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Aims: Māori and Pacific peoples in Aotearoa New Zealand experience significant inequities in heart failure rates, treatment and outcomes compared to NZ Europeans. We aimed to understand the experiences of Māori and Pacific people living with heart failure as they navigated care across primary and secondary settings., Methods: This research involved a secondary analysis of data collected in a wider qualitative study investigating evidence-practice gaps of cardiovascular care experienced by Māori and Pacific people. From the wider pool of semi-structured interviews, we identified 24 people (seven Māori and 17 Pacific peoples, 23 from the North Island) living with heart failure, and applied template and framework analysis to explore their distinct experiences., Results: Two major themes identified related to participants: 1) Condition-need for more support to understand and self-manage their heart failure condition, and 2) Journey-desire to feel well-connected to the health system in their heart failure journey., Conclusions: Addressing heart failure inequities for Māori and Pacific peoples requires that providers engage in clear and meaningful communication to support patient self-management. Strengthening pathways for Māori and Pacific patients and whānau (families) between primary and secondary services is required to reduce their likelihood of becoming disconnected from care., Competing Interests: Matire Harwood and Corina Grey report financial support was provided by the Heart Foundation of New Zealand. Matire Harwood and Corina Grey report financial support was provided by Healthier Lives National Science Challenge. Funding: This research was jointly funded by the Heart Foundation of New Zealand and Healthier Lives National Science Challenge, grant number 1819. The funders had no role in this research. Financial interests: Authors KB, VS and CG receive funding from the Health Research Council of New Zealand. KB and SH receive funding from Pūtahi Manawa Healthy Hearts for Aotearoa New Zealand Centre of Research Excellence (CoRE). SH receives funding from the Heart Foundation of New Zealand. KB received travel support from the Cardiac Society of Australia and New Zealand. VS receives funding from the Auckland Medical Research Foundation. Non-financial interests: SH is a member of the Whānau, Consumer and Clinician Digital Council and National Cardiac Clinical Network – Te Whatu Ora Health New Zealand. VS is a member of the Data Safety Monitoring Board for the Cess@Tion clinical trial and a board member and deputy chair of the medical assessment committee for the Auckland Medical Research Foundation. KB is co-director of Pūtahi Manawa. All other authors declare no relevant financial or nonfinancial interests., (© PMA.)

Clinical indicators are increasingly used to improve the quality of care, particularly with the emergence of 'big data', but physicians' views regarding their utility in practice is unclear. We reviewed the published literature investigating physicians' perspectives, focusing on the following objectives in relation to quality improvement: (1) the role of clinical indicators, (2) what is needed to strengthen them, (3) their key attributes, and (4) the best tool(s) for assessing their quality. A systematic literature search (up to November 2022) was carried out using: Medline, EMBASE, Scopus, CINAHL, PsycInfo, and Web of Science. Articles that met all of the following inclusion criteria were included: reported on physicians' perspectives on clinical indicators and/or tools for assessing the quality of clinical indicators, addressing at least one of the four review objectives; the clinical indicators related to care at least partially delivered by physicians; and published in a peer-reviewed journal. Data extracted from eligible studies were appraised using the Critical Appraisal Skills Programme tool. A thematic synthesis of data was conducted using NVivo software. Descriptive themes were inductively derived from codes, which were grouped into analytical themes answering each objective. A total of 14 studies were included, with 17 analytical themes identified for objectives 1-3 and no data identified for objective 4. Results showed that indicators can play an important motivating role for physicians to improve the quality of care and show where changes need to be made. For indicators to be effective, physicians should be involved in indicator development, recording relevant data should be straightforward, indicator feedback must be meaningful to physicians, and clinical teams need to be adequately resourced to act on findings. Effective indicators need to focus on the most important areas for quality improvement, be consistent with good medical care, and measure aspects of care within the control of physicians. Studies cautioned against using indicators primarily as punitive measures, and there were concerns that an overreliance on indicators can lead to narrowed perspective of quality of care. This review identifies facilitators and barriers to meaningfully engaging physicians in developing and using clinical indicators to improve the quality of healthcare., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Objectives: COVID-19 severity prediction scores need further validation due to evolving COVID-19 illness. We evaluated existing COVID-19 risk prediction scores in Aotearoa New Zealand, including for Māori and Pacific peoples who have been inequitably affected by COVID-19., Methods: We conducted a multicenter retrospective cohort study in adults hospitalized with COVID-19 from January to May 2022, including all Māori and Pacific patients, and every second non-Māori, non-Pacific (NMNP) patient to achieve equal analytic power by ethnic grouping. We assessed the accuracy of existing severity scores (4C Mortality, CURB-65, PRIEST, and VACO) to predict death in the hospital or within 28 days., Results: Of 2319 patients, 582 (25.1%) identified as Māori, 914 (39.4%) as Pacific, and 862 (37.2%) as NMNP. There were 146 (6.3%, 95% confidence interval 5.4-7.4%) deaths, with a predicted probability of death higher than observed mortality for VACO (10.4%), modified PRIEST (15.1%) and 4C mortality (15.5%) scores, but lower for CURB-65 (4.5%). C-statistics (95% CI) of severity scores were: 4C mortality: Māori 0.82 (0.75, 0.88), Pacific 0.87 (0.83, 0.90), NMNP 0.90 (0.86, 0.93); CURB-65: Māori 0.83 (0.69, 0.92), Pacific 0.87 (0.82, 0.91), NMNP 0.86 (0.80, 0.91); modified PRIEST: Māori 0.85 (0.79, 0.90), Pacific 0.81 (0.76, 0.86), NMNP 0.83 (0.78, 0.87); and VACO: Māori 0.79 (0.75, 0.83), Pacific 0.71 (0.58, 0.82), NMNP 0.78 (0.73, 0.83)., Conclusions: Following re-calibration, existing risk prediction scores accurately predicted mortality., Competing Interests: The authors have no competing interest to declare., (© 2024 The Authors.)

Objectives: This multicenter cohort study describes Aotearoa New Zealand children hospitalized during the country's first wave of sustained SARS-CoV-2 transmission, Omicron variant., Methods: Children younger than 16 years, hospitalized for >6 hours with COVID-19 across New Zealand from January to May 2022 were included. Admissions for all Māori and Pacific and every second non-Maori non-Pacific children were selected to support equal explanatory power for ethnic grouping. Attribution of hospital admission, demography, clinical presentation, comorbidity, treatment, and outcome data were collected., Results: Of 444 hospitalizations of children positive for COVID-19, 292 (65.5%) from 290 children were considered admissions attributable to COVID-19. Of these admissions, 126 (43.4%) were aged under 1; 118 (40.7%), 99 (34.1%), and 87 (30.0%) were children of Māori, Pacific, and non-Maori non-Pacific ethnicity, respectively. Underlying respiratory disease was the most common comorbidity, present in 22 children (7.6%); 16 children (5.5%) were immunosuppressed. Median length of stay was 1 day (interquartile range 0.0-2.0). Four children received antiviral, 69 (24%) antibacterial, and 24 (8%) supplemental oxygen. Although eight children required intensive care, there were no deaths., Conclusions: Children hospitalized during the first significant wave of SARS-CoV-2 infection in New Zealand presented with a multi-system viral illness and rarely with severe disease., Competing Interests: The authors have no competing interests to declare., (© 2024 The Author(s).)

Objective: This study aimed to understand the reasons behind evidence-practice gaps and inequities in cardiovascular care for Māori and Pacific people, as evidenced by the experiences and perspectives of patients and their families., Methods: The research was guided by Māori and Pacific worldviews, incorporating Kaupapa Māori Theory and Pacific conceptual frameworks and research methodologies. Template analysis was used to analyse interview data from 61 Māori and Pacific people who had experienced a cardiovascular disease (CVD) risk assessment, acute coronary syndrome, and/or heart failure., Results: The range of experiences relating to participants' heart health journeys are presented in five main themes: Context, Mana (maintaining control and dignity), Condition, People and Journey., Conclusions: Māori and Pacific people want to take charge of their heart health but face challenges. Participants described important obligations to family, community and tikanga (the culturally correct way of doing things). Participants described times when health care undermined existing responsibilities, their dignity and/or their mana, and they felt excluded from treatment as a result., Implications for Public Health: Good reciprocal communication, stemming from a high-quality relationship is essential for successful outcomes. A workforce that is representative of the population it serves and is culturally safe lays the foundation for excellence in care., Competing Interests: Conflicts of interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Matire Harwood and Corina Grey reports financial support was provided by Heart Foundation of New Zealand. Matire Harwood and Corina Grey reports financial support was provided by Healthier Live National Science Challenge. Funding: This research was jointly funded by The Heart Foundation of New Zealand and Healthier Lives National Science Challenge, grant number 1819. The funders had no role in this research. Financial interests: Authors KB, VS and CG receive funding from the Health Research Council of New Zealand. KB and SH receive funding from Pūtahi Manawa. SH receives funding from the Heart Foundation of New Zealand. KB received travel support from the Cardiac Society of Australia and New Zealand. VS receives funding from the Auckland Medical Research Foundation. Non-financial interests: SH is a member of the Whānau, Consumer and Clinician Digital Council – Te Whatu Ora Health New Zealand and an advisory board member for the Healthier Lives Implementation Network. VS is a member of the Data Safety Monitoring Board for the Cess@Tion clinical trial and a board member and deputy chair of the medical assessment committee for the Auckland Medical Research Foundation. KB is co-director of Pūtahi Manawa. All other authors declare no relevant financial or non-financial interests., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Māori (the Indigenous Peoples of Aotearoa New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD health care. Rural Māori experience additional barriers to treatment access, poorer health outcomes and a greater burden of CVD risk factors compared to Non-Māori and Māori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous Peoples in other nations impacted by colonisation. Given the scarcity of available literature, a systematic scoping review was conducted on literature exploring barriers and facilitators in accessing CVD health care for rural Māori and other Indigenous Peoples in nations impacted by colonisation., Methods: The review was underpinned by Kaupapa Māori Research methodology and was conducted utilising Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org was used to explore empirical research literature. A grey literature search was also conducted. Literature based in any healthcare setting providing care to adults for CVD was included. Rural or remote Indigenous Peoples from New Zealand, Australia, Canada, and the US were included. Literature was included if it addressed cardiovascular conditions and reported barriers and facilitators to healthcare access in any care setting., Results: A total of 363 articles were identified from the database search. An additional 19 reports were identified in the grey literature search. Following screening, 16 articles were included from the database search and 5 articles from the grey literature search. The literature was summarised using the Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles: tino rangatiratanga (self-determination), partnership, active protection, equity and options. Themes elucidated from the literature were described as key drivers of CVD healthcare access for rural Indigenous Peoples. Key driver themes included input from rural Indigenous Peoples on healthcare service design and delivery, adequate resourcing and support of indigenous and rural healthcare services, addressing systemic racism and historical trauma, providing culturally appropriate health care, rural Indigenous Peoples' access to family and wellbeing support, rural Indigenous Peoples' differential access to the wider social determinants of health, effective interservice linkages and communication, and equity-driven and congruent data systems., Conclusion: The findings are consistent with other literature exploring access to health care for rural Indigenous Peoples. This review offers a novel approach to summarising literature by situating the themes within the context of equity and rights for Indigenous Peoples. This review also highlighted the need for further research in this area to be conducted in the context of Aotearoa New Zealand.

