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Background: Older brain age - as estimated from structural MRI data - is known to be associated with detrimental mental and physical health outcomes in older adults. Social isolation, which has similar detrimental effects on health, may be associated with accelerated brain aging though little is known about how different trajectories of social isolation across the life course moderate this association. We examined the associations between social isolation trajectories from age 5 to age 38 and brain age assessed at age 45., Methods: We previously created a typology of social isolation based on onset during the life course and persistence into adulthood, using group-based trajectory analysis of longitudinal data from a New Zealand birth cohort. The typology comprises four groups: 'never-isolated', 'adult-only', 'child-only', and persistent 'child-adult' isolation. A brain age gap estimate (brainAGE) - the difference between predicted age from structural MRI date and chronological age - was derived at age 45. We undertook analyses of brainAGE with trajectory group as the predictor, adjusting for sex, family socio-economic status, and a range of familial and child-behavioral factors., Results: Older brain age in mid-adulthood was associated with trajectories of social isolation after adjustment for family and child confounders, particularly for the 'adult-only' group compared to the 'never-isolated' group., Conclusions: Although our findings are associational, they indicate that preventing social isolation, particularly in mid-adulthood, may help to avert accelerated brain aging associated with negative health outcomes later in life.

Purpose: Social isolation has been shown to have negative effects on mental health outcomes though little is known about trajectories across the life course. We examined the relationship between trajectory groups and selected mental health outcomes in mid-adulthood., Methods: We previously created a typology of social isolation based on onset during the life course and persistence into adulthood, using group-based trajectory analysis of longitudinal data from a New Zealand birth cohort. The typology comprises four groups: 'never-isolated', 'adult-only', 'child-only', and 'persistent (child-adult) isolation'. We undertook logistic regression analyses of three mental health outcomes with trajectory group as the predictor, adjusting for sex and a range of familial and child-behavioural factors., Results: Lifetime suicide attempt, and depression and suicide ideation in mid-adulthood were each associated with adult-only but not child-only social isolation. Depression in mid-adulthood was also associated with persistent child-adult social isolation., Conclusion: Although our findings are associational and not causal, they indicate that interrupting persistent social isolation may help to prevent adult depression whereas halting adult social isolation may ameliorate both depression and suicide outcomes., (© 2022. The Author(s).)

In 2020, COVID-19 mitigation measures, including lockdowns and travel bans to curtail disease transmission, inadvertently led to an "Anthropause" - a unique global pause to anthropogenic activities. While there was a spike in ecological studies measuring Anthropause effects on environmental indicators, people's experiences of the Anthropause or its potential to inspire change were hardly considered. Hence, we aimed to measure people's appreciation of the environmental outcomes of the Anthropause, ecophilosophical contemplations about the pandemic, and experiences of lockdown-triggered biophilia (human's innate love for and draw towards nature) and test the hypothesis that these experiences would be consistently more prominent among the already environmentally inclined. To that end, we developed and tested three measures on a representative sample of 993 New Zealanders. Anthropause Appreciation received the highest overall mean ratings, followed by Lockdown-Biophilia and Eco-Contemplation. Pre-existing pro-environmental dispositions and behaviours did not consistently influence our three measures as expected. Demographic variables had little influence, while experiences of financial and mental health impacts due to COVID-19 had no influence. We interpreted the limited influence of explanatory variables as indicative of a degree of uniformity in people's experiences. High appreciation of Anthropause benefits suggests that the public may be supportive of policies and ways of living that can lead to similar outcomes post-pandemic - offering environmental policymakers and communicators a basis for action. Ecophilosophical contemplations and biophilic draw among the public suggest an awareness of the significance of the human-nature relationship - offering a symbolic global keystone for communicating and advocating conservation and the many values of pauses in life to connect with nature. Building women's environmental leadership capabilities and the ongoing greening of Christianity may be essential steps for global post-pandemic environmental behaviour transformations., 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., (© 2022 The Author(s).)

Objectives: There is evidence that loneliness is detrimental to the subjective well-being of older adults. However, little is known on this topic for the cohort of those in advanced age (80 years or older), which today is the fastest-growing age group in the New Zealand population. We examined the relationships between loneliness and selected subjective well-being outcomes over 5 years., Methods: We used a regional, bicultural sample of those in advanced age from 2010 to 2015 (Life and Living in Advanced Age: a Cohort Study in New Zealand). The first wave enrolled 937 people (92% of whom were living in the community): 421 Māori (Indigenous New Zealanders aged 80-90 years) and 516 non-Māori aged 85 years. We applied standard regression techniques to baseline data and mixed-effects models to longitudinal data, while adjusting for sociodemographic factors., Results: For both Māori and non-Māori, strong negative associations between loneliness and subjective well-being were found at baseline. In longitudinal analyses, we found that loneliness was negatively associated with life satisfaction as well as with mental health-related quality of life., Discussion: Our findings of adverse impacts on subjective well-being corroborate other evidence, highlighting loneliness as a prime candidate for intervention-appropriate to cultural context-to improve well-being for adults in advanced age., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America.)

There has been growing recognition of the harmful consequences of loneliness for health and well-being, and the need for community intervention, particularly in times of global crisis such as the Covid-19 pandemic with its imperatives of distancing, isolation, and quarantine. Social capital and a sense of social cohesion are known to have roles in buffering against the effects of adverse life circumstances. Our study sought to investigate the association of a range of social attitudes and activities - as proxies for social capital - with loneliness while taking into account socio-demographic factors. We undertook a national survey on a stratified random sample of the New Zealand (NZ) adult population aged 18+ in 2017 (n = 1,358), data from which included the requisite variables. The prevalence of loneliness was highest in young adults (18-30), falling with age until a slight rise in older people (76+). Loneliness was associated with socio-demographic factors, being more prevalent in the more disadvantaged groups: the deprived, Māori (the indigenous people of NZ), the non-partnered, and the less educated. Controlling for these socio-demographic factors, pro-social attitudes (that is towards political efficacy, trust in others, not feeling exploited, or being committed to family) and participation in social activities (that is being employed or being involved in recreation groups) - were protective against loneliness. Our study supports asset-based approaches to tackling loneliness - with implications for health and social care - that emphasise mobilising existing social resources, building social capital, and raising social cohesion in our communities. Such intervention on loneliness would help to prevent and ameliorate its detrimental consequences for public health., (© 2021 John Wiley & Sons Ltd.)

Social isolation - the lack of social contacts in number and frequency - has been shown to have a negative impact on health and well-being. Using group-based trajectory analysis of longitudinal data from a New Zealand birth cohort, we created a typology of social isolation based on onset during the life course and persistence into adulthood. We then characterized each type according to risk factors related to family environment and child behavior that have been shown previously to be associated with social isolation. Based on fit statistics and distinctness of trajectories we considered the four-class model to be the most appropriate: (1) 'never isolated' (71.6 % of the cohort), (2) 'adult only' (10.1 %), (3) 'child only' (14.3 %), and (4) 'persistent isolation' (4.0 %). Family-environmental factors - i.e. having a teen-aged mother, having a single parent, frequent changes in residence, or maltreatment - tended to be associated with both child and adult onset and persistence of social isolation, whereas child-behavioral factors - i.e. self-control or internalizing symptoms - applied more to the child onset of social isolation. Sensitivity analyses using empirically defined groups - based on 15 % 'cut-offs' for isolation in childhood and adulthood - produced similar life-course groupings and similar associations. Our findings provide insights into the development of social isolation and demonstrate the changeability of social isolation across almost four decades of the life span. They also suggest family-based and child-based interventions could address child onset and the persistence of social isolation into adulthood., (Copyright © 2021. Published by Elsevier Ltd.)

