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Tube thoracostomy (TT) in trauma is lifesaving. A previous audit at Counties Manukau District Health Board (CMDHB), New Zealand, showed a 22% complication rate for trauma TT. Subsequently CMDHB introduced a procedural guideline to reduce complications. The Health and Disability Commission published a report concerning oversights in TT removal. This led us to evaluate complications, documentation and procedural monitoring to identify ways to improve patient safety.A 30-month retrospective audit of patients presenting to CMDHB, with injuries which may require TT. Those who had a TT in situ, did not require a TT or whose presentation was not secondary to trauma were excluded.One hundred and forty-three TTs were performed in one hundred and fifteen patients. About 87% had injuries secondary to blunt mechanism. Penetrating injuries were more likely to require TT (P = 0.015). Non-accidental injuries were more likely to need TT (P = 0.025). The complication rate was 25.2%. TT prior to imaging had a 31% complication rate (P 0.03). About 23% had no TT insertion note. 40% had no TT removal note. About 9% TT insertions had no tertiary information to identify the proceduralist and a complication rate of 46%. About 22% of insertions and 4% of removals documented consent. About 2% of insertions documented anticoagulation status. Interventional radiology had the best documentation of data points assessed (P 0.0001). Post-procedural monitoring recommendations were documented in 1% insertions and 11% removals.The complication rate has not reduced despite introduction of a guideline. Procedural documentation and monitoring were inadequate, potentially impacting patient safety.

Clinical quality registries (CQRs) systematically collect data on pre-agreed markers of quality of care for a given procedure, that can be reliably and reproducibly defined and collected across multiple sites. Data is then risk adjusted, and comparisons may be used to benchmark performance. These data then inform quality improvement initiatives. CQRs require an overarching independent governance structure and surety of funding. CQRs rely upon whole of population enrolment to minimize the risk of selection bias, and often rely on the secondary use of sensitive health information, meaning that the processes for ethical review and consent to participation are different to clinical trials. Despite several local examples of CQR improving practice in Australia and Aotearoa New Zealand, providing substantial cost-benefit to the community, there remain significant barriers to CQR implementation and functions. These include the difficulty of accurate data capture, lack of a fit for purpose ethical review system, the constraints of existing Qualified Privilege legislations and the need for protected funding. Whilst the Australian Government has released a 10-year strategy for CQR reform, and the Aotearoa New Zealand Government has included registries in the planned Health New Zealand reforms for the public sector, we believe more urgent implementation of strategies to overcome these barriers is needed if CQRs are to have the impact on quality of care our Communities deserve.

Accurate pancreatic and periampullary cancer staging with resectability assessment is vital to optimize surgical management and improve patient outcomes. The aim of this study is to assess the usefulness of a standardized reporting template.Retrospective review of all surgically managed patients with pancreatic or periampullary malignancy between January 2018 and June 2019. Pre-operative CT imaging report was anonymised and audited against a modified NCCN reporting template. The same imaging studies were re-reported by two experienced GI radiologists using the same template.Fifty-nine patients (37 male) with median age of 68 years (36-83) underwent surgery for suspected pancreatic/peri-ampullary malignancy. The median time between pre-operative CT scan and surgery was 56.5 days (14-225). The use of reporting template resulted in significant increase in number of reported key features (p 0.005), interobserver agreed features (p 0.005) and overall k-value assessed interobserver agreement (p 0.005). Template reports correlated closely with key intraoperative findings whilst primary free text reports did not (k-value 0.85-0.96 versus 0.20-0.46, p 0.05).The use of a reporting template resulted in a more complete and accurate pancreatic/peri-ampullary tumour evaluation, improved inter-observer relatability and correlation with intraoperative findings.

