At age 2 years, adjusting for study site, infant sex, parity, maternal smoking, maternal prepregnancy BMI, and gestational age, fewer children of mothers who received the intervention had a BMI of more than the 95th percentile (22 [9%] of 239 vs 44 [18%] of 245, adjusted risk ratio 0·51, 95% CI 0·31-0·82, p=0·006). Longitudinal data revealed that the children of mothers who received the intervention had a 24% reduced risk of experiencing rapid weight gain of more than 0·67 SD in the first year of life (58 [21·9%] of 265 vs 80 [31·1%] of 257, adjusted risk ratio 0·76, 95% CI 0·58-1·00, p=0·047). Risk was likewise decreased for sustained weight gain of more than 1·34 SD in the first 2 years (19 [7·7%] of 246 vs 43 [17·1%] of 251, adjusted risk ratio 0·55, 95% CI 0·34-0·88, p=0·014).

INTERPRETATION

Rapid weight gain in infancy is associated with future adverse metabolic health. The intervention supplement taken before and throughout pregnancy was associated with lower risk of rapid weight gain and high BMI at age 2 years among children. Long-term follow-up is required to assess the longevity of these benefits.

FUNDING

National Institute for Health Research; New Zealand Ministry of Business, Innovation and Employment; Société Des Produits Nestlé; UK Medical Research Council; Singapore National Research Foundation; National University of Singapore and the Agency of Science, Technology and Research; and Gravida.

Peripartum outcomes after combined myo-inositol, probiotics, and micronutrient supplementation from preconception: the NiPPeR randomized controlled trial

BACKGROUND

Evidence that nutritional supplementation before and during pregnancy improves peripartum outcomes is sparse. In the Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose Metabolism and Offspring Health (NiPPeR) trial, we previously reported that a combined myo-inositol, probiotics, and micronutrient supplement started at preconception showed no difference in the primary outcome of gestational glycemia, but did reduce the risk of preterm delivery, preterm prelabor rupture of membranes, and major postpartum hemorrhage.

OBJECTIVE

This study aimed to examine the hypothesis that a reduction in major postpartum hemorrhage following a combined nutritional (myo-inositol, probiotics, and micronutrients) intervention is linked with promotion of labor progress and reduced operative delivery.

STUDY DESIGN

This double-blind randomized controlled trial recruited 1729 women from the United Kingdom, Singapore, and New Zealand, aged 18 to 38 years, and planning conception between 2015 and 2017. The effects of the nutritional intervention compared with those of a standard micronutrient supplement (control), taken at preconception and throughout pregnancy, were examined for the secondary outcomes of peripartum events using multinomial, Poisson, and linear regression adjusting for site, ethnicity, and important covariates.

RESULTS

Of the women who conceived and progressed beyond 24 weeks' gestation with a singleton pregnancy (n=589), 583 (99%) provided peripartum data. Between women in the intervention (n=293) and control (n=290) groups, there were no differences in rates of labor induction, oxytocin augmentation during labor, instrumental delivery, perineal trauma, and intrapartum cesarean delivery. Although duration of the first stage of labor was similar, the second-stage duration was 20% shorter in the intervention than in the control group (adjusted mean difference, -12.0 [95% confidence interval, -22.2 to -1.2] minutes; P=.029), accompanied by a reduction in operative delivery for delayed second-stage progress (adjusted risk ratio, 0.61 [0.48-0.95]; P=.022). Estimated blood loss was 10% lower in the intervention than in the control group (adjusted mean difference, -35.0 [-70.0 to -3.5] mL; P=.047), consistent with previous findings of reduced postpartum hemorrhage.

CONCLUSION

Supplementation with a specific combination of myo-inositol, probiotics, and micronutrients started at preconception and continued in pregnancy reduced the duration of the second stage of labor, the risk of operative delivery for delay in the second stage, and blood loss at delivery.

Prediction of fat-free mass in a multi-ethnic cohort of infants using bioelectrical impedance: Validation against the PEA POD

Background

Bioelectrical impedance analysis (BIA) is widely used to measure body composition but has not been adequately evaluated in infancy. Prior studies have largely been of poor quality, and few included healthy term-born offspring, so it is unclear if BIA can accurately predict body composition at this age.

Aim

This study evaluated impedance technology to predict fat-free mass (FFM) among a large multi-ethnic cohort of infants from the United Kingdom, Singapore, and New Zealand at ages 6 weeks and 6 months (n = 292 and 212, respectively).

Materials and methods

Using air displacement plethysmography (PEA POD) as the reference, two impedance approaches were evaluated: (1) empirical prediction equations; (2) Cole modeling and mixture theory prediction. Sex-specific equations were developed among ∼70% of the cohort. Equations were validated in the remaining ∼30% and in an independent University of Queensland cohort. Mixture theory estimates of FFM were validated using the entire cohort at both ages.

Results

Sex-specific equations based on weight and length explained 75-81% of FFM variance at 6 weeks but only 48-57% at 6 months. At both ages, the margin of error for these equations was 5-6% of mean FFM, as assessed by the root mean squared errors (RMSE). The stepwise addition of clinically-relevant covariates (i.e., gestational age, birthweight SDS, subscapular skinfold thickness, abdominal circumference) improved model accuracy (i.e., lowered RMSE). However, improvements in model accuracy were not consistently observed when impedance parameters (as the impedance index) were incorporated instead of length. The bioimpedance equations had mean absolute percentage errors (MAPE) < 5% when validated. Limits of agreement analyses showed that biases were low (< 100 g) and limits of agreement were narrower for bioimpedance-based than anthropometry-based equations, with no clear benefit following the addition of clinically-relevant variables. Estimates of FFM from BIS mixture theory prediction were inaccurate (MAPE 11-12%).

Conclusion

The addition of the impedance index improved the accuracy of empirical FFM predictions. However, improvements were modest, so the benefits of using bioimpedance in the field remain unclear and require further investigation. Mixture theory prediction of FFM from BIS is inaccurate in infancy and cannot be recommended.

Cross-calibration of two dual-energy X-ray absorptiometry devices for the measurement of body composition in young children

This study aimed to cross-calibrate body composition measures from the GE Lunar Prodigy and GE Lunar iDXA in a cohort of young children. 28 children (mean age 3.4 years) were measured on the iDXA followed by the Prodigy. Prodigy scans were subsequently reanalysed using enCORE v17 enhanced analysis ("Prodigy enhanced"). Body composition parameters were compared across three evaluation methods (Prodigy, Prodigy enhanced, iDXA), and adjustment equations were developed. There were differences in the three evaluation methods for all body composition parameters. Body fat percentage (%BF) from the iDXA was approximately 1.5-fold greater than the Prodigy, whereas bone mineral density (BMD) was approximately 20% lower. Reanalysis of Prodigy scans with enhanced software attenuated these differences (%BF: - 5.2% [95% CI - 3.5, - 6.8]; and BMD: 1.0% [95% CI 0.0, 1.9]), although significant differences remained for all parameters except total body less head (TBLH) total mass and TBLH BMD, and some regional estimates. There were large differences between the Prodigy and iDXA, with these differences related both to scan resolution and software. Reanalysis of Prodigy scans with enhanced analysis resulted in body composition values much closer to those obtained on the iDXA, although differences remained. As manufacturers update models and software, researchers and clinicians need to be aware of the impact this may have on the longitudinal assessment of body composition, as results may not be comparable across devices and software versions.

