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Background: Disparities in cardiovascular outcomes between Māori and non-Māori persist despite technological advances in the treatment of cardiovascular disease and improved service provision. Little is known about how social determinants of health, such as income [in]security affect Māori men's access, treatment, and recovery from cardiovascular disease. This paper explores the contexts within which cardiovascular disease is experienced and healthcare becomes embedded. Methods: This study utilized a case-comparative narrative approach to document and make sense of the patient experiences of four male Māori patients who, in the previous 6 months, had come through cardiac investigation and treatment at Waikato Hospital, a large tertiary cardiac center in New Zealand. Participant accounts were elicited using a culturally patterned narrative approach to case development, informed by Kaupapa Māori Research practices. It involved three repeat 1–3-hour interviews recorded with participants (12 interviews); the first interviews took place 5–16 weeks after surgery/discharge. Results: Each of the four case studies firstly details a serious cardiac event(s) before describing the varying levels of financial worry they experienced. Major financial disruptions to their lives were at the forefront of the concerns of those facing financial insecurity—as opposed to their medical problems. Financial hardship within the context of an unresponsive welfare system impacted the access to care and access to funding contributed to psychological distress for several participants. Economic security and reciprocal relationships between employers and employees facilitated positive treatment experiences and recovery. Conclusion: Findings suggest that although multiple factors influence participant experiences and treatment outcomes, financial [in]security, and personal income is a key determinant. The heterogeneity in participant narratives suggests that although general inequities in health may exist for Māori as a population group, these inequities do not appear to be uniform. We postulate diverse mechanisms, by which financial insecurity may adversely affect outcomes from treatment and demonstrate financial security as a significant determinant in allowing patients to respond to and recover from cardiovascular disease more effectively. [ABSTRACT FROM AUTHOR]

Introduction: The Revised Cardiac Risk Index (RCRI) is a six-parameter model that is commonly used in assessing individual 30-day perioperative cardiovascular risk before general surgery, but its use in patients on chronic kidney replacement therapy (KRT) is unvalidated. This study aimed to externally validate RCRI in this patient group over a 15-year period. Methods: Data linkage was used between the the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and jurisdictional hospital admisisons data across Australia and New Zealand to identify all incident and prevalent patients on chronic KRT between 2000 and 2015 who underwent elective abdominal surgery. Chronic KRT was categorised as haemodialysis (HD), peritoneal dialysis (PD), home haemodialysis (HHD) and kidney transplant. The outcome of interest was major adverse cardiovascular event (MACE) which was defined as nonfatal myocardial infarction, nonfatal stroke, non-fatal cardiac arrest and cardiovascular mortality at 30 days. Logistic regression was used with the RCRI score included as a continuous variable to estimate discrimination by area under the receiver operating curve (AUROC). Calibration was evaluated using a calibration plot. Clinical utility was assessed using a decision curve analysis to determine the net benefit. Results: A total of 5094 elective surgeries were undertaken, and MACE occurred in 153 individuals (3.0%). Overall, RCRI had poor discrimination in patients on chronic KRT undergoing elective surgery (AUROC 0.67), particularly in patients aged greater than 65 years (AUROC 0.591). A calibration plot showed that RCRI overestimated risk of MACE. The expected-to-observed outcome ratio was 6.0, 5.1 and 2.5 for those with RCRI scores of 1, 2 and ≥ 3, respectively. Discrimination was moderate in patients under 65 years and in kidney transplant recipients, with AUROC values of 0.740 and 0.718, respectively. Overestimation was common but less so for kidney transplant recipients. Decision curve analysis showed that there was no net benefit of using the tool in neither the overall cohort nor patients under 65 years, but a slight benefit associated with threshold probability > 5.5% in kidney transplant recipients. Conclusions: The RCRI tool performed poorly and overestimated risk in patients on chronic dialysis, potentially misinforming patients and clinicians about the risk of elective surgery. Further research is needed to define a more comprehensive means of estimating risk in this unique population. [ABSTRACT FROM AUTHOR]

Background: Cardiometabolic disease (CMD) risk often begins early in life. Healthy lifestyle behaviors can mitigate risk, but the optimal combination of behaviors has not been determined. This cross-sectional study simultaneously examined the associations between lifestyle factors (fitness, activity behaviors, and dietary patterns) and CMD risk in preadolescent children. Methods: 1480 New Zealand children aged 8–10 years were recruited. Participants included 316 preadolescents (50% female, age: 9.5 ± 1.1 years, BMI: 17.9 ± 3.3 kg/m2). Fitness (cardiorespiratory fitness [CRF], muscular fitness), activity behaviors (physical activity, sedentary, sleep), and dietary patterns were measured. Factor analysis was used to derive a CMD risk score from 13 variables (adiposity, peripheral and central hemodynamics, glycemic control, and blood lipids). Results: Only CRF (β = −0.45, p < 0.001) and sedentary time (β = 0.12, p = 0.019) were associated with the CMD risk score in the adjusted multivariable analysis. CRF was found to be nonlinear (VO2 max ≤ ≈42 mL/kg/min associated with higher CMD risk score), and thus a CRF polynomial term was added, which was also associated (β = 0.19, p < 0.001) with the CMD risk score. Significant associations were not found with sleep or dietary variables. Conclusion: The findings indicate that increasing CRF and decreasing sedentary behavior may be important public health targets in preadolescent children. [ABSTRACT FROM AUTHOR]

