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INTRODUCTION Life expectancy in patients with schizophrenia is 15-20 years less than the general population. A dominant cause of morbidity and mortality in these patients is cardiovascular disease. Adverse consequences of modifiable cardiovascular risk factors can be reduced by regular monitoring of metabolic outcomes and intervention if required. AIM To evaluate the metabolic screening in primary care for patients with schizoaffective disorders managed in primary care. To show the usefulness of combining simple practice audits in evaluating such areas of clinical practice. METHODS An audit was undertaken in eight general practices in the Waikato and Bay of Plenty regions of New Zealand. Specifically, the monitoring of patients with schizophrenia or schizoaffective disorder whose antipsychotic medication was prescribed by primary care doctors was audited. Patient monitoring was compared to the guideline recommendation of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Best Practice Advisory Centre (BPAC). RESULTS In total, 117 patients were included in the audit and none were fully monitored, as recommended by the RANZCP guidelines. Although two-thirds of patients had been evaluated for glycosylated haemoglobin (HbA1c), lipids, blood pressure, complete blood count and weight, <10% of patients had had prolactin, waist circumference or electrocardiogram measurements recorded. The proportion of patients having a HbA1c measured was also significantly higher in younger patients and patients who were non-Māori or enrolled with an urban practice (all P<0.05). When using the simplified BPAC guidelines, half of all patients were correctly monitored. DISCUSSION These findings show there is room for improvement in the monitoring of patients receiving antipsychotic medication in primary care. This may indicate the need for clear guidance and general practitioner education around the monitoring requirements of these patients. Alternatively, a more simplified monitoring protocol may need to be developed. This audit has also shown that there is value in several practices completing the same audit and providing a larger cohort of patients for pooled data analysis.

Backgrounds: This study aims to understand the factors that influence whether patients receive potentially curative treatment for early stage lung cancer. A key question was whether indigenous Māori patients were less likely to receive treatment., Methods: Patients included those diagnosed with early stage lung cancer in 2011-2018 and resident in the New Zealand Midland Cancer Network region. Logistic regression model was used to estimate the odds ratios of having curative surgery/ treatment. The Kaplan Meier method was used to examine the all-cause survival and Cox proportional hazard model was used to estimate the hazard ratio of death., Results: In total 419/583 (71.9%) of patients with Stage I and II disease were treated with curative intent - 272 (46.7%) patients had curative surgery. Patients not receiving potentially curative treatment were older, were less likely to have non-small cell lung cancer (NSCLC), had poorer lung function and were more likely to have an ECOG performance status of 2+. Current smokers were less likely to be treated with surgery and more likely to receive treatment with radiotherapy and chemotherapy. Those who were treated with surgery had a 2-year survival of 87.8% (95% CI: 83.8-91.8%) and 5-year survival of 69.6% (95% CI: 63.2-76.0%). Stereotactic ablative body radiotherapy (SABR) has equivalent effect on survival compared to curative surgery (hazard ratio: 0.77, 95% CI: 0.37-1.61). After adjustment we could find no difference in treatment and survival between Māori and non-Māori., Conclusions: The majority of patients with stage I and II lung cancer are managed with potentially curative treatment - mainly surgery and increasingly with SABR. The outcomes of those being diagnosed with stage I and II disease and receiving treatment is positive with 70% surviving 5 years.

This study aims to explore the length of stay (LOS) of publicly funded osteoarthritic primary hip and knee replacement surgeries in New Zealand. Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgery in 2005-2017 were included. We have identified 53,439 osteoarthritic primary hip replacements and 50,072 osteoarthritic primary knee replacements. LOS has been reduced by almost 40% over the last 13 years. Logistic regression showed that women, Māori, Pacific and Asian patients, older patients, people with more comorbidities and those having opiates on discharge and patients in earlier years were more likely to have extended LOS following hip replacements and knee replacements. Regional differences were noted in LOS between the Waitemata District Health Board (DHB) compared to Tairāwhiti DHB where patients were the most likely to have a LOS of more than 5 days after hip and knee replacements. LOS after hip and knee replacements has been reduced dramatically. Women, Māori, Pacific and Asian patients, older patients and people with more comorbidities are more likely to have extended LOS. Patients dispensed opiates on discharge had a longer LOS. There are great geographical variations in LOS for primary hip and knee surgeries in New Zealand.

Aims: To evaluate costs associated with a diagnosis of spondyloarthritis (SpA) in an Aotearoa/New Zealand cohort., Methods: Patients with SpA attending specialist SpA clinics in Auckland and Hamilton completed a series of questionnaires on costs associated with ankylosing spondylitis, disease parameters (BASDAI), work productivity (WPAI, WLQ) and quality of life measures (EQ-5D, ASAS-HI)., Results: Eighty-one patients (median age 43 years) completed the study. All fulfilled the ASAS criteria for axial spondyloarthritis and 44 (58%) fulfilled the Modified New York Criteria for ankylosing spondylitis. The mean (SD) score on the EQ-VAS was 69mm (24.1). More than half reported difficulties with usual activities and more than 80% had moderate pain or discomfort despite current treatment. Sixty-six (82%) were in the workforce, and the mean work productivity loss was 4.8%. The mean (SD) annual cost was NZ$15,677 (NZ$11,269) with NZ$12,189 direct cost and NZ$3,488 productivity loss. The largest cost driver was use of biologic medications, which were used by 48% patients., Conclusions: This study has quantified the direct and indirect costs of spondyloarthritis (SpA) in Aotearoa/New Zealand, and demonstrates meaningful reduction in quality of life and work productivity in patients with SpA. The major driver of direct costs in SpA are biologic medications., Competing Interests: Douglas White reports speaker fees for Abbvie outside the submitted work and has been an investigator on several clinical trials sponsored by Abbvie. Nicola Dalbeth reports speaker fees from Abbvie and Janssen, outside the submitted work.

Introduction: Measuring the diameter of the inferior vena cava (IVC) or the height of the jugular venous pressure (JVP) with point-of-care ultrasound (POCUS) is a practical alternative method for estimating a patient's intravascular volume in the rural setting. This study aims to determine whether or not POCUS of the IVC or JVP generates additional useful clinical information over and above routine physical examination in this context., Methods: Twenty generalist physicians, working in five New Zealand rural hospitals, recorded their estimation of a patient's intravascular volume based on physical examination and then again after performing POCUS of the IVC or JVP, using a visual scale from 1 to 11., Results: Data were available for 150 assessments. There was an only moderate agreement between the pre- and post-test findings (Spearman's correlation coefficient = 0.46). In 28% (42/150) of cases, the difference was four or more points on the scale, and therefore, had the potential to be clinically significant., Conclusion: In the rural context, POCUS provides new information that frequently alters the clinician's estimation of a patient's intravascular volume., Competing Interests: None

Introduction: Geographic measures of accessibility can quantify inequitable distributions of health care. Although closest distance measures are often used in Aotearoa New Zealand these may not reflect patient use of health care. This research examines patterns of patient enrolment in general practitioner (GP) services from a geospatial perspective., Methods: Patient enrolment records (n=137 596) from one primary health organisation were examined and geographic information systems used to determine whether patients enrolled with their closest GP service. A binomial logistic regression was performed to examine factors associated with the bypass of GP services closer to patients' homes., Results: Overall 68.1% of patients in the sample bypassed the GP service closest to their home, while rates of GP bypass varied across the Waikato region and between rural and urban areas. A binary logistic regression analysis revealed that rurality of patient residence, patient ethnicity, patient age, area-level socioeconomic deprivation, sex, distance to the closest GP clinic, clinic after-hours availability, M&#257;ori service provider status, GP and nurse full time equivalent hours, and clinic fees were statistically significant predictors of increased closest-GP bypass. While residents of major urban areas had high rates of GP bypass, this was followed by patients living in rural areas - patients living more than 20 km from the closest GP service had exceptionally high rates of GP bypass., Conclusion: This study suggests that most patients in the Waikato region do not enrol with the GP service closest to their home and it outlines several factors, including rurality of residence, associated with the GP bypass. Closest distance accessibility measures may be inappropriate in mixed urban-rural settings, and researchers should consider other approaches to quantifying spatial equity. Health services should also be designed to better reflect the realities of the populations they serve.