Aims: Multiple health administrative databases can be individually linked in Aotearoa New Zealand, using encrypted identifiers. These databases were used to develop cardiovascular risk prediction equations for patients with known cardiovascular disease (CVD)., Methods and Results: Administrative health databases were linked to identify all people aged 18-84 years with known CVD, living in Auckland and Northland, Aotearoa New Zealand, on 1 January 2014. The cohort was followed until study outcome, death, or 5 years. The study outcome was death or hospitalization due to ischaemic heart disease, stroke, heart failure, or peripheral vascular disease. Sex-specific 5-year CVD risk prediction equations were developed using multivariable Fine and Gray models. A total of 43 862 men {median age: 67 years [interquartile range (IQR): 59-75]} and 32 724 women [median age: 70 years (IQR: 60-77)] had 14 252 and 9551 cardiovascular events, respectively. Equations were well calibrated with good discrimination. Increasing age and deprivation, recent cardiovascular hospitalization, Mori ethnicity, smoking history, heart failure, diabetes, chronic renal disease, atrial fibrillation, use of blood pressure lowering and anti-thrombotic drugs, haemoglobin A1c, total cholesterol/HDL cholesterol, and creatinine were statistically significant independent predictors of the study outcome. Fourteen per cent of men and 23% of women had predicted 5-year cardiovascular risk <15%, while 28 and 24% had ≥40% risk., Conclusion: Robust cardiovascular risk prediction equations were developed from linked routine health databases, a currently underutilized resource worldwide. The marked heterogeneity demonstrated in predicted risk suggests that preventive therapy in people with known CVD would be better informed by risk stratification beyond a one-size-fits-all high-risk categorization., Competing Interests: Conflict of interest: S.C. reports board meeting fees from Te Aka Whai Ora and WellSouth Primary Heath Network. M.L. reports speaker fees from Bayer, BMS, and Astra Zeneca. All other authors report no disclosures., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The recommended duration of dual anti-platelet therapy (DAPT) following acute coronary syndrome (ACS) varies from 1 month to 1 year depending on the balance of risks of ischaemia and major bleeding. We designed paired ischaemic and major bleeding risk scores to inform this decision., Methods: New Zealand (NZ) patients with ACS investigated with coronary angiography are recorded in the All NZ ACS Quality Improvement registry and linked to national health datasets. Patients were aged 18-84 years (2012-2020), event free at 28 days postdischarge and without atrial fibrillation. Two 28-day to 1-year postdischarge multivariable risk prediction scores were developed: (1) cardiovascular mortality/rehospitalisation with myocardial infarction or ischaemic stroke (ischaemic score) and (2) bleeding mortality/rehospitalisation with bleeding (bleeding score)., Findings: In 27 755 patients, there were 1200 (4.3%) ischaemic and 548 (2.0%) major bleeding events. Both scores were well calibrated with moderate discrimination performance (Harrell's c-statistic 0.75 (95% CI, 0.74 to 0.77) and 0.69 (95% CI, 0.67 to 0 .71), respectively). Applying these scores to the 2020 European Society of Cardiology ACS antithrombotic treatment algorithm, the 31% of the cohort at elevated (>2%) bleeding and ischaemic risk would be considered for an abbreviated DAPT duration. For those at low bleeding risk, but elevated ischaemic risk (37% of the cohort), prolonged DAPT may be appropriate, and for those with low bleeding and ischaemic risk (29% of the cohort) short duration DAPT may be justified., Conclusion: We present a pair of ischaemic and bleeding risk scores specifically to assist clinicians and their patients in deciding on DAPT duration beyond the first month post-ACS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The purpose of this study was to explore the experiences of Māori patients and their families accessing care for an acute out-of-hospital cardiac event and to identify any barriers or enablers of timely access to care., Design: Eleven interviews with patients and their families were conducted either face-to-face or using online conferencing. Interviews were audio-recorded and transcribed for thematic analysis using Kaupapa Māori methodology., Results: Data analysis identified three themes: (1) me and the event, (2) the people (3) upholding te mana ō te wā or self-determined heart wellbeing. Knowledge of symptoms and a desire to maintain personal dignity at the time of the event affected emergency medical service initiation. Participants described relationships with health professionals, the importance of good quality information, having family support, and drawing on cultural practices as vital for their health care journey., Conclusion: Systemic barriers including racism, discrimination, and inadequate resourcing exist for Māori journeying to and through care following an out of hospital cardiac event. Improving the cultural safety of health professionals, better access to community defibrillation, and improving understanding of the life-long impacts a cardiac event has on patients and whānau is recommended., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Given advances in the management of cancer, it is increasingly important for clinicians to appropriately manage the risk of cardiovascular disease (CVD) among cancer survivors. It is unclear whether CVD risk is increased among cancer survivors overall, and there is inconsistency in evidence to date about CVD incidence and mortality by cancer type., Methods: Patients aged 30-74 years entered an open cohort study at the time of first CVD risk assessment, between 2004 and 2018, in primary care in New Zealand. Patients with established CVD or cancer within 2 years prior to study entry were excluded. Cancer diagnosis (1995-2016) was determined from a national cancer registry. Cause-specific hazard models were used to examine the association between history of cancer and two outcomes: (1) CVD-related hospitalization and/or death and (2) CVD death., Results: The study included 446,384 patients, of whom 14,263 (3.2%) were cancer survivors. Risk of CVD hospitalization and/or death was increased among cancer survivors compared with patients without cancer at cohort entry (multivariable-adjusted hazard ratio, mHR, 1.11, 95% CI 1.05-1.18), more so for CVD death (1.31, 1.14-1.52). Risk of CVD hospitalization and/or death was increased in patients with myeloma (2.66, 1.60-4.42), lung cancer (2.19, 1.48-3.24) and non-Hodgkin lymphoma (1.90, 1.42-2.54), but not for some cancers (e.g., colorectal, 0.87, 0.71-1.06). Risk of CVD death was increased in several cancer types including melanoma (1.73, 1.25-2.38) and breast cancer (1.56, 1.16-2.11)., Conclusion: CVD risk management needs to be prioritized among cancer survivors overall, and particularly in those with myeloma, lung cancer and non-Hodgkin lymphoma given consistent evidence of increased risk., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: The aggregation of Indigenous peoples from Pacific Island nations as 'Pacific peoples' in literature may mask diversity in the health needs of these different groups. The aim of this study was to examine the heterogeneity of Pacific groups according to ethnicity and country of birth., Methods: Anonymised individual-level linkage of administrative data identified all NZ residents aged 30-74 years on 31 March 2013 with known ethnicity and country of birth. All participants were described according to ethnicity and country of birth. Pacific participants were also described according to the number of ethnicities they identified., Findings: A total of 2,238,039 NZ residents were included, of whom 117,957 (5·0%) were Pacific. Nearly two-thirds of Pacific peoples (65·7%) were born overseas, ranging from 45·3% (Cook Islands Māori) to 82·7% (Fijian) (Māori 2·3%, non-Māori non-Pacific 28·9%). Among NZ-born Pacific peoples, 46·9% (Samoan) to 81·9% (Fijian) were multi-ethnic; the proportion was much lower for overseas-born Pacific peoples (ranging from 3·7% [Tongan] to 23·9% [Tokelauan])., Interpretation: There is substantial heterogeneity among Pacific peoples in their country of birth and identification with sole or multiple ethnicities. Assumptions regarding homogeneity in the needs of Pacific peoples are not appropriate and government statistics should therefore disaggregate Pacific peoples whenever possible., Funding: Supported by the Health Research Council of New Zealand and a part of Manawataki Fatu Fatu, a programme of research funded by the National Heart Foundation of New Zealand and Healthier Lives - He Oranga Hauora - National Science Challenge of New Zealand., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Julie Winter-Smith reports financial support was provided by Health Research Council of New Zealand. Matire Harwood, Corina Grey reports financial support was provided by The National Heart Foundation of New Zealand and Healthier Lives - He Oranga Hauora - National Science Challenge of NZ. Vanessa Selak, Matire Harwood reports a relationship with Health Research Council of New Zealand that includes: funding grants. Vanessa Selak reports a relationship with Auckland Medical Research Foundation that includes: board membership and funding grants., (© 2023 The Authors. Published by Elsevier Inc. CC BY-NC-ND 4.0.)

Aim: To determine Pacific patients' reasons for Emergency Department (ED) use for non-urgent conditions by Pacific people at Counties Manukau Health., Methods: Patients who self-presented to Counties Manukau ED with a non-urgent condition in June 2019 were surveyed. Responses to open-ended questions were analysed using a general inductive approach, in discussion with key stakeholders., Results: Of 353 participants with ethnicity reported, 139 (39%) were Pacific, 66 (19%) Māori and 148 (42%) were non-Māori non-Pacific, nMnP. A total of 58 (42%) of Pacific participants had been to their general practitioner prior to presenting to the ED; this proportion was similar for Māori (19 [30%]) and nMnP (59 [40%]) (p=0.215). The most common reasons for ED attendance among Pacific (as well as other) participants were 1) advice by a health professional (41%, 95% CI 33-50%), 2) usual care unavailable (28%, 20-36%), 3) symptoms not improving (21%, 14-28%), and 4) symptoms too severe to be managed elsewhere (19%, 12-26%)., Conclusions: Multiple reasons underlie non-urgent use of EDs by Pacific and other ethnic groups. These reasons need to be considered simultaneously in the design, implementation, and evaluation of multi-dimensional initiatives that discourage non-urgent use of EDs to ensure that such initiatives are effective, equitable, and unintended consequences are avoided., Competing Interests: Catherine Yang was employed as Acting Manager of Hospital Funding at Counties Manukau Health at the time this research was conducted. Catherine Yang undertook this research under the supervision of Vanessa Selak and Vili Nosa, in partial fulfilment of public health medicine specialist training requirements. Vanessa Selak and Vili Nosa have no competing interests to declare., (© PMA.)