A systematic review was undertaken to identify existing quality performance indicators (QPI) for the surgical treatment of gastric adenocarcinoma (GA) with the aim of defining a set of QPIs that can be used to assist in the accreditation of institutions for training, allow cross jurisdiction comparison of treatment and outcomes, as well as provide a basis to develop quality improvement programs. These QPI's capture key components of patient care that are fundamental to overall outcome.A systematic literature review was conducted searching MEDLINE, PubMed, EMBASE, and SCOPUS with all literature available until the date of 1 August 2021 included. Search terms utilized were 'Quality of health care OR Quality improvement or Quality control OR Quality indicators', AND 'Gastrectomy' OR 'Stomach neoplasm' OR 'Adenocarcinoma' OR 'Gastric resection' OR 'Gastric cancer'.Twelve articles were included in the final analysis. The selected studies included editorials (n = 2), retrospective review of institutional experience (n = 5), cohort studies (n = 2), survey methodology (n = 1), expert guidelines (n = 1) and consensus statement (n = 1). For GC QPIs, process measures included patient discussion at multi-disciplinary meetings, access to perioperative multimodal diagnostic pathways, and specific surgical metrics (margin negative resections and adequate lymphadenectomy). Outcome measures included the RO resection rate, reoperation, readmission rate, and length of hospital stay.There is a relative paucity of internationally agreed QPI for the surgical management of gastric adenocarcinoma. The data from this review will form the basis of a project to develop internationally agreed and feasible QPI for gastric cancer resections.

BACKGROUND Bariatric surgery has become topical in the media worldwide, influencing wider societal attitudes towards obesity and obesity management. This study aims to explore the media portrayal of bariatric surgery in all print news articles published in New Zealand (NZ) over a decade. METHODS An electronic search of two databases (Proquest Australia/NZ Newsstream and Newztext) and two NZ news media websites (Stuff and the NZ Herald) was performed to retrieve print news articles reporting stories, opinion pieces or editorials regarding bariatric surgery published between January 2007 to June 2017. Qualitative thematic analysis was performed on all included articles. RESULTS From January 2007 to December 2017, 252 articles related to bariatric surgery were published. Seven major themes emerged centred around barriers to accessing bariatric surgery, deficit attitudes towards obesity and social justice. These views were driven by articles that debated the limited number of publicly funded bariatric procedures offered in NZ. In addition, healthcare professionals used the media as a platform to challenge discriminatory attitudes towards obesity and bariatric surgery. CONCLUSION The NZ media is a powerful tool that still bolsters binary perspectives of obesity and bariatric surgery which may work against addressing the obesity epidemic.

BACKGROUND Bariatric surgery, in recent times, has gained media attention that has influenced individual, healthcare provider and wider societal attitudes towards bariatric surgery. Studies exploring public and media levels of interest in bariatric surgery have been performed overseas but studies within New Zealand (NZ) are scarce. Analysis of Google Trends data may be a useful source of information in investigating public interest levels in bariatric surgery. We aimed to analyse Google Trends information on Internet searches in NZ and to explore sequential relationships with relevant changes in policy. METHODS Key search terms for our Google Trends query were retrieved by independently reviewing news articles relating to bariatric surgery in NZ published between January 2007 and December 2017 and following a brainstorming session. Trend analyses were performed using Microsoft Excel 14.7.2. Data were captured for both NZ and worldwide search interests in Google Trends. RESULTS Trend analyses showed that total search volumes for 'lap band' and 'lap band surgery' declined while 'gastric sleeve' and 'gastric sleeve surgery' increased exponentially over the 10-year period. Furthermore, search interests for key terms in NZ were comparable with those worldwide. CONCLUSION Our findings reveal that search interests related to bariatric surgery in NZ mirror those worldwide. This includes the popularity of some bariatric procedures over others. The use of Google Trends may provide us with an additional tool to evaluate public interest levels related to bariatric surgery in NZ and could add value in examining the socio-cultural and political contexts of obesity and bariatric surgery.