We explore the intergenerational pattern of resource transfer and possible associated factors. A scoping review was conducted of quantitative, peer-reviewed, English-language studies related to intergenerational transfer or interaction. We searched AgeLine, PsycINFO, Social Work Abstracts, and Sociological Abstracts for articles published between Jane 2008 and December 2018. Seventy-five studies from 25 countries met the inclusion criteria. The scoping review categorised resource transfers into three types: financial, instrumental, and emotional support. Using an intergenerational solidarity framework, factors associated with intergenerational transfer were placed in four categories: (1) demographic factors (e.g., age, gender, marital status, education, and ethno-cultural background); (2) needs and opportunities factors, including health, financial resources, and employment status; (3) family structures, namely, family composition, family relationship, and earlier family events; and (4) cultural-contextual structures, including state policies and social norms. Those factors were connected to the direction of resource transfer between generations. Downward transfers from senior to junior generations occur more frequently than upward transfers in many developed countries. Women dominate instrumental transfers, perhaps influenced by traditional gender roles. Overall, the pattern of resource transfer between generations is shown, and the impact of social norms and social policy on intergenerational transfers is highlighted. Policymakers should recognise the complicated interplay of each factor with different cultural contexts. The findings could inform policies that strengthen intergenerational solidarity and support.

Background: New Zealand has high rates of child overweight and obesity when compared with other countries. Despite an abundance of research documenting the problem, it is unclear what the most effective policy changes or interventions are, and how policy changes might unfold over time within complex systems., Methods: We use estimates derived from meta-analyses to create a dynamic microsimulation model of child overweight (including obesity). Using census records we created a synthetic birth cohort of 10,000 children. Information on parental education, ethnicity and father's socio-economic position at birth were taken from census records. We used the New Zealand Health Survey to estimate population base rates for the prevalence of overweight and obesity. Information on other modifiers (such as maternal smoking, breastfeeding, preterm birth, regular breakfast consumption and so forth) were taken from three birth cohorts: Christchurch Health and Development Study, The Dunedin Multidisciplinary Health and Development Study and the Pacific Islands Families Study. Published intervention studies were used to derive plausible estimates for changes to modifiers., Results: Reducing the proportion of mothers classified as overweight and obesity (-3.31(95% CI -3.55; -3.07) percentage points), reducing the proportion of children watching two or more hours of TV (-3.78(95% CI -4.01; -3.54)), increasing the proportion of children eating breakfast regularly (-1.71(95% CI -1.96; -1.46)), and reducing the proportion of children born with high birth weights (-1.36(95% CI -1.61; -1.11)), lead to sizable decreases in the estimated prevalence of child overweight (including obesity). Reducing the proportion of mothers giving birth by caesarean (-0.23(95% CI -0.49; -0.23)) and increasing parental education (-0.07(95% CI -0.31; 0.18)) did not impact upon child overweight rates., Conclusions: We created a working simulation model of New Zealand children that can be accessed by policy makers and researchers to determine known relationships between predictors and child overweight, as well as potential gains from targeting specific pathways.

Aim: The aim of this study was to describe trends in intentional self-harm for Pacific peoples in New Zealand by reviewing official data over the period 1996-2015., Method: Publicly funded hospitalisations where the external cause was intentional self-harm were examined and areas of interest were identified and are presented., Results: Over a 19-year period (1996-2015), there were 1,608 intentional self-harm events for Pacific peoples (2.8%) out of 58,643 intentional self-harm events nationally for New Zealand's total population., Conclusion: This study has been able to delineate Pacific ethnic-specific information not previously available for a prolonged period of 19 years. There are differences in Pacific peoples' experiences between ethnic groups. Furthermore, disparities persist between Pacific and non-Pacific. This study exposes priority areas for more targeted interventions according to ethnic, socioeconomic status, gender and age variations., Competing Interests: Nil.

The demographic ageing of New Zealand society, as elsewhere in the developed world, has dramatically increased the proportion of older people (aged 65 years and over) in the population. This has major policy implications for the future organisation of social care. Our objective was to test the effects on social care use, first, of putative changes in the overall disability profile of older people, and second, of alterations to the balance of their care, i.e. whether it was community-based or residential. In order to undertake these experiments, we developed a microsimulation model of the later life course using individual-level data from two official national survey series on health and disability, respectively, to generate a synthetic version which replicated original data and parameter settings. A baseline projection under current settings from 2001 to 2021 showed moderate increases in disability and associated social care use. Artificially decreasing disability levels, below the baseline projection, only moderately reduced the use of community care (both informal and formal). Scenarios implemented by rebalancing towards informal care use moderately reduced formal care use. However, only moderate compensatory increases in community-based care were required to markedly decrease the transition to residential care. The disability impact of demographic ageing may not have a major negative effect on system resources in developed countries like New Zealand. As well as healthy ageing, changing the balance of social care may alleviate the impact of increasing demand due to an expanding population of older people., (© 2016 John Wiley & Sons Ltd.)

Aim: The aim of this study was to describe trends in suicide mortality for Pacific peoples in New Zealand by reviewing official data over the period 1996-2013., Method: Death registrations where the underlying causes of death were intentional self-harm was examined and area of interest was identified and presented., Results: Over a 17-year period (1996-2013), there were 380 total Pacific suicides (4.1%) out of 9,307 suicides nationally for New Zealand's total population., Conclusion: Priority areas for effective suicide prevention include: Pacific young males, Pacific ethnic foci, clear ethnic disparities and inequalities for Pacific suicide mortality when compared to New Zealand's total population; safe, ethical and culturally appropriate messaging around suicide methods; the importance of the role of mental health and addictions in suicide prevention. On average, there are at least 22 Pacific suicides annually in New Zealand. Irrespective of small numbers, further Pacific ethnic breakdown is needed other than Samoan, Cook Islands and Tongan, as this is problematic for suicide prevention efforts for the exclusion of other Pacific groups., Competing Interests: Nil.

Aims: The demographic ageing of New Zealand society has greatly increased the proportion of older people (aged 65 years and over), with major policy implications. We tested the effects on health service use of alterations to morbidity profile and the balance of care., Methods: We developed a microsimulation model using data from an official national health survey series to generate a synthetic replicate for scenario testing., Results: Projections on current settings from 2001 to 2021 showed increases in morbidity-long-term illness (2%)-and in health service use-doctor visits (21%), public hospital admissions (16%). Scenarios with decreasing morbidity levels showed moderate reductions in health service use. By contrast, rebalancing towards the use of practice nurses showed a large decrease in public hospital admissions for people aged 85 years and over., Conclusion: Demographic ageing may not have a major negative effect on system resources in New Zealand and other developed countries. Rebalancing between modalities of care may soften the impact of increasing health service use required by a larger older population.

