Health equity in the New Zealand health care system: a national survey

<p>Abstract</p> <p>Introduction</p> <p>In all countries people experience different social circumstances that result in avoidable differences in health. In New Zealand, Māori, Pacific peoples, and those with lower socioeconomic status experience higher levels of chronic illness, which is the leading cause of mortality, morbidity and inequitable health outcomes. Whilst the health system can enable a fairer distribution of good health, limited national data is available to measure health equity. Therefore, we sought to find out whether health services in New Zealand were equitable by measuring the level of development of components of chronic care management systems across district health boards. Variation in provision by geography, condition or ethnicity can be interpreted as inequitable.</p> <p>Methods</p> <p>A national survey of district health boards (DHBs) was undertaken on macro approaches to chronic condition management with detail on cardiovascular disease, chronic obstructive pulmonary disease, congestive heart failure, stroke and diabetes. Additional data from expert informant interviews on program reach and the cultural needs of Māori and Pacific peoples was sought. Survey data were analyzed on dimensions of health equity relevant to strategic planning and program delivery. Results are presented as descriptive statistics and free text. Interviews were transcribed and NVivo 8 software supported a general inductive approach to identify common themes.</p> <p>Results</p> <p>Survey responses were received from the majority of DHBs (15/21), some PHOs (21/84) and 31 expert informants. Measuring, monitoring and targeting equity is not systematically undertaken. The Health Equity Assessment Tool is used in strategic planning but not in decisions about implementing or monitoring disease programs. Variable implementation of evidence-based practices in disease management and multiple funding streams made program implementation difficult. Equity for Māori is embedded in policy, this is not so for other ethnic groups or by geography. Populations that conventional practitioners find hard to reach, despite recognized needs, are often underserved. Nurses and community health workers carried a disproportionate burden of care. Cultural and diversity training is not a condition of employment.</p> <p>Conclusions</p> <p>There is a struggle to put equity principles into practice, indicating will without enactment. Equity is not addressed systematically below strategic levels and equity does not shape funding decisions, program development, implementation and monitoring. Equity is not incentivized although examples of exceptional practice, driven by individuals, are evident across New Zealand.</p

A qualitative study of recruiting for investigations in primary care: Plan, pay, minimise intermediaries and keep it simple

Objectives: We sought successful strategies to recruit patient and practitioner participants for studies from primary care. Methods: We interviewed people who had participated and who had not participated in a randomised controlled trial that did not reach recruitment target and successful primary care researchers. The participants and non-participants were mostly Pacific peoples. Interviews were recorded, transcribed, and analysed and reported using qualitative description. The study took place in New Zealand in 2013–2014. Results: A total of 31 people were interviewed. Researchers agreed that recruitment was usually the single most important phase of research but was usually under-planned and under-funded. All researchers recommended a pilot study that addressed recruitment. Successful researchers actively monitored recruitment and adapted the process as needed. Most projects were undertaken by our researchers recruited via an intermediary such as a general practice nurse. Strategies were adapted to the target population, such as specific acute or chronic conditions, age, ethnicity and gender. Intermediaries were actively recruited and retained in a manner that was often more intense than actual participant recruitment and retention. ‘Layers’ of intermediaries were kept to a minimum as each layer needed to be actively recruited and retained and each layer reduced participant recruitment rates. The task of intermediaries was kept simple and minimal and they were paid in some manner. Similarly, participant workload was kept to a minimum and they were paid in some manner that was intended to cover their participation costs and perhaps a little more. Even the most experienced researchers did not always achieve recruitment targets. Our interviews focused on patient participants but included recruiting general practitioners, nurses and others as research subjects. Conclusion: Strategy details varied with the target population but had in common the need to intensively recruit and retain intermediaries, minimise layers of intermediaries, and the need to pay and minimise workload for both intermediaries and participants

Should we embed randomized controlled trials within action research: arguing from a case study of telemonitoring

Abstract Background Action research (AR) and randomized controlled trials (RCTs) are usually considered to be theoretically and practically incompatible. However, we argue that their respective strengths and weaknesses can be complementary. We illustrate our argument from a recent study assessing the effect of telemonitoring on health-related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals in two urban hospital services and one remote rural primary care service in New Zealand. Methods Data came from authors’ observations and field notes of discussions with three groups: the healthcare providers and healthcare consumers who participated in the research, and a group of 17 researchers and collaborators. The consumers had heart failure (Site A, urban), airways disease (Site B, urban), and diabetes (Site C, rural). The research ran from 2008 (project inception) until 2012 (project close-off). Researchers came from a wide range of disciplines. Both RCT and AR methods were recognised from early in the process but often worked in parallel rather than together. In retrospect, we have mapped our observed research processes to the AR cycle characteristics (creation of communicative space, democracy and participation, iterative learning and improvement, emergence, and accommodation of different ways of knowing). Results We describe the context, conduct and outcomes of the telemonitoring trial, framing the overall process in the language of AR. Although not fully articulated at the time, AR processes made the RCT sensitive to important context, e.g. clinical processes. They resulted in substantive changes to the design and conduct of the RCT, and to interpretation and uptake of findings, e.g. a simpler technology procurement process emerged. Creating a communicative space enabled co-design between the researcher group and collaborators from the provider participant group, and a stronger RCT design. Conclusions It appears possible to enhance the utility of RCTs by explicitly embedding them in an AR framework to shape stronger RCT design. The AR process and characteristics may enable researchers to evaluate telehealth while enhancing rather than compromising the quality of an RCT, where research results are returned to practice as part of the research process. Trial registration Australian New Zealand Clinical Trials Registry, reference ACTRN12610000269033