Importance: Intimate partner violence (IPV) is increasingly recognized as a contributing factor for long-term health problems; however, few studies have assessed these health outcomes using consistent and comprehensive IPV measures or representative population-based samples., Objective: To examine associations between women's lifetime IPV exposure and self-reported health outcomes., Design, Setting, and Participants: The cross-sectional, retrospective 2019 New Zealand Family Violence Study, adapted from the World Health Organization's Multi-Country Study on Violence Against Women, assessed data from 1431 ever-partnered women (63.7% of eligible women contacted) in New Zealand. The survey was conducted from March 2017 to March 2019, across 3 regions, which accounted for approximately 40% of the New Zealand population. Data analysis was performed from March to June 2022., Exposures: Exposures were lifetime IPV by types (physical [severe/any], sexual, psychological, controlling behaviors, and economic abuse), any IPV (at least 1 type), and number of IPV types., Main Outcomes and Measures: Outcome measures were poor general health, recent pain or discomfort, recent pain medication use, frequent pain medication use, recent health care consultation, any diagnosed physical health condition, and any diagnosed mental health condition. Weighted proportions were used to describe the prevalence of IPV by sociodemographic characteristics; bivariate and multivariable logistic regressions were used for the odds of experiencing health outcomes by IPV exposure., Results: The sample comprised 1431 ever-partnered women (mean [SD] age, 52.2 [17.1] years). The sample was closely comparable with New Zealand's ethnic and area deprivation composition, although younger women were slightly underrepresented. More than half of the women (54.7%) reported any lifetime IPV exposure, of whom 58.8% experienced 2 or more IPV types. Compared with all other sociodemographic subgroups, women who reported food insecurity had the highest IPV prevalence for any IPV (69.9%) and all specific types. Exposure to any IPV and specific IPV types was significantly associated with increased likelihood of reporting adverse health outcomes. Compared with those unexposed to IPV, women who experienced any IPV were more likely to report poor general health (adjusted odds ratio [AOR], 2.02; 95% CI, 1.46-2.78), recent pain or discomfort (AOR, 1.81; 95% CI, 1.34-2.46), recent health care consultation (AOR, 1.29; 95% CI, 1.01-1.65), any diagnosed physical health condition (AOR, 1.49; 95% CI, 1.13-1.96), and any mental health condition (AOR, 2.78; 95% CI, 2.05-3.77). Findings suggested a cumulative or dose-response association because women who experienced multiple IPV types were more likely to report poorer health outcomes., Conclusions and Relevance: In this cross-sectional study of women in New Zealand, IPV exposure was prevalent and associated with an increased likelihood of experiencing adverse health. Health care systems need to be mobilized to address IPV as a priority health issue.

Background: People with cancer have an increased risk of cardiovascular disease. Risk prediction equations developed in New Zealand accurately predict 5-year cardiovascular disease risk in a general primary care population in the country. We assessed the performance of these equations for survivors of cancer in New Zealand., Methods: For this validation study, patients aged 30-74 years from the PREDICT open cohort study, which was used to develop the New Zealand cardiovascular disease risk prediction equations, were included in the analysis if they had a primary diagnosis of invasive cancer at least 2 years before the date of the first cardiovascular disease risk assessment. The risk prediction equations are sex-specific and include the following predictors: age, ethnicity, socioeconomic deprivation index, family history of cardiovascular disease, smoking status, history of atrial fibrillation and diabetes, systolic blood pressure, total cholesterol to HDL cholesterol ratio, and preventive pharmacotherapy (blood-pressure-lowering, lipid-lowering, and antithrombotic drugs). Calibration was assessed by comparing the mean predicted 5-year cardiovascular disease risk, estimated using the risk prediction equations, with the observed risk across deciles of risk, for men and women, and according to the three clinical 5-year cardiovascular disease risk groups in New Zealand guidelines (<5%, 5% to <15%, and ≥15%). Discrimination was assessed by Harrell's C statistic., Findings: 14 263 patients were included in the study. The mean age was 61 years (SD 9) for men and 60 years (SD 8) for women, with a median follow-up of 5·8 years for men and 5·7 years for women. The observed cardiovascular disease risk was underpredicted by a maximum of 2·5% in male and 3·2% in female decile groups. When patients were grouped according to clinical risk groups, observed cardiovascular disease risk was underpredicted by less than 2% in the lower risk groups and overpredicted by 2·2% for men and 3·3% for women in the highest risk group. Harrell's C statistics were 0·67 (SE 0·01) for men and 0·73 (0·01) for women., Interpretation: The New Zealand cardiovascular disease risk prediction equations reasonably predicted the observed 5-year cardiovascular disease risk in survivors of cancer in the country, in whom risk prediction was considered clinically appropriate. Prediction could be improved by adding cancer-specific variables and considering competing risks. Our findings suggest that the equations are reasonable clinical tools for use in survivors of cancer in New Zealand., Funding: Auckland Medical Research Foundation, Health Research Council of New Zealand., Competing Interests: Declaration of interests ET's salary was supported by the Auckland Medical Research Foundation (AMRF) grant, project number 3722609, grant reference 1120015. VS's research was supported by grants from the AMRF, the Health Research Council of New Zealand (HRC), the National Heart Foundation of New Zealand (NHF), and the National Science Challenge (Healthier Lives) (NSCHL). VS is an unpaid member of data safety monitoring boards for investigator-led trials. RP's research was supported by the HRC. STT's research was supported by grants from the HRC, the AMRF, and the Breast Cancer Foundation of New Zealand. JME's research was supported by the AMRF. MM's research was supported by the HRC. CG's research was supported by the NHF and the NSCHL. MH's research was supported by grants from the HRC, the NHF, and the NSCHL. SW's research was supported by the HRC, the NHF, and the Stevenson Foundation., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Importance: Health implications of intimate partner violence (IPV) against men is relatively underexplored, although substantial evidence has identified associations between IPV and long-term physical health problems for women. Given the gendered differences in IPV exposure patterns, exploration of men's IPV exposure and health outcomes using population-based samples is needed., Objective: To assess the association between men's lifetime IPV exposure and self-reported health outcomes., Design, Setting, and Participants: This cross-sectional study analyzed data from the 2019 New Zealand Family Violence Study, which was conducted across 3 regions of New Zealand. The representative sample included ever-partnered men aged 16 years or older. Data analysis was performed between May and September 2022., Exposures: Lifetime IPV against men by types (physical [severe or any], sexual, psychological, controlling behaviors, and economic abuse), any IPV (at least 1 type), and number of IPV types experienced., Main Outcomes and Measures: The 7 health outcomes were poor general health, recent pain or discomfort, recent use of pain medication, frequent use of pain medication, recent health care consultation, any diagnosed physical health condition, and any diagnosed mental health condition., Results: The sample comprised 1355 ever-partnered men (mean [SD] age, 51.3 [16.9] years), who predominantly identified as heterosexual (96.9%; 95% CI, 95.7%-97.8%). Half of the sample (49.9%) reported experiencing any lifetime IPV, of whom 62.1% reported at least 2 types. Of all sociodemographic subgroups, unemployed men had the greatest prevalence of reporting exposure to any IPV (69.2%) and all IPV types. After adjustment for sociodemographic factors, men's exposure to any lifetime IPV was associated with an increased likelihood of reporting 4 of the 7 assessed health outcomes: poor general health (adjusted odds ratio [AOR], 1.78; 95% CI, 1.34-2.38), recent pain or discomfort (AOR, 1.65; 95% CI, 1.21-2.25), recent use of pain medication (AOR, 1.27; 95% CI, 1.00-1.62), and any diagnosed mental health condition (AOR, 1.66; 95% CI, 1.11-2.49). Specific IPV types were inconsistently associated with poor health outcomes. Any physical IPV exposure was associated with poor general health (AOR, 1.80; 95% CI, 1.33-2.43), recent pain or discomfort (AOR, 2.23; 95% CI, 1.64-3.04), and frequent use of pain medication (AOR, 1.69; 95% CI, 1.08-2.63), which appeared to be associated with exposure to severe physical IPV. Exposure to sexual IPV, controlling behaviors, and economic abuse was not associated with any assessed outcomes after sociodemographic adjustment. Experience of a higher number of IPV types did not show a clear stepwise association with number of health outcomes., Conclusions and Relevance: Results of this study indicate that exposure to IPV can adversely affect men's health but is not consistently a factor in men's poor health at the population level. These findings do not warrant routine inquiry for IPV against men in clinical settings, although appropriate care is needed if IPV against men is identified.

We investigated whether diabetes mellitus (DM) affects the efficacy of a low-dose triple combination pill and usual care among people with mild-moderate hypertension. TRIUMPH (TRIple pill vs Usual care Management for Patients with mild-to-moderate Hypertension) was a randomised controlled open-label trial of patients requiring initiation or escalation of antihypertensive therapy. Patients were randomised to a once-daily low-dose triple combination polypill (telmisartan-20mg/amlodipine-2.5 mg/chlorthalidone-12.5 mg) or usual care. This analysis compared BP reduction in people with and without DM, both in the intervention and control groups over 24-week follow-up. Predicted efficacy of prescribed therapy was calculated (estimation methods of Law et al.). The trial randomised 700 patients (56 ± 11 yrs, 31% DM). There was no difference in the number of drugs prescribed or predicted efficacy of therapy between people with DM and without DM. However, the observed BP reduction from baseline to week 24 was lower in those with DM compared to non-diabetics in both the triple pill (25/11 vs 31/15 mmHg, p ≤ 0.01) and usual care (17/7 vs 22/11 mmHg, p ≤ 0.01) groups, and these differences remained after multivariable adjustment. DM was a negative predictor of change in BP (β-coefficient -0.08, p = 0.02). In conclusion, patients with DM experienced reduced efficacy of BP lowering therapies as compared to patients without DM, irrespective of the type of BP lowering therapy received., (© 2022. The Author(s), under exclusive licence to The Japanese Society of Hypertension.)