Ambulatory sensitive hospitalizations (ASH) are those thought to be preventable by timely and effective primary health care. Better access to primary health care has been associated with lower ASH rates. Funding increases to primary health care in New Zealand beginning in 2001 led to an improvement in access. Analysis of hospitalizations to all New Zealand public hospitals revealed that, for most age groups, ASH rates did not show long-term reductions from 2001 to 2009, while socioeconomic differences in ASH rates widened across this period. We conclude that increasing funding and access to primary health care will not, by itself, reduce ASH rates.

Though there is much agreement on the importance of the social determinants of health, debate continues on suitable empirically-based models to underpin efforts to tackle health and health care disparities. We demonstrate an approach that uses a dynamic micro-simulation model of the early life course, based on longitudinal data from a New Zealand cohort of children born in 1977, and counterfactual reasoning applied to a range of outcomes. The focus is on health service use with a comparison to outcomes in non-health domains, namely educational attainment and antisocial behaviour. We show an application of the model to test scenarios based on modifying key determinants and assessing the impact on putative outcomes. We found that appreciable improvement was only effected by modifying multiple determinants; structural determinants were relatively more important than intermediary ones as potential policy levers; there was a social gradient of effect; and interventions bestowed the greatest benefit to the most disadvantaged groups with a corresponding reduction in disparities between the worst-off and the best-off. Our findings provide evidence on how public policy initiatives might be more effective acting broadly across sectors and across social groups, and thus make a real difference to the most disadvantaged., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Increasing interest has focused on the safety of hospital care. The AusPSIs are a set of indicators developed from Australian administrative data to reliably identify inpatient adverse events in hospitals. The main aim of this study was to explore the application of the AHRQ/AusPSIs to New Zealand administrative hospital data related to medical and surgical care. Variation over time and across hospitals were also considered for a subset of the more common indicators., Method: AHRQ/AusPSIs were adapted for use with New Zealand National Minimum Dataset administrative data for the period 2001-9. Crude positive event rates for each of the 16 indicators were assessed across New Zealand public hospitals. Variation over time for six more common indicators is presented using statistical control charts. Variation between hospitals was explored using rates adjusted for differences in patient variables including age, sex, ethnicity, rurality of residence, NZDep score and comorbidities., Results: The AHRQ/AusPSIs were applied to New Zealand administrative hospital data and some 99,366 admissions were associated with a positive indicator event. However rates for some indicators were low (<1% of denominator admissions). Over the study period considerable variation in the rate of positive events was evident for the six most common indicators. Likewise there was substantial variation between hospitals in relation to risk adjusted positive event rates, Discussion: Patient safety indicators can be applied to New Zealand administrative hospital data. While infrequent rates hinder the use of some of the indicators, several could now be readily employed as warning flags to help monitor rates of adverse events at particular hospitals. In conjunction with other established or emerging tools, such as audit and trigger tools, the PSIs are now available to promote ongoing quality improvement activities in New Zealand hospitals.

There are well-established frameworks for comparing the performance of health systems cross-nationally on multiple dimensions. A sub-set of such comprehensive schema is taken up by criteria specifically applied to health service delivery, including hospital performance. We focus on evaluating hospital performance, using the New Zealand public hospital sector over the period 2001-2009 as a pragmatic and illustrative case study for cross-national application. We apply a broad three-dimensional matrix--efficiency, effectiveness, equity--each based on two measures, and we undertake ranking comparisons of 35 hospitals. On the efficiency dimension--relative stay, day surgery--we find coefficients of variation of 10.8% and 8.5% respectively in the pooled data, and a slight trend towards a narrowing of inter-hospital variation over time. The correlation between these indicators is low (.20). For effectiveness--post-admission mortality, unplanned readmission--the coefficient of variation is generally higher (24.1% and 12.2%), and the trend is flat. The correlation is again low (.21). The equity dimension is assessed by quantifying the degree of ethnic and socio-economic variation for each hospital. The coefficient of variation is much higher--40.7-66.5% for ethnicity, 55.8-84.4% for socio-economic position--the trend over time is mixed, and the correlation is moderate (.41). On averaging the rank of hospitals across all measures it is evident that there is limited consistency across the three constituent dimensions. While it is possible to assess hospital performance across three dimensions using an illustrative set of standard measures derived from routine data, there appears to be little consistency in hospital rankings on these New Zealand data for the period 2001-2009. However, the methodology of using rankings derived from readily available data--possibly allied with multiple or composite indicator models--has potential for the cross-national comparison of hospital profiles, and assessments in three dimensions provide a more holistic and rounded account of performance., (Copyright © 2013 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Medical practice variation and social disparities in health are pervasive features of health care systems. But what impact might everyday clinical decision making have in shaping such aggregate patterns, and could this in turn be influenced by the immediate environment in which family doctors practise? We investigate this by studying inter-practitioner variation in clinical activity across four payment types in New Zealand, a "gatekeeper" primary care system. We do this for four measures of clinical activity by patient ethnic and socio-economic status in a 2001/2002 representative sample of 9272 encounters at 185 family practices. Initial analysis showed little variation in clinical activity either by patient status or by practice type. However, with the application of multi-level statistical techniques it was evident that, while there was still little systematic difference in practitioner activity rates by patient status, inter-practitioner variation was greater for patients of ethnic minority background and from socio-economically deprived areas. Furthermore, this variability was particularly marked in fee-for-service practice settings. Thus, to the extent that family doctor decision-making behaviour within practice context helps shape aggregate patterns of medical practice variation and social disparity, treatment differences are likely associated not with the level of service but with its variability., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To describe changes in aged care residents' dependency over a 20-year period., Design: All residents in 1988, 1993, 1998, and 2008 were assessed using the same 23-item functional ability survey., Setting: Residential aged care facilities in Auckland, New Zealand., Participants: In 1988 there were 7516 participants (99% response rate), 6972 in 1993 (85% response rate), 5056 in 1998 (65% response rate), and 6828 in 2008 (89% response rate). Data were weighted to accommodate variation in response., Measurements: A composite dependency score with 5 ordinal levels was derived from a census-type survey reporting mobility, activities of daily living ability, continence, and cognitive function., Results: The proportion of "apparently independent" residents decreased from 18% in 1988 to 9% in 1993, 5% in 1998, and 4% in 2008, whereas those "highly dependent" increased from 16% in 1988, to 18% in 1993, 19% in 1998, to 21% in 2008. All functional indicators demonstrated increased dependency over the 20-year period (P < .0001). However, between 1998 and 2008 there were significant increases in dependency for continence, mobility, self-care, and orientation, but no significant changes in memory and behavior., Conclusion: The increased dependency over 20 years directly affects care requirements for this population., (Copyright © 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Background: in Auckland, New Zealand in 1988, 7.7% of those aged over 65 years lived in licenced residential aged care. Age-specific rates approximately doubled for each 5-year age group after the age of 65 years. Even with changes in policies and market forces since 1988, population increases are forecast to drive large growth in demand. This study shows previously unrecognised 20-year trends in rates of care in a geographically defined population., Methods: four cross-sectional surveys of all facilities (rest homes and hospitals) licenced for long-term care of older people were conducted in Auckland, New Zealand in 1988, 1993, 1998 and 2008. Facility staff completed survey forms for each resident. Numbers of licenced and occupied beds and trends in age-specific and age-standardised rates in residential aged care are reported., Results: over the 20-year period, Auckland's population aged over 65 years increased by 43% (from 91,000 to 130,000) but actual numbers in care reduced slightly. Among those aged over 65 years, the proportion living in care facilities reduced from 1 in 13 to 1 in 18. Age-standardised rates in rest-home level care reduced from 65 to 33 per thousand, and in hospital level care, from 29 to 23 per thousand. Had rates remained stable, over 13,200 people, 74% more than observed, would have been in care in 2008., Conclusion: growth predicted in the residential aged care sector is not yet evident. The introduction of standardised needs assessments before entry, increased availability of home-based services, and growth in retirement villages may have led to reduced utilisation.