Objectives: To (1) explore the regional and ethnic differences in rates of publicly funded osteoarthritis-associated hip and knee replacement surgeries and (2) investigate the mortality after surgery., Design: Population-based, retrospective, cross-sectional study., Setting: General population in New Zealand., Participants: Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgeries in 2005-2017. Patients aged 14-99 years were included., Primary and Secondary Outcome Measures: Age-standardised rate, standardised mortality ratio (SMR) and 30 days, 90 days and 1 year mortality., Results: We identified 53 439 primary hip replacements and 50 072 primary knee replacements with a diagnosis of osteoarthritis. The number and age-standardised rates of hip and knee replacements increased over time. Māori had the highest age-standardised rate of hip replacements, followed by European/others and Pacific, and Asian had the lowest rate. Pacific had the highest age-standardised rate of knee replacements, followed by Māori and European/others, and Asian had the lowest rate. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. The SMRs of patients undergoing hip and knee replacements were lower than the general population: 0.92 (95% CI 0.89 to 0.95) for hip and 0.79 (95% CI 0.76 to 0.82) for knee. The SMRs were decreasing over time. The patterns of 30 days, 90 days and 1 year mortality were similar to the SMR., Conclusions: The numbers of publicly funded osteoarthritis-associated primary hip and knee replacements are steadily increasing. Māori people had the highest age-standardised rate of hip replacements and Pacific people had the highest rate of knee replacements. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. Compared with the general population, patients who had hip and knee replacements have a better life expectancy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study aims to examine the differences in characteristics, treatment and survival between Asian and European women diagnosed with stage I-III breast cancer in New Zealand., Methods: The studied population included European women and Asian women diagnosed with stage I-III breast cancer between June 2000 and May 2013 identified from the combined Waikato and Auckland Breast Cancer Registers. Characteristics and treatment were compared between Asian and European women. Kaplan-Meier method was used to examine the survival difference. Cox proportional hazards model was used to estimate the hazard ratio (HR) of mortality., Results: The studied cohort included 8608 European and 949 Asian women. Asian women were younger, had less comorbidities and were less likely to be obese than European women. Asian women were more likely to have grade 3, larger and HER2+  breast cancers. Asian women were more likely to receive mastectomy, less likely to have reconstruction after mastectomy, less likely to have chemotherapy, less likely to be treated with trastuzumab if HER2+, and had better adherence to endocrine therapy (adjusted odds ratio: 1.54; 95% CI 1.22-1.93). Asian women had better cancer-specific survival and all-cause survival than European women. The adjusted HR of cancer-specific mortality and all-cause mortality were 0.64 (95% CI 0.49-0.82) and 0.68 (95% CI 0.55-0.84), respectively., Conclusions: Asian women are more likely to have high grade, larger and HER2+ breast cancers than European women. In spite of this, they had better breast cancer outcomes. Possible explanations include the differences in adherence to endocrine therapy, age, BMI and comorbidities.

Objective: To understand the challenges managing medication use and knowledge of people living with multimorbidity., Methods: A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand., Results: Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects., Conclusion: The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines., (© 2018 AJA Inc.)

Introduction: This study aims to examine the impact of radiotherapy on the cardiovascular health of women diagnosed with breast cancer in the Waikato region in New Zealand., Methods: Women diagnosed with stage 0-III breast cancer and recorded in the Waikato Breast Cancer Registry were divided into two groups: a radiotherapy group and a no-radiotherapy group. Baseline characteristics and treatments were compared in the two groups. Kaplan-Meier survival analysis was performed to compare cardiovascular morbidity and mortality. Cox Proportional Hazard regression analysis was used to estimate the hazard ratio of radiotherapy on the risk of cardiovascular morbidity and mortality while adjusting for other factors., Results: A total of 3528 women were included in this study, with 2303 in the radiotherapy group and 1225 in the no-radiotherapy group. At 10-year follow-up, 11.7% of women in the radiotherapy group and 19.4% in the no-radiotherapy group experienced cardiovascular events. Only 2.3% of patients who received radiotherapy died of cardiovascular disease by 10 years compared to 7.0% in the no-radiotherapy group. After adjusting for clinically significant factors, there was unexplained reduced risk of developing cardiovascular disease in the radiotherapy group compared to the no-radiotherapy group (HR 0.73, 95% CI: 0.59-0.92). No significant difference was found in cardiovascular mortality between the two groups., Conclusions: Radiotherapy appears less likely to be offered to patients at higher risk of cardiovascular disease. No evidence of increased risk of a cardiovascular event was found in the group of women with breast cancer treated with radiotherapy and current regimens appear safe. Traditional cardiovascular risk factors remain the main culprits in this setting. Clinicians should work with patients in managing these risk factors for optimal results., (© 2018 The Royal Australian and New Zealand College of Radiologists.)

Background: Lung cancer is typically diagnosed at a late stage. Early presentation and detection of lung cancer symptoms is critical to improving survival but can be clinically complicated and as yet a robust screening method for diagnosis is not available in routine practice. Accordingly, the barriers to help-seeking behaviour and diagnosis need to be considered. This review aimed to document the barriers to early presentation and diagnosis of lung cancer, based on patient and carer perspectives., Methods: A systematic review of databases was performed for original, English language articles discussing qualitative research on patient perceived barriers to early presentation and diagnosis of lung cancer. Three major databases were searched: Scopus, PubMed and EBSCOhost. References cited in the selected studies were searched for further relevant articles., Results: Fourteen studies met inclusion criteria for review. Barriers were grouped into three categories: healthcare provider and system factors, patient factors and disease factors., Conclusions: Studies showed that the most frequently reported barriers to early presentation and diagnosis of lung cancer reported by patients and carers related to poor relationships between GPs and patients, a lack of access to services and care for patients, and a lack of awareness of lung cancer symptoms and treatment. Addressing these barriers offers opportunities by which rates of early diagnosis of lung cancer may be improved.