BACKGROUND The prioritization of elective surgical wait-lists remains a contentious issue. Multiple new tools and systems have been developed to attempt to reliably prioritize patients. This study pilots one such system, the General Surgery Prioritization Tool and compares it to the existing triage system of clinical judgement. The aim was to determine if the new tool reflects clinical judgement. Secondary aims were to assess for any bias in its application to different patient groups or its application by different scorers. METHOD A cohort of 392 patients was identified who were wait-listed for non-cancer elective surgery between July 2015 and February 2016. The General Surgery Prioritization Tool was applied after traditional prioritization using clinical judgement. The scores produced by the new tool were compared to the clinical judgement categories. Differences in scores based on gender, ethnicity, age, surgical condition and surgeon were then analysed. RESULTS There was statistically significant correlation in the new tool scores with traditional triage groups (P < 0.0001). There were no statistically significant differences in mean scores attributable to gender, age or ethnicity. There were minimal differences in mean scores between common surgical conditions. Except for one outlier the mean scores were consistent across 17 surgeons. CONCLUSION This pilot study has found the General Surgery Prioritization Tool to reflect clinical judgement and to be generalizable by age, gender, ethnicity and prioritizing surgeon. The tool is at least as clinically reliable as traditional methods in the triage for elective general surgery with the advantage of being a more explicit process.

BACKGROUND To investigate whether a text message intervention improves adherence to preoperative exercise advice prior to laparoscopic sleeve gastrectomy (LSG). METHODS A single-blinded parallel design 1:1 ratio randomized controlled trial was performed in patients undergoing LSG as a single-stage bariatric procedure for morbid obesity. The intervention group received preoperative daily text messages. The primary outcome was adherence to preoperative exercise advice as assessed by the number of participants partaking in ≥450 metabolic equivalent minutes (METmin-1 ) exercise activity per week preoperatively. RESULTS Eighty-eight patients were included in the analysis with 44 allocated to each arm. Adherence and exercise activity increased significantly from baseline in the exposure group (EG) but not in the control group (CG). Adherence was significantly higher in the EG at the end of the intervention period compared to the CG. Despite increased exercise activity, there was no improvement in 6-min walk test or surgical recovery. CONCLUSION A daily text message intervention improved adherence to preoperative exercise advice, but this did not correlate with improved surgical recovery.

BACKGROUND Publicly funded bariatric surgery in New Zealand (NZ) is steadily on the rise to meet the obesity epidemic. Ethnic disparities in obesity rates exist in NZ with Māori and Pacific people having three to five times higher rates than all other ethnic groups within NZ. Ethnic disparities in rates of bariatric surgery have been reported internationally. This research sought to describe rates of publically funded bariatric surgery by self-identified ethnicity in NZ. METHODS Using reported census and hospitalization discharge data from Statistics NZ and the NZ Ministry of Health, we calculated estimate rates of publicly funded bariatric surgery in the morbidly obese population from June 2009 to July 2014. RESULTS The average number of publicly funded bariatric procedures performed per 1000 morbidly obese patients from June 2009 to July 2014 was 3.0 for European, 1.4 for Māori and 0.7 for Pacific ethnicities. CONCLUSION While these data should be interpreted cautiously due to data limitations, the estimated rates may indicate that bariatric services are currently being provided inequitably across the major ethnic groups within NZ. We suggest that further studies should be performed to explore potential patient, healthcare provider and system-level factors that may contribute to ethnic disparities in the rates of publicly funded bariatric surgery in NZ.

Background Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population. Method This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested. Results The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate. Conclusion A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.