Evaluating diabetes care quality improvement strategies used by clinical teams in five primary care practices in New Zealand

BACKGROUND

Diabetes care is often sub-optimal. Quality improvement (QI) initiatives are intended to improve care processes and thereby improve patient outcomes. There is a need to assess the degree of implementation of QI strategies, as a prerequisite to managing implementation.

AIMS

Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders).

METHODS

A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice.

RESULTS

Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process.

CONCLUSIONS

It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible.

Bioelectrical impedance analysis for assessment of body composition in infants and young children-A systematic literature review

Bioelectrical impedance analysis (BIA) is an easy to use, portable tool, but the accuracy of the technique in infants and young children (<24 months) remains unclear. A systematic literature review was conducted to identify studies that have developed and validated BIA equations in this age group. MEDLINE, Scopus, EMBASE, and CENTRAL were searched for relevant literature published up until June 30, 2020, using terms related to bioelectrical impedance, body composition, and paediatrics. Two reviewers independently screened studies for eligibility, resulting in 15 studies that had developed and/or validated equations. Forty-six equations were developed and 34 validations were conducted. Most equations were developed in young infants (≤6 months), whereas only seven were developed among older infants and children (6-24 months). Most studies were identified as having a high risk of bias, and only a few included predominantly healthy children born at term. Using the best available evidence, BIA appears to predict body composition at least as well as other body composition tools; however, among younger infants BIA may provide little benefit over anthropometry-based prediction equations. Currently, none of the available equations can be recommended for use in research or in clinical practice.

The influence of body position on bioelectrical impedance spectroscopy measurements in young children

Bioelectrical impedance techniques are easy to use and portable tools for assessing body composition. While measurements vary according to standing vs supine position in adults, and fasting and bladder voiding have been proposed as additional important influences, these have not been assessed in young children. Therefore, the influence of position, fasting, and voiding on bioimpedance measurements was examined in children. Bioimpedance measurements (ImpediMed SFB7) were made in 50 children (3.38 years). Measurements were made when supine and twice when standing (immediately on standing and after four minutes). Impedance and body composition were compared between positions, and the effect of fasting and voiding was assessed. Impedance varied between positions, but body composition parameters other than fat mass (total body water, intra- and extra-cellular water, fat-free mass) differed by less than 5%. There were no differences according to time of last meal or void. Equations were developed to allow standing measurements of fat mass to be combined with supine measurements. In early childhood, it can be difficult to meet requirements for fasting, voiding, and lying supine prior to measurement. This study provides evidence to enable standing and supine bioimpedance measurements to be combined in cohorts of young children.

Myo-Inositol, Probiotics, and Micronutrient Supplementation From Preconception for Glycemia in Pregnancy: NiPPeR International Multicenter Double-Blind Randomized Controlled Trial

OBJECTIVE

Better preconception metabolic and nutritional health are hypothesized to promote gestational normoglycemia and reduce preterm birth, but evidence supporting improved outcomes with nutritional supplementation starting preconception is limited.

RESEARCH DESIGN AND METHODS

This double-blind randomized controlled trial recruited from the community 1,729 U.K., Singapore, and New Zealand women aged 18-38 years planning conception. We investigated whether a nutritional formulation containing myo-inositol, probiotics, and multiple micronutrients (intervention), compared with a standard micronutrient supplement (control), taken preconception and throughout pregnancy could improve pregnancy outcomes. The primary outcome was combined fasting, 1-h, and 2-h postload glycemia (28 weeks gestation oral glucose tolerance test).

RESULTS

Between 2015 and 2017, participants were randomized to control (n = 859) or intervention (n = 870); 585 conceived within 1 year and completed the primary outcome (295 intervention, 290 control). In an intention-to-treat analysis adjusting for site, ethnicity, and preconception glycemia with prespecified P < 0.017 for multiplicity, there were no differences in gestational fasting, 1-h, and 2-h glycemia between groups (β [95% CI] log_e mmol/L intervention vs. control -0.004 [-0.018 to 0.011], 0.025 [-0.014 to 0.064], 0.040 [0.004-0.077], respectively). Between the intervention and control groups there were no significant differences in gestational diabetes mellitus (24.8% vs. 22.6%, adjusted risk ratio [aRR] 1.22 [0.92-1.62]), birth weight (adjusted β = 0.05 kg [-0.03 to 0.13]), or gestational age at birth (mean 39.3 vs. 39.2 weeks, adjusted β = 0.20 [-0.06 to 0.46]), but there were fewer preterm births (5.8% vs. 9.2%, aRR 0.43 [0.22-0.82]), adjusting for prespecified covariates.

CONCLUSIONS

Supplementation with myo-inositol, probiotics, and micronutrients preconception and in pregnancy did not lower gestational glycemia but did reduce preterm birth.

Delayed antibiotic prescribing for respiratory tract infections: individual patient data meta-analysis

OBJECTIVE

To assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect.

DESIGN

Systematic review and individual patient data meta-analysis.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing.

MAIN OUTCOME MEASURES

The primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale.

RESULTS

Data were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference -0.003, 95% confidence interval -0.12 to 0.11) or delayed versus no antibiotics (0.02, -0.11 to 0.15). Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13). A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group.

CONCLUSIONS

Delayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children.

STUDY REGISTRATION

PROSPERO CRD42018079400.

Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses

AIMS/HYPOTHESIS

Few studies examine the association between age at diagnosis and subsequent complications from type 2 diabetes. This paper aims to summarise the risk of mortality, macrovascular complications and microvascular complications associated with age at diagnosis of type 2 diabetes.

METHODS

Data were sourced from MEDLINE and All EBM (Evidence Based Medicine) databases from inception to July 2018. Observational studies, investigating the effect of age at diabetes diagnosis on macrovascular and microvascular diabetes complications in adults with type 2 diabetes were selected according to pre-specified criteria. Two investigators independently extracted data and evaluated all studies. If data were not reported in a comparable format, data were obtained from authors, presented as minimally adjusted ORs (and 95% CIs) per 1 year increase in age at diabetes diagnosis, adjusted for current age for each outcome of interest. The study protocol was recorded with PROSPERO International Prospective Register of Systematic Reviews (CRD42016043593).

RESULTS

Data from 26 observational studies comprising 1,325,493 individuals from 30 countries were included. Random-effects meta-analyses with inverse variance weighting were used to obtain the pooled ORs. Age at diabetes diagnosis was inversely associated with risk of all-cause mortality and macrovascular and microvascular disease (all p < 0.001). Each 1 year increase in age at diabetes diagnosis was associated with a 4%, 3% and 5% decreased risk of all-cause mortality, macrovascular disease and microvascular disease, respectively, adjusted for current age. The effects were consistent for the individual components of the composite outcomes (all p < 0.001).

CONCLUSIONS/INTERPRETATION

Younger, rather than older, age at diabetes diagnosis was associated with higher risk of mortality and vascular disease. Early and sustained interventions to delay type 2 diabetes onset and improve blood glucose levels and cardiovascular risk profiles of those already diagnosed are essential to reduce morbidity and mortality. Graphical abstract.