Objectives: To assess micro-simulation for testing policy options under demographic ageing., Methods: Individual-level data were drawn from the New Zealand Health Survey (1996/7 and 2002/3), a national survey of ambulatory care in New Zealand (2001/2), and the Australian National Health Survey (1995). Health service effects assessed were visits to the family doctor, and rates of prescribing and referral. We created a representative set of synthetic health histories by imputation and tested the health service effects of different policy scenarios. These were created by varying ageing and morbidity trajectories, degree of social support available, and intensity of practitioner behaviour., Results: The set of synthetic health histories created by combining the data sources generated outcomes reasonably close to external benchmarks. Altering the age distribution of 2002 to approximate settings for 2021 produced no change in rates of visiting, prescribing, or referral for the 65-and-over population. Quantifying the health service effects of different scenarios showed no impact on visit rates by varying social support, but substantial differences for visits between high and low morbidity scenarios and for prescribing and referral rates according to practitioner behaviour., Conclusions: There is potential for micro-simulation to assist in the synthesis of data and to help quantify scenario options for policy development., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Aims: To describe the occurrence and pattern of patient dissatisfaction and/or litigation recorded in medical notes in New Zealand public hospitals., Methods: An analysis was carried out on 173 incidents of patient dissatisfaction and/or litigation recorded in medical notes. These were identified from a representative sample of 6579 medical records for 1998 drawn from 13 public hospitals as part of a screening exercise designed to detect the occurrence of adverse events., Results: Overall, 2.7% of medical notes carried mentions of patient dissatisfaction and/or litigation, varying slightly by hospital type and rising to a rate of 6.9% for adverse events. Such incidents were likely to be associated with other administrative and clinical complications, including the occurrence of an adverse event. Among diagnostic categories nervous system was predictive overall, and pregnancy or neonatal among adverse events. There was no consistent pattern by social background of the patient. A qualitative analysis showed that about a third of incidents were related to clinical matters, another third were more organisational in nature, and the remainder were mixed or non-specific. Issues of communication were more important for incidents that were not associated with adverse events., Conclusions: Levels of patient dissatisfaction and/or litigation recorded in patient notes are low. Nevertheless they are associated with other indicators of administrative and clinical complications in hospital care, including the occurrence of adverse events, and thus may be suggestive of wider systemic issues in the quality and experience of care requiring attention. While clinical and organisational matters appear to predominate in case descriptions, communication issues are also important.

Aims: To examine cardiovascular preventive and renal protective treatment for different ethnic groups with diabetes in primary care., Methods: The study population included patients with type 2 diabetes attending an annual review in New Zealand primary care during 2004. Primary care data were linked to hospital admission data to identify previous cardiovascular disease (CVD). For those without previous CVD, 5-year cardiovascular risk was calculated. Proportions on, and predictors of appropriate treatment according to guidelines were investigated., Results: Data were available on 29,179 patients. Maori and Pacific participants had high rates of obesity, poor glycaemic control and albuminuria. Two thirds of all participants with previous CVD (68% of Maori and 70% of Pacific) and 44% with high CVD risk received appropriate CVD treatment; 73% of Maori, 62% of Pacific and 65% of European patients with albuminuria received ACE-inhibitors. Those with high CVD risk were more likely, and those that were young were less likely, to receive anti-hypertensive and lipid-lowering treatment after controlling for other factors., Conclusion: Maori and Pacific people were receiving similar high rates of appropriate CVD and renal preventive drug therapy to Europeans, but their prevalence of smoking, obesity, raised HbA1c and albuminuria were substantially higher. Non-drug components of preventive care also need to be addressed to reduce major ethnic disparities in diabetes-related morbidity and mortality in New Zealand.

In this article, we examined the effect of gender concordance on physicians' perception of their patients and of their medical condition, analyzing a data set of 8,258 visit questionnaires from the New Zealand National Primary Care Medical Care Survey conducted in 2001 2002. Multivariate analysis indicated that the concordant female patient/female physician dyad had a positive independent association with physicians' reporting high rapport and a negative independent association with reporting uncertainty about the diagnosis. The discordant female patient/male physician dyad had a positive independent association with physicians' perceptions of uncertainty of diagnosis and hidden agenda, and a negative independent association with rating the patient's condition of high severity. The findings suggest a need to raise male physicians' awareness to possible biases when treating female patients. The findings also suggest the need to empower female patients to take an active partnership role to improve their communication with male physicians.

Background: The impact of hospital and system restructuring on the quality and pattern of care is an important issue of public policy concern., Objective: To assess the effect on patterns of care and patient outcomes of a substantial reduction in public hospital bed availability and multiple reorganizations in New Zealand through the 1990s., Research Design: Trend analysis using both tabular and multilevel techniques., Subjects: Access to discharge data, amounting to 6,639,487 records, was secured for all 34 major public hospitals in New Zealand over the period 1988-2001., Outcome Measures: Number of discharges, admission rate, access levels, mean length of stay, unplanned readmission rate, and 60-day postadmission mortality rate., Results: Although the number of inpatient beds in use declined by one-third over the period and the national population grew by nearly one-fifth, discharge volumes increased significantly and rates of inpatient admission were maintained, as were access levels for vulnerable groups. These changes were accompanied by workload adjustments (a halving in length of stay and an increase by a quarter in readmission rates). Yet age-adjusted postadmission patient mortality decreased by a quarter over the period of study, a rate of decline that was slowed by the major workload adjustments but not by reform phase., Conclusions: Other things being equal, a substantial reduction in inpatient bed availability can be effected in national public hospital systems, while largely maintaining access and quality of care. However, the workload adjustments that are required may slow improvements in patient outcomes.

Objectives: New Zealand has experienced restructuring and reform of primary health care since the 1980s, including the introduction of commercial clinics and increasing numbers of practices run by community-governed organizations. Our aim was to compare commercial, community-governed and traditional practices in five key domains: access; coordination and continuity of care; communication and patient centredness; population health and preventive health; and chronic disease management., Methods: A nationally representative, multistage probability sample of private general practitioners, stratified by geographical location and practice type, was drawn. Representative samples of urban commercial clinics and of practices governed by community organizations were obtained for the same period (2001-02). All doctors were asked to provide data on themselves, their practice, and to report on a 25% sample of patients in two periods of one week., Results: Among the three practice types, commercial clinics differed most in their organization; they charged higher fees and employed more staff, although their doctors were less experienced. Community-governed practices were visited by more people from lower socioeconomic groups. Commercial clinic patients were more likely to be younger and less likely to have an ongoing relationship with the clinic. They frequently attended for self-limiting problems related to injuries or respiratory problems. Investigations, follow-up and referral rates were similar between the three practice types. Treatment rates were higher at traditional and community-governed general practices., Conclusion: Rather than replicating traditional practices, new practice types provide complementary services and established services in innovative ways. The challenge is to achieve an appropriate mix of diverse providers.

