Examining the impact of COVID-19 on Māori:non-Māori health inequities in Aotearoa, New Zealand: an observational study protocol

INTRODUCTION

The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Mā te Mōhio ka Mārama: Impact of COVID-19 on Māori:non-Māori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Māori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Māori during the COVID-19 outbreak period across NZ.

METHODS AND ANALYSIS

This observational study is framed within a Kaupapa Māori research positioning that includes Kaupapa Māori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Māori and non-Māori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Māori and non-Māori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever.

ETHICS AND DISSEMINATION

This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Informed consent for medical student involvement in patient care: an updated consensus statement

Enabling patients to consent to or decline involvement of medical students in their care is an essential aspect of ethically sound, patient-centred, mana-enhancing healthcare. It is required by Aotearoa New Zealand law and Te Kaunihera Rata o Aotearoa Medical Council of New Zealand policy. This requirement was affirmed and explored in a 2015 Consensus Statement jointly authored by the Auckland and Otago Medical Schools. Student reporting through published studies, reflective assignments and anecdotal experiences of students and teachers indicate procedures for obtaining patient consent to student involvement in care remain substandard at times. Between 2020 and 2023 senior leaders of Aotearoa New Zealand's two medical schools, and faculty involved with teaching ethics and professionalism, met to discuss these challenges and reflect on ways they could be addressed. Key stakeholders were engaged to inform proposed responses. This updated consensus statement is the result. It does not establish new standards but outlines Aotearoa New Zealand's existing cultural, ethical, legal and regulatory requirements, and considers how these may be reasonably and feasibly met using some examples.

Medical students and informed consent-response to "Consent for Teaching"

Nil.

Analysis of deprivation distribution in New Zealand by ethnicity, 1991-2013

AIMS

To compare the distribution of Māori and New Zealand (NZ) European populations in Aotearoa New Zealand by neighbourhood deprivation, for the five censuses between 1991 and 2013, and to identify changes in the distribution pattern over time.

METHODS

Geographical meshblock data from the 1991-2013 New Zealand censuses, by NZDep Index deprivation score, and by prioritised ethnic group population, were combined to analyse ethnic population counts by deprivation decile and deprivation score. Trends over time were analysed.

RESULTS

Māori were over-represented in the more deprived NZDep deciles and under-represented in the least deprived deciles for all census periods. The NZ European population were over-represented in the least deprived deciles, and under-represented in the more deprived deciles. In each census, over 40% of the Māori population have been living in the two most deprived deciles, compared to less than 15% for NZ European.

CONCLUSION

The patterns of inequity in socio-economic deprivation between Māori and NZ Europeans have remained virtually unchanged since 1991, despite various Government commitments to reduce inequity. Socio-economic deprivation for Māori is a key determinant of health inequity, and bolder Government measures prioritised for Māori are needed to change this socio-economic gradient if health equity goals are to be met.

Estimating the economic costs of Indigenous health inequities in New Zealand: a retrospective cohort analysis

OBJECTIVES

Despite significant international interest in the economic impacts of health inequities, few studies have quantified the costs associated with unfair and preventable ethnic/racial health inequities. This Indigenous-led study is the first to investigate health inequities between Māori and non-Māori adults in New Zealand (NZ) and estimate the economic costs associated with these differences.

DESIGN

Retrospective cohort analysis. Quantitative epidemiological methods and 'cost-of-illness' (COI) methodology were employed, within a Kaupapa Māori theoretical framework.

SETTING

Data for 2003-2014 were obtained from national data collections held by NZ government agencies, including hospitalisations, mortality, outpatient and primary care consultations, laboratory and pharmaceutical usage and accident claims.

PARTICIPANTS

All adults in NZ aged 15 years and above who had engagement with the health system between 2003 and 2014 (deidentified).

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of 'potentially avoidable' hospitalisations and mortality as well as 'excess or underutilisation' of healthcare were calculated, as the difference between actual rates for Māori and the rate expected if Māori had the same rates as non-Māori. These differences were then quantified using COI methodology to estimate the financial cost of ethnic inequities.

RESULTS

In this conservative estimate, health inequities between Māori and non-Māori adults cost NZ$863.3 million per year. Direct costs of NZ$39.9 million per year included costs from ambulatory sensitive hospitalisations and outpatient care, with cost savings from underutilisation of primary care. Indirect costs of NZ$823.4 million per year came from years of life lost and lost wages.

CONCLUSIONS

Indigenous adult health inequities in NZ create significant direct and indirect costs. The 'cost of doing nothing' is predominantly borne by Indigenous communities and society. The net cost of adult health inequities to the government conceals substantial savings to the government from underutilisation of primary care and accident/injury care.