Bioelectrical Impedance Analysis-An Easy Tool for Quantifying Body Composition in Infancy?

There has been increasing interest in understanding body composition in early life and factors that may influence its evolution. While several technologies exist to measure body composition in infancy, the equipment is typically large, and thus not readily portable, is expensive, and requires a qualified operator. Bioelectrical impedance analysis shows promise as an inexpensive, portable, and easy to use tool. Despite the technique being widely used to assess body composition for over 35 years, it has been seldom used in infancy. This may be related to the evolving nature of the fat-free mass compartment during this period. Nonetheless, a number of factors have been identified that may influence bioelectrical impedance measurements, which, when controlled for, may result in more accurate measurements. Despite this, questions remain in infants regarding the optimal size and placement of electrodes, the standardization of normal hydration, and the influence of body position on the distribution of water throughout the body. The technology requires further evaluation before being considered as a suitable tool to assess body composition in infancy.

Understandings of disease among Pacific peoples with diabetes and end-stage renal disease in New Zealand

BACKGROUND

Compared with New Zealand Europeans, Pacific peoples in New Zealand develop type 2 diabetes at a higher rate and a younger age, and have 3.8 times higher incidence of end-stage renal disease (ESRD).

OBJECTIVE

To investigate contextual factors that shape understandings of disease for Pacific peoples with diabetes and ESRD.

METHODS

Focussed ethnography. In-depth interviews were conducted with 16 Pacific people on haemodialysis for diabetic ESRD, in Auckland, New Zealand. Study participants aged between 30 and 69 years old were of Samoan, Cook Islander, Tongan, Niuean or Tokelauan ethnicity. Thematic analysis was used to code and identify themes.

RESULTS

Participants were embedded in a multigenerational legacy of diabetes. The limited diabetes-related education of earlier generations influenced how future generations behaved and understood diabetes. Perceptions were compounded by additional factors including the invisibility of early-stage diabetes; misunderstandings of health risks during communication with health providers; and misunderstandings of multiple conditions' symptoms and management. Participants had limited engagement with health services until their diagnosis of ESRD acted as a trigger to change this behaviour. However, this trigger was not effective in itself-rather, it was in combination with relevant education delivered in a way that made sense to participants, given their current understandings.

CONCLUSIONS

Illness representations drive choices and behaviours with respect to self-management of diabetes and engagement with health services. Diabetes is often present in multiple generations of Pacific people; therefore, illness representations are developed and shared within a family. Changing illness representations requires engagement with the individual within a family context.

Self-management action and motivation of Pacific adults in New Zealand with end-stage renal disease

AIMS

To explore actions and motivations for self-management practices of Pacific adults following diagnosis of end stage renal disease (ESRD).

METHODS

Focused ethnography using in-depth interviews with 16 Pacific people on haemodialysis for diabetic ESRD, in Auckland, New Zealand. Study participants were of Samoan, Cook Islander, Tongan, Niuean, or Tokelauan ethnicity and aged between 30 to 69 years old. Thematic analysis was used to code and identify emergent themes.

RESULTS

All participants assumed active responsibility for their self-management following their diagnosis of ESRD. They reported positive differences in their current self-management behaviours, compared to pre-ESRD diagnosis. In the face of their terminal diagnosis, participant's motivations to self-manage their health were fuelled by hope; the hope to live long enough to change their family legacy of diabetes and ESRD. To achieve this, there was a dependency upon family members as a resource for self-management support. Yet at the same time, family members also had health concerns (including diabetes), and several participants themselves were carers for sick or elderly family members.

CONCLUSION

The growing number of members (within family units) progressing from moderate to late-stage diabetes raises concerns about the sustainability of future family support in Pacific families in New Zealand with histories of diabetes, ESRD, and other chronic diseases. While the burden upon informal carers (family) has been well documented throughout the past few decades, the dynamics of bi-directional carer support between (two or more) sick family members and their families have had less exposure. This has potentially significant implications for Pacific peoples in New Zealand, considering the increases in diabetes prevalence within their families.

Evaluating Glomerular Filtration Rate Slope as a Surrogate End Point for ESKD in Clinical Trials: An Individual Participant Meta-Analysis of Observational Data

BACKGROUND

Decline in eGFR is a biologically plausible surrogate end point for the progression of CKD in clinical trials. However, it must first be tested to ensure strong associations with clinical outcomes in diverse populations, including patients with higher eGFR.

METHODS

To investigate the association between 1-, 2-, and 3-year changes in eGFR (slope) with clinical outcomes over the long term, we conducted a random effects meta-analysis of 3,758,551 participants with baseline eGFR≥60 ml/min per 1.73 m² and 122,664 participants with eGFR<60 ml/min per 1.73 m² from 14 cohorts followed for an average of 4.2 years.

RESULTS

Slower eGFR decline by 0.75 ml/min per 1.73 m² per year over 2 years was associated with lower risk of ESKD in participants with baseline eGFR≥60 ml/min per 1.73 m² (adjusted hazard ratio, 0.70; 95% CI, 0.68 to 0.72) and eGFR<60 ml/min per 1.73 m² (0.71; 95% CI, 0.68 to 0.74). The relationship was stronger with 3-year slope. For a rapidly progressing population with predicted 5-year risk of ESKD of 8.3%, an intervention that reduced eGFR decline by 0.75 ml/min per 1.73 m² per year over 2 years would reduce the ESKD risk by 1.6%. For a hypothetical low-risk population with a predicted 5-year ESKD risk of 0.58%, the same intervention would reduce the risk by only 0.13%.

CONCLUSIONS

Slower decline in eGFR was associated with lower risk of subsequent ESKD, even in participants with eGFR≥60 ml/min per 1.73 m², but those with the highest risk would be expected to benefit the most.

HbA1c screening in the community: Lessons for safety and quality management of a point of care programme

AIM

To describe quality management processes and appropriate interpretation with respect to HbA_1c point-of-care (POC) testing in a national diabetes and cardiovascular risk screening programme.

METHODS

We compared HbA_1c results from capillary blood, measured by the cobas b 101 (Roche Diagnostics) POC testing system, with results from venous blood measured by accredited laboratory analysers to inform national screening practice and a (separately-reported) randomised controlled trial. Difference plots and regressions were used to aid interpretation around 40 and 50mmol/mol, the cut-offs used to identify "pre-diabetes" and diabetes in New Zealand.

RESULTS

After initial acceptable tests, subsequent batches delivered POC results that varied from laboratory HbA_1c by +6 to -14mmol/mol around the clinical cut-offs. Ten faulty batches of discs were recalled worldwide. POC testing was suspended in one region, as was the planned trial. The manufacturing defect was rectified, accuracy of the new batches was confirmed, and testing resumed.

CONCLUSION

POC testing must be conducted within stringent quality assurance processes prior to and while in use. Within such a system, POC testing for HbA_1c can be sufficiently accurate for screening and diagnosis of diabetes.

Delayed antibiotic prescribing for respiratory tract infections: protocol of an individual patient data meta-analysis

INTRODUCTION

Delayed prescribing can be a useful strategy to reduce antibiotic prescribing, but it is not clear for whom delayed prescribing might be effective. This protocol outlines an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) and observational cohort studies to explore the overall effect of delayed prescribing and identify key patient characteristics that are associated with efficacy of delayed prescribing.