Background: The aim of this study was to understand the factors influencing the use of surgical options by New Zealand women with newly diagnosed breast cancer., Methods: Using data from the Auckland and Waikato breast cancer registers, we included 11 798 women diagnosed with stage I-III breast cancer from June 2000 to May 2013. The characteristics of women receiving different surgical treatments and having immediate breast reconstruction following mastectomy were examined. A logistic regression was used to estimate the odds ratio of having breast-conserving surgery (BCS) versus mastectomy and immediate post-mastectomy reconstruction. Bilateral breast cancer cases and women with unilateral breast cancer, but who had bilateral surgery, were also identified., Results: Fifty-two percent of women received BCS and 44% had mastectomy over the study period. Key influences associated with BCS were age, mode of diagnosis, socio-economic status and public or private treatment. Just under half of the women who underwent bilateral surgery did not have bilateral cancer. Nineteen percent of women undergoing mastectomy underwent immediate reconstruction. Implant use increased slightly over the study period but there was a decrease in the use of autologous flap procedures., Conclusion: Surgical management of women with localized breast cancer was generally in line with guidelines, but with potential to further increase the use of breast conservation and immediate reconstruction in suitable cases., (© 2018 Royal Australasian College of Surgeons.)

Objective: To propose a framework for examining both the spatial equity and sustainability of GP services., Design: A conceptual discussion based on a systematic literature review of spatial equity definitions and methods., Setting: Improving the spatial equity of health services is a key step in achieving health equity. Health systems should contribute to achieving health equity and maintain equitable services into the future. The GP services are a key component of primary health care, which often aims to promote health equity. Despite the importance of spatially equitable and sustainable GP services, a framework for analysis has not yet been established., Main Outcome Measure: Examples of how the proposed framework could be implemented are provided from the New Zealand health care context., Result: The framework entails three steps: (i) defining spatial equity and sustainability; (ii) estimating current and future distributions of health services and needs; and (iii) quantifying spatial equity and sustainability. In step (i), a needs-based distribution is the most common definition of spatial equity, while sustainability is the ability to provide ongoing equitable access. Step (ii) depends on current and future estimates of access and need within a well-defined geographical area. In step (iii), spatial equity and sustainability should be quantified through measures, such as the Gini coefficient. Current and future levels of spatial equity should then be compared to assess the sustainability of equitable GP services., Conclusion: This article outlines a novel conceptual framework for examining the spatial equitability and sustainability of GP services., (© 2018 National Rural Health Alliance Ltd.)

Objective: To evaluate the safety, quality and impact of point-of-care ultrasound on patient management when performed by rural generalist doctors., Design: Cross-sectional descriptive study., Setting: Six rural small hospitals serving a range of communities in rural New Zealand., Participants: All generalist doctors practising ultrasound in the study hospitals., Main Outcome Measures: Technical quality, accuracy, impact on diagnostic certainty, patient disposition and overall patient care., Result: Participants correctly interpreted 90% of images and a similar percentage of point-of-care ultrasound findings when compared with the results of formal imaging or the final diagnosis. In total, 87% of scans contributed to the diagnostic process, changing the diagnostic probability. There was a 4% overall reduction in the number of patients needing hospital admission or transfer to an urban base hospital. The overall impact on patient care was positive for 71% of point-of-care ultrasound scans. Three percent of scans had the potential for patient harm., Conclusion: Rural generalists' practise a broad scope of point-of-care ultrasound that, when used as a part of the full clinical assessment, has a positive impact on patient care, improving diagnostic certainty and reducing the need for hospital admission and inter-hospital transfer. There are challenges in learning and maintaining the skills needed to practise a high standard of point-of-care ultrasound in this context. Further consideration needs to be given to the development safe scopes of practice, training, credentialing and quality assurance., (© 2018 National Rural Health Alliance Ltd.)

INTRODUCTION Point-of-care ultrasound (POCUS) is an increasingly common adjunct to the clinical assessment of patients in rural New Zealand. AIM To describe the scope of POCUS being practiced by rural generalist hospital doctors and gain insights, from their perspective, into its effect. METHODS This was a mixed-methods descriptive study. Main outcome measures were type and frequency of POCUS being undertaken. A questionnaire was given to POCUS-active rural hospital doctors to survey the effect of POCUS on clinical practice and assess issues of quality assurance. RESULTS The most commonly performed scans were: cardiac (18%) and volume scans (inferior vena cava and jugular venous pressure) (14%), followed by gallbladder (13%), kidney (11%), Focused Assessment with Sonography in Trauma (FAST) (7%), bladder (6%), leg veins (6%) and lungs (5%). There was large variation in frequency of scan types between the study hospitals that could not be accounted for by differences in training. DISCUSSION Rural generalists consider the broad scope of POCUS they practise to be an important but challenging skill set. Clinical governance, including an agreed scope and standards, may increase the benefits and improve the safety of rural POCUS.

Background: The only available predictive models for the outcome of breast cancer patients in New Zealand (NZ) are based on data in other countries. We aimed to develop and validate a predictive model using NZ data for this population, and compare its performance to a widely used overseas model, the Nottingham Prognostic Index (NPI)., Methods: We developed a model to predict 10-year breast cancer-specific survival, using data collected prospectively in the largest population-based regional breast cancer registry in NZ (Auckland, 9182 patients), and assessed its performance in this data set (internal validation) and in an independent NZ population-based series of 2625 patients in Waikato (external validation). The data included all women with primary invasive breast cancer diagnosed from 1 June 2000 to 30 June 2014, with follow up to death or Dec 31, 2014. We used multivariate Cox proportional hazards regression to assess predictors and to calculate predicted 10-year breast cancer mortality, and therefore survival, probability for each patient. We assessed observed survival by the Kaplan Meier method. We assessed discrimination by the C statistic, and calibration by comparing predicted and observed survival rates for patients in 10 groups ordered by predicted 10-year survival. We compared this NZ model with the Nottingham Prognostic Index (NPI) in this validation data set., Results: Discrimination was good: C statistics were 0.84 for internal validity and 0.83 for an independent external validity. For calibration, for both internal and external validity the predicted 10-year survival probabilities in all groups of patients, ordered by predicted survival, were within the 95% confidence intervals (CI) of the observed Kaplan-Meier survival probabilities. The NZ model showed good discrimination even within the prognostic groups defined by the NPI., Conclusions: These results for the New Zealand model show good internal and external validity, transportability, and potential clinical value of the model, and its clear superiority over the NPI. Further research is needed to assess other potential predictors, to assess the model's performance in specific subgroups of patients, and to compare it to other models, which have been developed in other countries and have not yet been tested in NZ.