Aims: To estimate (among different population groups and different practice types) average duration of visit to a general practitioner, average number of visits, and average population exposure to primary medical care in New Zealand., Methods: Observational study using a representative survey of visits to general practitioners in New Zealand. Average exposure to primary medical care for a particular class of patient (e.g. by age group) was calculated as the average of the product of number of visits over the past 12 months and duration of visit for the current visit. Comparisons were made across different demographic groups of patients and different practice types., Results: Annual exposure to primary medical care was highest amongst the elderly (65+ years), followed by adults (18-64 years). Adjusting for age, gender, NZDep2001, rural/urban, and organisation type, average annual exposure to primary medical care was higher in the European ethnic group than in the Maori, Pacific, and Asian ethnic groups. Exposure to primary medical care did not differ significantly across NZDep2001 quintiles after controlling for other co-variates., Conclusions: Annual exposure to primary medical care is both a direct measure of utilisation of primary medical care and also an indicator of access. Primary medical care exposure measurement can be used to monitor equity of service provision across different population groups: groups with high identified health care needs should have relatively high exposure to primary medical care. The most obvious breach of this principle is for Maori and Pacific users of primary medical care and for those living in deprived areas. Similarly, the low overall exposure to primary medical care for the Asian ethnic group is concerning and warrants further exploration.

Aims: The National Primary Medical Care survey was undertaken to describe primary health care in New Zealand, including the characteristics of accident and medical (A and M) clinic providers, their practices, the patients they see, the problems presented, and the management offered., Methods: Data were collected from a 50% random sample of all A and M clinics in New Zealand as part of the National Primary Medical Care survey carried out in 2001/2., Results: Data were obtained from 12 A and M clinics throughout New Zealand between usual hours (Monday-Friday 8 am-6 pm) and at other times. A and M clinics were staffed by an average of 2.7 full-time equivalent (FTE) A and M practitioners . Most clinics operated as a limited liability company. The majority of A and M practitioners were male and aged between 35-44 years. On average, A and M doctors had been in practice for over 10 years and had been in the sampled practice for only 2.9 years. More than a third of doctors had not trained in New Zealand. The doctors worked, on average, 6.3 half days and saw nearly 90 patients per week. The findings suggest that young patients and a diverse ethnic range attend A and M practices. Community Services Card holders were not usual patients. Few patients had an ongoing relationship with the practices. Most visits related to a single, new, and short-term problem that was often an injury or a respiratory illness. About a fifth of visits were associated with an order for an investigation or an X-ray, fewer investigations were arranged outside usual hours. About half the visits resulted in a prescription but more visits outside normal hours received pharmacological treatment and the number of items was higher. The most frequently prescribed items were antibiotics and analgesics. Follow-up was arranged for between a third to a half of visits, depending on the time of day. Referrals were often made to non-medical destinations. While patient and visit characteristics were generally similar regardless of whether the visit occurred during usual working hours or at other times, some differences were apparent in the type of problems that were presented out of hours and their management., Conclusions: The main impression is that the medical A and M clinics provide episodic treatment for relatively young patients mainly related to a new, short-term problem, particularly an injury or a respiratory illness. This picture is consistent with previous research and the role of similar clinics overseas. Further work is needed to compare A and M clinics with established general practice in relation to the services that are provided as well as the acceptability and quality of these services.

Aim: To describe the characteristics of patients who attended rural general practice offices in New Zealand in 2001/2 during normal hours along with the problems they presented and the management that they received. Comparisons are made with patients who attended non-rural practices., Methods: Data were collected from a stratified random survey of GPs in New Zealand as part of the National Primary Medical Care survey carried out in 2001/2., Results: Response rates at rural and non-rural general practices were high (72%). Comparing practice characteristics by locale, there were fewer full-time equivalent doctors in rural settings, their practice fees were lower, their throughput was slightly higher, and more services were provided (such as evening surgery, group health promotion and doctors involved in maternity care). More rural practitioners had graduated overseas than their urban counterparts but their characteristics were otherwise similar. Patients who presented to rural practices were similar in age and gender, but a higher proportion were M?ori and more were from more deprived areas. Patients made a similar number of visits as people in non-rural areas, although visits were slightly shorter in rural practices and more were funded by Accident Compensation Corporation (ACC). Rural patients presented slightly fewer reasons or problems per visit. Injury and respiratory conditions were more frequent problems managed at rural practices. Patient management was generally similar regardless of location, although laboratory tests and other investigations were ordered less frequently at rural practices. Prescriptions and non-drug treatments were also provided slightly less often at rural practices and follow-up was arranged less frequently., Conclusions: Aside from a few key differences, the characteristics of patients, practitioners, and practice were generally similar between rural and non-rural locations during normal hours in 2001/2. With some notable exceptions, patient problems and their management were also broadly consistent. Further work is needed to develop an ongoing database of patient morbidity encountered in primary care, ideally with more information about the complexity of each encounter and the nature of after-hours work.

Background: New Zealand has a substantial indigenous minority--the Māori--that has considerably worse health status than the majority population. We aimed to assess possible disparities in quality of hospital care for Māori with data on preventable adverse events as an indicator of suboptimum treatment., Methods: We undertook a nationally representative cross-sectional survey of admissions to general public hospitals with more than 100 beds providing acute care. A sample of 6579 patients admitted in 1998 to 13 hospitals was selected by stratified systematic list sample. We did a two-stage retrospective assessment of records by structured implicit review. Outcome measures were occurrence, effect, and preventability of adverse events., Findings: Māori accounted for just greater than 15% of admissions and were on average younger, were more likely to be from from deprived areas, had a different case mix, and were in hospital for a shorter stay compared with patients of non-Māori/non-Pacific origin. Overall, after age standardisation, 14% of admissions for Māori were associated with an adverse event, compared with 11% for non-Māori/non-Pacific patients (p=0.01 for difference between groups). For preventable, in-hospital events, this disparity persisted after controlling for age, other sociodemographic factors, and case mix (adjusted odds ratio 1.47; p=0.05). Analysis of potential causal factors showed no markedly or consistently different pattern between the groups., Interpretation: Despite a predominantly publicly funded hospital system, our findings suggest that hospital care received by Māori is marginally poorer than that received by New Zealand citizens of non-Māori/non-Pacific origin. Although no cause specific to Māori was evident, various policy and system issues can be addressed.

How can different schemes of compensation for treatment injury be evaluated? This article offers an empirical approach to assessment based on the simulation of alternative models of eligibility using real-world data. It draws on information about adverse events generated from a representative survey of public hospital admissions in New Zealand and classifies these under a range of eligibility criteria for different possible compensation systems. These are then evaluated according to a number of policy design considerations, using variables available from the New Zealand study.