Type 2 diabetes (T2DM), its related morbidities and entrenched diabetes‐related inequities pose significant challenges for health care delivery systems in Aotearoa New Zealand (NZ). Primary care services undertake the majority of diabetes prevention work by initially detecting and managing those with prediabetes. In this viewpoint, we present available NZ data to highlight NZ trends in prediabetes and consider the current NZ clinical guidelines and the prediabetes care pathway. Multiple areas for improvement are identified to optimise diabetes prevention, potentially reduce T2DM inequities, and sustain more effective prediabetes management in primary care in NZ. [ABSTRACT FROM AUTHOR]

Introduction. Type 2 diabetes mellitus (T2DM) is a highly prevalent and potentially preventable condition associated with significant health, social, and economic costs. The detection and management of pre-diabetes is an important opportunity to prevent or delay the onset of T2DM and associated morbidities; however, its importance is controversial as the health risks associated with pre-diabetes are poorly understood. Aim. To understand the cardio-metabolic health profile of a sample of adults with pre-diabetes in Aotearoa New Zealand. Methods. Secondary analyses of baseline data from all 153 adults recruited to an intervention trial for adults with pre-diabetes were carried out. A profile of cardio-metabolic risk was measured by describing the proportion with metabolic syndrome (MetS) calculated using Adult Treatment Panel III criteria, which includes blood pressure, lipids, and obesity in addition to glycaemic measures. The severity of MetS was calculated as MetS Z-scores. Subgroup analyses for sex, ethnicity and glycated haemoglobin (HbA1c) were performed. Results. Overall, 74% of this study population had MetS, and the proportion varied according to ethnicity and HbA1c level. The severity of MetS was highly variable, with MetS-Z-scores ranging from -1.0 to 2.8. Although mean MetS Z-scores differed according to ethnicity and HbA1c level, all subgroups included individuals with widely differing severity of MetS, suggesting likely quite different risks for progression to diabetes or cardiovascular disease across the range of pre-diabetes defined by HbA1c. Discussion. Single biochemical markers of glycaemia are insufficient to ascertain overall cardio-metabolic risk when prioritising clinical efforts for those with pre-diabetes, particularly in primary care, where the potential for preventing or delaying the onset of type 2 diabetes mellitus (T2DM) is significant. Findings indicate the importance of attending to all cardiometabolic risk factors when caring for people with pre-diabetes. The development of tools using multiple relevant variables and predicting a comprehensive range of outcomes would improve timely risk stratification and treatment effect monitoring of pre-diabetes populations. [ABSTRACT FROM AUTHOR]

Background: Simulation models can be used to quantify the projected health impact of interventions. Quantifying heterogeneity in these impacts, for example by socioeconomic status, is important to understand impacts on health inequalities. We aim to disaggregate one type of Markov macro-simulation model, the proportional multistate lifetable, ensuring that under business-as-usual (BAU) the sum of deaths across disaggregated strata in each time step returns the same as the initial non-disaggregated model. We then demonstrate the application by deprivation quintiles for New Zealand (NZ), for: hypothetical interventions (50% lower all-cause mortality, 50% lower coronary heart disease mortality) and a dietary intervention to substitute 59% of sodium with potassium chloride in the food supply. Methods: We developed a disaggregation algorithm that iteratively rescales mortality, incidence and case-fatality rates by time-step of the model to ensure correct total population counts were retained at each step. To demonstrate the algorithm on deprivation quintiles in NZ, we used the following inputs: overall (non-disaggregated) all-cause mortality & morbidity rates, coronary heart disease incidence & case fatality rates; stroke incidence & case fatality rates. We also obtained rate ratios by deprivation for these same measures. Given all-cause and cause-specific mortality rates by deprivation quintile, we derived values for the incidence, case fatality and mortality rates for each quintile, ensuring rate ratios across quintiles and the total population mortality and morbidity rates were returned when averaged across groups. The three interventions were then run on top of these scaled BAU scenarios. Results: The algorithm exactly disaggregated populations by strata in BAU. The intervention scenario life years and health adjusted life years (HALYs) gained differed slightly when summed over the deprivation quintile compared to the aggregated model, due to the stratified model (appropriately) allowing for differential background mortality rates by strata. Modest differences in health gains (HALYs) resulted from rescaling of sub-population mortality and incidence rates to ensure consistency with the aggregate population. Conclusion: Policy makers ideally need to know the effect of population interventions estimated both overall, and by socioeconomic and other strata. We demonstrate a method and provide code to do this routinely within proportional multistate lifetable simulation models and similar Markov models. [ABSTRACT FROM AUTHOR]