Introduction: Māori (the Indigenous peoples of New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD healthcare. Rural Māori experience additional barriers to treatment access, poorer health outcomes and a more significant burden of CVD risk factors compared with non-Māori and Māori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous peoples in other nations impacted by colonisation. Given the scarcity of available literature, we are conducting a scoping review of literature exploring barriers and facilitators in accessing quality CVD healthcare for rural Māori and other Indigenous peoples in nations impacted by colonisation., Methods and Analysis: A scoping review will be conducted to identify and map the extent of research available and identify any gaps in the literature. This review will be underpinned by Kaupapa Māori Research methodology and will be conducted using Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org will be used to explore empirical research literature. A grey literature search will also be conducted. Two authors will independently review and screen search results in an iterative manner. The New Zealand Ministry of Health Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles will be used as a framework to summarise and construct a narrative of existing literature. Existing literature will also be appraised using the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement., Ethics and Dissemination: Ethical approval has not been sought for this review as we are using publicly available data. We will publish this protocol and the findings of our review in an open-access peer-reviewed journal. This protocol has been registered on Open Science Framework (DOI:10.17605/osf.io/xruhy)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Heart failure (HF) is associated with high morbidity and mortality and contributes to substantial burden of disease, significant inequities and high healthcare cost globally as well as in Aotearoa. Management of chronic HF is driven by HF phenotype, defined by left ventricular ejection fraction (EF), as only those with reduced ejection fraction (HFrEF) have been shown to experience reduced mortality and morbidity with long-term pharmacotherapy. To ensure appropriate and equitable implementation of HF management we need to be able to identify clinically relevant cohorts of patients with HF, in particular, those with HFrEF. The ideal HF registry would incorporate and link HF diagnoses and phenotype from primary and secondary care with echocardiography and pharmacotherapy data. In this article we consider several options for identifying such cohorts from electronic health data in Aotearoa, as well as the potential and pitfalls of these options. Given the urgent need to identify people with HF according to EF phenotype, the options for identifying them from electronic health data, and the opportunities presented by health system reform, including a focus on digital solutions, we recommend the following four actions, with oversight from a national HF working group: 1) Establish a HF registry based on random and representative sampling of HF admissions; 2) investigate obtaining HF diagnosis and EF-phenotype from primary care-coded data; 3) amalgamate national echocardiography data; and 4) investigate options to enable the systematic collection of HF diagnosis and EF-phenotype from outpatient attendances. Future work will need to consider reliability and concordance of data across sources. The case for urgent action in Aotearoa is compounded by the stark inequities in the burden of HF, the likely contribution of health service factors to these inequities and the legislative requirement under the Pae Ora (Healthy Futures) Act 2022 that "the health sector should be equitable, which includes ensuring Māori and other population groups - (i) have access to services in proportion to their health needs; and (ii) receive equitable levels of service; and (iii) achieve equitable health outcomes"., Competing Interests: Nil., (© PMA.)

Competing Interests: Conflict of interest: All authors report grants from the Health Research Council of New Zealand, and SW reports a grant from the Stevenson Foundation during the conduct of the study. KP and CG report grants from the Heart Foundation of New Zealand outside the submitted work.

Introduction: In New Zealand, significant inequities exist between Māori and Pacific peoples compared with non-Māori, non-Pacific peoples in cardiovascular disease (CVD) risk factors, hospitalisations and management rates. This review will quantify and qualify already-reported gaps in CVD risk assessment and management in primary care for Māori and Pacific peoples compared with non-Māori/non-Pacific peoples in New Zealand., Methods and Analysis: We will conduct a systematic search of the following electronic databases and websites from 1 January 2000 to 31 December 2021: MEDLINE (OVID), EMBASE, Scopus, CINAHL Plus, NZresearch.org, National Library Catalogue (Te Puna), Index New Zealand (INNZ), Australia/New Zealand Reference Centre. In addition, we will search relevant websites such as the Ministry of Health and research organisations. Data sources will include published peer reviewed articles, reports and theses employing qualitative, quantitative and mixed methods.Two reviewers will independently screen the titles and abstracts of the citations and grade each as eligible, not eligible or might be eligible. Two reviewers will read each full report, with one medically qualified reviewer reading all reports and two other reviewers reading half each. The final list of included citations will be compiled from the results of the full report reading and agreed on by three reviewers. Data abstracted will include authors, title, year, study characteristics and participant characteristics. Data analysis and interpretation will involve critical inquiry and a strength-based approach that is inclusive of Māori and Pacific values. This means that critical appraisal includes an assessment of quality from an Indigenous perspective., Ethics and Dissemination: Ethical approval is not required. The findings will be published in a peer-reviewed journal and shared with stakeholders. This review contributes to a larger project which creates a Quality-Improvement Equity Roadmap to reduce barriers to Māori and Pacific peoples accessing evidence-based CVD care., Competing Interests: Competing interests: JP receives funding from GlaxoSmithKline for research on vaccine safety and effectiveness. MH is employed as a general practitioner at a marae-based clinic and holds board memberships including the Medical Research institute of New Zealand (MRINZ). CG holds board memberships including Vaka Tautua- a New Zealand-wide Pacific health, disability and social services provider. KMB, JW-S, SH, VS and SA report no conflicts., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Cumulative exposure to high blood pressure (BP) is an adverse prognostic marker. Assessments of BP control over time, such as time at target, have been developed but assessments of the effects of BP-lowering interventions on such measures are lacking., Objective: To evaluate whether low-dose triple combination antihypertensive therapy was associated with greater rates of time at target compared with usual care., Design, Setting, and Participants: The Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) trial was a open-label randomized clinical trial of low-dose triple BP therapy vs usual care conducted in urban hospital clinics in Sri Lanka from February 2016 to May 2017. Adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg or in patients with diabetes or chronic kidney disease, systolic BP >130 mm Hg and/or diastolic BP >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy were included. Patients were excluded if they were currently taking 2 or more blood pressure-lowering drugs or had severe or uncontrolled blood pressure, accelerated hypertension or physician-determined need for slower titration of treatment, a contraindication to the triple combination pill therapy, an unstable medical condition, or clinically significant laboratory values deemed by researchers to be unsuitable for the study. All 700 individuals in the original trial were included in the secondary analysis. This post hoc analysis was conducted from December 2020 to December 2021., Intervention: Once-daily fixed-dose triple combination pill (telmisartan 20 mg, amlodipine 2.5 mg, and chlorthalidone 12.5 mg) therapy vs usual care., Main Outcomes and Measures: Between-group differences in time at target were compared over 24 weeks of follow-up, with time at target defined as percentage of time at target BP., Results: There were a total of 700 randomized patients (mean [SD] age, 56 [11] years; 403 [57.6%] women). Patients allocated to the triple pill group (n = 349) had higher time at target compared with those in the usual care group (n = 351) over 24 weeks' follow-up (64% vs 43%; risk difference, 21%; 95% CI, 16-26; P < .001). Almost twice as many patients receiving triple pill therapy achieved more than 50% time at target during follow-up (64% vs 37%; P < .001). The association of the triple pill with an increase in time at target was seen early, with most patients achieving more than 50% time at target by 12 weeks. Those receiving the triple pill achieved a consistently higher time at target at all follow-up periods compared with those receiving usual care (mean [SD]: 0-6 weeks, 36.3% [30.9%] vs 21.7% [28.9%]; P < .001; 6-12 weeks, 55.2% [31.9%] vs 33.7% [33.0%]; P < .001; 12-24 weeks, 66.0% [31.1%] vs 43.5% [34.3%]; P < .001)., Conclusions and Relevance: To our knowledge, this analysis provides the first estimate of time at target as an outcome assessing longitudinal BP control in a randomized clinical trial. Among patients with mild to moderate hypertension, treatment with a low-dose triple combination pill was associated with substantially higher time at target compared with usual care.