Background Charcot's triad is a well-established diagnostic tool for acute cholangitis (AC). It has been recognized as an inaccurate test in clinical practice; however, its exact sensitivity and specificity remain unclear. This knowledge is key to informing the value of its continued clinical application. The objectives of this study are to calculate an estimate of the sensitivity and specificity of Charcot's triad based on published research and consider its applicability to clinical practice and medical education. Methods Electronic database search for relevant literature and review of reference lists of the subsequent articles for additional resources. Two independent researchers located articles which were qualitatively and quantitatively reviewed. The overall sensitivity and specificity values across all studies were subsequently calculated. Results The 16 articles included in the review varied widely in study design and the sensitivity of Charcot's triad was reported for AC. Across the included articles, there were 4288 patients studied. The overall sensitivity for Charcot's triad was calculated as 36.3%. The specificity was only analysed in three studies and had an overall value of 93.2%. Nine of the articles also investigated the sensitivity of Reynold's pentad which was consistently low with an overall value of 4.82%. The specificity of Reynold's pentad was not studied. Conclusion Charcot's triad has limited clinical utility as a diagnostic algorithm for AC. It is an effective rule-in test but a poor rule-out test and should be applied and taught accordingly. A more sensitive diagnostic tool is required to achieve superior outcomes for AC patients.

Background The quality of instruments and surgical expertise in minimally invasive surgery has developed markedly in the last two decades. Attention is now being turned to ways to allow surgeons to adopt more cost-effective and environmental-friendly approaches. This review explores current evidence on the cost and environmental impact of reusable versus single-use instruments. In addition, we aim to compare their quality, functionality and associated clinical outcomes. Method The Medline and EMBASE databases were searched for relevant literature from January 2000 to May 2015. Subject headings were Equipment Reuse/, Disposable Equipment/, Cholecystectomy/, Laparoscopic/, Laparoscopy/, Surgical Instruments/, Medical Waste Disposal/, Waste Management/, Medical Waste/, Environmental Sustainability/ and Sterilization/. Results There are few objective comparative analyses between single-use versus reusable instruments. Current evidence suggests that limiting use of disposal instruments to necessity may hold both economical and environmental advantages. Theoretical advantages of single-use instruments in quality, safety, sterility, ease of use and importantly patient outcomes have rarely been examined. Cost-saving methods, environmental-friendly methods, global operative costs, hidden costs, sterilization methods and quality assurance systems vary greatly between studies making it difficult to gain an overview of the comparison between single-use and reusable instruments. Conclusions Further examination of cost comparisons between disposable and reusable instruments is necessary while externalized environmental costs, instrument function and safety are also important to consider in future studies.

Bariatric surgery, in recent times, has gained media attention that has influenced individual, healthcare provider and wider societal attitudes towards bariatric surgery. Studies exploring public and media levels of interest in bariatric surgery have been performed overseas but studies within New Zealand (NZ) are scarce. Analysis of Google Trends data may be a useful source of information in investigating public interest levels in bariatric surgery. We aimed to analyse Google Trends information on Internet searches in NZ and to explore sequential relationships with relevant changes in policy.Key search terms for our Google Trends query were retrieved by independently reviewing news articles relating to bariatric surgery in NZ published between January 2007 and December 2017 and following a brainstorming session. Trend analyses were performed using Microsoft Excel 14.7.2. Data were captured for both NZ and worldwide search interests in Google Trends.Trend analyses showed that total search volumes for 'lap band' and 'lap band surgery' declined while 'gastric sleeve' and 'gastric sleeve surgery' increased exponentially over the 10-year period. Furthermore, search interests for key terms in NZ were comparable with those worldwide.Our findings reveal that search interests related to bariatric surgery in NZ mirror those worldwide. This includes the popularity of some bariatric procedures over others. The use of Google Trends may provide us with an additional tool to evaluate public interest levels related to bariatric surgery in NZ and could add value in examining the socio-cultural and political contexts of obesity and bariatric surgery.