Navigating fundamental tensions towards a decolonial relational vision of planetary health

Planetary health has an important role to play in guiding humanity towards a healthy, equitable, and sustainable future. However, given planetary health's dominant colonial and capitalist underpinning ideologies, it risks reinscribing the same exploitative power dynamics that are fundamental drivers of global ecological collapse. In this Personal View, we reaffirm the need for a vision of planetary health grounded in Indigenous epistemologies, which centre relational ecocentric norms and values. We identify key tensions that planetary health scholars, practitioners, and advocates need to engage with to inform action. Finally, we offer suggestions for working progressively towards a decolonial vision of planetary health that recognises our obligations to all our (human and more-than-human) relations. The themes explored in this Personal View bring together our perspectives, strongly centring Indigenous understandings but also referencing ideas and positions emerging from a relational space between Indigenous and non-Indigenous scholars.

The economic cost of Indigenous child health inequities in Aotearoa New Zealand-an updated analysis for 2003-2014

AIMS

This study estimates of the cost of Indigenous child health inequities in New Zealand.

METHODS

Standard quantitative epidemiological and cost of illness methodologies were used within a Kaupapa Māori framework. Data for 2003-2014 on children under 15 years were obtained from government datasets. Rates of potentially avoidable hospitalisations and mortality, as well as excess or under-utilisation were calculated. Publicly funded health sector costs, costs to families and costs of premature mortality were used to estimate the costs (or savings) of inequities.

RESULTS

Māori children had lower utilisation rates than non-Māori for primary healthcare, outpatient care, medicines, laboratory investigations and care after an accident/injury. Māori children had greater rates of avoidable hospitalisation (RR=1.36, 95% CI 1.35-1.37) and death (RR 1.98, 95% CI 1.84-2.13). Inequalities between Māori and non-Māori children cost in excess of $170 million NZD each year. This includes an annual net savings for the government health sector of $4 million NZD, with an annual cost to society of around $175 million NZD.

CONCLUSIONS

The under-serving of Māori children in the health sector saves the government health system money, yet imposes a huge cost on Māori families and society. In addition to avoiding considerable human suffering, reducing child health inequities would result in significant economic benefits.

Access to advanced-level hospital care: differences in prehospital times calculated using incident locations compared with patients' usual residence

Studies estimate that 84% of the USA and New Zealand's (NZ) resident populations have timely access (within 60 min) to advanced-level hospital care. Our aim was to assess whether usual residence (ie, home address) is a suitable proxy for location of injury incidence. In this observational study, injury fatalities registered in NZ's Mortality Collection during 2008-2012 were linked to Coronial files. Estimated access times via emergency medical services were calculated using locations of incident and home. Using incident locations, 73% (n=4445/6104) had timely access to care compared with 77% when using home location. Access calculations using patients' home locations overestimated timely access, especially for those injured in industrial/construction areas (18%; 95% CI 6% to 29%) and from drowning (14%; 95% CI 7% to 22%). When considering timely access to definitive care, using the location of the injury as the origin provides important information for health system planning.

Examining emergency department inequities in Aotearoa New Zealand: Findings from a national retrospective observational study examining Indigenous emergency care outcomes

OBJECTIVE

There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions.

METHODS

This retrospective observational study used a Kaupapa Māori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Māori:non-Māori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity.

RESULTS

Despite some ED process measures favouring Māori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Māori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Māori.

CONCLUSION

To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

Access to specialist hospital care and injury survivability: identifying opportunities through an observational study of prehospital trauma fatalities

BACKGROUND

Of the five million injury deaths that occur globally each year, an estimated 70% occur before the injured person reaches hospital. Although reducing the time from injury to definitive care has been shown to achieve better outcomes for patients, the relationship between injury incident location and access to specialist care has been largely unexplored.

OBJECTIVE

To determine the number and distribution of prehospital (on-scene/en route) trauma deaths without timely access to a hospital with surgical and intensive care capabilities, overall and by estimated injury survivability.

METHODS

New Zealand's Mortality Collection and Hospital Discharge dataset were used to select prehospital injury deaths in 2009-2012. These records were linked to files held by Australasia's National Coronial Information Service (NCIS) to estimate, for the trauma subset, injury survivability. Using geographical locations of injury for the prehospital trauma fatalities, time from Emergency Medical System call-out to arrival at the closest specialist hospital was estimated.

RESULTS

Of 1,752 prehospital trauma fatalities, 14.7% (95%CI 13.0, 16.4) had potentially survivable injuries that occurred in locations without timely access (prehospital phase >60 minutes). More than half (132 of 257) of the potentially survivable prehospital trauma fatalities without timely access died as a result of a motor vehicle traffic crash. Only 10% (95%CI 5.7, 16.0) of prehospital trauma fatalities from falls were estimated to be potentially survivable and without timely access compared to 24.6% (95%CI 18.5, 31.5) of prehospital firearm fatalities. Through using geospatial techniques, "hot spot" locations of potentially survivable injuries without timely access to specialist major trauma hospitals were apparent.