Aims: To examine a representative series of adverse events in New Zealand public hospitals where death was the final outcome recorded, with a view to determining the relationship between adverse event and death., Methods: A review was carried out of the 38 adverse events (AEs) in the New Zealand Quality of Healthcare Study where death was the outcome, and categories of relationship were established. These were identified from the total of 850 AEs determined by two-stage retrospective review of a representative sample of 6579 medical records drawn from 13 NZ public hospitals in 1998. A stricter definition of AEs, comparable with American studies, was then applied to estimate rates of death associated with AEs., Results: There were 118 deaths at discharge identified in the sample of medical records, giving a rate of 18.0 deaths per 1000 admissions overall. A total of 30 deaths, either at or after discharge, were associated with AEs (4.6 per 1000 admissions); 19 being judged attributable to the AE either "definitely" (10) or probably (9), giving a combined rate of 2.8 AE-attributable deaths per 1000 admissions. The "definite" group had an age, comorbidity, and added-bed-days profile that was close to the average for all deaths associated with an AE. The "probable" group departed from this profile in being younger, exhibiting higher comorbidity, and having twice the added bed-days. Based on population life tables, the average years of life lost was 11.8 years for the definite group and 25.0 years for the probable group. Assessed on the preventability of the associated AE, it was estimated that 2.2 deaths per 1000 admissions were highly preventable. However, once deaths that were not judged to be attributable to the AE were excluded, the rate reduced to 1.3 AE-preventable deaths per 1000., Conclusions: Because of the nature of the record review procedure used in the New Zealand Quality of Healthcare Study, a finding of death did not necessarily mean that an adverse event and death were causally related. Indeed, it is possible that extrapolations of mortality rates in this and other similar studies over-estimate by about a half the number of deaths caused by healthcare management.

Aims: To examine a representative case series of surgical adverse events in New Zealand public hospitals with a view to assessing their occurrence, causation, patient impact and preventability., Methods: An analysis was carried out on 326 surgical adverse events classified by reviewing physicians. These were identified from among 850 adverse events determined by two-stage retrospective review of a representative sample of 6579 medical records drawn from 13 public hospitals in 1998., Results: From the four surgical categories--operative, fracture management, therapeutic, and system--there were 326 surgical adverse events, 38.4% of all adverse events identified. Surgical events had the same profile as adverse events overall. Four-fifths of surgical events were directly related to a surgical operation; these affected older patients and were less preventable than adverse events overall. A third of operative events were attributable to technical problems, another third to infections, with the remainder divided between haemorrhagic and cardiovascular complications. Therapeutic and system events had high preventability, and a significant proportion was related to delay in treatment. Half of events in fracture management were infection-related, patients were younger and, system events apart, had fewer extra bed days than other surgical events or events overall. The major causes of preventable events were avoidable delay in treatment (19.9%) and inadequate monitoring and supervision (13.6%), followed by personnel practising outside their expertise (8.0%) and inappropriate treatment (7.4%)., Conclusions: On average, surgical events are associated with an extra 9.9 days in hospital, but they have a lower level of preventability than adverse events overall. Problems of infection, delay, and other aspects of the quality of care are identified for further consideration.

Aims: To describe the characteristics and workload of New Zealand general medical practitioners (GPs)., Methods: Data were collected from a stratified random sample of GPs as part of the The National Primary Medical Care Survey carried out in 2001., Results: Data were submitted by 244 practitioners; a 62% response rate. Women made up 63% of the GP workforce aged under 40 years, but only 19% of those aged over 50 years. New Zealand graduates made up 69% of GPs; graduates from other areas occupied particular niches in the GP workforce. Each week, GPs worked (on average) 4 days and saw 102 patients. Eighty percent undertook after-hours work, and the average on-call roster was 1-in-8. At least 8% of visits to GPs occurred after-hours. Parameters of workload were lower for women and for those working in community-owned clinics, and higher for those working outside cities., Conclusions: An increasing proportion of GPs are women, and more GPs are working part time. In addition, if the changes in primary healthcare add to GPs' responsibilities, then more doctors will be needed. At present, GPs' workload is high in rural areas, which suggests inadequate recruitment; the distribution of GPs is a more important workforce issue than absolute numbers.

Community-governed non-profit primary care organisations started developing in New Zealand in the late 1980s with the aim to reduce financial, cultural and geographical barriers to access. New Zealand's new primary health care strategy aims to co-ordinate primary care and public health strategies with the overall objective of improving population health and reducing health inequalities. The purpose of this study is to carry out a detailed examination of the composition and characteristics of primary care teams in community-governed non-profit practices and compare them with more traditional primary care organisations, with the aim of drawing conclusions about the capacity of the different structures to carry out population-based primary care. The study used data from a representative national cross-sectional survey of general practitioners in New Zealand (2001/2002). Primary care teams were largest and most heterogeneous in community-governed non-profit practices, which employed about 3% of the county's general practitioners. Next most heterogeneous in terms of their primary care teams were practices that belonged to an Independent Practitioner Association, which employed the majority of the country's general practitioners (71.7%). Even though in absolute and relative terms the community-governed non-profit primary care sector is small, by providing a much needed element of professional and organisational pluralism and by experimenting with more diverse staffing arrangements, it is likely to continue to have an influence on primary care policy development in New Zealand.

This study compared community-governed nonprofit and for-profit primary care practices in New Zealand to test two hypotheses: (1) nonprofits reduce financial and cultural barriers to access; and (2) nonprofits do not differ from for-profits in equipment, services, service planning, and quality management. Data were obtained from a nationally representative cross-sectional survey of GPs. Practices were categorized by ownership status: private community-governed nonprofit or private for-profit. Community-governed nonprofits charged lower patient fees per visit and employed more Maori and Pacific Island staff, thus reducing financial and cultural barriers to access compared with for-profits. Nonprofits provided a different range of services and were less likely to have specific items of equipment; they were more likely to have written policies on quality management, complaints, and critical events, and to carry out locality service planning and community needs assessments. The findings support the shift to nonprofit community governance occurring in New Zealand and elsewhere.

Objective: To compare the characteristics of patients, their disease patterns, and the investigation and referral patterns in private community-governed not-for-profit and private for-profit primary care practices in New Zealand., Methods: Observational study using a representative survey of visits to general practitioners in New Zealand. Practices were categorised according to their ownership: private for-profit or private community-governed not-for-profit. Patient socio-demographic characteristics, treated prevalence and other characteristics of presenting problems, morbidity burden, numbers of investigations and referral patterns were compared., Results: Compared with for-profit practices, community-governed not-for-profit practices served a younger, largely non-European population, nearly three-quarters of whom had a means-tested benefit card (community services card), 10.5% of whom were not fluent in English, and the majority of whom lived in the 20% of areas ranked as the most deprived (by the NZDep2001 index of socio-economic deprivation). Patients visiting not-for-profit practices were diagnosed with more problems, including higher rates of asthma, diabetes and skin infections, but lower rates of chest infections. The duration of visits was also significantly longer. No differences were observed in the average number of laboratory tests ordered. The odds of specialist referral were higher in for-profit patients when confounding variables were controlled for., Conclusions: Community-governed not-for-profit practices in New Zealand serve a poor, largely non-European population who present with somewhat different rates of various problems compared with patients at for-profit practices. The study highlights for communities, policy-makers and purchasers the importance of community-governed not-for-profit practices in meeting the needs of low-income and minority population groups.