The prioritization of elective surgical wait-lists remains a contentious issue. Multiple new tools and systems have been developed to attempt to reliably prioritize patients. This study pilots one such system, the General Surgery Prioritization Tool and compares it to the existing triage system of clinical judgement. The aim was to determine if the new tool reflects clinical judgement. Secondary aims were to assess for any bias in its application to different patient groups or its application by different scorers.A cohort of 392 patients was identified who were wait-listed for non-cancer elective surgery between July 2015 and February 2016. The General Surgery Prioritization Tool was applied after traditional prioritization using clinical judgement. The scores produced by the new tool were compared to the clinical judgement categories. Differences in scores based on gender, ethnicity, age, surgical condition and surgeon were then analysed.There was statistically significant correlation in the new tool scores with traditional triage groups (P0.0001). There were no statistically significant differences in mean scores attributable to gender, age or ethnicity. There were minimal differences in mean scores between common surgical conditions. Except for one outlier the mean scores were consistent across 17 surgeons.This pilot study has found the General Surgery Prioritization Tool to reflect clinical judgement and to be generalizable by age, gender, ethnicity and prioritizing surgeon. The tool is at least as clinically reliable as traditional methods in the triage for elective general surgery with the advantage of being a more explicit process.

To investigate whether a text message intervention improves adherence to preoperative exercise advice prior to laparoscopic sleeve gastrectomy (LSG).A single-blinded parallel design 1:1 ratio randomized controlled trial was performed in patients undergoing LSG as a single-stage bariatric procedure for morbid obesity. The intervention group received preoperative daily text messages. The primary outcome was adherence to preoperative exercise advice as assessed by the number of participants partaking in ≥450 metabolic equivalent minutes (METminEighty-eight patients were included in the analysis with 44 allocated to each arm. Adherence and exercise activity increased significantly from baseline in the exposure group (EG) but not in the control group (CG). Adherence was significantly higher in the EG at the end of the intervention period compared to the CG. Despite increased exercise activity, there was no improvement in 6-min walk test or surgical recovery.A daily text message intervention improved adherence to preoperative exercise advice, but this did not correlate with improved surgical recovery.

Background The aims of this paper were to review our experience with necrotizing fasciitis at Middlemore Hospital and to define the trends in incidence, inpatient mortality and microbiological profile. Methods A computerized search of the electronic medical records was undertaken to identify adult patients with a diagnosis of necrotizing fasciitis between January 2000 and December 2010. A retrospective review of the clinical records was performed. Results Of the 138 patients with necrotizing fasciitis identified, 129 had their diagnosis confirmed at operation. The mortality at 30 days was 20.3% (95% confidence interval (CI) 13.9%–28.0%). There was a significant reduction in hospital mortality in each successive year of the study period with an odds ratio of 0.84 (95% CI 0.71–0.98, P = 0.03). A pattern of increasing incidence was noted until February 2004 (95% CI September 2002–July 2005). This was followed by a significant decrease in incidence. The empirical antibiotic regime of clindamycin, gentamicin and penicillin provides satisfactory cover against 95% of the causative pathogens. Conclusion This represents the largest single-centre published case series in New Zealand. Despite concerns of increasing incidence and mortality associated with necrotizing fasciitis in New Zealand, the experience in South Auckland shows a decrease in incidence of necrotizing fasciitis since 2004 and a statistically significant decreasing trend in hospital mortality.

Publicly funded bariatric surgery in New Zealand (NZ) is steadily on the rise to meet the obesity epidemic. Ethnic disparities in obesity rates exist in NZ with Māori and Pacific people having three to five times higher rates than all other ethnic groups within NZ. Ethnic disparities in rates of bariatric surgery have been reported internationally. This research sought to describe rates of publically funded bariatric surgery by self-identified ethnicity in NZ.Using reported census and hospitalization discharge data from Statistics NZ and the NZ Ministry of Health, we calculated estimate rates of publicly funded bariatric surgery in the morbidly obese population from June 2009 to July 2014.The average number of publicly funded bariatric procedures performed per 1000 morbidly obese patients from June 2009 to July 2014 was 3.0 for European, 1.4 for Māori and 0.7 for Pacific ethnicities.While these data should be interpreted cautiously due to data limitations, the estimated rates may indicate that bariatric services are currently being provided inequitably across the major ethnic groups within NZ. We suggest that further studies should be performed to explore potential patient, healthcare provider and system-level factors that may contribute to ethnic disparities in the rates of publicly funded bariatric surgery in NZ.

Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population.This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested.The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate.A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.

The quality of instruments and surgical expertise in minimally invasive surgery has developed markedly in the last two decades. Attention is now being turned to ways to allow surgeons to adopt more cost-effective and environmental-friendly approaches. This review explores current evidence on the cost and environmental impact of reusable versus single-use instruments. In addition, we aim to compare their quality, functionality and associated clinical outcomes.The Medline and EMBASE databases were searched for relevant literature from January 2000 to May 2015. Subject headings were Equipment Reuse/, Disposable Equipment/, Cholecystectomy/, Laparoscopic/, Laparoscopy/, Surgical Instruments/, Medical Waste Disposal/, Waste Management/, Medical Waste/, Environmental Sustainability/ and Sterilization/.There are few objective comparative analyses between single-use versus reusable instruments. Current evidence suggests that limiting use of disposal instruments to necessity may hold both economical and environmental advantages. Theoretical advantages of single-use instruments in quality, safety, sterility, ease of use and importantly patient outcomes have rarely been examined. Cost-saving methods, environmental-friendly methods, global operative costs, hidden costs, sterilization methods and quality assurance systems vary greatly between studies making it difficult to gain an overview of the comparison between single-use and reusable instruments.Further examination of cost comparisons between disposable and reusable instruments is necessary while externalized environmental costs, instrument function and safety are also important to consider in future studies.

The aims of this paper were to review our experience with necrotizing fasciitis at Middlemore Hospital and to define the trends in incidence, inpatient mortality and microbiological profile.A computerized search of the electronic medical records was undertaken to identify adult patients with a diagnosis of necrotizing fasciitis between January 2000 and December 2010. A retrospective review of the clinical records was performed.Of the 138 patients with necrotizing fasciitis identified, 129 had their diagnosis confirmed at operation. The mortality at 30 days was 20.3% (95% confidence interval (CI) 13.9%-28.0%). There was a significant reduction in hospital mortality in each successive year of the study period with an odds ratio of 0.84 (95% CI 0.71-0.98, P = 0.03). A pattern of increasing incidence was noted until February 2004 (95% CI September 2002-July 2005). This was followed by a significant decrease in incidence. The empirical antibiotic regime of clindamycin, gentamicin and penicillin provides satisfactory cover against 95% of the causative pathogens.This represents the largest single-centre published case series in New Zealand. Despite concerns of increasing incidence and mortality associated with necrotizing fasciitis in New Zealand, the experience in South Auckland shows a decrease in incidence of necrotizing fasciitis since 2004 and a statistically significant decreasing trend in hospital mortality.

Background: Priority scoring tools are mooted as means for dealing with burgeoning elective surgical waiting lists. There is ongoing development work in New Zealand, Canada and the UK. This emerging international perspective is invaluable in determining the application of these tools and addressing any pitfalls. Methods: A systematic electronic literature review was performed. Information was also retrieved using a search of reference lists of all papers included in the review and contact with those who were involved in the development of such criteria. Results: The ethical basis of prioritization differed among priority scoring tools and in a number was not stated. The majority of tools covered criteria for specific procedures. Delphi consensus methods and regression were the predominant methods for ­deter­mining ­specific criteria. Authors’ opinions were the main source of generic criteria. Linear and non-linear models or matrices sum­mated criteria. Conclusion: There is debate over the ethical basis for prioritization. It is a concern that it is not addressed in many studies. The development of generic criteria showed a dearth of consensus approaches that represents a significant gap in our knowledge. On the aspects of summation and weighting, the impact of assumptions on the prioritization of patients may not have been fully explored.