Aims: This study aims to report the characteristics of newly diagnosed lung cancer cases, and to examine the data accuracy of registrations in the New Zealand Cancer Registry (NZCR) in 2011-2015., Methods: The accuracy and completeness of lung cancer registrations in the NZCR was explored using the Midland Lung Cancer Register (MLCR, including Lakes, Waikato, Tairawhiti and Bay of Plenty District Health Boards) and clinical records. A combined Midland Lung Cancer Dataset was created based on the NZCR and the MLCR. The characteristics of lung cancer cases was described and compared between Māori and non-Māori patients. The subgroup differences were examined by Chi-Square tests. The odds ratio of having small cell lung cancer compared to non-small cell lung cancer between Māori patients and non-Māori patients was estimated using the logistic regression model., Results: The combined Midland Lung Cancer Dataset included 2,057 verified lung cancer registrations, including 656 (31.9%) Māori patients and 1,401 (68.1%) non-Māori patients. Māori patients were more likely to be diagnosed at a younger age, more likely to be female, more likely to be a current or ex-smoker and more likely to have small cell lung cancer than non-Māori. The difference of cancer stage at diagnosis between Māori and others was not significant. After adjustment, the odds ratio of having small cell lung cancer for Māori patients compared to non-Māori patients was 1.55 (95% CI: 1.17-2.05). The adjusted odds ratio of having small cell lung cancer was 4.06 (95% CI: 1.72-9.60) for current smokers and 2.68 (95% CI: 1.14-6.30) for ex-smokers compared to patients who never smoked., Conclusions: Combining the two sources of data gives a more complete picture of the incidence and tumour characteristics of lung cancer in our region. Our dataset suggests that Māori patients are more likely to have small cell lung cancer than non-Māori patients., Competing Interests: All authors report grants from Waikato Medical Research Foundation during the conduct of the study. Dr Lawrenson and Mrs Firth report grants from Health Research Council during the conduct of the study.

Aims: To describe the experiences of people living with multimorbidity in New Zealand., Methods: We conducted a cross-sectional survey of adults with multimorbidity enrolled in two primary health organisations in New Zealand. Potential participants with multimorbidity were identified using retrospective hospital discharge data coded for long-term conditions. Sampling was stratified by ethnicity (Māori, Pacific and non-Māori/non-Pacific). Analysis was descriptive, with some responses compared to the general population estimates from the New Zealand Health Survey., Results: A total of 234 participants completed the survey (mean age 65.2). Self-reported physical health was poor among the cohort: forty-one percent of participants reported only 'fair' or 'poor' general health, compared to 13.5% in the general population (age and sex standardised), with similar results for both self-reported mental health and physical health. Self-reported health was poorer for Māori and Pacific participants. The majority (70%) of those who were working reported their health had affected their productivity, while nearly 20% of participants reported financial difficulty in taking care of their health needs., Conclusions: These results emphasise the serious impact multimorbidity has on patients' health status compared to the general population. This research supports the development of holistic patient-centred care models designed to improve patient outcomes., Competing Interests: Professor Lawrenson is both an employee of the University of Waikato and Waikato District Health Board; Dr Sarfati and Dr Millar reports grants from the Health Research Council during the conduct of the study.

The aim of this study was to understand the characteristics of older women with breast cancer and to describe the current patterns of treatment and outcomes. The study included data from the combined Auckland and Waikato breast cancer registers, which hold information for 12, 372 women diagnosed with stage I-IV breast cancer between June 2000 and May 2013. Of these women, 2671 (21.6%) were over 70 years of age. Patient characteristics, treatment type and survival were compared across four-year age groups (70-74, 75-79, 80-84, 85+) and hormone receptor status. Of the women aged over 70 years, 2485 (93.0%) had stage I-III disease. Increasing age was significantly associated with decreasing use of surgery, adjuvant radiotherapy, endocrine therapy and chemotherapy, even after adjustment for stage and level of co-morbidity. Nine hundred and one women (33.7%) had co-morbidities at the time of diagnosis. The 5-year breast cancer-specific survival rate for women aged 70-74 and that for women aged 75-79 were similar, but was worse in women aged over 80. Generally, older women are treated as per guidelines, although chemotherapy may be under-used. However, age is a significant factor influencing whether women are treated or not., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aims: This study aims to describe the prevalence and characteristics of the different ER/PR/HER2 subtypes in New Zealand women with breast cancer, and to explore their treatment and outcomes., Methods: This study included women diagnosed with Stage I-III breast cancer between January 2006 and May 2013, recorded in the combined Waikato and Auckland Breast Cancer Registers, and with complete data on their ER, PR and HER2 status. Five ER/PR/HER2 phenotypes were classified. Kaplan-Meier method and Cox proportional hazards model were used to examine the survival differences among these subtypes., Results: Of the 6,875 eligible women, 4,274 (62.2%) were classified as Luminal A, 836 (12.2%) as Luminal B HER2-, 605 (8.8%) as Luminal B HER2+, 401 (5.8%) as HER2+ non-Luminal and 759 (11.0%) as Triple Negative. Māori and Pacific women were less likely to have Triple Negative disease, while Pacific women were more likely to be HER2+ non-Luminal. The five-year breast cancer-specific survival was worst for HER2+ non-Luminal (80.1%) and Triple Negative (81.9%), followed by Luminal B HER2- (89.3%) and Luminal B HER2+ (91.6%), and was the best for Luminal A (96.8%). The adjusted breast cancer-specific mortality hazard ratio for Triple Negative and HER2+ non-Luminal compared to Luminal A was 4.91 (95% CI: 3.86-6.26) and 3.94 (95% CI: 2.94-5.30), respectively., Conclusions: The pattern of phenotype in women with Stage I-III breast cancer is similar to the overseas cohorts. Most New Zealand women with Luminal A breast cancer have a very good prognosis, but the less common subtypes have relatively poor outcomes., Competing Interests: RL, SS, IC, ME, CL and DS report grants from Health Research Council of New Zealand during the conduct of the study.

Aim: Trastuzumab was first funded in New Zealand for use in HER2+ve stage I-III breast cancer in 2007. This observational study aims to ascertain the patterns of use of trastuzumab in women with invasive HER2+ve breast cancer, and assess the effectiveness of adjuvant trastuzumab in women with stage I-III HER2+ve breast cancer., Methods: The Waikato and Auckland Breast Cancer Registries have clinical details of 12 372 women diagnosed with invasive breast cancer between June 2000 and May 2013. The proportion of women with HER2+ve breast cancer treated with trastuzumab was examined by age, ethnicity, stage and year of diagnosis. Differences in outcomes including the development of metastases and death were assessed for women with stage I-III HER2+ve breast cancer treated with both chemotherapy and trastuzumab, compared to women treated with chemotherapy alone., Results: Among the 1587 HER2+ve breast cancer patients, 888 (56.0%) women received trastuzumab. The probability of having trastuzumab decreased with higher age and comorbidity score and increased with year of diagnosis, tumor size and cancer stage. Māori and Pacific women were less likely to be treated with trastuzumab. After adjustment for potential confounding factors, the treatment with trastuzumab improved breast cancer-specific mortality (adjusted hazard ratio 0.57, 95% CI: 0.35-0.93)., Conclusion: Overall, this observational study has shown a substantial improvement in survival for women with HER2+ve stage I-III breast cancer, and much of this improvement can be attributed to the introduction of trastuzumab. Changes in chemotherapy also appear to have led to improved outcomes., (© 2017 John Wiley & Sons Australia, Ltd.)

More people now live with multimorbidity than with a single long-term condition. Despite this, clinical guidelines remain focused on the management of individual conditions. When the treatment recommendations from multiple different disease-specific guidelines are combined for one individual it frequently leads to interactions between treatments, along with a high burden of treatment for patients. It is also recognised that people with multimorbidity are often excluded from the trials that generate the underlying evidence for these guidelines, and that treatment goals from guidelines often fail to align with patient goals. This viewpoint discusses the main issues with applying disease-specific guidelines to individuals with multiple long-term conditions, and presents a set of eight recommendations to improve care for people with multimorbidity in New Zealand., Competing Interests: Dr Millar, Dr Dowell, Dr Mangin and Dr Sarfati report grants from Health Research Council, during the conduct of the study. Professor Lawrenson is both an employee of the University of Waikato and Waikato District Health Board.