CONCLUSION

Approximately 15% of prehospital trauma fatalities in New Zealand that are potentially survivable occur in locations without timely access to advanced level hospital care. Continued emphasis is required on both improving timely access to advanced trauma care, and on primary prevention of serious injuries. Decisions regarding trauma service delivery, a modifiable system-level factor, should consider the geographic distribution of locations of these injury events alongside the resident population distribution.

58 The Benefits of A Virtual Ward Model in the Management of Care of Elderly Patients Admitted with Decompensated Heart Failure

Introduction

Heart failure in elderly patients is associated with increasing rates of hospitalisation and readmission. The Care of Elderly department at Bradford Royal Infirmary has developed a virtual ward service to support patients at home on discharge from hospital. We wished to assess if patients admitted with heart failure and discharged under the virtual ward model had a reduced length of stay in hospital and if their readmission rate was altered, compared to patients not discharged under the virtual ward.

Method

A retrospective study of patients admitted under the Care of Elderly team with decompensated heart failure was undertaken. Patients admitted over 12 months were identified and assessed length of stay and readmission rates at 7 and 30 days post admission. There were no set criteria for discharge to the virtual ward, but patients were selected for virtual ward care based on; symptom burden, renal function and ongoing PT/OT support.

Results

Of the 358 patients identified in this study, 83 (23%) were discharged to the virtual ward (VW). On average patients spent 7 days (+/− 5.3) under the virtual ward service. Average length of hospital stay for VW patients was 2.3 days compared to 6.5 days for patients not discharged under the virtual ward (p < 0.0001). Of the patients discharged to the virtual ward, 8 (10%) were readmitted within 7 days and 23 (28%) were readmitted within 30 days, similar to readmission rates in patients not discharged under the virtual ward with 25 (11%) and 62 (27%) patients readmitted after 7 and 30 days respectively.

Conclusions

Climate Change Mitigation Policies and Co-Impacts on Indigenous Health: A Scoping Review

Climate change mitigation policies can either facilitate or hinder progress towards health equity, and can have particular implications for Indigenous health. We sought to summarize current knowledge about the potential impacts (co-benefits and co-harms) of climate mitigation policies and interventions on Indigenous health. Using a Kaupapa Māori theoretical positioning, we adapted a validated search strategy to identify studies for this scoping review. Our review included empirical and modeling studies that examined a range of climate change mitigation measures, with health-related outcomes analyzed by ethnicity or socioeconomic status. Data were extracted from published reports and summarized. We identified 36 studies that examined a diverse set of policy instruments, with the majority located in high-income countries. Most studies employed conventional Western research methodologies, and few examined potential impacts of particular relevance to Indigenous peoples. The existing body of knowledge is limited in the extent to which it can provide definitive evidence about co-benefits and co-harms for Indigenous health, with impacts highly dependent on individual policy characteristics and contextual factors. Improving the quality of evidence will require research partnerships with Indigenous communities and study designs that centralize Indigenous knowledges, values, realities and priorities.

Examining emergency department inequities: Descriptive analysis of national data (2006-2012)

OBJECTIVE

Internationally, Indigenous and minoritised ethnic groups experience longer wait times, differential pain management and less evaluation and treatment for acute conditions within emergency medicine care. Examining ED Inequities (EEDI) aims to investigate whether inequities between Māori and non-Māori exist within EDs in Aotearoa New Zealand (NZ). This article presents the descriptive findings for the present study.

METHODS

A retrospective observational study framed from a Kaupapa Māori positioning, EEDI uses secondary data from emergency medicine admissions into 18/20 District Health Boards in NZ between 2006 and 2012. Data sources include variables from the Shorter Stays in ED National Research Project database and comorbidity data from NZ's National Minimum Dataset. The key predictor of interest is patient ethnicity with descriptive variables, including sex, age group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and trauma status.

RESULTS

There were a total of 5 972 102 ED events (1 168 944 Māori, 4 803 158 non-Māori). We found an increasing proportion of ED events per year, with a higher proportion of Māori from younger age groups and areas of high deprivation compared to non-Māori events. Māori also had a higher proportion of self-referral and were triaged to be seen within a longer time frame compared to non-Māori.

CONCLUSION

Our findings show that there are different patterns of ED usage when comparing Māori and non-Māori events. The next level of analysis of the EEDI dataset will be to examine whether there are any associations between ethnicity and ED outcomes for Māori and non-Māori patients.