Background: The New Zealand health reforms have resulted in the requirement that surgeons utilize Clinical Priority Access Criteria (CPAC) to ration patient access to elective surgery. The validity of the tools used as CPAC has been challenged. An alter­native tool, the Linear Analogue Scale (LAS), is therefore used in our institution. Our objectives were to determine the variables that influence the priority score generated using the LAS, and the length of time waited by patients awaiting general surgical procedures. Methods: A cohort of 918 patients who were listed for elective general surgical procedures at Auckland Hospital, Auckland, New Zealand between 1 July 1998 and 31 March 1999 were studied. Patients were given a priority score generated using the LAS. For each patient, the time from assessment until his or her procedure was documented. Linear and logistic regression models were used to investigate variables (age, gender, diagnosis and surgical team) that influence priority score. Cox proportional hazards models were used to investigate variables (priority score, age, gender, and diagnosis) that influence the length of time waited. Results: Graphical presentation showed a pattern of priority scores falling into ‘bands’ for different diagnoses. Diagnosis, and to a lesser extent surgical team, influenced priority score. Survival analysis showed ‘time waited’ to be influenced by priority score, diagnosis, and patient age and gender. Conclusion: The LAS may have a useful role in the difficult sphere of patient prioritization. Its strength lies in its simplicity. Further investigation of reliability and effect on patient outcomes is required.

Background: To assess the presentation, management and risk factors for mortality in necrotizing fasciitis at Middlemore Hospital in South Auckland, New Zealand. Methods: A retrospective review of the medical records of patients presenting to Middlemore Hospital over a 6-year period (1997−2002) with a diagnosis of necrotizing fasciitis. Results: Forty eight patients were identified. There were 27 men and 21 women whose age ranged from 19 to 80 years (median 51 years) at presentation. Maori and Pacific Islanders accounted for 64% of total admissions despite making up only 31% of the referral population. Streptococcus Pyogenes was the most common bacterial isolate (54%). 31% of patients had polymicrobial infections. Sixty-two per cent of cases involved extremities. The median number of operations and length of stay were 4 and 31 days, respectively. Overall mortality was 29%. In multivariate analysis, delay in surgical intervention (P = 0.015) and diabetes mellitus (P = 0.023) were found to be associated with increased mortality. Ethnicity, sex, type of pathogen, site of infection and increasing age did not affect mortality. Conclusion: Necrotizing fasciitis remains a significant problem in our community especially in the Maori and Pacific population. Early surgical debridement decreases mortality rates.

Background: The introduction of health reforms in New Zealand included the setting of an arbitrary waiting time threshold of 6 months for surgery. The aim of the present study was to investigate the differences in waiting times for different diagnoses in elective general surgery, and the interplay between diagnoses and waiting time thresholds. Methods: A survival curve analysis of 918 patients placed on the elective general surgical waiting lists was conducted. This was undertaken in a tertiary level hospital in New Zealand before the implementation of the waiting time thresholds. The difference between diagnoses of time waited for elective surgery (plotted on survival curves), and hazard function for patients waiting at 180, 360 and 540 days, was investigated. Results: Survival curves for malignancy, cholelithiasis, hernias and anorectal disease were different on log−rank test (P

Background: Clinical priority assessment criteria (CPAC) are used to generate a score by which patients are prioritized and rationed for elective surgery. It is widely believed that surgeons elevate scores to ensure their patients’ acceptance for elective surgery, colloquially called gaming. The purpose of the present paper was therefore to investigate whether there was a temporal trend to an increase in the assigned priority score from the inception of CPAC to the present. Methods: Priority and weighted inlier equivalent separations (WIES) scores between 23 April 1999 and 23 July 2002 were collected for elective general surgical cases at Auckland Hospital. A total of 5440 cases was retrospectively analysed using multiple regression techniques. Priority score was included as the dependent variable and time as an independent variable. Any change in case complexity over that period was accounted for by including the WIES score as a covariate. Multiple regression was undertaken for the combined surgeons and for individuals. Results: The combined model was statistically significant but accounted for only 17% of the priority score variance. An increase of one WIES unit leads to an increase of 2.7 in priority score (P = 0.0001). The relationship of priority score with time was dependent on the surgeon performing the prioritization. However, only half the surgeons had individual models that indicated gaming. Conclusions: The results show that gaming is occurring but that not all surgeons participate in this. The difference between surgeons’ participation in gaming is a potential source of practice variation in the prioritization process.

