Medical Research & Journals | Free Research Review Medical Studies Publications

ISSN ISSN 1178-6191

In this issue:

Lung cancer screening to reduce health inequities for Māori
Inequity in screening rates for diabetes in pregnancy
High amenable mortality in the homeless
Prioritisation of funded cataract surgery
Ethnic disparity in metformin prescribing
Cardiovascular health in Indigenous women
Disparities in access to funded insulin pumps
Ethnic disparities in diabetes care
Patterns of cycling in Māori
Decolonising the health system
Prevention of chronic conditions in Māori

Abbreviations used in this issue

CT = computed tomography

HbA1c = glycated haemoglobin

MOH = Ministry of Health

OECD = Organisation for Economic Co-operation and Development

Tēnā koutou katoa

Nau mai, haere mai ki a Māori Health Review. We aim to bring you top Māori and Indigenous health research from Aotearoa and internationally. Ngā mihi nui ki Manatu Hauora Māori for sponsoring this review, which comes to you every two months. Ko te manu e kai i te miro nōna te ngahere, Ko te manu kai i te mātauranga, nōna te ao.

Welcome to the 89th issue of Māori Health Review.

Happy New Year. Inequity and disparities in the care of Māori with diabetes feature in several papers reviewed in this issue. Hopefully the decision by PHARMAC to fund two new medications for type 2 diabetes with criteria specifically targeting Māori patients will help to reduce the gap.

We hope you find this issue informative and of value in your daily practice. We welcome your comments and feedback.

Nga mihi
Dr Matire Harwood
matireharwood@researchreview.co.nz

Impact of low-dose CT screening for lung cancer on ethnic health inequities in New Zealand

Authors: McLeod M, et al.

Summary: A national biennial low-dose CT screening programme for lung cancer in New Zealand adults aged 55–74 years improved total population health, reduced health inequities for Māori and would likely be costeffective compared with usual care in a Markov macrosimulation model. The model estimated health benefits and costs of screening smokers with a 30-pack-year history and former smokers who had quit within the last 15 years. Using a threshold of NZ$45,000 (based on gross domestic product per capita), the cost of screening was NZ$34,000 per health-adjusted life-years gained for both the total population and for Māori. Health gains for Māori vs non-Māori were doubled with screening in females and 25% greater in males.

Comment: Fantastic news! Let’s hope the recommendations made here are implemented asap.

Reference: BMJ Open. 2020;10(9):e037145.

Abstract

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Ethnic inequities in screening for diabetes in pregnancy in New Zealand—adherence to national guidelines

Authors: Chepulis L, et al.

Summary: Adherence to screening guidelines for diabetes in pregnancy was poor in a review of clinical records in 807 women without known diabetes before pregnancy. Clinical records were obtained for women who had delivered in hospitals or community birth centres in the Waikato region during June–August 2017. Although 94% of women received some form of screening for diabetes in pregnancy, only 26.4% received screening as per the 2014 MOH guidelines. The most commonly performed screening was HbA1c testing, which was recorded in 83.9% of pregnancies. Screening rates by all measures were lower for Māori vs non-Māori with 17.5% of Māori receiving HbA1c testing and glucose load screening vs 31.6% of non-Māori (p<0.0005).

Comment: The numbers confirm what we’d already heard four years ago from wahine Māori living in Northland. This is unacceptable. Undiagnosed, and therefore under-managed, gestational diabetes is associated with poor birth outcomes, and long-term complications including diabetes and heart disease in māmā and their pēpi.

Reference: N Z Med J. 2020;133(1525):106-113.

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Disclaimer: This publication is not intended as a replacement for regular medical education but to assist in the process. The reviews are a summarised interpretation of the published study and reflect the opinion of the writer rather than those of the research group or scientific journal. It is suggested readers review the full trial data before forming a final conclusion on its merits.

Research Review publications are intended for New Zealand health professionals.

Amenable mortality within the New Zealand homeless population: we can do better!

Authors: Charvin-Fabre S, et al.