METHODS AND ANALYSIS

A systematic search of the databases Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus and Web of Science was conducted to identify relevant studies from inception to October 2017. Outcomes of interest include duration of illness, severity of illness, complication, reconsultation and patient satisfaction. Study authors of eligible papers will be contacted and invited to contribute raw IPD data. IPD data will be checked against published data, harmonised and aggregated to create one large IPD database. Multilevel regression will be performed to explore interaction effects between treatment allocation and patient characteristics. The economic evaluation will be conducted based on IPD from the combined trial and observational studies to estimate the differences in costs and effectiveness for delayed prescribing compared with normal practice. A decision model will be developed to assess potential savings and cost-effectiveness in terms of reduced antibiotic usage of delayed prescribing and quality-adjusted life years.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Southampton Faculty of Medicine Research Ethics Committee (Reference number: 30068). Findings of this study will be published in peer-reviewed academic journals as well as General Practice trade journals and will be presented at national and international conferences. The results will have important public health implications, shaping the way in which antibiotics are prescribed in the future and to whom delayed prescriptions are issued.

PROSPERO REGISTRATION NUMBER

CRD42018079400.

Adiposity and risk of decline in glomerular filtration rate: meta-analysis of individual participant data in a global consortium

OBJECTIVE

To evaluate the associations between adiposity measures (body mass index, waist circumference, and waist-to-height ratio) with decline in glomerular filtration rate (GFR) and with all cause mortality.

DESIGN

Individual participant data meta-analysis.

SETTING

Cohorts from 40 countries with data collected between 1970 and 2017.

PARTICIPANTS

Adults in 39 general population cohorts (n=5 459 014), of which 21 (n=594 496) had data on waist circumference; six cohorts with high cardiovascular risk (n=84 417); and 18 cohorts with chronic kidney disease (n=91 607).

MAIN OUTCOME MEASURES

GFR decline (estimated GFR decline ≥40%, initiation of kidney replacement therapy or estimated GFR <10 mL/min/1.73 m²) and all cause mortality.

RESULTS

Over a mean follow-up of eight years, 246 607 (5.6%) individuals in the general population cohorts had GFR decline (18 118 (0.4%) end stage kidney disease events) and 782 329 (14.7%) died. Adjusting for age, sex, race, and current smoking, the hazard ratios for GFR decline comparing body mass indices 30, 35, and 40 with body mass index 25 were 1.18 (95% confidence interval 1.09 to 1.27), 1.69 (1.51 to 1.89), and 2.02 (1.80 to 2.27), respectively. Results were similar in all subgroups of estimated GFR. Associations weakened after adjustment for additional comorbidities, with respective hazard ratios of 1.03 (0.95 to 1.11), 1.28 (1.14 to 1.44), and 1.46 (1.28 to 1.67). The association between body mass index and death was J shaped, with the lowest risk at body mass index of 25. In the cohorts with high cardiovascular risk and chronic kidney disease (mean follow-up of six and four years, respectively), risk associations between higher body mass index and GFR decline were weaker than in the general population, and the association between body mass index and death was also J shaped, with the lowest risk between body mass index 25 and 30. In all cohort types, associations between higher waist circumference and higher waist-to-height ratio with GFR decline were similar to that of body mass index; however, increased risk of death was not associated with lower waist circumference or waist-to-height ratio, as was seen with body mass index.

CONCLUSIONS

Elevated body mass index, waist circumference, and waist-to-height ratio are independent risk factors for GFR decline and death in individuals who have normal or reduced levels of estimated GFR.

Mechanisms, contexts and points of contention: operationalizing realist-informed research for complex health interventions

Background

The concept of “mechanism” is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).

Methods

In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.

Results

We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.

Conclusions

We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

A brief campaign to prevent diabetic ketoacidosis in children newly diagnosed with type 1 diabetes mellitus: The NO-DKA Study

OBJECTIVE

New-onset diabetic ketoacidosis (NO-DKA) is entirely preventable with early recognition of the symptoms of type 1 diabetes mellitus (T1D). In this study, we aimed to assess whether a simple and easily delivered educational campaign could reduce the risk of DKA.

METHODS

A poster highlighting key features of new-onset T1D was delivered once a year over 2 years to mailboxes of over 460 000 individual residential households in the Auckland region (New Zealand). In the first year, the campaign poster was also delivered to all general practices in the region. Families of all newly diagnosed cases of T1D in children answered a brief questionnaire to ascertain whether the campaign reached them.

RESULTS

Over the 24-month period covered by this study, 132 new cases of T1D were diagnosed in children and adolescents in Auckland. There were 38 cases (28.8%) of DKA, which is similar to the average over the previous 5-year period (27.0%). The caregivers of three children reported both seeing the campaign poster and seeking medical attention as a result. None of these three children were in DKA at diagnosis; they were aged 6.3 to 9.7 years, and of New Zealand European ethnicity.

CONCLUSIONS

A non-targeted campaign to raise awareness of diabetes symptoms in youth led only a few caregivers to seek timely medical attention. Overall, this once-yearly untargeted campaign to raise awareness of diabetes symptoms in youth had limited impact. More effective strategies are required, possibly involving sustained targeted education of medical practitioners.

Understanding 'context' in the self-management of type 2 diabetes with comorbidities: A systematic review and realist evaluation

OBJECTIVE

To identify contextual factors that affect self-management of diabetes with comorbidities, and to evaluate in what way these factors affect self-management effectiveness.

METHODS

A systematic review of literature considered English language articles published within Medline, PsycINFO, Pubmed, CINAHL Plus, and Scopus databases that focussed on individuals' experiences of type 2 diabetes from primary intervention or observational studies. A realist evaluation approach was used to analyse themes identified within the literature. Context-mechanism-outcome theories were constructed to identify underlying contextual factors and to construct a model illustrating diabetes self-management effectiveness.

RESULTS

Of 1519 articles identified, 30 met inclusion criteria. Adherence was found to be the common mechanism that (within given contexts) determined self-management effectiveness. Limited financial resources were identified as the key context. Our model makes explicit a structural weaknesses of diabetes self-management.

CONCLUSIONS

Coping with diabetes in the context of people's lives requires attention to issues that are often outside the remit of the person with diabetes, the health care team, and the health system within which self-management is located. Realist evaluations illuminate programme mechanisms and fine-tune context. They aid initial understandings of how an intervention or programme is thought to work, in order to influence and (re)design (new) programmes.

Implementing Community Based Primary Healthcare for Older Adults with Complex Needs in Quebec, Ontario and New-Zealand: Describing Nine Cases

The aim of this paper is to set the foundation for subsequent empirical studies of the "Implementing models of primary care for older adults with complex needs" project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on "meso level" integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of community-based primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based.

AbstractsUnderstanding the impact of a QI intervention on newborn mortality in 3 central districts in Malawi: a post-hoc theory-based evaluationAdvancing Implementation Science for Quality and Safety in Primary Health Care: The Integrated Care for Older Adults with Complex Health Needs Study (iCOACH)

Introduction

A recent WHO multi-country study on maternal and newborn health concluded that there was no evidence of an association between high coverage with essential interventions and reduced mortality in health care facilities, or improvement in other outcomes.1 According to Horton the missing ingredient in this relation is quality of care.2 Quality improvement in healthcare has adopted techniques mainly from industries such as manufacturing and has been used widely in Europe and US. However, evidence of success of these techniques in healthcare is not very conclusive, especially in low and middle-income countries. There have been limited efforts to critically analyse the techniques used in quality improvement interventions. One of the main challenges in evaluating quality improvement is the complexity of the interventions themselves and the complex nature of the systems in which they are implemented. Robust evidence regarding quality improvement interventions for resource poor settings is generally lacking.