INTRODUCTION Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians. AIM To understand the experiences of people with multimorbidity in the NZ health care system. METHODS A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey. RESULTS Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population. DISCUSSION Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.

Background: Obesity has been reported as an adverse prognostic factor in breast cancer, but inconsistently, and under-treatment with chemotherapy may occur. We provide the first assessment of obesity and breast cancer outcomes in a population-based, multi-ethnic cohort of New Zealand patients treated with chemotherapy., Methods: All 3536 women diagnosed with invasive breast cancer in the Waikato region of New Zealand from 2000-2014 were registered and followed until last follow-up in specialist or primary care, death or Dec 2014; median follow-up 4.1 years. For the 1049 patients receiving chemotherapy, mortality from breast cancer, other causes, and all causes, and rates of loco-regional and of distant recurrence, were assessed by body mass index (BMI), recorded after diagnosis, adjusting for other clinico-pathological and demographic factors by Cox regression., Results: BMI was known for 98% (n=1049); 33% were overweight (BMI 25-29.9), 21% were obese (BMI 30-34.9), and 14% were very obese (BMI 35+). There were no significant associations between obesity and survival, after adjustment for demographic and clinical factors (hazard ratios, HR, for very obese compared to BMI 21-24, for breast cancer deaths 0.96 (0.56-1.67), and for all deaths 1.03 (0.63-1.67), respectively, and only small non-significant associations for loco-regional or metastatic recurrence rates (HR 1.17 and 1.33 respectively). Subgroup analyses by age, menopausal status, ethnicity, stage, post-surgical radiotherapy, mode of diagnosis, type of surgery, and receptor status, showed no associations. No associations were seen with BMI as a continuous variable. The results in all patients irrespective of treatment but with recorded BMI data (n=2296) showed similar results., Conclusions: In this population, obesity assessed post-diagnosis had no effect on survival or recurrence, based on 1049 patients with chemotherapy treatment with follow-up up to 14 years.

Background: New Zealand has major ethnic disparities in breast cancer survival with Māori (indigenous people) and Pacific women (immigrants or descended from immigrants from Pacific Islands) faring much worse than other ethnic groups. This paper identified underlying factors and assessed their relative contribution to this risk differential., Methods: This study involved all women who were diagnosed with primary invasive breast cancer in two health regions, covering about 40% of the national population, between January 2000 and June 2014. Māori and Pacific patients were compared with other ethnic groups in terms of demographics, mode of diagnosis, disease factors and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of excess mortality from breast cancer for Māori and Pacific patients were assessed., Results: Of the 13,657 patients who were included in this analysis, 1281 (9.4%) were Māori, and 897 (6.6%) were Pacific women. Compared to other ethnic groups, they were younger, more likely to reside in deprived neighbourhoods and to have co-morbidities, and less likely to be diagnosed through screening and with early stage cancer, to be treated in a private care facility, to receive timely cancer treatment, and to receive breast conserving surgery. They had a higher risk of excess mortality from breast cancer (age and year of diagnosis adjusted hazard ratio: 1.76; 95% CI: 1.51-2.04 for Māori and 1.97; 95% CI: 1.67-2.32 for Pacific women), of which 75% and 99% respectively were explained by baseline differences. The most important contributor was late stage at diagnosis. Other contributors included neighbourhood deprivation, mode of diagnosis, type of health care facility where primary cancer treatment was undertaken and type of loco-regional therapy., Conclusions: Late diagnosis, deprivation and differential access to and quality of cancer care services were the key contributors to ethnic disparities in breast cancer survival in New Zealand. Our findings underscore the need for a greater equity focus along the breast cancer care pathway, with an emphasis on improving access to early diagnosis for Māori and Pacific women.

Aim: Breast cancer in New Zealand-based Pasifika women is a significant issue. Although Pasifika women have a lower incidence of breast cancer compared to New Zealand European women, they have higher breast cancer mortality and lower five-year survival. The aim of this study was to describe the characteristics and tumour biology of Pasifika women and to compare New Zealand European women to identify what factors impact on early (Stage 1 and 2) vs advanced stage (Stage 3 and 4) at diagnosis., Method: Data on all Pasifika and New Zealand European women diagnosed with breast cancer (C50) during the period 1 June 2000 to 31 May 2013 was extracted from the Auckland and Waikato Breast Cancer Registries. Descriptive tables and Chi-square test were used to examine differences in characteristics and tumour biology between Pasifika and New Zealand European women. Logistic regression was used to identify factors that contributed to an increased risk of advanced stage at diagnosis., Results: A significantly higher proportion of Pasifika women had advanced disease at diagnosis compared to New Zealand European women (33.3% and 18.3%, respectively). Cancer biology in Pasifika women was more likely to be: 1) HER2+, 2) ER/PR negative and 3) have a tumour size of ≥50mm. Pasifika women live in higher deprivation areas of 9-10 compared to New Zealand European women (55% vs 14%, respectively) and were less likely to have their cancer identified through screening. Logistic regression showed that if Pasifika women were on the screen-detected pathway they had similar odds (not sig.) of having advanced disease at diagnosis to New Zealand European women., Conclusion: Mode of detection, deprivation, age and some biological factors contributed to the difference in odds ratio between Pasifika and New Zealand European women. For those of screening age, adherence to the screening programme and improvements in access to earlier diagnosis for Pasifika women under the current screening age have the potential to make a substantial difference in the number of Pasifika women presenting with late-stage disease., Competing Interests: Dr Brown, Dr Tin Tin and Dr Campbell report grants from Health Research Council of New Zealand during the conduct of the study.

Purpose: This study aims to look at the distribution of different subtypes of stage I-III breast cancer in Māori and Pacific versus non-Māori/Pacific women, and to examine cancer outcomes by ethnicity within these different subtypes., Method: This study included 9,015 women diagnosed with stage I-III breast cancer between June 2000 and May 2013, recorded in the combined Waikato and Auckland Breast Cancer Registers, who had complete data on ER, PR and HER2 status. Five ER/PR/HER2 subtypes were defined. Kaplan-Meier method and Cox proportional hazards model were used to examine ethnic disparities in breast cancer-specific survival., Results: Of the 9,015 women, 891 were Māori, 548 were Pacific and 7,576 others. Both Māori and Pacific women were less likely to have triple negative breast cancer compared to others (8.6, 8.9 vs. 13.0%). Pacific women were more than twice as likely to have ER-, PR- and HER2+ cancer than Māori and others (14.2 vs. 6.0%, 6.7%). After adjustment for age, year of diagnosis, stage, grade and treatment, the hazard ratios of breast cancer-specific mortality for Māori and Pacific women with ER+, PR+ and HER2- were 1.52 (95% CI 1.06-2.18) and 1.55 (95% CI 1.04-2.31) compared to others, respectively. Māori women with HER2+ cancer were twice more likely to die of their cancer than others., Conclusions: Outcomes for Māori and Pacific women could be improved by better treatment regimens especially for those with HER2+ breast cancer and for women with ER+, PR+ and HER2- breast cancer.