Summary: The rate of amenable mortality among homeless people in New Zealand was examined using coroners’ findings for 171 deaths of persons with no fixed abode from 2008 to 2019. The mean age of death was 45.7 years in the homeless population, which corresponded to a reduced life expectancy of 30 years compared with the housed population. Most homeless people had died alone in public places (56%) or private vehicles (14%) as a result of natural causes (45.7%) or suicide (41.5%). Over 75% of deaths were amenable to timely and effective healthcare interventions. The authors commented that the high amenable mortality rate is indicative of the considerable challenges homeless people experience accessing the healthcare system.

Comment: Like many of you providing health services for people without housing, I see the impact. Some suggest that the stress of it ages people, resulting in long-term conditions. COVID brought this to the fore too, and some places, including our clinic, set up swabbing services (i.e., mobile clinics, clinics close to soup kitchens) with homeless communities in mind. I hope such targeted services continue.

Reference: N Z Med J. 2020;133(1527):26-38.

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Cataract surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity

Authors: Chilibeck C, et al.

Summary: Access to publicly funded cataract surgery in New Zealand was found to vary by region and ethnicity in a retrospective cohort study of the National Prioritisation Web Service used by the MOH. A total of 61,095 prioritisation events for 44,403 patients were identified between November 2014 and March 2019. Mean age at prioritisation for publicly funded cataract surgery was 74.4 years and 56% of the cohort were female. The majority of patients were European (69.8%) and 9.6% were Māori. Mean best spectacle-corrected visual acuity at prioritisation was 6/30-2 and was significantly worse in Māori and Pasifika patients, who presented at a younger age (~10 years earlier) than other ethnic groups. Publicly funded cataract surgery was approved for 74.4% of prioritisation events and the surgical intervention rate varied by region.

Comment: This is a really important study as cataracts have significant impact on peoples’ lives, including their ability to drive, work and participate in ways that are meaningful to them. The results provide some clarity on the rates, severity and access to best-practice care for one eye condition. Further work is required to understand the effects of other eye health issues for Māori.

Reference: N Z Med J. 2020;133(1524):40-49.

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www.maorihealthreview.co.nz a Research Review Publication

Metformin adherence in patients with type 2 diabetes and its association with glycated haemoglobin levels

Authors: Chepulis L, et al.

Summary: Ethnic disparity in metformin prescribing was uncovered in an investigation of metformin adherence in patients with type 2 diabetes. Prescription and dispensing data during the period from October 2016 to March 2018 were collected for 1595 patients from 10 general practices. The mean medication possession ratio was 0.87. Optimal medication cover for ≥80% of days was achieved by 63.8% of Māori vs 81.2% of European patients. Prescription adherence did not differ by ethnicity, but significantly fewer Māori patients received a prescription for metformin (p=0.002) leading to an overall reduction in metformin coverage for Māori patients. Adherence to metformin was associated with a 3.2 mmol/mol reduction in HbA1c (p<0.01).

Comment: Too often we hear the ‘non-compliance’ narrative when attempting to explain inequities in outcomes for long-term conditions such as diabetes (spoiler alert, it’s not true!). Really useful to have this paper in our ‘resource kete’ and pull it out when needed, to counter incorrect assumptions.

Reference: J Prim Health Care. 2020;12(4):318-326.

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Māori, Pacific, Aboriginal and Torres Strait Islander women’s cardiovascular health: Where are the opportunities to make a real difference?

Authors: McBride KF, et al.

Summary: This review article explored the cardiovascular care experiences of Māori, Pacific, Aboriginal and Torres Strait Islander women. The continuum of care from risk assessment to acute care and secondary prevention was addressed in the context of a holistic and culturally responsive approach. Priorities to improve care and address inequities were identified and reflected an approach tailored to women’s specific needs with recognition of the unique roles and strengths of Indigenous women.

Comment: So good to see this paper. A great summary of the issues and guidance on the next steps.

Reference: Heart Lung Circ. 2021;30(1):52-58.

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Youth and non-European ethnicity are associated with increased loss of publicly funded insulin pump access in New Zealand people with type 1 diabetes

Authors: Hennessy LD, et al.