The MaiKhanda trial looked at the effect of QI interventions and community women's groups on maternal and newborn mortality in 3 central districts in Malawi.3 The impact evaluation measuring effect on newborn mortality for the QI interventions, using a cluster RCT approach, remained inconclusive. We use a Theory-Based Evaluation (TBE) approach to understand why improvement interventions undertaken by MaiKhanda for new-born care did not show an effect. Absence of effect could be attributed to a failure of theory, a failure of implementation, an evaluation failure or a combination of these.

Our primary objective was to understand the mechanisms by which the QI interventions worked (or not) and explore the interaction between the various factors that mediated the lack of effect on neonatal mortality that was observed in the cluster randomized control trial.

Methods

Our research strategy consisted of developing a post-hoc Theory of Change, consolidating and synthesizing all the available evidence using an appropriate framework, and analysing the program and implementation theory using theory based approaches to evaluation.

Data synthesis was conducted using the Consolidate Framework for Implementation Research (CFIR).4 The synthesis takes into consideration the various reports and documents accumulated through the life of the project and complements the process evaluation studies conducted during the same period. In doing so, it draws a picture of the intervention with a multi-dimensional perspective, which provides insights into the evolution of the project. The framework is very comprehensive covering 5 major domains and a range of constructs, not all of which were included in our study. As this was post-hoc analysis, the choice of constructs was based on the availability of data rather than prioritizing the key constructs to consider.

CFIR helps to produce structured and comprehensive data that is then used for analysing the program theory in relation to the intervention outcome. The program theory thus generated for the MaiKhanda intervention is compared with the program theories of the Michigan Keystone Project, which used similar collaborative methods to successfully reduce their central venous line blood stream infections in 106 participating ICUs.5 The rationale for such a comparison is that while the interventions per se are very unique and specific to their context, the program theories underlying the use of collaborative methods in both the interventions is the same and therefore comparable. Theories offer a higher level of abstraction that can be comparable across different settings.6

Results

The key finding from analysis of the program theory is that similar intervention strategies that triggered successful mechanisms for improvement in the Keystone Project failed to generate such mechanisms in MaiKhanda project.

The Model for Improvement used in MaiKhanda was built around Deming's improvement theory7 and Roger's diffusion of innovation theory.8 The former theory considers improvement as a product of subject matter knowledge and profound knowledge. Subject matter knowledge on essential and emergency newborn care was generally lacking among health care providers in Malawi. Similarly, understanding variations within the health systems is an acquired skill. While the implementing partners, provided ample opportunities for the Malawian health system to learn the Institute for Healthcare Improvement (IHI) model for improvement, in general, QI teams lacked capacity to collate data and analyse the variations between the health facilities. QI was a fairly new concept in Malawi and MaiKhanda's attempts to embed it within existing health system was limited by challenges of the health systems context, MaiKhanda's own organizational transition and QI and clinical capacity of health care providers.

The main challenge for MaiKhanda was to simultaneously implement and sustain the various change packages it had introduced in the different facilities. While there were isolated instances of successful intervention activities within MaiKhanda, it did not build enough momentum to generate mechanisms across a critical mass of the facilities that would eventually result in improved newborn outcomes. This can be attributed to the implementation strength, context and complexity of MaiKhanda's interventions. This is explored further using the implementation theory.

Implementation was based on diffusion theories where better performing facilities were to act as role models for other facilities to emulate. The cRCT design for measuring impact evaluation required a random allocation of the improvement facilities and this conflicted with innovation diffusion theories, which prescribed a gradual organic spread of the interventions by strategically engaging the innovators and early adapters.

Limitations of the evaluation design notwithstanding, the implementation strength characterized by the dose, duration, intensity and specificity of the intervention was sub-optimal.

Implementation strength is not the only factor triggering an intervention mechanism and cannot be measured independent of the intervention complexity or the intervention context. For example, MaiKhanda struggled to show an effect of its interventions, despite having a long pre-intervention period to refine its interventions, while the Michigan study produced results within 18 month period. This could be because of other factors related to intervention complexity such as the long implementation chain for intervention delivery, the subjective perception of the agency (QI teams) regarding QI and contextual factors such as organizational readiness, the health systems context, QI team capacity to deliver QI interventions and MaiKhanda's own internal capacity.

Human agency is at the heart of implementation and the intervention required a continuous and prolonged time and effort, than was anticipated, to engage and train the health facility QI teams on the improvement model.

One of the key factors affecting the uptake of strategies was MaiKhanda's positioning within the health system and the degree of influence it could exert on other actors. This factor has a significant role to play in country where projects are donor supported and perhaps also donor driven. The period of the intervention also saw MaiKhanda going through a period of rapid organizational transition, which affected intervention implementation on the ground. Furthermore, MaiKhanda's own understanding of QI concepts was evolving gradually and this coupled with its long implementation chain, influenced the subjective understanding of the QI teams regarding QI concepts. Health facility staff also lacked the necessary skills and knowledge related to management of newborn health.

Limited resources within the health facilities meant that gains achieved in some aspects of the intervention could not be sustained in the long run. External contextual factors such as fuel shortages contributed to poor implementation. Changes in policy such as government ban on TBAs, affected intervention uptake and resulted in an increase in health facility deliveries, overwhelming the already under-resourced staff capacity in the health facilities. It is conceivable that quality improvement was not on top of their priority list. But, ‘motivation’ to be involved in QI Collaboratives remained high. In resource constrained settings, ‘motivation’ can be influenced by the lure of personal incentives (such as per diems for attending workshops and meetings) as much as individual's commitment to broader social gains (ie reduction in newborn case fatality rates in their facility). The improvement model was competing against other existing models and it was difficult to get enough stakeholder commitment to the prescribed model as there were huge expectations fuelled by the poverty and poor governance structures and a culture of “perdiemitis” was prevalent in Malawian health care system.9

Discussion

As is evident from the study, a single research method will not be able to provide justice to evaluation of a complex set of factors that influence newborn outcomes. We propose a research strategy that includes developing a Theory of Change, followed by evaluation of the program theory, measuring implementation strength, analysing implementation theory and comparing this in relation to the outcomes of the intervention observed through the impact evaluation. The results arising from such a comprehensive evaluation will contribute to the growth of improvement science with the accumulation of knowledge and explanation rather than being just a bedrock of observational facts.

More generally, we propose that design, implementation and evaluation of QI activities, particularly in resource-poor settings, should consider five key principles i.e it should include whole systems thinking, accountability, participatory approach, should be evidence-based and adapt innovative methods.10

The impact of a point-of-care testing device on CVD risk assessment completion in New Zealand primary-care practice: A cluster randomised controlled trial and qualitative investigation

Objectives

To assess the effect of a point of care (POC) device for testing lipids and HbA_1c in addition to testing by community laboratory facilities (usual practice) on the completion of cardiovascular disease (CVD) risk assessments in general practice.