Examining emergency department inequities between Māori and non-Māori: do they exist?

Despite Māori (Indigenous population of New Zealand, NZ) having high Emergency Department (ED) use, few studies have explored for ethnic inequities in ED within NZ. ED healthcare can be time-pressured, complex and demanding. Clinical decision-making in this context may facilitate provider prejudice, stereotyping and bias.

The Examining Emergency Department Inequities (EEDI) is a retrospective observational study, designed from a Kaupapa Māori Research position, examining ED admissions in NZ between 2006 and 2012 using the existing Shorter Stays in Emergency Department National Research Project dataset combined with clinical information extracted from NZ’s National Minimum Dataset. The key predictor variable is patient ethnicity with covariates: sex, age-group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co-morbidities. Generalised linear regression models investigated the associations between pre-admission variables and the measures of ED care, and mortality.

There were a total of 5,972,102 ED events (1,168,944 Māori, 4,803,158 non-Māori). We found an increasing proportion of ED events/year, a higher proportion of Māori ED events from younger age groups and areas of high deprivation compared to non-Māori. Māori had a higher proportion of self-referral and were triaged to be seen within a longer timeframe compared to non-Māori. After controlling for year of ED event, gender, triage category, age at presentation, NZ Deprivation decile and M3 Comorbidity score: Māori had shorter ED arrival to assessment time; shorter ED Length of Stay and less Access Block (>8 hour ED LOS before ward admission). Despite this, Māori mortality within ED or within 10 days of discharge was higher than non-Māori.

These findings suggest different patterns in ED usage between Māori and non-Māori. Of concern, inequities in mortality exist despite positive indicators of ED care.

Key messages

There is evidence of different patterns in emergency department use between Māori and non-Māori in New Zealand. Māori:non-Māori inequities in mortality exist despite positive indicators of emergency department care.

Thyrotoxicosis in an Indigenous New Zealand Population - a Prospective Observational Study

Background

Reported international incidence rates of thyrotoxicosis vary markedly, ranging from 6 to 93 cases per 100 000 per annum. Along with population demographics, exposures, and study design factors, ethnicity is increasingly being recognized as a potential factor influencing incidence. This study aimed to document the epidemiology and clinical presentation of thyrotoxicosis for Māori, the indigenous population in New Zealand.

Methods

A prospective study of adult patients presenting with a first diagnosis of thyrotoxicosis between January 2013 and October 2014 to a single New Zealand center. Demographic data were collected, and detailed clinical assessment performed.

Results

With 375 patients, an incidence rate of thyrotoxicosis of 73.0 per 100 000 per annum was identified. Of these, 353 (94.1%) participated in the study. The median age of the cohort was 47 years, 81% were female, and 58% had Graves disease. The overall incidence of thyrotoxicosis for Māori, the indigenous people of New Zealand, was higher than non-Māori (123.9 vs 57.3 per 100 000 per annum). Rates of both Graves disease and toxic multinodular goiter were higher in Māori as compared to non-Māori (incidence rate ratios of 1.9 [1.4, 2.6] and 5.3 [3.4, 8.3], respectively), with this increase being maintained after controlling for age, deprivation, and smoking.

Conclusions

Māori, the indigenous people of New Zealand, have an increased incidence of thyrotoxicosis compared to non-Māori and, in particular, toxic multinodular goiter. A greater understanding of the epidemiology of thyrotoxicosis in other indigenous and marginalized ethnic groups may help to optimize therapeutic pathways, equitable care and outcomes.

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition

Background

Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them.

Methods

A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA.

Results

Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity.

Conclusions

A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand: a cross-sectional study

OBJECTIVE

Rapid access to advanced emergency medical and trauma care has been shown to significantly reduce mortality and disability. This study aims to systematically examine geographical access to prehospital care provided by emergency medical services (EMS) and advanced-level hospital care, for the smallest geographical units used in New Zealand and explores national disparities in geographical access to these services.

DESIGN

Observational study involving geospatial analysis estimating population access to EMS and advanced-level hospital care.

SETTING

Population access to advanced-level hospital care via road and air EMS across New Zealand.

PARTICIPANTS

New Zealand population usually resident within geographical census meshblocks.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportion of the resident population with calculated EMS access to advanced-level hospital care within 60 min was examined by age, sex, ethnicity, level of deprivation and population density to identify disparities in geographical access.

RESULTS

An estimated 16% of the New Zealand population does not have timely EMS access to advanced-level hospital care via road or air. The 700 000 New Zealanders without timely access lived mostly in areas of low-moderate population density. Indigenous Māori, New Zealand European and older New Zealanders were less likely to have timely access.