Objective: To describe the epidemiological characteristics of patients with work-related injuries (WRI) admitted to hospitals in New Zealand's Midland Trauma System (MTS) during a four year period., Methods: A retrospective review was conducted of trauma registry records for adults (≥15years) admitted to four hospitals in the MTS as a result of WRI between 1 January 2012 and 31 December 2015. We describe the patterns of injury incidence by demographic characteristics, employment industry, mechanism of injury, body regions injured, injury severity score (ISS), month, day and time of injury, duration of hospital stay, domicile District Health Board (DHB), and discharge destination., Results: The 2169 WRI trauma admissions, corresponded to an annualised rate of 205.8 per 100,000 workers or 234.3 per 100,000 full time employment employees (FTE). Injury rates were highest among males (238.0 per 100,000 workers) and those aged 15-24 years (227.1 per 100,000 workers), and lowest among Asians (83 per 100,000 workers). The highest injury rates occurred among the 'agriculture/forestry/fishing', 'manufacturing', and 'transport/postal/warehousing' industries. 'Contact with machinery' was the most common mechanism of injury, and the 'extremities or pelvic girdle' the most common body region injured. The in-hospital case fatality rate was <0.5%., Conclusion: The predominance of WRI in the 'agriculture/forestry/fishing' industries in the Midland region is consistent with national estimates. The high rate of injuries amongst males, young adults, and Māori requires further exploration., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Reduction in bone mineral density (BMD) is a common side effect of androgen deprivation therapy (ADT). We aimed to examine the cross-sectional and longitudinal variation in BMD and associated bone markers in patients with nonmetastatic prostate cancer (PCa) managed with and without ADT., Methods: Bone mineral density of the total body, lumbar spine, femoral neck, ultradistal forearm, and one-third distal radius was measured in 88 patients with PCa without bone metastases at baseline and at 6 months. Patients were categorized into 4 groups: (1) acute ADT (≤6 months), (2) chronic ADT (>6 months), (3) former ADT, and (4) no ADT (controls). Serum levels of bone metabolism markers, procollagen type I N-terminal propeptide (PINP) and C-terminal cross-linking telopeptide of type I collagen (CTX), were also measured., Results: In the cross-sectional analysis, men receiving chronic ADT had significantly lower total body BMD as compared with former ADT users and men with no ADT. In longitudinal analysis, a significant reduction in ultradistal forearm BMD was observed in both acute and chronic ADT users after 6 months (4.08% and 2.7%, P = .012 and .026, respectively). A significant reduction in total body BMD was observed in acute ADT users (2.99%, P = .032). Former ADT users had a significant increase in both lumbar spine and femoral neck BMD (2.84% and 1.59%, P = .008 and .002, respectively). The changes in BMD were not significantly different between acute and chronic ADT users. In the cross-sectional analysis, higher levels of PINP and CTX were observed in acute and chronic ADT users than former ADT users or PCa controls. In longitudinal analysis, the level of serum PINP and CTX did not change significantly from baseline to 6 months in acute, chronic, and former ADT users, or PCa controls, and the percentage change did not differ among the 4 groups., Conclusions: Men on acute ADT had a similar rate of bone loss to men on chronic ADT. Reversibility in ADT-induced bone loss was observed in those who discontinued ADT. Serum levels of PINP and CTX were higher in acute and chronic ADT users and levels returned to the range of PCa controls when treatment was withdrawn., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Sepsis is a life-threatening complication of infection. The incidence of sepsis is thought to be on the increase, but estimates making use of administrative data in the United States may be affected by administrative bias., Methods: We studied the population-based incidence of sepsis in the Waikato region of New Zealand from 2007 to 2012 using International Classification of Diseases, Tenth Revision, Australian Modification , which lacks a specific code for sepsis., Results: Between 2007 and 2012, 1643 patients met coding criteria for sepsis in our hospitals. Sixty-three percent of patients were 65 or over, 17% of cases were admitted to an intensive care unit, and the in-hospital and 1-year mortality with sepsis was 19% and 38%, respectively. Age-standardized rate ratios (ASRRs) demonstrated that sepsis was associated with male sex (ASRR 1.4; 95% confidence interval [CI], 1.23-1.59), Maori ethnicity (ASRR 3.22 compared with non-Maori; 95% CI, 2.85-3.65), study year (ASRR 1.62 comparing 2012 with 2008; 95% CI, 1.18-2.24), and socioeconomic deprivation (ASRR 1.72 comparing the highest with the lowest quintile of socioeconomic deprivation; 95% CI, 1.5-1.97). Multiorgan failure was present in approximately 20% of cases in all age groups. Intensive care unit admission rate fell from 30% amongst 25- to 34-year-olds to less than 10% amongst those aged 75 and over., Conclusions: In a 9% sample of the New Zealand population, the incidence of sepsis increased by 62% over a 5-year period. Maori, elderly, and disadvantaged populations were most affected.

Background: Radical prostatectomy is the most common treatment for localised prostate cancer in New Zealand. Active surveillance was introduced to prevent overtreatment and reduce costs while preserving the option of radical prostatectomy. This study aims to evaluate the cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy., Methods: Markov models were constructed to estimate the life-time cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer patients aged 45-70 years, using national datasets in New Zealand and published studies including the SPCG-4 study. This study was from the perspective of the Ministry of Health in New Zealand., Results: Radical prostatectomy is less costly than active surveillance in men aged 45-55 years with low risk localised prostate cancer, but more costly for men aged 60-70 years. Scenario analyses demonstrated significant uncertainty as to the most cost-effective option in all age groups because of the unavailability of good quality of life data for men under active surveillance. Uncertainties around the likelihood of having radical prostatectomy when managed with active surveillance also affect the cost-effectiveness of active surveillance against radical prostatectomy., Conclusions: Active surveillance is less likely to be cost-effective compared to radical prostatectomy for younger men diagnosed with low risk localised prostate cancer. The cost-effectiveness of active surveillance compared to radical prostatectomy is critically dependent on the 'trigger' for radical prostatectomy and the quality of life in men on active surveillance. Research on the latter would be beneficial.

Background: Indigenous Māori are known to experience inferior quality cancer care compared with non-Indigenous Europeans in New Zealand. However, limited data are available on ethnic/socio-economic differences in surgical treatment of breast cancer, or reasons for such variations within the local context. We investigated ethnic/socio-economic differences in rates of mastectomy, sentinel node biopsy (SNB), post-mastectomy breast reconstruction and definitive local therapy for breast cancer in New Zealand., Methods: A retrospective review of prospective data in the Waikato Breast Cancer Register for women diagnosed during 1999-2012 was performed. Differences in rates of mastectomy (for stage I/II, T1/T2 cancers), SNB (for stage I/II, T1/T2, cN0 cancers), post-mastectomy breast reconstruction (for non-metastatic cancers in women <70 years) and definitive local therapy (for stage I/II cancers) were analysed in univariate and multivariate regression models, adjusting for covariates., Results: Significantly lower mastectomy and higher reconstruction rates were associated with younger age, private compared with public hospital care and screen compared with non-screen detection. Compared with NZ Europeans, Māori (41% versus 33%, P = 0.025) were significantly more likely to undergo mastectomy for cancers, which were potentially amenable for breast conserving surgery, but were significantly less likely to undergo post-mastectomy breast reconstruction (12% versus 35%, P < 0.001). No significant ethnic or socio-economic differences were observed in rates of SNB or definitive local therapy., Conclusions: This study has demonstrated lower rates of breast conserving surgery and reconstructions in Māori compared with NZ European women, and highlight the need for future research to focus on understanding the reasons behind these findings., (© 2015 Royal Australasian College of Surgeons.)