Methods

We conducted a pragmatic, cluster randomised controlled trial in 20 New Zealand general practices stratified by size and rurality and randomised to POC device plus usual practice or usual practice alone (controls). Patients aged 35–79 years were eligible if they met national guideline criteria for CVD risk assessment. Data on CVD risk assessments were aggregated using a web-based decision support programme common to each practice. Data entered into the on-line CVD risk assessment form could be saved pending blood test results. The primary outcome was the proportion of completed CVD risk assessments. Qualitative data on practice processes for CVD risk assessment and feasibility of POC testing were collected at the end of the study by interviews and questionnaire. The POC testing was supported by a comprehensive quality assurance programme.

Results

A CVD risk assessment entry was recorded for 7421 patients in 10 POC practices and 6217 patients in 10 control practices; 99.5% of CVD risk assessments had complete data in both groups (adjusted odds ratio 1.02 [95%CI 0.61–1.69]). There were major external influences that affected the trial: including a national performance target for CVD risk assessment and changes to CVD guidelines. All practices had invested in systems and dedicated staff time to identify and follow up patients to completion. However, the POC device was viewed by most as an additional tool rather than as an opportunity to review practice work flow and leverage the immediate test results for patient education and CVD risk management discussions. Shortly after commencement, the trial was halted due to a change in the HbA_1c test assay performance. The trial restarted after the manufacturing issue was rectified but this affected the end use of the device.

Conclusions

Performance incentives and external influences were more powerful modifiers of practice behaviours than the POC device in relation to CVD risk assessment completion. The promise of combining risk assessment, communication and management within one consultation was not realised. With shifts in policy focus, the utility of POC devices for patient engagement in CVD preventive care may be demonstrated if fully integrated into the clinical setting.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000607774

Patient resistance as a resource: candidate obstacles in diabetes consultations

This study uses conversation analysis to explore 'candidate obstacles', a practice observed in sequences of patient resistance to lifestyle advice within health professional consultations. This article presents illustrative analyses of selected data excerpts drawn from audio-visual recordings of 116 tracked consultations between health professionals and 34 patients newly diagnosed with type 2 diabetes mellitus in New Zealand. The analysis shows that in consultations where health promotion activities are central, patient resistance can provide space for patients to identify obstacles to their compliance with lifestyle advice. Identifying candidate obstacles provides opportunities for health professionals to align advice with concerns of patients and potentially improve patient outcomes.

Childhood immunisations in Northland, New Zealand: declining care and the journey through the immunisation pathway

AIM

In a region with high rates of immunisation refusal, we examine whether refusing an immunisation at 6 weeks (the first scheduled immunisation) predicts the pattern for subsequent scheduled immunisations, and the characteristics of those who declined these immunisations.

METHOD

We used data from the National Immunisation Register to identify 11,972 children born between 1 January 2009 and 31 December 2013 (inclusive), and who had their first immunisation (due at 6 weeks age) in Northland, New Zealand. At each immunisation event, individual vaccines are recorded as being delivered or declined. This cohort was 'followed' to determine which of these children received or declined the scheduled 3-month and 5-month immunisations.

RESULTS

Immunisation providers delivered a full immunisation programme to 10,828/11,927 (90%) of the cohort. Caregivers of 897 (7%) of children declined the 6-week vaccination. Of this group, 872 (97%) also declined the 3-month and 850 (95%) declined the 5-month immunisations, constituting 872/962 (91%) and 850/923 (92%) of all declined immunisations, respectively. In the decline group, there was variability with primary care practice, and differences according to ethnic group and deprivation profile.

CONCLUSION

Increasing Northland's immunisation coverage may require primary care providers to more actively engage with declining caregivers prior to the 3-month and 5-month vaccinations. Immunisation information and decision-making programmes targeted at parents and providers in the antenatal and prenatal period may also be of benefit, in addition to considering regulatory and incentive strategies.

Geography matters: the prevalence of diabetes in the Auckland Region by age, gender and ethnicity

AIM

To determine whether the prevalence of diagnosed diabetes in the greater Auckland Region varies by General Electoral District (GED).

METHODS

Using encrypted National Health Identifiers and record linkage of routine health datasets, we identified a regional cohort of people with diagnosed diabetes in 2011 from inpatient records and medication dispensing. The geographical unit of a person's residence (meshblock) was used to determine the GED of residence. We calculated prevalence estimates and 95% confidence intervals and used binary logistic regression to map geographical variations in diabetes.

RESULTS

An estimated 63,014 people had diagnosed diabetes in Auckland in 2011, a prevalence of 8.5% of the adult population ≥30 years of age. We found significant variation in diabetes prevalence by age, gender, ethnicity and GED. There was a more than five-fold difference in the unadjusted prevalence of diabetes by GED, ranging from 3.2% (3.1 to 3.4%) in the North Shore to 17.3% (16.8 to 17.7%) in Mangere. Such variations remained after binary logistic regression adjusting for socio-demographic variables. Compared to New Zealand Europeans, Indian people had the highest odds of having diabetes at 3.85 (3.73 to 3.97), while the odds of people living in the most deprived areas having diabetes was nearly twice that of those living in least deprived areas (OR 1.93, [1.87 to 1.99]). Geographic variations in diabetes remained after adjusting for socio-demographic circumstances: people living in GEDs in south-west Auckland were at least 60% more likely than people living in the North Shore GED to have diabetes.

CONCLUSIONS

There is significant variation in the prevalence of diabetes by GED in Auckland that persists across strata of age group, gender and ethnicity, and persists after controlling for these same variables. These inequities should prompt action by politicians, policymakers, funders, health providers and communities for interventions aimed at reducing such inequities. Geography and its implications on access to and availability of health resources appears to be a key driver of inequity in diabetes rates, supporting an argument for interventions based on geography, especially a public health rather than an individual risk approach.

Ethnicity and risk of lower limb amputation in people with Type 2 diabetes: a prospective cohort study

AIM

Lower limb amputation is a serious complication of diabetic foot disease and there are unexplained ethnic variations in incidence. This study investigates the risk of amputation among different ethnic groups after adjusting for demographic, socio-economic status and clinical variables.

METHODS

We used primary care data from a large national multi-ethnic cohort of patients with Type 2 diabetes in New Zealand and linked hospital records. The primary outcome was time from initial data collection to first lower limb amputation. Demographic variables included age of onset and duration since diabetes diagnosis, gender, ethnicity and socio-economic status. Clinical variables included smoking status, height and weight, blood pressure, HbA1c , total cholesterol/HDL ratio and albuminuria. Cox proportional hazards models were used.

RESULTS

There were 892 lower limb amputations recorded among 62 002 patients (2.11 amputations per 1000 person-years), followed for a median of 7.14 years (422 357 person-years). After adjusting for demographic and socio-economic variables and compared with Europeans, Māori had the highest risk [hazard ratio (HR) 1.84 (95%CI:1.54-2.19)], whereas East Asians [HR 0.18, (0.08-0.44)] and South Asians [HR 0.39 (0.22-0.67)] had the lowest risk. Adjusting for available clinical variables reduced the differences but they remained substantial [HR 1.61 (1.35-1.93), 0.23 (0.10-0.56) and 0.48 (0.27-0.83), respectively].