Objective: To investigate whether the risk of motorcycle crash related injuries is associated with the conspicuity of the driver or vehicle., Design: Population based case-control study., Setting: Auckland region of New Zealand from February 1993 to February 1996., Participants: 463 motorcycle drivers (cases) involved in crashes leading to hospital treatment or death; 1233 motorcycle drivers (controls) recruited from randomly selected roadside survey sites., Main Outcome Measures: Estimates of relative risk of motorcycle crash related injury and population attributable risk associated with conspicuity measures, including the use of reflective or fluorescent clothing, headlight operation, and colour of helmet, clothing, and motorcycle., Results: Crash related injuries occurred mainly in urban zones with 50 km/h speed limit (66%), during the day (63%), and in fine weather (72%). After adjustment for potential confounders, drivers wearing any reflective or fluorescent clothing had a 37% lower risk (multivariate odds ratio 0.63, 95% confidence interval 0.42 to 0.94) than other drivers. Compared with wearing a black helmet, use of a white helmet was associated with a 24% lower risk (multivariate odds ratio 0.76, 0.57 to 0.99). Self reported light coloured helmet versus dark coloured helmet was associated with a 19% lower risk. Three quarters of motorcycle riders had their headlight turned on during the day, and this was associated with a 27% lower risk (multivariate odds ratio 0.73, 0.53 to 1.00). No association occurred between risk and the frontal colour of drivers' clothing or motorcycle. If these odds ratios are unconfounded, the population attributable risks are 33% for wearing no reflective or fluorescent clothing, 18% for a non-white helmet, 11% for a dark coloured helmet, and 7% for no daytime headlight operation., Conclusions: Low conspicuity may increase the risk of motorcycle crash related injury. Increasing the use of reflective or fluorescent clothing, white or light coloured helmets, and daytime headlights are simple, cheap interventions that could considerably reduce motorcycle crash related injury and death.

Aims: To examine a representative case series of drug and related therapeutic adverse events in New Zealand public hospitals with a view to assessing their occurrence, causation, patient impact and preventability., Methods: An analysis was carried out on 192 drug and related therapeutic adverse events classified by reviewing physicians. These were identified from among 850 adverse events determined by two-stage retrospective review of a representative sample of 6579 medical records drawn from 13 public hospitals in 1998., Results: One fifth of all adverse events were in the combined group, comprising drug (15.4%) and related therapeutic (7.3%) incidents. In comparison with other adverse events these incidents appeared to be more common among older patients, were less likely to have occurred in hospital, and had slightly less impact on patients. Cardiovascular drugs accounted for nearly half of drug events; poor infection management, by contrast, was the dominant factor among related therapeutic events, with problems in cardiovascular management also important. Inadequate monitoring and follow up of medication was identified as the most common reason for failure to prevent both drug and related therapeutic adverse events., Conclusions: This study shows that morbidity related to medications is extensive. Drug-related adverse events are frequent and many are preventable. Better monitoring and more appropriate medication choice for individuals are the most common prevention strategies identified.

Aims: To assess the preventability and clinical context of adverse events identified in New Zealand public hospitals., Methods: Two-stage retrospective review of 6579 medical records randomly sampled from admissions for 1998 in 13 generalist hospitals providing acute care. Initial screening and medical review according to a standardised protocol., Results: Eight hundred and fifty adverse events were identified, of which over one third (315) were preventable to a significant degree. Preventability of events increased with age of patient, and was more characteristic of certain diagnostic categories. Half of all events (413/850) were both preventable and occurred in hospital, giving an occurrence rate of 6.3%. This rate increased with patient age, as did impact on patients and extended stay. There were also variations by diagnostic category. Over half of the events were associated with surgery (489) and one third with medicine (303); operative incidents were predominant in the former, drug-related in the latter, and system issues in both. Events in medicine had greater patient impact, and were less likely to have occurred in a public hospital. System errors featured prominently as an area for prevention, being associated with nearly half of all preventable in-hospital events. Consultation and education were also important, resources less so., Conclusions: Preventable adverse events have a major impact on patient outcomes and extended hospital stay. A substantial proportion of these are system related and, hence, in principle susceptible to quality improvement.

Objectives: To describe the pattern of preventable in-hospital medical injury under the "no fault" system and to assess the level of serious preventable patient harm., Design: Cross sectional survey using a two stage retrospective assessment of medical records conducted by structured implicit review., Setting: General hospitals with over 100 beds providing acute care in New Zealand., Participants: A sample of 6579 patients admitted in 1998 to 13 hospitals selected by stratified systematic list sample., Main Outcome Measures: Occurrence, preventability, and impact of adverse events., Results: Over 5% of admissions were associated with a preventable in-hospital event, of which nearly half had an element of systems failure. The elderly, ethnic minority groups, and particular clinical areas were at higher risk. The chances of a patient experiencing a serious preventable adverse event subsequent to hospital admission were just under 1%, a figure close to published results from comparable studies under tort. On average, these events required an additional 4 weeks in hospital. System related issues of protocol use and development, communication, and organisation, as well as requirements for consultation and education, were pre-eminent., Conclusions: The risk of serious preventable in-hospital medical injury for patients in New Zealand, a well established "no fault" jurisdiction, is within the range reported in comparable investigations under tort.

Aim: To assess the occurrence and impact of adverse events in New Zealand public hospitals., Methods: Two-stage retrospective review of 6579 medical records, selected by systematic list sample from admissions for 1998 in 13 generalist hospitals providing acute care. After initial screening, medical records were reviewed by trained medical practitioners using a standardised protocol., Results: Except for hospital stay, the sample appeared to be closely representative of New Zealand public hospital admissions for 1998 on key demographic and clinical criteria. The proportion of hospital admissions associated with an adverse event was 12.9% (incidence rate, 11.2%), of which nearly one fifth had occurred outside a public hospital (mainly doctor s rooms, patient s home, rest home, or private hospital). Most adverse events had minor patient impact, with less than 15% associated with permanent disability or death. Hospital workload was strongly affected, however, with adverse events adding an average of over nine days (median 4 days) to the expected hospital stay. There was limited evidence of patterning by diagnostic category. The elderly were disproportionately affected., Conclusions: The study provides representative base parameters that can contribute to the wider understanding, and potential improvement, of patient safety and the quality of care in New Zealand public hospitals.

The issues of patient safety and quality of care have gained policy attention with a growing appreciation of the scale and impact of medical injury in health systems. While the focus is clearly on the prevention of iatrogenic injury, the question of patient compensation is now also considered important, if only because in fault-based tort systems the fear of litigation may itself be a barrier to the disclosure and open discussion of medical error. No-fault systems, by contrast, do not require proof of culpability, and thus may both reduce barriers to compensation and increase disclosure of error. Little evidence, however, is available on the performance of such systems. This article reports on the analysis of two data sources-a sample of hospital admissions and a complete set of compensation claims for medical injury. Both are for the same year and region of New Zealand, a country that has maintained a no-fault system of accident compensation for a quarter of a century. Just over 2 percent of hospital admissions were associated with an adverse event that was potentially compensable under scheme criteria. While the claims process was well targeted, the level of claims making and receipt was low, with the ratio of successful claims to potentially compensable events being approximately 1:30. Comparison of social and clinical characteristics of the two data sets revealed a degree of selectivity. Compared with the hospital events, the typical successful claimant was younger and female and was much more likely to have experienced a surgical adverse event that, while unexpected, was not due to substandard care. It is concluded that, in interpreting these results, account needs to be taken of a number of features unique to the New Zealand system. These include: the limited payoff for a compensation claim (no pain and suffering or lump sum, free hospital care); the relative complexity of the grounds for claim (either rarity and severity or practitioner error); and a history of limited litigation for medical error. This suggests that, while the New Zealand system is well targeted, cheap, and free of financial and legal barriers, a change in legal doctrine alone has not in itself been sufficient to remove completely the selective and low level of claims making traditionally associated with patient compensation under tort.