The introduction of health reforms in New Zealand included the setting of an arbitrary waiting time threshold of 6 months for surgery. The aim of the present study was to investigate the differences in waiting times for different diagnoses in elective general surgery, and the interplay between diagnoses and waiting time thresholds.A survival curve analysis of 918 patients placed on the elective general surgical waiting lists was conducted. This was undertaken in a tertiary level hospital in New Zealand before the implementation of the waiting time thresholds. The difference between diagnoses of time waited for elective surgery (plotted on survival curves), and hazard function for patients waiting at 180, 360 and 540 days, was investigated.Survival curves for malignancy, cholelithiasis, hernias and anorectal disease were different on log-rank test (P0.001). Those with a diagnosis of malignancy show that at 180 days the hazard function was 0.0049 but by 360 days had dropped to zero. With hernias and anorectal disease, the drop to zero appeared to be delayed until 540 days; however, the confidence intervals at 360 days included zero. In the case of cholelithiasis, the hazard functions indicate surgery occurring until 540 days.There are different waiting time thresholds for different surgical illnesses. Setting a universal waiting time for elective surgery is not supported.

Priority scoring tools are moot as means for dealing with burgeoning elective surgical waiting lists. There is ongoing development work in New Zealand, Canada and the UK. This emerging international perspective is invaluable in determining the application of these tools and addressing any pitfalls.A systematic electronic literature review was performed. Information was also retrieved using a search of reference lists of all papers included in the review and contact with those who were involved in the development of such criteria.The ethical basis of prioritization differed among priority scoring tools and in a number was not stated. The majority of tools covered criteria for specific procedures. Delphi consensus methods and regression were the predominant methods for -deter-mining -specific criteria. Authors' opinions were the main source of generic criteria. Linear and non-linear models or matrices sum-mated criteria.There is debate over the ethical basis for prioritization. It is a concern that it is not addressed in many studies. The development of generic criteria showed a dearth of consensus approaches that represents a significant gap in our knowledge. On the aspects of summation and weighting, the impact of assumptions on the prioritization of patients may not have been fully explored.

The New Zealand health reforms have resulted in the requirement that surgeons utilize Clinical Priority Access Criteria (CPAC) to ration patient access to elective surgery. The validity of the tools used as CPAC has been challenged. An alter-native tool, the Linear Analogue Scale (LAS), is therefore used in our institution. Our objectives were to determine the variables that influence the priority score generated using the LAS, and the length of time waited by patients awaiting general surgical procedures.A cohort of 918 patients who were listed for elective general surgical procedures at Auckland Hospital, Auckland, New Zealand between 1 July 1998 and 31 March 1999 were studied. Patients were given a priority score generated using the LAS. For each patient, the time from assessment until his or her procedure was documented. Linear and logistic regression models were used to investigate variables (age, gender, diagnosis and surgical team) that influence priority score. Cox proportional hazards models were used to investigate variables (priority score, age, gender, and diagnosis) that influence the length of time waited.Graphical presentation showed a pattern of priority scores falling into 'bands' for different diagnoses. Diagnosis, and to a lesser extent surgical team, influenced priority score. Survival analysis showed 'time waited' to be influenced by priority score, diagnosis, and patient age and gender.The LAS may have a useful role in the difficult sphere of patient prioritization. Its strength lies in its simplicity. Further investigation of reliability and effect on patient outcomes is required.