Background: Patients with invasive melanoma are at increased risk of developing subsequent invasive melanoma, but the risks for those with primary in situ melanoma are unclear., Objectives: To assess and compare the cumulative risk of subsequent invasive melanoma after primary invasive or in situ melanoma. To estimate the standardized incidence ratio (SIR) of subsequent invasive melanoma compared to population incidence in both cohorts., Methods: Patients with a first diagnosis of melanoma (invasive or in situ) between 2001 and 2017 were identified from the New Zealand national cancer registry, and any subsequent invasive melanoma during follow-up to the end of 2017 identified. Cumulative risk of subsequent invasive melanoma was estimated by Kaplan-Meier analysis separately for primary invasive and in situ cohorts. Risk of subsequent invasive melanoma was assessed using Cox proportional hazard models. SIR was assessed, allowing for age, sex, ethnicity, year of diagnosis and follow up time., Results: Among 33 284 primary invasive and 27 978 primary in situ melanoma patients, median follow up time was 5.5 and 5.7 years, respectively. A subsequent invasive melanoma developed in 1777 (5%) of the invasive and 1469 (5%) of the in situ cohort, with the same median interval (2.5 years) from initial to first subsequent lesion in both cohorts. The cumulative incidence of subsequent invasive melanoma at 5 years was similar in the two cohorts (invasive 4.2%, in situ 3.8%); the cumulative incidence increased linearly over time in both cohorts. The risk of subsequent invasive melanoma was marginally higher for primary invasive compared to in situ melanoma after adjustment for age, sex, ethnicity and body site of the initial lesion (hazard ratio 1.11, 95% CI 1.02-1.21). Compared to population incidence, the SIR of invasive melanoma was 4.6 (95% CI 4.3-4.9) for the primary invasive and 4 (95% CI 3.7-4.2) for the primary in situ melanoma cohorts., Conclusions: The risk of subsequent invasive melanoma is similar whether patients present with in situ or invasive melanoma. Thus follow-up surveillance for new lesions should be similar, although patients with invasive melanoma require more surveillance for recurrence., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Skin Health and Disease published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Aims: To examine trends in ischaemic heart disease (IHD) incidence and prevalence in New Zealand from 2005 to 2016, using comprehensive linked national hospitalization and mortality data as proxy measures of all significant events., Methods and Results: Incident and prevalent cases of IHD in people aged ≥25 years were identified using individual patient-linkage of routinely collected ICD-10-coded hospitalization and mortality data. Incidence rates and prevalence proportions were calculated by sex and age group and then age-standardized to the 2016 New Zealand population. Ischaemic heart disease incidence and prevalence declined in men and women in all age groups. The average annual rate of decline in age-standardized IHD incidence was 3.3% for women and 2.7% for men, and the rate of decline in age-standardized IHD prevalence was 3.2% for women and 2.2% for men. Despite a 17% increase in the New Zealand population aged 25 years and over during the study period, the total number of people living with IHD also decreased, particularly in those aged 65 years and older., Conclusion: In contrast to observations from other countries, where IHD incidence but not IHD prevalence has been falling, declining IHD incidence in New Zealand in recent decades is now mirrored by declining IHD prevalence., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: Cardiovascular disease (CVD) risk management guided by predicted CVD risk is widely recommended internationally. This is the first study to examine CVD preventive pharmacotherapy in a whole-of-country primary prevention population, stratified by CVD risk., Methods and Results: Anonymized individual-level linkage of New Zealand administrative health and non-health data identified 2 250 201 individuals without atherosclerotic CVD, alive, and aged 30-74 years on 31 March 2013. We identified individuals with ≥1 dispensing by community pharmacies of blood pressure lowering (BPL) and/or lipid-lowering (LL) medications at baseline (1 October 2012-31 March 2013) and in 6-month periods between 1 April 2013 and 31 March 2016. Individuals were stratified using 5-year CVD risk equations specifically developed for application in administrative datasets. One-quarter of individuals had ≥5% 5-year risk (the current New Zealand guideline threshold for discussing preventive medications) and 5% met the ≥15% risk threshold for recommended dual therapy. By study end, dual therapy was dispensed to 2%, 18%, 34%, and 49% of individuals with <5%, 5-9%, 10-14%, and ≥15% 5-year risk, respectively. Among those dispensed baseline dual therapy, 83-89% across risk strata were still treated after 3 years. Dual therapy initiation during follow-up occurred among only 13% of high-risk individuals untreated at baseline. People without diabetes and those aged ≥65 years were more likely to remain untreated., Conclusion: Cardiovascular disease primary preventive pharmacotherapy was strongly associated with predicted CVD risk and, once commenced, was generally continued. However, only half of high-risk individuals received recommended dual therapy and treatment initiation was modest. Individually linked administrative datasets can identify clinically relevant quality improvement opportunities for entire populations., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Objective: Studies indicate that age-standardised heart failure (HF) incidence has been decreasing internationally; however, contrasting trends in different age groups have been reported, with rates increasing in younger people and decreasing in the elderly. We aimed to describe age-specific trends in HF incidence in New Zealand (NZ)., Methods: In this nationwide data linkage study, we used routinely collected hospitalisation data to identify incident HF hospitalisations in NZ residents aged ≥20 years between 2006 and 2018. Age-specific and age-standardised incidence rates were calculated for each calendar year. Joinpoint regression was used to compare incidence trends., Results: 116 113 incident HF hospitalisations were identified over the 13-year study period. Between 2006 and 2013, age-standardised incidence decreased from 403 to 323 per 100 000 (annual percentage change (APC) -2.6%, 95% CI -3.6 to -1.6%). This reduction then plateaued between 2013 and 2018 (APC 0.8%, 95% CI -0.8 to 2.5%). Between 2006 and 2018, rates in individuals aged 20-49 years old increased by 1.5% per year (95% CI 0.3 to 2.7%) and decreased in those aged ≥80 years old by 1.2% per year (95% CI -1.7 to -0.7%). Rates in individuals aged 50-79 years old initially declined from 2006 to 2013, and then remained stable or increased from 2013 to 2018. The proportion of HF hospitalisations associated with ischaemic heart disease decreased from 35.1% in 2006 to 28.0% in 2018., Conclusion: HF remains an important problem in NZ. The decline in overall incidence has plateaued since 2013 due to increasing rates of HF in younger age groups despite an ongoing decline in the elderly., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes., Methods: New Zealanders aged ≥65 years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither., Results: Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79-87% were dispensed BPL and 73-79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65-69 years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65-69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26-31% across the 65-84 year age groups, falling to 17% at 85+ years., Conclusion: The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Pacific people experience a disproportionate burden of cardiovascular disease (CVD), whether they remain in their country of origin or migrate to higher-income countries, such as Australia, Aotearoa New Zealand or the United States of America. We sought to determine whether the CVD health needs of Pacific people vary according to their ethnicity or place of birth., Methods: We conducted a systematic review of medical research databases and grey literature to identify relevant data published up to 2020. Texts were included if they contained original data stratified by Pacific-specific ethnicity or place of birth on the burden or management of CVD, and were assessed as having good quality using a National Heart, Lung, and Blood Institute quality assessment tool. The protocol for this review was registered with the Open Science Forum ( https://doi.org/10.17605/OSF.IO/X7NR6 )., Results: Of 3679 texts identified, 310 full texts were reviewed and the quality of 23 of these assessed, using the pre-defined search strategy. Six items (four reports, one article, one webpage) of good quality met the review eligibility criteria. All included texts provided data on epidemiology but only one reported on the management of CVD. Four texts were of Pacific populations in Pacific Island countries and two were of Pacific diaspora in other countries. Data from the Global Burden of Disease study, which provided estimates for the greatest number of Pacific countries, showed substantial differences in mortality rates between Pacific countries for every CVD type. For example, the mortality rate per 100,000 for ischemic heart disease (IHD) ranged from 103.41 in the Cook Islands to 430.35 in the Solomon Islands. A New Zealand-based report showed differences in CVD rates by Pacific ethnicity (e.g. the age-standardised prevalence of IHD per 1,000 population in Auckland ranged from 107.8 (Niuean) to 138 among Cook Islands Māori (p < 0.001))., Conclusions: This review of published studies reveals that the epidemiology of CVD among Pacific people varies by specific ethnic groups, place of birth, and country of residence. There is a critical need for high-quality contemporary ethnic-specific Pacific data to respond to the diverse CVD health needs in these underrepresented groups., (© 2021. The Author(s).)

Aim: Type 2 diabetes mellitus (T2DM) disproportionately affects Māori and Pacific peoples in Aotearoa (New Zealand). Despite this, the lived experiences of T2DM and its management by Māori and Pacific peoples are scarcely acknowledged in health literature. The present study examines the lived experiences of T2DM by Māori and Pacific participants in the Mana Tū diabetes programme. Mana Tū is a Māori-led diabetes support programme co-designed by the National Hauora Coalition (NHC) alongside patients with diabetes, clinicians, health service planners and whānau ora providers., Method: The study used qualitative methods underpinned by Kaupapa Māori (Māori approaches) approaches. Twenty-two semi-structured interviews were conducted with participants of the Mana Tū diabetes programme and their whānau (thirteen Māori, 9 Pacific) from Tāmaki Makaurau (Auckland) and Te Tai Tokerau (Northland)., Results: The study identified barriers, facilitators and motivators for participants to live well with T2DM. Four key themes were constituted: (1) whānau experience of T2DM, (2) cultural safety in healthcare interactions, (3) whānau ora (collective family wellbeing) and (4) Kaupapa Māori approaches to health interventions. Themes were consistent across Māori and Pacific participants., Conclusion: Findings suggest that Māori-led health interventions can better support Māori and Pacific people living with T2DM and are needed to ensure these communities receive appropriate, responsive and equitable healthcare., Competing Interests: MH received research funding from NSC Healthier Lives, Health Research Council and Ministry of Health to undertake this research and is a member of the Steering Group for the Māori Health Authority.

Aim: To quantify staff burnout and wellbeing in emergency departments (EDs) throughout New Zealand (NZ)., Methods: A national cross sectional electronic survey of New Zealand clinical and non-clinical ED staff was conducted between 9 March and 3 April 2020. Burnout and wellbeing were assessed using the Copenhagen Burnout Inventory (CBI) and a variety of quantitative measures. Differences between measures were assessed by demography and work role using univariate analyses. Multivariate analyses assessed associations between burnout and wellbeing., Results: 1,372 staff responded from 22 EDs around New Zealand (response rate 43%). Most were female (n=678, 63%), NZ European (n=799, 59%), aged 20-39 years (n=743, 54%) and nurses (n=711, 52%). The overall prevalence of personal burnout was 60%, work-related burnout 55% and patient-related burnout 19%. There was a wide variation of burnout across all EDs. Females and nurses showed the highest degree of burnout by gender and role, respectively. Measures of wellbeing with significant negative correlations with burnout were work-related happiness, work-life balance, job satisfaction and perceived workplace excellence. Work stress had significant positive correlation with burnout., Conclusion: New Zealand ED staff have a high degree of burnout. Safety, financial sustainability and quality of care are likely being adversely affected. Stakeholders can be informed by findings from this study to inspire meaningful interventions in EDs and throughout the New Zealand healthcare system., Competing Interests: Natalie Cadzow and Alastair Cadzow declare working for South Canterbury District Health Board in emergency departments during the time of this study.

Aim: To (1) describe the distribution of Ministry of Health (MOH) COVID-19 emergency funding to general practices in March and April 2020 and (2) consider whether further funding to general practices should be allocated differently to support equity for patients., Methods: Emergency funding allocation criteria and funding amounts by general practice were obtained from the MOH. Practices were stratified according to their proportion of high-needs enrolled patients (Māori, Pacific or living in an area with the highest quintile of socioeconomic deprivation). Funding per practice was calculated for separate and total payments according to practice stratum of high-needs enrolled patients., Results: The median combined March and April funding for general practices with 80% high-needs patients was 28% higher per practice ($36,674 vs $28,686) and 48% higher per patient ($10.50 vs $7.11) compared with the funding received by general practices with fewer than 20% high-needs patients. Although the March allocation did increase funding for high-needs patients, the April allocation did not., Conclusions: Emergency support funding for general practices was organised by the MOH at short notice and in exceptional circumstances. In the future, the MOH should apply pro-equity resource allocation in all emergencies, as with other circumstances., Competing Interests: There was no external funding source for preparing this article. The views, opinions, findings and conclusions or recommendations expressed in this paper are strictly those of the authors. They do not necessarily reflect the views of the institution where the authors currently work. The paper is presented not as policy, but with a view to inform and stimulate wider debate. Dr Murton is President of the RNZCGP and she also has an academic appointment at the University of Otago; the views expressed here are her own and not those of the College. Prof Crengle reports other from New Zealand Ministry of Health, personal fees from RNZCGP and other from WellSouth PHN, outside the submitted work.