Objectives: There is considerable policy interest in medical practice variation (MPV). Although the extent of MPV has been quantified for secondary care, this has not been investigated adequately in general practice. Technical obstacles to such analyses have been presented by the reliance on ecological small area variation (SAV) data, the binary nature of many clinical outcomes in primary care and by diagnostic variability. The study seeks to quantify the extent of variation in clinical activity between general practitioners by addressing these problems., Methods: A survey of nearly 10 000 encounters drawn from a representative sample of general practitioners in the Waikato region of New Zealand was carried out in the period 1991-1992. Participating doctors recorded all details of clinical activity for a sample of encounters. Measures used in this analysis are the issuing of a prescription, the ordering of a laboratory test or radiology examination, and the recommendation of a future follow-up office visit at a specified date. An innovative statistical technique is adopted to assess the allocation of variance for binary outcomes within a multi-level analysis of decision-making., Results: As expected, there was considerable variability between doctors in levels of prescribing, ordering of investigations and requests for follow up. These differences persisted after controlling for case-mix and patient and practitioner attributes. However, analysis of the components of variance suggested that less than 10% of remaining variability occurred at the practitioner level for any of the measures of clinical activity. Further analysis of a single diagnostic group--upper respiratory tract infection--marginally increased the practitioner contribution., Conclusions: The amount of variability in clinical activity that can definitively be linked to the practitioner in primary care is similar to that recorded in studies of the secondary sector. With primary care doctors increasingly being grouped into larger professional organisations, we can expect application of multi-level techniques to the analysis of clinical activity in primary care at different levels of organisational complexity.

Background: Giardia is one of the leading protozoal causes of human gastrointestinal illnesses. It is prevalent in both developed and developing countries. Currently, giardiasis is the most commonly notified waterborne disease in New Zealand. The aim of the study was to identify potentially modifiable risk factors for Giardia infection in the adult population in Auckland., Methods: This case-control study involved 183 Giardia-positive cases and 336 randomly selected controls, aged between 15 and 64 years. Exposure information was collected retrospectively over the telephone for the 21 days preceding the date of onset of symptoms. Both univariate and multiple logistic regression analyses were carried out., Results: The majority of cases were in the 25-44-year age group and in the New Zealand European ethnic group. Housewives and nursing mothers were at significant risk of the disease (odds ratio (OR)=2.06; 95% CI=1.4-3.74), as were the occupational groups exposed to human wastes (OR=4.04, 95% CI=1.85-8.85). Consumption of drinking water from New Zealand supplies other than metropolitan mains supplies (OR=2.11, 95% CI=1.36-3.27) or from sources outside New Zealand (OR=7.97, 95% CI=4.20-15.12) represented a significantly higher risk, as did traveling (OR=7.57, 95% CI=4.03-14.23) and swimming in pools or fresh water at least once a week (OR=2.04, 95% CI= 1.33-3.12)., Conclusions: The study identified potentially modifiable risk factors for Giardia infection. These findings should be investigated further in different groups and settings to ensure better protection of the public health.

Objective: To estimate the cost of treating medical injury associated with hospital admissions in New Zealand and the patient characteristics of costly adverse events., Methods: As part of the New Zealand Quality in Healthcare Study (NZQHS), a retrospective examination of medical records in 13 public hospitals identified the occurrence of clinical procedures and hospital bed days attributable to adverse events. The prices charged to foreign patients were used to estimate the cost of the health care resources used., Results: 850 adverse events were identified in the NZQHS which cost an average of $NZ 10,264 per patient. For New Zealand, adverse events are estimated to cost the medical system $NZ 870 million, of which $NZ 590 million went toward treating preventable adverse events. The results suggest that up to 30% of public hospital expenditure goes toward treating an adverse event. The results also suggest that older patients, neonates and those with moderately serious co-morbidity tended to have more costly adverse events., Conclusions: Adverse events lead to a significant use of health care resources in New Zealand. These findings suggest that substantial resources could be saved by eliminating preventable adverse events.

Aims: To establish the burden of co-morbid disease using the Charlson Index among hospital inpatients and its relationship to key health outcomes., Methods: An initial screen was carried out on 1575 medical records selected by systematic list sample from admissions for 1995 in three public hospitals in the Auckland region. In the course of the administration of the instrument, screeners were required to record the occurrence of co-morbid disease using the Charlson Index., Results: A third of patients had co-morbid disease, of which chronic pulmonary disease and congestive heart failure were the most frequently recorded. While the Charlson Index was associated with age of patient, length of stay, inpatient mortality, and adverse event status, the simple presence or absence of co-morbidity was as an effective predictor as the extended index. Co-morbidity was more likely to be recorded for Maori, for patients from deprived areas, and for circulatory or respiratory diagnoses. Specific co-morbid conditions were predictive of health outcomes., Conclusions: Levels of co-morbid disease established for patients using the Charlson Index in three Auckland public hospitals are similar to those recorded internationally. Co-morbidity is predictive of key health outcomes that are of clinical and managerial significance. Controlling for co-morbidity will be important in making comparisons of the quality of care.

Aims: To assess the feasibility of research into the occurrence, causation and prevention of adverse events (AEs) in New Zealand public hospitals., Methods: A two-stage retrospective review was carried out on 1,575 medical records selected by systematic list sample from admissions for 1995 in three public hospitals in the Auckland region. Following initial screening, medical records were subject to structured implicit review using a standardised protocol. Feasibility measures, using international benchmarks where possible, were: adequacy of sample selection; completeness of medical records; reliability and validity of screener and reviewer judgements; internal consistency and face validity of AE determination and preventability assessment., Results: The sample selection procedure was effective, although nearly 10% of records could not be secured. Information in medical records was sufficient for the identification and analysis of AEs. Adequate levels of agreement were achieved for screener and reviewer judgements, with kappa scores ranging between 0.302 and 0.622 and positive predictive values between 50.0% and 89.7%. The criteria for AE determination showed internal consistency and face validity, as did those for preventability., Conclusions: Research into the occurrence, causation and prevention of AEs in New Zealand health care settings is methodologically feasible and meets international benchmark standards.

Aims: To identify substantive findings of potential clinical and managerial significance from a regional feasibility study of adverse events (AEs)., Methods: A standardised protocol using structured implicit review was applied to 142 AEs generated in an audit study of three public hospitals in the Auckland region for admissions in 1995. Areas of potential significance addressed were: timing, location and impact of AEs; preventability; and clinical context and predictability., Results: 142 cases were identified as AEs (10.7% of 1,326 screened records). In 102 cases, 7.7% of all screened records, it was considered to be more likely than not that health care management contributed to the AE. About half the reported AEs occurred before the index admission, the majority outside hospital. Over half of all events resulted in disability that was resolved within a month. An average 6.7 extra days stay in hospital were attributable to AEs. For 60% of AEs the evidence for preventability was either low or nonexistent. Areas of potential prevention were predominantly educational. Over half of all AEs occurred in a surgical context. Medical AEs were more likely to have occurred outside hospital, to be drug-related, to be associated with an acute admission, to be classified as highly preventable, and to have a greater impact on hospital stay., Conclusions: Although the data generated by a feasibility study must be treated with caution, the pattern of results is consistent with comparable Australian findings and is of potential clinical and managerial significance.