Aim: The aim of this study was to establish the prevalence of diabetic foot disease by utilising the retinal eye screening register in the Waikato region of New Zealand. Understanding both the prevalence and the degree of foot disease across the general diabetes population will help to determine what podiatry services are required for people with diabetes., Method: 2192 people aged 15years and over, who attended the Waikato Regional Diabetes Service mobile retinal photo screening service for the six-month period between May and November 2014, consented to a foot screen including testing for sensation and pedal pulses. A digital image was taken of the dorsal and plantar aspect of each foot for review by a registered Podiatrist., Results: Thirteen percent of the study sample was identified as having a high-risk foot including active foot complications. 65% were categorised as low risk and a further 22% at moderate risk of diabetic foot disease. Factors identified as significant included age, type of diabetes, duration of diabetes, and smoking. These factors placed people at greater risk of diabetic foot disease., Conclusion: A significant number of people with diabetes are at risk of diabetic foot disease. This study has highlighted the need for targeted podiatry services to address diabetic foot disease., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aims: Multimorbidity is common, yet there are major gaps in research, particularly among younger and indigenous populations. This research aimed to understand patients' perspectives of living with multimorbidity., Methods: A qualitative study of 61 people living with multimorbidity, 27 of whom were Māori and a third aged under 65, from urban and rural regions in New Zealand. Six focus groups and 14 interviews were conducted, recorded, transcribed and analysed., Results: For many participants, living with multimorbidity disrupted their 'normal' lives, posing challenges in everyday activities such as eating and toileting, working and managing medications. Dealing with the health system posed challenges such as accessing appointments and having enough time in consultations. Cultural competency, good communication and continuity of care from healthcare providers were all valued. Participants had many recommendations to improve management, including a professional single point of contact to coordinate all specialist care., Conclusions: Living with multimorbidity is often challenging requiring people to manage their conditions while continuing to live their lives. This research suggests changes are needed in the health system in New Zealand and elsewhere to better manage multimorbidity thus improving patient's lives and reducing costs to the health sector and wider society., Competing Interests: Dr Lawrenson is an employee of the University of Waikato and Waikato District Health Board; Dr Sarfati reports grants from the Health Research Council during the conduct of the study.

A national internet-based survey of New Zealand (NZ) primary care physicians (n = 192) used the survey instrument developed by the International Cancer Benchmarking Partnership (ICBP). Practitioners were recruited by a range of methods assisted by NZ general practice networks and contacts. Compared to 11 other ICBP jurisdictions, direct access to diagnostic tests was more limited and took more time than in most other areas; the average wait for a test to be done and reported was 3.0 weeks for X-rays and 8.0 for ultrasound, compared to ICBP averages of 1.6 and 4.7 weeks respectively. Forty-five per cent of respondents could get specialist advice within 48 hr. Sixty-six per cent were aware of NZ guidelines for cancer in primary care, and of those 44% consulted them sometimes or often. Access to tests was greater, and time required much less, in the private than the public care system. NZ respondents each answered two of five clinical vignettes, with results similar to other ICBP areas. The survey also included general practice trainees (N = 42); their results were similar to the main group. The results suggest that improvements in prompt access to diagnostic tests and referrals for suspected cancer need to be given priority in NZ., (© 2017 John Wiley & Sons Ltd.)

New Zealand has a maldistributed workforce that is heavily dependent on recruiting international medical graduates. Shortages are particularly apparent in high needs communities and in general scope specialties in provincial regions. The University of Waikato in partnership with the Waikato District Health Board has proposed a third medical school for New Zealand which will concentrate on addressing the workforce needs of disadvantaged rural and provincial communities. The proposed program is a community engaged, graduate entry medical course., Competing Interests: Dr Town was retained as a consultant to the Business Case project currently being considered by the Government and paid fees for reviewing the drafts of the BC and attending relevant meetings; Dr Tapsell is the Director of Clinical Services for the Mental Health and Addictions service, Waikato District Health Board; Dr Lawrenson is both an employee of the University of Waikato and Waikato District Health Board; Dr Murray reports as Chief Executive Officer, Waikato District Health Board.

Aim: To assess the completeness of data on body mass index (BMI) in a regional breast cancer register, and its association with patient characteristics and clinical outcomes., Methods: This analysis used the data from the Waikato Breast Cancer Register and involved all women who were diagnosed with primary breast cancer in the Waikato District Health Board Region between January 2000 and June 2014. Patients with recorded BMI were compared with those with missing data in terms of demographics, disease factors and treatment factors. Cox regression modelling was performed, and hazards of specific outcomes associated with missing data on BMI were assessed., Results: Of the 3,536 patients included in this analysis, 27.4% had missing data on BMI. Missing data was more frequent in older patients, rural dwellers, patients with comorbidities, screen detected patients, patients with early stage or low grade cancer and hormone receptor positive patients, but was minimal in patients who received chemotherapy. Patients with missing data were less likely to experience loco-regional recurrence (although not significant), metastasis and breast cancer specific mortality, but more likely to experience death from other causes even after demographic, disease and treatment factors were adjusted., Conclusions: Height or weight or both were not recorded for more than one quarter of the patients. Missing data was differential by specific patient characteristics and clinical outcomes., Competing Interests: All authors report grants from Health Research Council of New Zealand during the conduct of the study.

Background: Ethnic and socioeconomic inequities in use of breast cancer adjuvant therapy are well documented in many countries including the USA, and are known to contribute to lower breast cancer survival among minority ethnic and socioeconomically deprived women. We investigated ethnic and socioeconomic inequities in use of adjuvant radiotherapy and chemotherapy in a cohort of women with invasive breast cancer in New Zealand., Methods: All women with newly diagnosed invasive breast cancer during 1999-2012 were identified from the Waikato Breast Cancer Register. Rates of chemotherapy use and radiotherapy use were assessed in women who were deemed to be eligible for chemotherapy (n = 1212) and radiotherapy (n = 1708) based on guidelines. Factors associated with use of chemotherapy and radiation therapy were analysed in univariate and multivariate regression models, adjusting for covariates., Results: Overall, rates of chemotherapy and radiotherapy use were 69% (n = 836) and 87.3% (n = 1491), respectively. In the multivariate model, significantly lower rates of radiotherapy use were associated with Māori compared with NZ European (Odds Ratio [OR] = 0.63, 0.40-0.98), presence of comorbidity (OR = 0.49, 0.34-0.72), distance from hospital of over 100km (OR = 0.47, 0.23-0.96), mastectomy compared with breast conserving surgery (OR = 0.32, 0.17-0.56) and non-screen compared with screen detection (OR = 0.53, 0.35-0.79). No significant associations were observed between chemotherapy use and ethnic or socio-demographic factors., Conclusions: Improving access for radiotherapy, especially for women who are at a higher risk of not receiving optimum cancer therapy due to ethnicity, geography or socioeconomic status need to be recognized as a priority to reduce inequities in breast cancer care in New Zealand.