Background: New Zealand health services are responsible for equitable health service delivery, particularly for Māori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities., Objectives: To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities., Setting: New Zealand primary care., Methods: A cohort study of New Zealanders aged 30-79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities., Results: A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46-62], 54% European, 13% Māori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1-6.9). The likelihood of receipt of bariatric surgery was lower for Māori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69-.96] and .24 [.20-.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality., Conclusions: Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Emergency department (ED) staff face daily exposure to the illness, injury, intoxication, violence and distress of others. Rates of clinician burnout are high and associated with poor patient outcomes. This study sought to measure the prevalence of burnout in ED personnel as well as determine the important facilitators of and barriers to workplace wellbeing., Method: An anonymous online survey including six open-ended questions on workplace wellbeing was completed by 1372 volunteer participants employed as nurses, doctors, allied health or nonclinical roles at 22 EDs in Aotearoa, New Zealand in 2020. Responses to the questions were analysed using a general inductive approach., Results: The three key themes that characterise what matters most to participants' workplace wellbeing are: (1) Supportive team culture (2) Delivering excellent patient-centred care and (3) Professional development opportunities. Opportunities to improve wellbeing also focused on enhancements in these three areas., Conclusion: In order to optimise workplace wellbeing, emergency departments staff value adequate resourcing for high-quality patient care, supportive and cohesive teams and professional development opportunities. Initiatives in these areas may facilitate staff wellbeing as well as improving safety and quality of patient care., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Until recently, most patients with diabetes worldwide have been diagnosed when symptomatic and have high cardiovascular risk, meaning most should be prescribed cardiovascular preventive medications. However, in New Zealand, a world-first national programme led to approximately 90% of eligible adults being screened for diabetes by 2016, up from 50% in 2012, identifying many asymptomatic patients with recent-onset diabetes. We hypothesised that cardiovascular risk prediction equations derived before widespread screening would now significantly overestimate risk in screen-detected patients., Methods: New Zealanders aged 30-74 years with type 2 diabetes and without known cardiovascular disease, heart failure, or substantial renal impairment were identified from the 400 000-person PREDICT primary care cohort study between Oct 27, 2004, and Dec 30, 2016, covering the period before and after widespread screening. Sex-specific equations estimating 5-year risk of cardiovascular disease were developed using Cox regression models, with 18 prespecified predictors, including diabetes-related and renal function measures. Equation performance was compared with an equivalent equation derived in the New Zealand Diabetes Cohort Study (NZDCS), which recruited between 2000 and 2006, before widespread screening., Findings: 46 652 participants were included in the PREDICT-1° Diabetes subcohort, of whom 4114 experienced first cardiovascular events during follow-up (median 5·2 years, IQR 3·3-7·4). 14 829 (31·8%) were not taking oral hypoglycaemic medications or insulin at baseline. Median 5-year cardiovascular risk estimated by the new equations was 4·0% (IQR 2·3-6·8) in women and 7·1% (4·5-11·2) in men. The older NZDCS equation overestimated median cardiovascular risk by three times in women (median 14·2% [9·7-20·0]) and two times in men (17·1% [4·5-20·0]). Model and discrimination performance measures for PREDICT-1° Diabetse equations were also significantly better than for the NZDCS equation (eg, for women: R 2 =32% [95% CI 29-34], Harrell's C=0·73 [0·72-0·74], Royston's D=1·410 [1·330-1·490] vs R 2 =24% [21-26], C=0·69 [0·67-0·70], and D=1·147 [1·107-1·187])., Interpretation: International treatment guidelines still consider most people with diabetes to be at high cardiovascular risk; however, we show that recent widespread diabetes screening has radically changed the cardiovascular risk profile of people with diabetes in New Zealand. Many of these patients have normal renal function, are not dispensed glucose-lowering medications, and have low cardiovascular risk. These findings have clear international implications as increased diabetes screening is inevitable due to increasing obesity, simpler screening tests, and the introduction of new-generation glucose-lowering medications that prevent cardiovascular events. Cardiovascular risk prediction equations derived from contemporary diabetes populations, with multiple diabetes-related and renal function predictors, will be required to better differentiate between low-risk and high-risk patients in this increasingly heterogeneous population and to inform appropriate non-pharmacological management and cost-effective targeting of expensive new medications., Funding: Health Research Council of New Zealand, Heart Foundation of New Zealand, and Healthier Lives National Science Challenge., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Whilst positive ethnic identity is associated with higher self-esteem, prosocial tendencies and peer acceptance, it is inversely associated with depressive symptoms and drug use among ethnic minority individuals. Negotiating ethnic identity is particularly challenging for 1.5-and second-generation migrant populations, finding themselves positioned between host culture and culture of origin. To inform positive youth development policies and practices, this systematic literature review aimed to identify factors influencing the negotiation of ethnic identity for 1.5-and second-generation Asian migrants living in high-income countries., Methods: A mixed-methods systematic review was conducted of peer-reviewed literature in four databases: MEDLINE, EMBASE, PsychInfo and Scopus. Articles were screened by title, abstract and full text to ascertain whether they met the inclusion criteria. Quality of studies were assessed using MMAT Version 2011. Mixed-method thematic analysis was used to synthesis the data according to Bronfenbrenner's Ecological Model., Results: Forty-seven studies met the inclusion criteria. The review findings confirm a wide range of factors influencing the negotiation of ethnic identity from three systems in Bronfenbrenner's Ecological Model, most commonly from the macrosystem (e.g stereotyping), followed by microsystem (e.g family) and individual factors (e.g heritage language use)., Conclusions: Results indicate negotiating ethnic identity can be challenging and difficult, where the culture/norms of country of origin and host country play a significant role. Positive youth development policies and practices need to reflect these wide range of factors. More research is needed in countries where data is not available to facilitate greater response to needs of this increasing population group., (Copyright © 2021 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.)

Background: Antithrombotic medications (antiplatelets and anticoagulants) reduce the risk of cardiovascular disease (CVD), but with the disadvantage of increasing bleeding risk. Ethnicity and socioeconomic deprivation are independent predictors of major bleeds among patients without CVD, but it is unclear whether they are also predictors of major bleeds among patients with CVD or atrial fibrillation (AF) after adjustment for clinical variables., Methods: Prospective cohort study of 488,107 people in New Zealand Primary Care (including 64,420 Māori, the indigenous people of New Zealand) aged 30-79 years who had their CVD risk assessed between 2007 and 2016. Participants were divided into three mutually exclusive subgroups: (1) AF with or without CVD (n = 15,212), (2) CVD and no AF (n = 43,790), (3) no CVD or AF (n = 429,105). Adjusted hazards ratios (adjHRs) were estimated from Cox proportional hazards models predicting major bleeding risk for each of the three subgroups to determine whether ethnicity and socioeconomic deprivation are independent predictors of major bleeds in different cardiovascular risk groups., Results: In all three subgroups (AF, CVD, no CVD/AF), Māori (adjHR 1.63 [1.39-1.91], 1.24 [1.09-1.42], 1.57 [95% CI 1.45-1.70], respectively), Pacific people (adjHR 1.90 [1.58-2.28], 1.30 [1.12-1.51], 1.62 [95% CI 1.49-1.75], respectively) and Chinese people (adjHR 1.53 [1.08-2.16], 1.15 [0.90-1.47], 1.13 [95% CI 1.01-1.26], respectively) were at increased risk of a major bleed compared to Europeans, although for Chinese people the effect did not reach statistical significance in the CVD subgroup. Compared to Europeans, Māori and Pacific peoples were generally at increased risk of all bleed types (gastrointestinal, intracranial and other bleeds). An increased risk of intracranial bleeds was observed among Chinese and Other Asian people and, in the CVD and no CVD/AF subgroups, among Indian people. Increasing socioeconomic deprivation was also associated with increased risk of a major bleed in all three subgroups (adjHR 1.07 [1.02-1.12], 1.07 [1.03-1.10], 1.10 [95% CI 1.08-1.12], respectively, for each increase in socioeconomic deprivation quintile)., Conclusion: Ethnicity and socioeconomic status should be considered in bleeding risk assessments to guide the use of antithrombotic medication for the management of AF and CVD.

INTRODUCTION Indigenous peoples' rights include the right to self-determine one's identity. For Māori, this includes self-assignment of ethnicity, and traditional identities such as Iwi (tribe). New Zealand's Ministry of Health requires health services to collect ethnicity data using standard protocols. Iwi data are also collected by some health services; however, with no health-specific protocols, little is known about Iwi data collection and quality. The National Hauora Coalition (NHC) Primary Healthcare Organisation (PHO) sought to understand Iwi data collection across its network of primary care providers. AIM To understand Iwi data collection at the NHC PHO; specifically, is it being routinely collected, how is it being collected and what are the results? METHODS In 2017, NHC's general practice clinics were invited to submit their enrolment forms, which capture ethnicity and potentially Iwi information, by e-mail to the audit team. Forms were reviewed to determine whether Iwi information was being collected and if so, what question was being used. Iwi numbers were collated from the annual data extract. RESULTS Thirty-three of a total of 35 clinics (94%) submitted their enrolment forms to the audit team. Nine of the 33 clinics (27%) sought Iwi name/s with a specific question on their enrolment form. Six different 'Iwi' questions were used by the nine clinics. The data extract revealed that the NHC had Iwi data for 13% (2672/20,814) of its Māori enrolments. Ngāpuhi were the largest Iwi group at the NHC. DISCUSSION This is the first study to describe the quantity and quality of Iwi data collection in NZ primary care. Standard procedures for collecting, recording and using Iwi data are being developed by the NHC PHO. These could inform national protocols to optimise the quality of Iwi data.