CONCLUSIONS

These findings suggest that in New Zealand, geographically marginalised groups which tend to be rural and remote communities with disproportionately more indigenous Māori and older adults have poorer EMS access to advanced-level hospitals. Addressing these inequities in rapid access to medical care may lead to improvements in survival that have been documented for people who experience medical or surgical emergencies.

The effect of implementing an aseptic practice bundle for anaesthetists to reduce postoperative infections, the Anaesthetists Be Cleaner (ABC) study: protocol for a stepped wedge, cluster randomised, multi-site trial

Background

Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Māori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces.

Methods

We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental “champions”. Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle.

Discussion

If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618000407291. Registered on 21 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3402-8) contains supplementary material, which is available to authorized users.

Colonial histories, racism and health-The experience of Māori and Indigenous peoples

The health of Māori, the Indigenous peoples of Aotearoa, New Zealand, like that of almost all Indigenous peoples worldwide, is characterised by systematic inequities in health outcomes, differential exposure to the determinants of health, inequitable access to and through health and social systems, disproportionate marginalisation and inadequate representation in the health workforce. As health providers, we are often taught that 'taking a history' is a critical component of a patient consultation to ensure that the underlying conditions are treated rather than the often superficial presenting symptoms. In the same way, attempts to make sense of the health and well-being of Indigenous peoples is inadequate unless health providers engage critically with the history of their respective nations and any subsequent patterns of privilege or disadvantage. Understanding this history, within the framework of western imperialism and other similar colonial projects, allows us to make sense of international patterns of Indigenous health status. While health commentators acknowledge the unequal health outcomes of Indigenous people, and an increasing number also link these inequities to Indigenous marginalisation resulting from historic events, very few go further and expose the deep relationship between racism and coloniality and how these continue to be the basic determinants of Indigenous health today. This work includes honest examination of the role that science and the health disciplines have played historically in colonisation through the subjugation of Indigenous ways of knowing and knowledge production, as well as being complicit in the creation and maintenance of a fabricated hierarchy of humankind. Despite the 'science' of this racial hierarchy being discredited, it retains a false validity in our societies. As long as oppressive systems that continue to re-inscribe racism and white privilege remain in communities, including our academic communities, coloniality continues its discrimination. Indigenous voices on migration, ethnicity, racism^a and health will always demand the elimination of inequities in health but to do so will require a parallel commitment to critically interrogating all of our histories and our disciplines, as well as examining how our practice, including research, disrupts or maintains global systems of racism and coloniality.

Effect of a text message intervention on alcohol-related harms and behaviours: secondary outcomes of a randomised controlled trial

OBJECTIVE

Mobile Health approaches show promise as a delivery mode for alcohol screening and brief intervention. The 'YourCall' trial evaluated the effect of a low-intensity mobile phone text message brief intervention compared with usual care on hazardous drinking and alcohol-related harms among injured adults. This paper extends our previously published primary outcome analysis which revealed a significant reduction in hazardous drinking associated with the intervention at 3 months, with the effect maintained across 12 months follow-up. The objective of the current study was to evaluate the effect of the intervention on alcohol-related harms and troubles and help-seeking behaviours (secondary outcomes) at 12-months follow-up.

RESULTS

A parallel two-group, single-blind, randomised controlled trial was conducted in 598 injured inpatients aged 16-69 years identified as having medium-risk hazardous drinking. Logistic regression models applied to 12-month follow-up data showed no significant differences between intervention and control groups in self-reported alcohol-related harms and troubles and help-seeking behaviours. Although this text message intervention led to a significant reduction in hazardous alcohol consumption (previously published primary outcome), changes in self-reported alcohol-related harms and troubles and help seeking behaviours at 12-months follow up (secondary outcomes) were small and non-significant.

TRIAL REGISTRATION

ACTRN12612001220853. Retrospectively registered 19 November 2012.

Examining emergency department inequities: Do they exist?

Objectives

Ethnic inequities in health outcomes have been well documented with Indigenous peoples experiencing a high level of healthcare need, yet low access to, and through, high‐quality healthcare services. Despite Māori having a high ED use, few studies have explored the potential for ethnic inequities in emergency care within New Zealand (NZ). Healthcare delivery within an ED context is characterised by time‐pressured, relatively brief, complex and demanding environments. When clinical decision‐making occurs in this context, provider prejudice, stereotyping and bias are more likely. The examining emergency department inequities (EEDI) research project aims to investigate whether clinically important ethnic inequities between Māori and non‐Māori exist.

Methods

EEDI is a retrospective observational study examining ED admissions in NZ between 2006 and 2012 (5 976 126 ED events). EEDI has been designed from a Kaupapa Māori Research position.