CONCLUSIONS

Ethnic groups had significantly different risk of lower limb amputation, even after adjusting for demographic and some major clinical risk factors. Barriers to care should be addressed and intensive prevention strategies known to reduce the incidence of lower limb amputations could be prioritized to those at greatest risk.

Gestational diabetes mellitus screening, management and outcomes in the Cook Islands

AIM

To describe current practices for screening for gestational diabetes mellitus in the Cook Islands and consider the implications of alternative screening strategies.

METHODS

Eligible women had antenatal care from January 2009 to December 2012. A non-fasting 50 g glucose challenge between 24 and 28 weeks gestation (positive if 1-hour glucose greater than or equal to 7.8 mmol/L) was followed by a 75 g oral glucose tolerance test (gestational diabetes mellitus diagnosed if fasting glucose greater than or equal to 5.2 mmol/L or 2-hour glucose greater than or equal to 8.0 mmol/L; pregnancy impaired glucose tolerance if positive screen and negative diagnostic test).

RESULTS

Uptake of the screening programme rose from 49.0% to 99.6% by the end of the study period. 646 women had a glucose challenge; for 186/646 (28.8%) the challenge was positive; 183 had an oral glucose tolerance test; 89/646 (13.8%) had pregnancy impaired glucose tolerance; 94/646 (13.9%) had gestational diabetes mellitus. Median maternal weight gain was 6 kg (gestational diabetes mellitus) and 10 kg (normal glucose tolerance); caesarean section rates were 25% and 11% respectively; baby birthweights were not significantly different. 59 women with gestational diabetes mellitus had a post-natal glucose tolerance test at their 6-week check and 21 (35.6%) had diabetes confirmed.

CONCLUSION

The gestational diabetes mellitus screening programme has a high uptake and current management appears effective in reducing maternal and fetal weight gain. A proposed new screening programme is outlined.

Management of diabetes by primary health care nurses in Auckland, New Zealand

INTRODUCTION

The increasing prevalence of diabetes has led to expanded roles for primary health care nurses in diabetes management.

AIM

To describe and compare anthropometric and glycaemic characteristics of patients with diabetes and their management by practice nurses, district nurses and specialist nurses.

METHODS

Primary health care nurses in Auckland randomly sampled in a cross-sectional survey, completed a postal self-administered questionnaire (n=284) and telephone interview (n=287) between 2006 and 2008. Biographical and diabetes management details were collected for 265 (86%) of the total 308 patients with diabetes seen by participants on a randomly selected day.

RESULTS

Nurses were able to access key clinical information for only a proportion of their patients: weight for 68%; BMI for 16%; HbA1c for 76% and serum glucose levels for 34% (for either measure 82%); although most (96%) records were available about whether patients self-monitored blood glucose levels. Most nursing management activities focused on giving advice on dietary intake (70%) and physical activity (66%), weighing patients (58%), and testing or discussing blood glucose levels (42% and 43%, respectively). These proportions varied by nurse group (p<0.05), generally being highest for specialist nurses and lowest for district nurses.

DISCUSSION

Most practice and specialist nurses could access patients' weight and HbA1c levels and focused their clinical management on health education to decrease these if indicated. Communication and organisational systems and contracts that allow district nurses to work across both primary and secondary health services are necessary to improve community-based nursing services for patients with diabetes.

Management of diabetes by primary health care nurses in Auckland, New Zealand

INTRODUCTION: The increasing prevalence of diabetes has led to expanded roles for primary health care nurses in diabetes management. AIM: To describe and compare anthropometric and glycaemic characteristics of patients with diabetes and their management by practice nurses, district nurses and specialist nurses. METHODS: Primary health care nurses in Auckland randomly sampled in a cross-sectional survey, completed a postal self-administered questionnaire (n=284) and telephone interview (n=287) between 2006 and 2008. Biographical and diabetes management details were collected for 265 (86%) of the total 308 patients with diabetes seen by participants on a randomly selected day. RESULTS: Nurses were able to access key clinical information for only a proportion of their patients: weight for 68%; BMI for 16%; HbA1c for 76% and serum glucose levels for 34% (for either measure 82%); although most (96%) records were available about whether patients self-monitored blood glucose levels. Most nursing management activities focused on giving advice on dietary intake (70%) and physical activity (66%), weighing patients (58%), and testing or discussing blood glucose levels (42% and 43%, respectively). These proportions varied by nurse group (p<0.05), generally being highest for specialist nurses and lowest for district nurses. DISCUSSION: Most practice and specialist nurses could access patients' weight and HbA1c levels and focused their clinical management on health education to decrease these if indicated. Communication and organisational systems and contracts that allow district nurses to work across both primary and secondary health services are necessary to improve community-based nursing services for patients with diabetes. KEYWORDS: Blood glucose; diabetes mellitus type 1; diabetes mellitus type 2; nurses; primary health care; risk management

Do primary health care nurses address cardiovascular risk in diabetes patients?

AIMS

To identify factors associated with assessment and nursing management of blood pressure, smoking and other major cardiovascular risk factors by primary health care nurses in Auckland, New Zealand.

METHODS

Primary health care nurses (n = 287) were randomly sampled from the total (n=1091) identified throughout the Auckland region and completed a self-administered questionnaire (n = 284) and telephone interview. Nurses provided details for 86% (n =265) of all diabetes patients they consulted on a randomly selected day.

RESULTS

The response rate for nurses was 86%. Of the patients sampled, 183 (69%) patients had their blood pressure measured, particularly if consulted by specialist (83%) and practice (77%) nurses compared with district (23%, p = 0.0003). After controlling for demographic variables, multivariate analyses showed patients consulted by nurses who had identified stroke as a major diabetes-related complication were more likely to have their blood pressure measured, and those consulted by district nurses less likely. Sixteen percent of patients were current smokers. Patients consulted by district nurses were more likely to smoke while, those >66 years less likely. Of those who wished to stop, only 50% were offered nicotine replacement therapy. Patients were significantly more likely to be advised on diet and physical activity if they had their blood pressure measured (p < 0.0001).

CONCLUSIONS

Measurement of blood pressure and advice on diet or physical activity were not related to patient's cardiovascular risk profile and management of smoking cessation was far from ideal. Education of the community-based nursing workforce is essential to ensure cardiovascular risk management becomes integrated into diabetes management.

Diabetes knowledge of nurses providing community care for diabetes patients in Auckland, New Zealand

AIMS

To quantify and compare knowledge of diabetes including risk factors for diabetes-related complications among the three main groups of primary health care nurses.

METHODS

In a cross-sectional survey of practice, district and specialist nurses (n=1091) in Auckland, New Zealand, 31% were randomly sampled to complete a self-administered questionnaire and telephone interview, designed to ascertain nurses' knowledge of diabetes and best practice, in 2006-2008.

RESULTS

All 287 nurses (response rate 86%) completed the telephone interview and 284 the self-administered questionnaire. Major risk factors identified by nurses were excess body weight for type 2 diabetes (96%) and elevated plasma glucose levels or glycosylated haemoglobin (86%) for diabetes-related complications. In contrast, major cardiovascular risk factors were less well identified, particularly smoking, although by more specialist nurses (43%) than practice (14%) and district (12%) nurses (p=0.0005). Cardiovascular complications, particularly stroke, were less well known than microvascular complications, and by significantly fewer practice (13%) and district (8%) nurses than specialist nurses (36%, p=0.002).