Background: A diet rich in fruits and vegetables is recommended for cardiovascular health. However, the majority of Australians do not consume the recommended number of vegetable servings each day. Furthermore, intakes of vegetables considered to have the greatest cardiovascular benefit are often very low. Results from prospective observational studies indicate that a higher consumption of cruciferous vegetables (e.g. broccoli, cabbage, cauliflower) is associated with lower cardiovascular disease risk. This may be due to the presence of specific nutrients and bioactive compounds found almost exclusively, or at relatively high levels, in cruciferous vegetables. Therefore, the aim of this randomised controlled crossover trial is to determine whether regular consumption of cruciferous vegetables results in short-term improvement in measures related to cardiovascular disease risk, including ambulatory blood pressure, arterial stiffness, glycaemic control, and circulating biomarkers of oxidative stress and inflammation.Methods: Twenty-five participants (50-75 years) with mildly elevated blood pressure (systolic blood pressure 120-160 mmHg) will complete two 2-week intervention periods in random order, separated by a 2-week washout period. During the intervention period, participants will consume 4 servings (~ 300 g) of cruciferous vegetables per day as a soup (~ 500-600 mL/day). The 'control' soup will consist of other commonly consumed vegetables (potato, sweet potato, carrot, pumpkin). Both soups will be approximately matched for energy, protein, fat, and carbohydrate content. All measurements will be performed at the beginning and end of each intervention period.Discussion: The findings of this study will provide evidence regarding the potential cardiometabolic health benefits of cruciferous vegetables, which may contribute to the revision of dietary and clinical guidelines.Trial Registration: The trial was registered with the Australian New Zealand Clinical Trial Registry on 19th September 2019 (ACTRN12619001294145). [ABSTRACT FROM AUTHOR]

It has been 50 years since the Woodhouse Report was published, resulting in the creation of the first ACC scheme for New Zealand. Work and the working environment have changed a great deal in this time, as have scientific understandings of the relationship between work and health. The Accident Compensation Act 2001, as it stands, is struggling to provide fair and equitable compensation to New Zealand workers, with significant gaps in cover, inequalities in the treatment of different occupations and a detrimental flow-on effect for worker health and safety. This article outlines some of the key areas of legal reform required to ensure that the ACC scheme can meet the needs of New Zealand working people in the future and help improve work health and safety. [ABSTRACT FROM AUTHOR]

Background: Internationally, ethnic inequalities in mortality within countries are increasingly recognized as a public health concern. But few countries have data to monitor such inequalities. We aimed to provide a detailed description of ethnic inequalities (Maori [indigenous], Pacific, and European/Other) in mortality for a country with high quality ethnicity data, using both standard and novel visualization methods. Methods: Cohort studies of the entire New Zealand population were conducted, using probabilistically-linked Census and mortality data from 1981 to 2011 (68.9 million person years). Absolute (standardized rate difference) and relative (standardized rate ratio) inequalities were calculated, in 1-74-year-olds, for Maori and Pacific peoples in comparison to European/Other. Results: All-cause mortality rates were highest for Maori, followed by Pacific peoples then European/Other, and declined in all three ethnic groups over time. Pacific peoples experienced the slowest annual percentage fall in mortality rates, then Maori, with European/Other having the highest percentage falls - resulting in widening relative inequalities. Absolute inequalities, however, for both Maori and Pacific males compared to European/Other have been falling since 1996. But for females, only Maori absolute inequalities (compared with European/Other) have been falling. Regarding cause of death, cancer is becoming a more important contributor than cardiovascular disease (CVD) to absolute inequalities, especially for Maori females. Conclusions: We found declines in all-cause mortality rates, over time, for each ethnic group of interest. Ethnic mortality inequalities are generally stable or even falling in absolute terms, but have increased on a relative scale. The drivers of these inequalities in mortality are transitioning over time, away from CVD to cancer and diabetes; such transitions are likely in other countries, and warrant further research. To address these inequalities, policymakers need to enhance prevention activities and health care delivery, but also support wider improvements in educational achievement and socioeconomic position for highest need populations. [ABSTRACT FROM AUTHOR]