Summary: The loss of access to publicly funded continuous subcutaneous insulin infusion was investigated using nationally held data including the New Zealand Virtual Diabetes Register. Cessation rates for publicly funded insulin pumps were approximately 4% per year, with youth aged 10–29 years and Māori and Pasifika patients being over-represented. These same patient groups were also less likely to gain initial access to public funding for continuous insulin infusion.

Reference: Diabet Med. 2021;38(1):e14450.

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Ethnic inequity in diabetes outcomes — inaction in the face of need

Authors: Jansen RM, et al.

Summary: The long-standing ethnic disparities in hyperglycaemia and diabetes care support services for Māori and Pasifika compared with European New Zealanders were discussed in this editorial. The authors commented that programmes to support lifestyle change to prevent or delay diabetes in the wider Māori and Pasifika communities, and prevent diabetes complications among those with diabetes receive inconsistent Government funding and resourcing. They noted that access to newer anti-diabetes agents is often limited to patients who meet certain criteria or are able to pay.

Comment: I’ve included these papers together to highlight one important point. We may think that having a treatment (in the first instance, insulin pumps) that is made available to all is being equitable. However, as the authors demonstrated in this first paper, this isn’t the case and in fact unequal access leads to inequitable outcomes. Instead a targeted approach is required, as argued in the second paper by Jansen and others. Thankfully PHARMAC heeded the call from the numerous submissions, including the College of GPs

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Cycling amongst Māori: Patterns, influences and opportunities

Authors: Jones R, et al.

Summary: This mixed-methods study found that cycling patterns and barriers to cycling were similar for Māori and New Zealand Europeans. However, cycling was more commonly out of necessity rather than choice for Māori. Barriers to cycling included inflexible work conditions, safety concerns, lack of support for social cycling and poor access to places important to Māori. Suggested solutions included development of whānau-friendly and culturally safe cycling infrastructure, and provision of cycling programmes designed around Māori commitments to whanaungatanga and kaitiakitanga.

Comment: Love this paper from one of my favourite people (Rhys Jones). Not only an interesting read but the recommendations to support cycle safety for Māori were simple, practical and whānau-centred.

Reference: N Z Geog. 2020;76:182-193.

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The Waitangi Tribunal’s WAI 2575 Report: Implications for decolonizing health systems

Authors: Came H, et al.

Summary: This report provides five recommendations to decolonise the New Zealand health system and guarantee protection of hauora as agreed in Te Tiriti o Waitangi. Recommendations included adoption of Tiriti legislation and policy, recognition of Māori political authority, strengthening of accountability, investment in Māori health and embedding equity and anti-racism in the health sector.

Comment: An excellent summary of the WAI 2575 claim and its five themes. I see many have been using these five points (Te Tiriti principles, tino rangatiratanga, equity and anti-racism policy, accountability and investment) as foundational components in strategic plans, and would endorse this for those of you about to embark on planning/service development. Importantly Heather and her team have gone a step further, with recommendations to the Crown and how to decolonise and transform the health system.

Reference: Health Hum Rights. 2020;22(1):209-220.

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Chronic conditions in the community: Preventative principles and emerging practices among Māori health services providers

Authors: Gifford H, et al.

Summary: The efforts of Māori health service providers in preventing chronic conditions in Māori were investigated in a three-phase research project using Kaupapa Māori methodology. The study included chronic disease prevention case studies for three Māori health service providers, small group interviews with seven participants and individual interviews with 44 participants. Strategies to improve prevention of chronic conditions included consolidation of prevention practices from different providers, increased resources and broader health services systems.

Comment: I personally find it challenging to deliver better approaches to preventing chronic conditions in my clinic, for the very reasons outlined here. And I’d worry that this would be worse post-COVID/lockdown. However, we’ve reduced the numbers of people hospitalised with respiratory disease this last year with simple preventative measures like separating people with respiratory symptoms from others; thorough handwashing; encouraging people to stay away from work/school when unwell. I’d love to hear from readers about innovative yet simple preventative activities for chronic disease that are being delivered in your clinics.

Reference: Health Promot J Austr. 2020 Apr 18. doi: 10.1002/hpja.346. Epub ahead of print.

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