CONCLUSIONS

In general, nurses had better knowledge of overweight as a risk factor for type 2 diabetes mellitus and elevated plasma glucose levels as a risk factor for diabetes-related complications compared with knowledge of cardiovascular risk factors, particularly smoking.

Foot examinations of diabetes patients by primary health care nurses in Auckland, New Zealand

AIMS

To identify factors associated with patients receiving foot examinations by primary health care nurses.

METHODS

A cross-sectional survey of 287 randomly sampled primary health care nurses, from a total of 1091 in Auckland, completed a postal self-administered questionnaire and telephone interview. Biographical and diabetes management details were collected for 265 diabetes patients consulted by the nurses on a randomly selected day.

RESULTS

A response rate of 86% was achieved. Nurses examined patient's feet in 46% of consultations. Controlling for demographic variables, foot examinations were associated with age, odds ratio (1.25, 95% CI 0.57-2.74) for patients aged 51-65 years and >66 years (2.50, 1.08-5.75) compared with those ≤50 years, consultations by district compared with practice nurses (14.23, 95% CI 3.82-53.05), special programme consultations compared with usual follow-up consults (8.81, 95% CI 2.99-25.93) and length of consultation (1.89, 0.72-4.97) for 15-30 min and (4.45, 95% CI 1.48-13.41) >30 min compared with consultations ≤15 min, or for wound care (2.58, 1.01-6.61).

CONCLUSIONS

Diabetes foot examinations by primary health care nurses varies greatly, and are associated with characteristics of the patient (age, need for wound care) and the consultation (district nurses, diabetes programme and duration).

Assessment without action; a randomised evaluation of the interRAI home care compared to a national assessment tool on identification of needs and service provision for older people in New Zealand

Comprehensive geriatric assessment (CGA) is considered the cornerstone of good practice, as it identifies need across multiple domains such as social, physical and psychological. The interRAI home care (interRAI-HC), probably the most well-researched and supported community-based CGA has been implemented globally, often at considerable expense. Policy-makers, managers and clinicians anticipate significant gains in health outcomes following such investment; however, the implementation of CGA is often undertaken in the absence of community service development. This study sought to compare the interRAI-HC with an existing CGA [the Support Needs Assessment (SNA)] in community-dwelling older people. A randomised controlled trial was undertaken from January 2006 to January 2007 comparing the interRAI-HC and the SNA in 316 people (65+) referred for assessment of needs with follow-up at 1 and 4 months. Outcomes included health-related quality of life, physical function, social support, cognitive status, mood and health service usage as well as identified need. The study found that significantly more support needs were identified using the interRAI-HC compared to the SNA. More social and carer support were recommended by SNA and more rehabilitation and preventive health screens were recommended by interRAI-HC. Despite these differences, the mean healthcare use was similar at 4 months, although interRAI-HC participants had more Emergency Department presentations and hospital admissions. No statistically significant differences between groups were reported in terms of outcomes. In conclusion, the interRAI-HC was found to identify more unmet support needs than the SNA though resulted in no favourable outcomes for the older person or their carer. The study highlights the need to invest attention around the service context to maximise outcomes based on identified needs.

Contribution by primary health nurses and general practitioners to the Diabetes Annual Review (Get Checked) programme in Auckland, New Zealand

AIM

To describe primary health care (practice and specialist) nurses involvement in the government-funded annual diabetes review 'Get Checked' programme and the division of care between nurses and general practitioners in Auckland, New Zealand.

METHOD

Of the total 911 practice and specialist nurses identified and working in the greater Auckland region, 276 (30%) were randomly selected and invited to undertake a self-administered questionnaire and telephone interview in 2006-8.

RESULTS

An 86% response rate was achieved. Over 60% of practice nurses and over half of specialist nurses participate in 'Get Checked' reviews. Of those nurses, 40% of practice and 70% specialist nurses, reported completing over half of the total number of 'Get Checked' reviews at their practice. Of the nurses sampled who work in general practice (n=198), 38% reported that 'nurses mostly complete' the reviews, 45% stated that 'nurses and doctors equally complete' them and 17% reported that only 'doctors' did so. For the nurses who reported that 'nurses and doctors equally complete' the reviews (n=89), most nurses undertake blood pressure measurements (90%), weigh patients (88%), give lifestyle advice (87%), examine patient's feet (73%), and 44% carried out the complete review of the patients they consult.

CONCLUSION

These findings show the 'Get Checked' programme was successful in engaging practice and community-based specialist nurses in the community management of diabetes and has revealed positive relationships between nurses and doctors, extended roles for nurses and the importance of engaging nurses in the design of health care programmes.

Hunger can be taught: Hunger Recognition regulates eating and improves energy balance

A set of spontaneous hunger sensations, Initial Hunger (IH), has been associated with low blood glucose concentration (BG). These sensations may arise pre-meal or can be elicited by delaying a meal. With self-measurement of BG, subjects can be trained to formally identify and remember these sensations (Hunger Recognition). Subjects can then be trained to ensure that IH is present pre-meal for most meals and that their pre-meal BG is therefore low consistently (IH Meal Pattern). IH includes the epigastric Empty Hollow Sensation (the most frequent and recognizable) as well as less specific sensations such as fatigue or light-headedness which is termed inanition. This report reviews the method for identifying IH and the effect of the IH Meal Pattern on energy balance. In adults, the IH Meal Pattern has been shown to significantly decrease energy intake by one-third, decrease preprandial BG, reduce glycosylated hemoglobin, and reduce insulin resistance and weight in those who are insulin resistant or overweight. Young children as well as adults can be trained in Hunger Recognition, giving them an elegant method for achieving energy balance without the stress of restraint-type dieting. The implications of improving insulin sensitivity through improved energy balance are as wide as improving immune activity.

Characteristics of nurses providing diabetes community and outpatient care in Auckland

INTRODUCTION

There is a worldwide trend for diabetes care to be undertaken in primary care. Nurses are expected to take a leading role in diabetes management, but their roles in primary care are unclear in New Zealand, as are the systems of care they work in as well as their training.

AIM

To describe and compare demographic details, education and diabetes experience, practice setting and facilities available for the three main groups of primary health care nurses working in the largest urban area in New Zealand.

METHOD

Of the total number of practice nurses, district nurses and specialist nurses working in Auckland (n=1091), 31% were randomly selected to undertake a self-administered questionnaire and telephone interview in 2006-2008.

RESULTS

Overall response was 86% (n=284 self-administered questionnaires, n=287 telephone interviews). Almost half (43%) of primary care nurses were aged over 50 years. A greater proportion of specialist nurses (89%) and practice nurses (84%) had post-registration diabetes education compared with district nurses (65%, p=0.005), from a range of educational settings including workshops, workplaces, conferences and tertiary institutions. More district nurses (35%) and practice nurses (32%) had worked in their current workplace for >10 years compared with specialist nurses (14%, p=0.004). Over 20% of practice nurses and district nurses lacked access to the internet, and the latter group had the least administrative facilities and felt least valued.

DISCUSSION

These findings highlight an ageing primary health care nursing workforce, lack of a national primary health care post-registration qualification and a lack of internet access.