Results

The primary data source is the existing Shorter Stays in Emergency Department National Research Project (SSED) dataset that will be combined with clinical information extracted from NZ's National Minimum Dataset. The key predictor variable is patient ethnicity with other covariates including: sex, age‐group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co‐morbidities. Generalised linear regression models will be used to investigate the associations between pre‐admission variables and the measures of ED care, and to examine the contribution of each measure of ED care on ethnic inequities in mortality.

Conclusion

The present study will provide the largest, most comprehensive investigation of ED outcomes by ethnicity to date in NZ.

Educating for Indigenous Health Equity: An International Consensus Statement

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

The experience of gestational diabetes for indigenous Māori women living in rural New Zealand: qualitative research informing the development of decolonising interventions

Background

Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation.

Method

A qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes.

Results

Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management.

Conclusion

Māori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2103-8) contains supplementary material, which is available to authorized users.

Time to CT head in adult patients with suspected traumatic brain injury: Association with the 'Shorter Stays in Emergency Departments' health target in Aotearoa New Zealand

A national health target for length of stay in emergency departments (ED) was introduced in 2009 to reduce crowding and improve quality of care. We aimed to determine whether the target was associated with changes in time to CT and appropriateness of CT imaging, as markers of care quality for suspected acute traumatic brain injury (TBI). We undertook a retrospective review of the case records of a random sample of people aged ≥15 years presenting to the ED with TBI from 2006 to 2013. General linear models were used to investigate changes in outcomes along with routine process times before and after the introduction of the target. Among 501 eligible cases the median (IQR) time to CT was 136 (76-247) pre target versus 119 (59-209) minutes post target, p = 0.014. The proportion of appropriate imaging was similar between periods: 77.9% (95% CI 71-83%) versus 76.6% (95%CI 72-81%), p = 0.825. Interactions suggested that the time to CT and appropriateness of imaging before and after the introduction of the target varied by ethnicity, although the changes were not clinically important. Time to assessment and length of stay did not change importantly. We found no evidence of a clinically important change in time to CT or appropriateness of imaging for suspected TBI in association with the introduction of the SSED time target. Additional research with larger cohorts of Māori and Pacific participants is recommended to understand our observed patterns by ethnicity.

Estimating the economic costs of ethnic health inequities: protocol for a prevalence-based cost-of-illness study in New Zealand (2003-2014)

INTRODUCTION

There is significant international interest in the economic impacts of persistent inequities in morbidity and mortality. However, very few studies have quantified the costs associated with unfair and preventable ethnic/racial inequities in health. The proposed study will investigate inequities in health between the indigenous Māori and non-Māori adult population in New Zealand (15 years and older) and estimate the economic costs associated with these differences.

METHODS AND ANALYSIS

The study will use national collections data that is held by government agencies in New Zealand including hospitalisations, mortality, outpatient consultations, laboratory and pharmaceutical claims, and accident compensation claims. Epidemiological methods will be used to calculate prevalences for Māori and non-Māori, by age-group, gender and socioeconomic deprivation (New Zealand Deprivation Index) where possible. Rates of 'potentially avoidable' hospitalisations and mortality as well as 'excess or under' utilisation of healthcare will be calculated as the difference between the actual rate and that expected if Māori were to have the same rates as non-Māori. A prevalence-based cost-of-illness approach will be used to estimate health inequities and the costs associated with treatment, as well as other financial and non-financial costs (such as years of life lost) over the person's lifetime.

ETHICS AND DISSEMINATION

This analysis has been approved by the University of Auckland Human Participants Research Committee (Ref: 018621). Dissemination of findings will occur via published peer-reviewed articles, presentations to academic, policy and community-based stakeholder groups and via social media.

Achieving health equity in Aotearoa: strengthening responsiveness to Māori in health research

Excellent health research is essential for good health outcomes, services and systems. Health research should also build towards equity and in doing so ensure that no one is left behind. As recipients of government funding, researchers are increasingly required to demonstrate an understanding of their delegated responsibilities to undertake research that has the potential to address Māori health needs and priorities. These requirements form the basis of responsiveness to Māori in health research, and several research institutions have implemented systems to support their organisational approach to this endeavour. However, many health researchers have a narrow view of responsiveness to Māori and how it might be relevant to their work. In this viewpoint paper we provide an overview of existing frameworks that can be used to develop thinking and positioning in relation to the Treaty of Waitangi and responsiveness to Māori. We also describe an equity-based approach to responsiveness to Māori and highlight four key areas that require careful consideration, namely: (1) relevance to Māori; (2) Māori as participants; (3) promoting the Māori voice, and; (4) human tissue. Finally, we argue for greater engagement with responsiveness to Māori activities as part of our commitment to achieving equitable health outcomes.