Background: Despite substantial investment in detection, early intervention and evidence-based treatments, current management strategies for diabetes-associated retinopathy and cardiovascular disease are largely based on real-time and face-to-face approaches. There are limited data re telehealth facilitation in type 2 diabetes management. Therefore, we aim to investigate efficacy of telehealth facilitation of diabetes and cardiovascular disease care in high-risk vulnerable Aboriginal and Torres Strait Islanders in remote/very remote Australia.Methods: Using a pre-post intervention design, 600 Indigenous Australians with type 2 diabetes will be recruited from three primary-care health-services in the Northern Territory. Diabetes status will be based on clinical records. There will be four technological interventions: 1. Baseline retinal imaging [as a real-time patient education/engagement tool and telehealth screening strategy]. 2. A lifestyle survey tool administered at ≈ 6-months. 3. At ≈ 6- and 18-months, an electronic cardiovascular disease and diabetes decision-support tool based on current guidelines in the Standard Treatment Manual of the Central Australian Rural Practitioner's Association to generate clinical recommendations. 4. Mobile tablet technology developed to enhance participant engagement in self-management. Data will include: Pre-intervention clinical and encounter-history data, baseline retinopathy status, decision-support and survey data/opportunistic mobile tablet encounter data. The primary outcome is increased participant adherence to clinical appointments, a marker of engagement and self-management. A cost-benefit analysis will be performed.Discussion: Remoteness is a major barrier to provision and uptake of best-practice chronic disease management. Telehealth, beyond videoconferencing of consultations, could facilitate evidence-based management of diabetes and cardiovascular disease in Indigenous Australians and serve as a model for other conditions.Trial Registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN 12616000370404 was retrospectively registered on 22/03/2016. [ABSTRACT FROM AUTHOR]

Background: A "diet high in sodium" is the second most important dietary risk factor for health loss identified in the Global Burden of Disease Study 2013. We therefore aimed to model health gains and costs (savings) of salt reduction interventions related to salt substitution and maximum levels in bread, including by ethnicity and age. We also ranked these four interventions compared to eight other modelled interventions.Methods: A Markov macro-simulation model was used to estimate QALYs gained and net health system costs for four dietary sodium reduction interventions, discounted at 3 % per annum. The setting was New Zealand (NZ) (2.3 million adults, aged 35+ years) which has detailed individual-level administrative cost data.Results: The health gain was greatest for an intervention where most (59 %) of the sodium in processed foods was replaced by potassium and magnesium salts. This intervention gained 294,000 QALYs over the remaining lifetime of the cohort (95 % UI: 238,000 to 359,000; 0.13 QALY per 35+ year old). Such salt substitution also produced the highest net cost-savings of NZ$ 1.5 billion (US$ 1.0 billion) (95 % UI: NZ$ 1.1 to 2.0 billion). All interventions generated relatively larger per capita QALYs for men vs women and for the indigenous Māori population vs non-Māori (e.g., 0.16 vs 0.12 QALYs per adult for the 59 % salt substitution intervention). Of relevance to workforce productivity, in the first 10 years post-intervention, 22 % of the QALY gain was among those aged <65 years (and 37 % for those aged <70).Conclusions: The benefits are consistent with the international literature, with large health gains and cost savings possible from some, but not all, sodium reduction interventions. Health gain appears likely to occur among working-age adults and all interventions contributed to reducing health inequalities. [ABSTRACT FROM AUTHOR]

Background: Dietary salt reduction is included in the top five priority actions for non-communicable disease control internationally. We therefore aimed to identify health gain and cost impacts of achieving a national target for sodium reduction, along with component targets in different food groups.Methods: We used an established dietary sodium intervention model to study 10 interventions to achieve sodium reduction targets. The 2011 New Zealand (NZ) adult population (2.3 million aged 35+ years) was simulated over the remainder of their lifetime in a Markov model with a 3 % discount rate.Results: Achieving an overall 35 % reduction in dietary salt intake via implementation of mandatory maximum levels of sodium in packaged foods along with reduced sodium from fast foods/restaurant food and discretionary intake (the "full target"), was estimated to gain 235,000 QALYs over the lifetime of the cohort (95 % uncertainty interval [UI]: 176,000 to 298,000). For specific target components the range was from 122,000 QALYs gained (for the packaged foods target) down to the snack foods target (6100 QALYs; and representing a 34-48 % sodium reduction in such products). All ten target interventions studied were cost-saving, with the greatest costs saved for the mandatory "full target" at NZ$1260 million (US$820 million). There were relatively greater health gains per adult for men and for Māori (indigenous population).Conclusions: This work provides modeling-level evidence that achieving dietary sodium reduction targets (including specific food category targets) could generate large health gains and cost savings for a national health sector. Demographic groups with the highest cardiovascular disease rates stand to gain most, assisting in reducing health inequalities between sex and ethnic groups. [ABSTRACT FROM AUTHOR]