Population health in New Zealand 2000–2013: From determinants of health to targets

Objective: To determine how ‘population health’ has been understood in practice and policy and has influenced health system restructuring in New Zealand since 2000. Methods: Interviews in 2007–2008 with managers, clinicians, government policy advisors and academics were undertaken to explore the relationships between population health, determinants of health, and health system restructuring. This was augmented by a review of major government health policies from 2009 to 2013 to establish which notions of population health were reflected. Results: Population health shifted from a broad notion of health determinants to focus on a small number of quantifiable health targets driven by financial incentives. Meantime, an emphasis on ‘quality and safety’ impeded population health activities. District Health Board programmes to identify high risk individuals, by disease or hospital service utilisation, diverted attention from broader population health outcomes. District Health Boards were not held accountable for integrating a population health approach in service planning and did not initiate or lead intersectoral work. Community consultation was limited. Primary Health Organisations, although mandated to address population health, typically aligned with the small-business model of general practice making service integration difficult to achieve. In policy, ‘population health’ dropped from favour in the mid-2000s, although many documents, outside the health sector, carried forward these values. Conclusion: A progressively narrower focus on a small number of health targets and on organisational processes undermined earlier policy intentions and health system restructuring that sought to improve broader population health outcomes

Final Report on Development of Thermoanaerobacterium saccharolyticum for the conversion of lignocellulose to ethanol

This project addressed the need for economical technology for the conversion of lignocellulosic biomass to fuels, specifically the conversion of pretreated hardwood to ethanol. The technology developed is a set of strains of the bacterium Thermoanaerobacterium saccharolyticum and an associated fermentation process for pretreated hardwood. Tools for genetic engineering and analysis of the organism were developed, including a markerless mutation method, a complete genome sequence and a set of gene expression profiles that show the activity of its genes under a variety of conditions relevant to lignocellulose conversion. Improved strains were generated by selection and genetic engineering to be able to produce higher amounts of ethanol (up to 70 g/L) and to be able to better tolerate inhibitory compounds from pretreated hardwood. Analysis of these strains has generated useful insight into the genetic basis for desired properties of biofuel producing organisms. Fermentation conditions were tested and optimized to achieve ethanol production targets established in the original project proposal. The approach proposed was to add cellulase enzymes to the fermentation, a method called Simultaneous Saccharification and Fermentation (SSF). We had reason to think SSF would be an efficient approach because the optimal temperature and pH for the enzymes and bacterium are very close. Unfortunately, we discovered that commercially available cellulases are inactivated in thermophilic SSF by a combination of low redox potential and ethanol. Despite this, progress was made against the fermentation targets using bacterial cellulases. Thermoanaerobacterium saccharolyticum may still prove to be a commercially viable technology should cellulase enzyme issues be addressed. Moreover, the organism was demonstrated to produce ethanol at approximately theoretical yield from oligomeric hemicellulose extracts, an ability that may prove to be uniquely valuable in pretreatment configurations in which cellulose and hemicellulose are separated

Baseline demographic and clinical characteristics of participants by intervention group.

<p>Results are numbers, or median (interquartile range), mean (SD) or number (%).</p><p>Baseline demographic and clinical characteristics of participants by intervention group.</p

Trial numbers flow diagram.

<p>Trial numbers flow diagram.</p

Baseline and 6 month scores on measurement scales.

<p>Results are mean (SD). Statistics are coefficient of interaction between intervention and time (positive indicates increasing score over time in telecare compared to usual care except diabetes self-care indicates increase score from baseline to six months). The first statistic is the unadjusted model, the second adjusts for age and gender and the third excludes Site C (for measures collected at all Sites). Heart Failure – Site A; Respiratory—Site B; Diabetes—Site C. SF36, Self Efficacy for Managing Chronic Disease, Self Care for Heart Failure Index, Summary of Diabetes Self Care Activities—favourable results higher; Hospital Anxiety and Depression, St George Respiratory Questionnaire—favourable results lower</p><p>Baseline and 6 month scores on measurement scales.</p