Examining the predictors of academic outcomes for indigenous Māori, Pacific and rural students admitted into medicine via two equity pathways: a retrospective observational study at the University of Auckland, Aotearoa New Zealand

OBJECTIVE

To determine associations between admission markers of socioeconomic status, transitioning, bridging programme attendance and prior academic preparation on academic outcomes for indigenous Māori, Pacific and rural students admitted into medicine under access pathways designed to widen participation. Findings were compared with students admitted via the general (usual) admission pathway.

DESIGN

Retrospective observational study using secondary data.

SETTING

 6-year medical programme (MBChB), University of Auckland, Aotearoa New Zealand. Students are selected and admitted into Year 2 following a first year (undergraduate) or prior degree (graduate).

PARTICIPANTS

1676 domestic students admitted into Year 2 between 2002 and 2012 via three pathways: GENERAL admission (1167), Māori and Pacific Admission Scheme-MAPAS (317) or Rural Origin Medical Preferential Entry-ROMPE (192). Of these, 1082 students completed the programme in the study period.

MAIN OUTCOME MEASURES

Graduated from medical programme (yes/no), academic scores in Years 2-3 (Grade Point Average (GPA), scored 0-9).

RESULTS

735/778 (95%) of GENERAL, 111/121 (92%) of ROMPE and 146/183 (80%) of MAPAS students graduated from intended programme. The graduation rate was significantly lower in the MAPAS students (p<0.0001). The average Year 2-3 GPA was 6.35 (SD 1.52) for GENERAL, which was higher than 5.82 (SD 1.65, p=0.0013) for ROMPE and 4.33 (SD 1.56, p<0.0001) for MAPAS. Multiple regression analyses identified three key predictors of better academic outcomes: bridging programme attendance, admission as an undergraduate and admission GPA/Grade Point Equivalent (GPE). Attending local urban schools and higher school deciles were also associated with a greater likelihood of graduation. All regression models have controlled for predefined baseline confounders (gender, age and year of admission).

CONCLUSIONS

There were varied associations between admission variables and academic outcomes across the three admission pathways. Equity-targeted admission programmes inclusive of variations in academic threshold for entry may support a widening participation agenda, however, additional academic and pastoral supports are recommended.

Predictors of medical student remediation and their underlying causes: early lessons from a curriculum change in the University of Auckland Medical Programme

AIMS

The purpose of this study was to identify predictors of remediation in a medical programme and assess the underlying causes and the quality of remediation provided within the context of a recent curriculum change.

METHODS

A mixed methods study incorporating a retrospective cohort analysis of demographic predictors of remediation during 2013 and 2014, combined with thematic qualitative analysis of educator perspectives derived by interview on factors underlying remediation and the quality of that currently provided by the faculty.

RESULTS

17.7% of all students required some form of remedial assistance and 93% of all students offered remediation passed their year of study. Multivariate analysis showed international students (OR 4.59 95% CI 2.62-7.98) and students admitted via the Māori and Pacific Admission Scheme (OR 3.43 2.29-5.15) were significantly more likely to require remediation. Male students were also slightly more likely than their female classmates to require assistance. No effect was observed for rural origin students, completion of a prior degree or completion of clinical placement in a peripheral hospital. Knowledge application and information synthesis were the most frequently identified underlying problems. Most faculty believed remediation was successful, however, flexibility in the programme structure, improved diagnostics and improved access to dedicated teaching staff were cited as areas for improvement.

CONCLUSIONS

Remediation is required by nearly a fifth of University of Auckland medical students, with MAPAS and international students being particularly vulnerable groups. Remediation is largely successful, however, interventions addressing reasoning and knowledge application may improve its effectiveness.

Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand

AIM

Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI.

METHODS

We retrospectively reviewed a random sample of charts of children <15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009.

RESULTS

Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006).

CONCLUSION

Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent.

Effect of the Shorter Stays in Emergency Departments time target policy on key indicators of quality of care

AIM

To determine whether implementation of a national health target called Shorter Stays in Emergency Departments impacted on clinical markers of quality of care.

METHOD

A retrospective pre- and post-intervention study from 2006 to 2012 examined quality of care metrics for five different indicators at different sites in relation to the implementation of the target using a general linear model for times to treatment. Explanatory variables included period (pre- or post-target), ethnicity, age, deprivation and severity of condition. Back transformed least square means were used to describe the outcomes.