Purpose: To examine prostate-specific antigen (PSA) screening patterns and outcomes in rural and urban men in New Zealand., Methods: Men aged 40+ years were identified from 18 rural and 13 urban general practices across the Midland Cancer Network region. Computerized practice records were cross-referenced with community laboratory data to ascertain the number and level of PSA tests undertaken in 2010 and 3 years prior. For men with an elevated PSA result in 2010, practice records were searched for information on specialist visits, and they were cross-referenced with histology reports regarding biopsy and prostate cancer diagnosis., Findings: The study population included 34,960 men aged 40+ years, of whom 48% were enrolled in rural practices. Men in rural practices were 43% less likely to be screened with a PSA test in 2010, but they were 53% more likely to have an elevated PSA result. The prostate cancer detection rate from all screened men was 6 per 1,000 for rural men compared with 3 per 1,000 for urban men. Rural men were more likely diagnosed with Gleason score 9 tumors and metastatic disease., Conclusion: Significant differences were found in PSA screening patterns between rural and urban general practices. Due to lower screening rates, rural men were more likely to be diagnosed with prostate cancer when screened and also seemed to be diagnosed with more advanced disease compared with urban men. Despite ongoing discussions about the benefits and harms of PSA screening, PSA testing as such seems to be under-utilized in New Zealand rural practices., (© 2015 National Rural Health Association.)

Many rural communities have poor access to health services due to a combination of distance from specialist services and a relative shortage of general practitioners. Our aims were to compare the characteristics of urban and rural women with breast cancer in New Zealand, to assess breast cancer-specific and all-cause survival using the Kaplan-Meier method and Cox proportional hazards model, and to assess whether the impact of rurality is different for Māori and New Zealand (NZ) European women. We found that rural women tended to be older and were more likely to be Māori. Overall there were no differences between urban and rural women with regards their survival. Rural Māori tended to be older, more likely to be diagnosed with metastatic disease and less likely to be screen detected than urban Māori. Rural Māori women had inferior breast cancer-specific survival and all-cause survival at 10 years at 72.1% and 55.8% compared to 77.9% and 64.9% for urban Māori. The study shows that rather than being concerned that more needs to be done for rural women in general it is rural Māori women where we need to make extra efforts to ensure early stage at diagnosis and optimum treatment., Competing Interests: The authors declare no conflict of interest.

INTRODUCTION Rural women face many challenges with regards to maternity services. Many rural primary birthing facilities in New Zealand have closed. The Lead Maternity Carer (LMC) model of maternity care, introduced in 1990, has moved provision of rural maternity care from doctors to independent midwifery services. Shortages of rural midwives in the Midland region led to rural maternity care being seen as a vulnerable service. AIM To understand the views and experiences of rural women concerning maternity care, to inform the future design and provision of rural maternity services. METHODS Participants were drawn from areas purposively selected to represent the five District Health Boards comprising the Midland health region. A demographic questionnaire, focus groups and individual interviews explored rural women's perspectives of antenatal care provision. These were analysed thematically. RESULTS Sixty-two women were recruited. Key themes emerging from focus groups and interviews included: access to services, the importance of safety and quality of care, the need for appropriate information at different stages, and the role of partners, family and friends in the birthing journey. While most women were happy with access to services, quality of care, provision of information, and the role of family in their care, for some women, this experience could be enhanced. CONCLUSION Midwives are the frontline service for women seeking antenatal services. Support for rural midwives and for local birthing units is needed to ensure rural women receive services equal to that of their urban counterparts.

There is a considerable mismatch between the population that accesses rural healthcare in New Zealand and the population defined as 'rural' using the current statistics New Zealand rural and urban categorisations. Statistics New Zealand definitions (based on population size or density) do not accurately identify the population of New Zealanders who actually access rural health services. In fact, around 40% of people who access rural health services are classified as 'urban' under the Statistics New Zealand definition, while a further 20% of people who are currently classified as 'rural' actually have ready access to urban health services. Although there is some recognition that current definitions are suboptimal, the extent of the uncertainty arising from these definitions is not widely appreciated. This mismatch is sufficient to potentially undermine the validity of both nationally-collated statistics and also any research undertaken using Statistics New Zealand data. Under these circumstances it is not surprising that the differences between rural and urban health care found in other countries with similar health services have been difficult to demonstrate in New Zealand. This article explains the extent of this mismatch and suggests how definitions of rural might be improved to allow a better understanding of New Zealand rural health.

Background: Patients who received private health care appear to have better survival from breast cancer compared to those who received public care. This study investigated if this applied to New Zealand women and identified factors that could explain such disparities., Methods: This study involved all women who were diagnosed with primary breast cancer in two health regions in New Zealand, covering about 40% of the national population, between June 2000 and May 2013. Patients who received public care for primary treatment, mostly surgical treatment, were compared with those who received private care in terms of demographics, mode of presentation, disease factors, comorbidity index and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of breast cancer specific mortality associated with the type of health care received was assessed., Results: Of the 14,468 patients, 8,916 (61.6%) received public care. Compared to patients treated in private care facilities, they were older, more likely to be Māori, Pacifika or Asian and to reside in deprived neighbourhoods and rural areas, and less likely to be diagnosed with early staged cancer and to receive timely cancer treatments. They had a higher risk of mortality from breast cancer (hazard ratio: 1.95; 95% CI: 1.75, 2.17), of which 80% (95% CI: 63%, 100%) was explained by baseline differences, particularly related to ethnicity, stage at diagnosis and type of loco-regional therapy. After controlling for these demographic, disease and treatment factors, the risk of mortality was still 14% higher in the public sector patients., Conclusions: Ethnicity, stage at diagnosis and type of loco-regional therapy were the three key contributors to survival disparities between patients treated in public and private health care facilities in New Zealand. The findings underscore the need for more efforts to improve the quality, timeliness and equitability of public cancer care services.

This study aims to examine the survival disparity between Māori men and New Zealand (NZ) Europeans diagnosed with prostate cancer. We identified men aged 40+ years in the Midland Cancer Network region registered with prostate cancer in 2007-2010 in the Cancer Registry. Data were extracted from patient notes of all Māori men and a sample of NZ Europeans. The survival disparity between Māori men and Europeans was estimated by the Kaplan-Meier method and Cox proportional-hazards regression models after adjusting for other factors. This study included 535 men with prostate cancer (135 Māori men and 400 Europeans). The 5-year cancer-specific survival was 98.6% for men diagnosed with localised cancer, 88.8% for locally advanced disease and 19.1% for metastatic cancer. The all-cause survival and the cancer-specific survival were both significantly poorer for Māori men than for NZ Europeans (log rank test: P = 0.004, 0.006 respectively). The hazard ratio of cancer-specific survival for Māori men was 2.01 (95% CI: 1.21-3.36) compared with NZ Europeans. Māori men with prostate cancer had poorer all-cause survival and cancer-specific survival than NZ Europeans. Māori men were at risk of having more advanced disease at diagnosis, which explains most of the survival inequity between Māori men and NZ Europeans., (© 2016 John Wiley & Sons Ltd.)