Importance: Fixed-dose combination (FDC) therapies are being increasingly recommended for initial or early management of patients with hypertension, as they reduce treatment complexity and potentially reduce therapeutic inertia., Objective: To investigate the association of antihypertensive triple drug FDC therapy with therapeutic inertia and prescribing patterns compared with usual care., Design, Setting, and Participants: A post hoc analysis of the Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) study, a randomized clinical trial of 700 patients with hypertension, was conducted. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. Data were analyzed from September to November 2019., Interventions: Once-daily FDC antihypertensive pill (telmisartan, 20 mg; amlodipine, 2.5 mg; and chlorthalidone, 12.5 mg) or usual care., Main Outcomes and Measures: Therapeutic inertia, defined as not intensifying therapy in those with blood pressure (BP) above target, was assessed at baseline and during follow-up visits. Prescribing patterns were characterized by BP-lowering drug class and treatment regimen potency. Predictors of therapeutic inertia were assessed with binomial logistic regression., Results: Of the 700 included patients, 403 (57.6%) were female, and the mean (SD) age was 56 (11) years. Among patients who did not reach the BP target, therapeutic inertia was more common in the triple pill group compared with the usual care group at the week 6 visit (92 of 106 [86.8%] vs 124 of 194 [63.9%]; P < .001) and week 12 visit (81 of 90 [90%] vs 116 of 179 [64.8%]; P < .001). At the end of the study, 221 of 318 patients in the triple pill group (69.5%) and 182 of 329 patients in the usual care group (55.3%) reached BP targets. Among those who received treatment intensification, the increase in estimated regimen potency was greater in the triple pill group compared with the usual care group at baseline (predicted mean [SD] increase in regimen potency: triple pill, 15 [6] mm Hg; usual care, 10 [5] mm Hg; P < .001), whereas there were no significant differences at the week 6 or at week 12 visit. Clinic systolic BP level was the only consistent predictor of treatment intensification during follow-up. During follow-up, there were 23 vs 54 unique treatment regimens per 100 treated patients in the triple pill vs usual care groups, respectively (P < .001)., Conclusions and Relevance: Triple pill FDC therapy was associated with greater rates of therapeutic inertia compared with usual care. Despite this, triple pill FDC therapy substantially simplified prescribing patterns and improved 6-month BP control rates compared with usual care. Further improvements in hypertension control could be achieved by addressing therapeutic inertia among the minority of patients who do not achieve BP control after initial FDC therapy., Trial Registration: ANZCTR Identifier: ACTRN12612001120864.

Aim: In Aotearoa, New Zealand, cardiovascular disease (CVD) burden is greatest among Indigenous Māori, Pacific and Indian people. The aim of this study was to describe CVD risk profiles by ethnicity., Methods: We conducted a cross-sectional analysis of a cohort of people aged 35-74 years who had a CVD risk assessment in primary care between 2004 and 2016. Primary care data were supplemented with linked data from regional/national databases. Comparisons between ethnic groups were made using age-adjusted summaries of continuous or categorical data., Results: 475,241 people (43% women) were included. Fourteen percent were Māori, 13% Pacific, 8% Indian, 10% Other Asian and 55% European. Māori and Pacific people had a much higher prevalence of smoking, obesity, heart failure, atrial fibrillation and prior CVD compared with other ethnic groups. Pacific and Indian peoples, and to a lesser extent Māori and Other Asian people, had markedly elevated diabetes prevalence compared with Europeans. Indian men had the highest prevalence of prior coronary heart disease., Conclusions: Māori and Pacific people experience the most significant inequities in exposure to CVD risk factors compared with other ethnic groups. Indians have a high prevalence of diabetes and coronary heart disease. Strong political commitment and cross-sectoral action to implement effective interventions are urgently needed., Competing Interests: The authors report grants from the Health Research Council of New Zealand, Heart Foundation New Zealand, Stevenson Foundation, to conduct this study.

Objectives: Characterisation of trends in acute coronary syndrome (ACS) outcomes are critical to informing clinical practice and quality improvement, but there are few recent population studies for ACS. We reviewed the recent trends in the outcomes of ACS in New Zealand (NZ)., Methods: All patients with ACS admitted to NZ public hospitals in 2006-2016 were identified from hospital discharge records, and their first ACS hospitalisations per year extracted for analysis. Thirty-day and 1-year death, myocardial infarction, stroke, heart failure and bleeding rates were calculated for each calendar year. Trends in outcome rates were assessed using generalised linear mixed models., Results: Total annual ACS hospitalisations decreased from 685 to 424 per 100 000. Using first patient hospitalisations per year (n=1 55 060), we found significant annual declines in all major outcomes except for non-cardiovascular deaths. All-cause mortality fell from 10.5% to 9.1% at 30 days (adjusted OR 0.985 per year change, p<0.001) and from 21.8% to 18.7% at 1 year (OR=0.994, p=0.016). This was related to significant decreases in cardiovascular death at both time points (OR=0.982 and 0.987, respectively, p<0.001), outweighing a slight increase in non-cardiovascular death at 1 year (OR=1.009, p=0.014). One-year rates of myocardial infarction, heart failure, stroke and bleeding rates all decreased significantly over time., Conclusion: ACS outcomes including all-cause mortality, cardiovascular death, myocardial infarction, stroke, heart failure and bleeding at 30 days and 1 year improved over the last decade in NZ, reflecting successful implementation and advances in prevention, medical and invasive management in ACS over time., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

There is uncertainty about the long-term benefits and risks of diabetes medications in older people. We investigated differences in hypoglycaemia, cardiovascular disease (CVD) or mortality in older people according to diabetes medication, using linked national hospitalisation and mortality data from New Zealand. Adults aged ≥65 years dispensed diabetes medication in 2010 with a baseline glycated haemoglobulin (HbA1c) level (n=18099, mean age 73 years, 50% female) were included and stratified into four groups: metformin-only (42%); metformin-plus-other-oral-hypoglycaemic/s (27%); other-oral/s-only (11%); and any-insulin (20%). Time to first event was analysed with Cox models adjusted for sociodemographic factors; clinical history (prior hospitalisation for diabetes or CVD, and comorbidities); glycated haemoglobin; and CVD medications. Over 7-year follow up, 16% of participants experienced hypoglycaemia, 36% a CVD event and 31% died. Compared with metformin-only, insulin and other oral hypoglycaemic/s were associated with five- to 10-fold long-term increased risk of hypoglycaemia, and increased risk of CVD and death although adjusted survival curves showed no important separation between medication groups for CVD and death with the possible exception of insulin. Although confounding by indication is unable to be eliminated, this study raises further questions about the use of second-line diabetes medications in older people.

Introduction: While teaching patient safety and quality improvement (QI) skills to medical students is endorsed as being important, best practice for achieving learner outcomes in QI is particularly unclear. We systematically reviewed QI curricula for medical students to identify approaches to QI training that are associated with positive learner outcomes., Methods: We searched databases (Medline, EMBASE, and Scopus) and article bibliographies for studies published from 2009 to 2018. Studies evaluating QI teaching for medical students in any setting and reporting learner outcomes were included. Educational content, teaching format, achievement of learning outcomes, and methodological features were abstracted. Outcomes assessed were learners' satisfaction, attitudes, knowledge and skills, changes in behavior and clinical processes, and benefits to patients., Results: Twenty of 25 curricula targeted medical students exclusively. Most curricula were well accepted by students (11/13 studies), increased their confidence in QI (9/11) and led to knowledge acquisition (17/20). Overall, positive learner outcomes (Kirkpatrick Levels 1 to 4A) were demonstrated across a range of curricular content and teaching modalities. In particular, 2 curricula demonstrated positive changes in learners' behavior (Kirkpatrick Level 3), both incorporating a clinical audit or QI project based in hospitals, and supplemented by didactic lectures. Seven curricula were associated with improvements in processes of care (Kirkpatrick Level 4A) all of which were set in a clinical setting and supplemented by didactic lectures and/or small group sessions. None of the curricula evaluated patient benefits (Kirkpatrick Level 4B)., Conclusions: Whilst there is heterogeneity in educational content and teaching methods, most curricula are well accepted and led to learners' knowledge acquisition. Although there is limited evidence for the impact of QI curricula on learner behavior and benefit to patients, and for interprofessional QI curricula, teaching QI in the clinical setting leads to better learner outcomes with location being potentially a surrogate for clinical experience., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Aims: To investigate how well the New Zealand PREDICT-CVD risk equations, derived in people aged 30-74 years and US Pooled Cohort Equations (PCEs) derived in people aged 40-79 years, perform for older people., Methods: The PREDICT cohort study automatically recruits participants when clinicians use PREDICT software to conduct a CVD risk assessment. We identified patients aged 70 years and over, without prior CVD, renal disease or heart failure who had been risk assessed between 2004 and 2016. Equation performance was assessed in five-year age bands using calibration graphs and standard discrimination metrics., Results: 40,161 patients (median 73 years; IQR 71-77) experienced 5,948 CVD events during 185,150 person-years follow-up. PREDICT-CVD equations were well calibrated in 70-74 year olds but underestimated events for women from 75 years and men from 80 years. Discrimination metrics were also poor for these age groups. Recalibrated PCEs overestimated CVD risk in both sexes and had poor discrimination from age 70 years for men and from age 75 years for women., Conclusions: While PREDICT-CVD equations performed better than PCEs, neither performed well. Multimorbidity and competing risks are likely to contribute to the poor performance and new CVD risk equations need to include these factors., Competing Interests: All authors report grants from Health Research Council of New Zealand during the conduct of the study; Drs Wells, Poppe, Jackson and Corina report grants from Heart Foundation of New Zealand during the conduct of the study; Drs Wells and Jackson report grants from New Zealand Ministry of Business, Innovation and Enterprise during the conduct of the study; Dr Wells reports grants from Stevenson Foundation during the conduct of the study.