RESULTS

The times to treatment for ST elevation myocardial infarction; 36.9 (28-49) vs 47.6 (36-63) minutes p=0.14, antibiotics for severe sepsis; 105.9 (73-153) vs 104.3 (70-155) minutes p=0.93, analgesia for moderate or severe pain; 48 (31-75) vs 46 (32-66) minutes p =0.77, theatre for fractured neck of femur; 35.4 (32.1-39.1) vs 32.4 (29.2-36.1) hours, and to theatre for appendicitis; 14.1 (12-17) vs 16.4 (14-20) hours were unchanged after implementation of the target. Treatment adequacy was also unchanged for these indicators.

CONCLUSION

Introduction of the Shorter Stays in Emergency Departments target was not associated with any clinically important or statistically significant changes in the time to treatment and adequacy of care for five different clinical indicators of quality of care in Aotearoa New Zealand. For those indicators measured at one site only, it is unknown whether these results can be generalised to other sites.

Impact of a national time target for ED length of stay on patient outcomes

AIM

The impact of national targets for emergency department (ED) length of stay (LOS) on patient care is unclear. This study aimed to determine the effect of New Zealand's six-hour time target (95% of ED patients discharged or admitted to hospital within six hours) on a range of quality indicators.

METHODS

A nationwide observational study from 2006 to 2012 modelled differences in changes over time before and after target introduction in 2009. The observed model estimates in 2012 were compared to those predicted if pre-target trends had continued. Differences are absolute values except for morality, which is presented as a relative change.

RESULTS

There were 5,793,767 ED presentations and 2,082,374 elective admissions from 18 out of a possible 20 district health boards included in the study. There were clinically important reductions in hospital LOS (-0.29 days), EDLOS (-1.1 hours), admitted patients EDLOS (-2.9 hours), ED crowding (-26.8%), ED mortality (-57.8%), elective inpatient mortality (-42.2%) and the proportion not waiting for assessment (-2.8%). Small changes were seen in time to assessment in the ED (-3.4 minutes), re-presentation to ED within 48 hours of the index ED discharge (-0.7%), re-presentation to ED within 48 hours from ward discharge (+0.4%) and acute admissions (+3.9%). An increase was observed in re-admission to a ward within 30 days of discharge (1.0%). These changes were all statistically significant (p<0.001).

CONCLUSION

Most outcomes we investigated either improved or were unchanged after the introduction of the time target policy in New Zealand. However, attention is required to ensure that reductions in hospital length of stay are not at the expense of subsequent re-admissions.

Predictors of academic success for Māori, Pacific and non-Māori non-Pacific students in health professional education: a quantitative analysis

Tertiary institutions internationally aim to increase student diversity, however are struggling to achieve equitable academic outcomes for indigenous and ethnic minority students and detailed exploration of factors that impact on success is required. This study explored the predictive effect of admission variables on academic outcomes for health professional students by ethnic grouping. Kaupapa Māori and Pacific research methodologies were used to conduct a quantitative analysis using data for 2686 health professional students [150 Māori, 257 Pacific, 2279, non-Māori non-Pacific (nMnP)]. The predictive effect of admission variables: school decile; attending school in Auckland; type of admission; bridging programme; and first-year bachelor results on academic outcomes: year 2-4 grade point average (GPA); graduating; graduating in the minimum time; and optimal completion for the three ethnic groupings and the full cohort was explored using multiple regression analyses. After adjusting for admission variables, for every point increase in first year bachelor GPA: year 2-4 GPA increased by an average of 0.46 points for Māori (p = 0.0002, 95% CI 0.22, 0.69), 0.70 points for Pacific (p < 0.0001, CI 0.52, 0.87), and 0.55 points for nMnP (p < 0.0001, CI 0.51, 0.58) students. For the total cohort, ethnic grouping was consistently the most significant predictor of academic outcomes. This study demonstrated clear differences in academic outcomes between both Māori and Pacific students when compared to nMnP students. Some (but not all) of the disparities between ethnic groupings could be explained by controlling for admission variables.

Proposed new industry code on unhealthy food marketing to children and young people: will it make a difference?

Reducing the exposure of children and young people to the marketing of unhealthy foods is a core strategy for reducing the high overweight and obesity prevalence in this population. The Advertising Standards Authority (ASA) has recently reviewed its self-regulatory codes and proposed a revised single code on advertising to children. This article evaluates the proposed code against eight criteria for an effective code, which were included in a submission to the ASA review process from over 70 New Zealand health professors. The evaluation found that the proposed code largely represents no change or uncertain change from the existing codes, and cannot be expected to provide substantial protection for children and young people from the marketing of unhealthy foods. Government regulations will be needed to achieve this important outcome.

Effectiveness of the YourCall™ text message intervention to reduce harmful drinking in patients discharged from trauma wards: protocol for a randomised controlled trial

BACKGROUND

Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care.

METHODS/DESIGN

Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Māori compared with non-Māori).

DISCUSSION

If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking.

TRIAL REGISTRATION

Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.