Background: Invasive coronary angiography plays a pivotal role in the management of acute coronary syndromes (ACS). Wide variability in its use has been previously documented. Our aim was to investigate whether coronary angiography is being used appropriately prior to discharge after ACS, taking into account relative contraindications of the procedure., Methods: Patients presenting with ACS in 2015 to two large, demographically distinct New Zealand (NZ) District Health Boards (DHBs)-Counties Manukau (CMDHB) and Waitemata (WDHB)-were identified from the NZ Ministry of Health National Dataset using ICD-10-AM codes. Patients' clinical data were obtained from the electronic and paper clinical records. Pre-defined relative contraindications to coronary angiography were identified., Results: Of the 3,809 patient admissions coded with ACS, 600 patient admissions (300 from each DHB) were reviewed. Sixty-one (61) (10%) did not meet diagnostic criteria for ACS on review of clinical data and were excluded. Of the patients reviewed, 55% received coronary angiography, with a higher rate in WDHB than CMDHB (61% and 49%, respectively) and 37.5% had relative contraindications documented. The overall rate of angiography was appropriately high in those without a relative contraindication (90.3%) and low in those with one (7.4%). There were fewer patients with relative contraindications in WDHB than CMDHB (36.7% and 48.5%) but the rate of angiography in those with (6.9% and 7.8%) and without (92.5% and 87.5%) contraindications in the two DHBs was similar., Conclusions: The decision to offer coronary angiography after ACS appears to be appropriately influenced by the presence or absence of relative contraindications. Approximately 60% of patients had no documented relative contraindication suggesting that this may be an appropriate angiography rate in New Zealand practice. However, differences between the two DHBs of around 10% appear to be clinically appropriate due to variation in contraindication rates., (Copyright © 2019. Published by Elsevier B.V.)

Background: Whether the benefits of aspirin for the primary prevention of cardiovascular disease (CVD) outweigh its bleeding harms in some patients is unclear., Objective: To identify persons without CVD for whom aspirin would probably result in a net benefit., Design: Individualized benefit-harm analysis based on sex-specific risk scores and estimates of the proportional effect of aspirin on CVD and major bleeding from a 2019 meta-analysis., Setting: New Zealand primary care., Participants: 245 028 persons (43.6% women) aged 30 to 79 years without established CVD who had their CVD risk assessed between 2012 and 2016., Measurements: The net effect of aspirin was calculated for each participant by subtracting the number of CVD events likely to be prevented (CVD risk score × proportional effect of aspirin on CVD risk) from the number of major bleeds likely to be caused (major bleed risk score × proportional effect of aspirin on major bleeding risk) over 5 years., Results: 2.5% of women and 12.1% of men were likely to have a net benefit from aspirin treatment for 5 years if 1 CVD event was assumed to be equivalent in severity to 1 major bleed, increasing to 21.4% of women and 40.7% of men if 1 CVD event was assumed to be equivalent to 2 major bleeds. Net benefit subgroups had higher baseline CVD risk, higher levels of most established CVD risk factors, and lower levels of bleeding-specific risk factors than net harm subgroups., Limitations: Risk scores and effect estimates were uncertain. Effects of aspirin on cancer outcomes were not considered. Applicability to non-New Zealand populations was not assessed., Conclusion: For some persons without CVD, aspirin is likely to result in net benefit., Primary Funding Source: Health Research Council of New Zealand.

Background: Elevated blood pressure incurs a major health and economic burden, particularly in low-income and middle-income countries. The Triple Pill versus Usual Care Management for Patients with Mild-to-Moderate Hypertension (TRIUMPH) trial showed a greater reduction in blood pressure in patients using fixed-combination, low-dose, triple-pill antihypertensive therapy (consisting of amlodipine, telmisartan, and chlorthalidone) than in those receiving usual care in Sri Lanka. We aimed to assess the cost-effectiveness of the triple-pill strategy., Methods: We did a within-trial (6-month) and modelled (10-year) economic evaluation of the TRIUMPH trial, using the health system perspective. Health-care costs, reported in 2017 US dollars, were determined from trial records and published literature. A discrete-time simulation model was developed, extrapolating trial findings of reduced systolic blood pressure to 10-year health-care costs, cardiovascular disease events, and mortality. The primary outcomes were the proportion of people reaching blood pressure targets (at 6 months from baseline) and disability-adjusted life-years (DALYs) averted (at 10 years from baseline). Incremental cost-effectiveness ratios were calculated to estimate the cost per additional participant achieving target blood pressure at 6 months and cost per DALY averted over 10 years., Findings: The triple-pill strategy, compared with usual care, cost an additional US$9·63 (95% CI 5·29 to 13·97) per person in the within-trial analysis and $347·75 (285·55 to 412·54) per person in the modelled analysis. Incremental cost-effectiveness ratios were estimated at $7·93 (95% CI 6·59 to 11·84) per participant reaching blood pressure targets at 6 months and $2842·79 (-28·67 to 5714·24) per DALY averted over a 10-year period., Interpretation: Compared with usual care, the triple-pill strategy is cost-effective for patients with mild-to-moderate hypertension. Scaled up investment in the triple pill for hypertension management in Sri Lanka should be supported to address the high population burden of cardiovascular disease., Funding: Australian National Health and Medical Research Council., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Wald and Law, who popularised the term 'polypill' in 2003, proposed giving everyone above a certain age a polypill to reduce the burden of cardiovascular disease (CVD). A more compelling potential application, proposed in 2001 by the World Health Organization, is to use a polypill containing antiplatelet, statin and blood pressure-lowering therapy among people with established CVD, in whom the components are already indicated but in whom guideline implementation and adherence are suboptimal. This article outlines relevant international and New Zealand evidence on the likely benefits and harms of a polypill for the secondary prevention of CVD. The evidence indicates that the benefits are likely to outweigh the harms, particularly given the persistence of substantial treatment gaps and inequities in the management of and outcomes in CVD. The time is long overdue for the polypill to be funded for the secondary prevention of CVD., Competing Interests: Nil.

Background: Many prognostic models for cardiovascular risk can be used to estimate aspirin's absolute benefits, but few bleeding risk models are available to estimate its likely harms., Objective: To develop prognostic bleeding risk models among persons in whom aspirin might be considered for the primary prevention of cardiovascular disease (CVD)., Design: Prospective cohort study., Setting: New Zealand primary care., Participants: The study cohort comprised 385 191 persons aged 30 to 79 years whose CVD risk was assessed between 2007 and 2016. Those with indications for or contraindications to aspirin and those who were already receiving antiplatelet or anticoagulant therapy were excluded., Measurements: For each sex, Cox proportional hazards models were developed to predict major bleeding risk; participants were censored at the earliest of the date on which they first met an exclusion criterion, date of death, or study end date (30 June 2017). The main models included the following predictors: demographic characteristics (age, ethnicity, and socioeconomic deprivation), clinical measurements (systolic blood pressure and ratio of total-high-density lipoprotein cholesterol), family history of premature CVD, medical history (smoking, diabetes, bleeding, peptic ulcer disease, cancer, chronic liver disease, chronic pancreatitis, or alcohol-related conditions), and medication use (nonsteroidal anti-inflammatory agents, corticosteroids, and selective serotonin reuptake inhibitors)., Results: During 1 619 846 person-years of follow-up, 4442 persons had major bleeding events (of which 313 [7%] were fatal). The main models predicted a median 5-year bleeding risk of 1.0% (interquartile range, 0.8% to 1.5%) in women and 1.1% (interquartile range, 0.7% to 1.6%) in men. Plots of predicted-against-observed event rates showed good calibration throughout the risk range., Limitation: Hemoglobin level, platelet count, and body mass index were excluded from the main models because of high numbers of missing values, and the models were not externally validated in non-New Zealand populations., Conclusion: Prognostic bleeding risk models were developed that can be used to estimate the absolute bleeding harms of aspirin among persons in whom aspirin is being considered for the primary prevention of CVD., Primary Funding Source: The Health Research Council of New Zealand.

Aim: To investigate eGFR as an independent risk factor for CVD in a New Zealand primary care cohort, stratified by disease status (prior CVD, diabetes or no CVD or diabetes)., Method: The PREDICT-CVD open cohort study is a large, ethnically diverse, New Zealand primary care cohort, generated by using a web-based CVD risk assessment tool. Using encrypted identifiers, participant profiles were linked anonymously to a regional laboratory database (to determine renal function) and to national hospitalisation and mortality datasets. Analyses using a single baseline eGFR measurement were undertaken in three clinical sub-cohorts of participants: those with prior CVD (n=29,742), with diabetes (n=44,416) and with neither CVD nor diabetes (n=192,696). The association between baseline eGFR (by category ≥90, 60-89.9, 30-59.9, and <30ml/min/1.73m2) and incident CVD was analysed with Kaplan Meier plots and Cox regression models., Results: After adjustment for traditional CVD risk factors, there was an inverse relationship between CVD risk and eGFR, up to an eGFR of 60ml/min/1.73m2 in all three clinical sub-cohorts, and up to an eGFR of 90ml/min/1.73m2 in the sub-cohort with CVD or diabetes. Compared to eGFR ≥90ml/min/1.73m2, the adjusted hazard ratios of a new CVD event for eGFR <30ml/min/1.73m2 in the CVD, diabetes and no CVD/no diabetes sub-cohorts were 2.29 (95% CI 2.00-2.61), 4.71 (3.92-5.67) and 2.78 (2.05-3.77), respectively. Compared to European/Other ethnic groups, Māori participants remained at greater adjusted risk of a new CVD event in all clinical sub-cohorts and Pacific people only in the no CVD/no diabetes sub-cohort, whereas Indian participants had a similar adjusted risk to European/Other, and Other Asian patients were consistently at lower adjusted risk. Sensitivity analyses for individuals with consecutive eGFR results (>90 days apart) yielded similar results., Conclusion: This study has confirmed that, in a large ethnically diverse primary care cohort, eGFR is a significant independent predictor of CVD risk, and the risk varies by ethnic group., Competing Interests: SW had a Stevenson Fellowship in Health Innovation and Quality Improvement during the conduct of the study. KP holds the Heart Foundation Hynds Senior Fellowship. MM is a full-time employee of Baxter Healthcare (Asia) Pte Ltd. CG holds a fellowship from the National Heart Foundation. SM, VS, CG and KP report grants from Health Research Council of New Zealand during the conduct of the study. EC reports grants from NZ College of Public Medicine during the conduct of the study.